The Silo Effect

by Gillian Tett

  IN JANUARY 2004, THE chief executive of Cleveland Clinic, Floyd Loop, a renowned heart surgeon, announced that he was stepping down after fifteen years. There was fierce competition to succeed him.33 But in June that year, after it had “deliberated hundreds of hours,” the trustees finally announced that Cosgrove (or Dr. Delos “Toby” Cosgrove, as he had been christened) was appointed the new CEO.34

  When the news was announced the next day to senior staff, it sparked “spontaneous applause and a standing ovation,” the Plain Dealer reported.35 Cosgrove had a glittering career in medicine, and was running a twelve-strong team of surgeons at the thoracic and cardiovascular surgery unit. This department was producing a third of the hospital’s revenue. “He’s run one of the most successful cardiac departments in the world,” as John Castor, a University of Maryland cardiologist, observed.36 Cosgrove was also admired for having a legendary work ethic. Born in 1940, he grew up in Watertown, a small town on the edge of Lake Ontario in upstate New York. He had a comfortable childhood: Delos (he acquired the nickname “Toby” as a child) was the son of a lawyer and grew up obsessed with sailing. (Decades later, when he moved to Cleveland, he kept a boat in Nantucket off the coast of Massachusetts.)37 But at the age of eight, Cosgrove made friends with a local surgeon and this instilled a passion for medicine. Becoming a doctor, though, was a bitter struggle. He worked hard at school, but never achieved good grades and in his first semester in college (Williams) he scored Ds. It was not until the age of thirty-one that he understood why: dyslexia. “My learning problem was identified by a girl I was dating at the time . . . who was a teacher,” he later recalled. “I was trying to read her selected stories from The New York Times and struggling with phrases. She said to me: ‘Toby, you’re dyslexic.’ A light went on.”38

  Cosgrove eventually was accepted to the University of Virginia medical school, and once he got into the practical world of medicine he blossomed. He did a medical internship at the University of Rochester.39 He then served in Vietnam where he worked at the Air Force’s Casualty Staging Flight Center, an evacuation hospital on the perimeter of Da Nang, which shipped back over 22,000 wounded soldiers to the United States in the course of just five months. “Not a day goes by when I don’t think of Vietnam,” he said. “Many things bring it back, like when I hear a helicopter fly by or a loud noise. It changed all of us.”40

  On his return, Cosgrove worked at Massachusetts General, then in 1975 he got his big break: a chance to join the team of cardiac surgeons at Cleveland Clinic.41 Although Cosgrove could have moved to Harvard, he chose the Midwest because of his admiration for René Favaloro and his coronary bypass techniques.42 He also liked the concept of working as a unit. “In the military I learned all about collaboration,” he liked to say. “So naturally I wondered why the rest of medicine wasn’t organized in the same way.”

  In the next two decades, Cosgrove worked ferociously hard and earned a legendary reputation as a surgeon. His colleagues did not always like him. Surgeons are infamous for being arrogant and Cosgrove often matched the stereotype. He was a man prone to strong judgments. “He had one of those 360 degree evaluations when he was department chair and people wrote that ‘he is very effective except when he becomes angry and loses control and then he loses all of us’, ” observed Eric Klein, a fellow surgeon who ran the urology department. But Cosgrove could also, on occasion, be self-deprecating and kind. And he was as harsh on himself as others. “What is really unusual about Toby is that he has the capacity to change and learn from mistakes, and he has really changed over the years in terms of how he handles people,” Klein added. He was also willing to take unorthodox risks.

  Soon after he arrived at Cleveland Clinic he decided that he was fed up with the way that heart surgeons were repairing patients’ heart valves. At the time, surgeons were typically using either a mechanical unit or valve taken from a pig to fix the human heart; these were stitched into a human valve in a solid ring to act as a collar.43 However, this solid ring was so inflexible that it did not move with the beat of that human heart, and surgeons did not know how to fix that. But one day, by chance, Cosgrove saw an old-fashioned embroidery hoop, of the sort that nineteenth-century seamstresses had once used to make dresses, and decided to adapt it for surgery. It was an odd leap of thought. “Heart surgery and embroidery [are phrases] that don’t usually appear in the same sentence,” Cosgrove said.44 But the innovation was a success. In subsequent years Cosgrove filed thirty patents for other inventions, many of which were equally offbeat.

  Later in life, he often attributed his ability to produce unconventional ideas to his dyslexia. Not being able to read had forced him to develop a photographic mind, and find his own solutions to problems. “This condition has proved to be a blessing in disguise,” he observed. “Because of the limitations it imposed, I never fell prey to the herd mentality. I had to forge my own way of learning about and understanding what went on around me.”45 He believed that his dyslexia had taught him a second lesson too: the key to being innovative was to challenge boundaries. Creativity tended to erupt when people mixed up ideas from different sources. “Many of my . . . ideas were inspired by comparisons and objects outside heart surgery that required the collaboration of professionals in other disciplines,” he observed.46 “Innovation happens at the margins, where one discipline rubs up against another.”47 Or, as it were, where silos break down.

  A COUPLE OF YEARS after his appointment, Cosgrove convened a meeting of the board of governors and told them that he wanted to change how the hospital was run. On one level, his colleagues were not surprised. They knew that Cosgrove was an ambitious man who was determined to create a legacy, and the senior staff had already been engaged in a wider, lively debate about whether the hospital should reorganize the department boundaries. “We were all talking a lot about change,” Bruce Lytle, the head of surgery, observed.48 However, the scale of Cosgrove’s ambitions took his colleagues aback. Rather than shuffling a few departments, Cosgrove declared that he wanted to implement two big revolutions. First, he announced that it was time for the hospital’s now 43,000 staff to rip up their existing taxonomy for defining a “doctor” or “nurse.” Instead of simply defining this in purely medical terms, all of the staff would now be considered “caregivers” and responsible for treating not just the physical ailments but the spirit and emotions as well.49 Second, Cosgrove wanted to change how the hospital was organized.

  Until then, the hospital’s organizational tree had been based on the tools and procedures that doctors used. One of the most crucial distinctions was that “surgery” (or cutting people open) was considered distinct from “medicine” (or treating people’s bodies). Numerous subdivisions existed within those categories that reflected how doctors had been trained. But Cosgrove wanted to turn this map upside down. In a sense, he hoped to replicate in medical terms what Ursus Wehrli, the contemporary Swiss artist and comedian, does with paintings and performances: namely reshuffle the way that things are normally organized, to give everyone a new way to think.50 Thus, instead of organizing Cleveland Clinic’s departments on the basis of doctor labels, Cosgrove wanted to define it around the patients and their illnesses. In essence this meant creating new multidisciplinary institutes that handled diseases (such as cancer) or body systems (say, the brain)—and thus forced surgeons, physicians, and others to work together in treating patients.51

  “When I got here, there were cardiac surgeons on one side of the hall and cardiologists on the other side of the hall and the only place we met was the waiting room,” Cosgrove liked to say. “I had nothing in common with most of the other surgeons [I was supposed to be with] since they were rectum surgeons or whatever. But I had everything in common with cardiologists because we were all working on the heart—even though they were in a different department of medicine.”

  The news caused shock. Compared to most of the other hospitals in America, the staff at Cleveland Clinic already operated in an unusually collaborative ma
nner, or as a unit, as its founders had liked to say. In most parts of the American system, doctors tend to work specialist units, divided from each other, and are paid according to what they earn as separate individuals. In that sense, the medical systems echoes the “eat what you kill” approach seen in many parts of the financial world (although in medicine it might be better described as “eat what you treat”). But at Cleveland Clinic doctors got paid a fixed salary, rather than earning fees on the basis of each separate procedure. While the doctors could get bonuses, these tended to be paid out on a shared basis, rather than on an “eat what you treat” system.52 This model was (and is) standard practice in much of Europe; the British National Health Service is entirely run on a salaried, collective basis. But it was an outlier in the United States: according to government data about half of the 800,000 doctors in America operate as self-standing entrepreneurs and most of the rest work in teams that are self-standing units in financial terms, even if they are attached to a big hospital.53 In 2005 just 4.5 percent of American doctors worked in a unit of more than fifty people with a collective, salaried system.54

  That made Cleveland Clinic unusual. However, it still split its operations into departments, and these departments did not always cooperate that well, partly because there were subtle and not-so-subtle status distinctions that created a quasi–caste structure. Cardiac surgeons, such as Cosgrove, sat at the top of this status system, commanding high salaries and ultra-high status. General practitioners sat in a different niche, with lower salaries. Groups such as radiologists or anesthesiologists were on another notch of the ladder again, and nurses even lower down. Often these groups collaborated. But sometimes the different departments could end up duplicating each other, particularly when new technologies or diseases cut across department lines.

  Heart catheters encapsulated the challenge. In the first half of the twentieth century, catheters were primarily used for issues such as bladder problems, and handled by physicians who practiced medicine, not surgeons. Inserting a catheter did not involve cutting into human tissue, so it was not defined as a surgeon’s job. But at the end of the century, physicians started cutting people to insert catheters and surgeons used catheters during heart surgery. “There was a blurring of the lines between medicine and surgery,” Bruce Lytle, explained. “You started to see cardiologists doing things with catheters which were interventions, but that was what surgeons were supposed to do! Then vascular surgeons started using more catheters—these guys were all trained to do open operations, but they shifted to the catheter area.” This sparked tension. “As lines blurred, we were facing more and more conflicts about money and pride,” Lytle admitted. Or as Eric Klein, the kidney expert, observed: “When Toby took over, you had five different [departments] doing carotid stents—cardiology, neurology, neurosurgery, neuro radiology, and vascular surgery.” Logic suggested that the teams should consolidate, since replicating these procedures was a huge waste of resources. But none of the departments wanted to cede ground. “We tried to get those groups on the same stage to work together and share databases and protocols, but we couldn’t do it,” Klein admitted. “They were different cost centers.”

  So Cosgrove announced a radical step: he summoned the two men who held the plum posts of Head of Medicine and Head of Surgery into his office, James Young and Kenneth Ouriel, and told them that he planned to abolish the departments of medicine and surgery, taking away their jobs.55 In most hospitals those two posts are considered sacrosanct. However Cosgrove was determined to rip up the traditional model. Instead of having departments divided into surgeons and medical doctors, he wanted to create multidisciplinary institutes instead. “I said to them both: ‘I value you but we need to change,’ ” he explained. To soften the blow, he offered Ouriel the chance to run the satellite operation in Abu Dhabi. The genial Young simply stayed on at the hospital, and ceded his top job. “At other places, there might have been a huge fight. Abolishing this division would be unimaginable at most hospitals!” Young recalled. “But I could see the sense of what he was suggesting.”

  The next step was to imagine medicine without the sharp distinctions between physicians and surgeons. When Cosgrove and the other doctors listened to patients talk about their illnesses, they noticed that sick people tended to describe their experiences in terms of body parts or broad ailments. They would say that their skin was sore, or their head hurt, or they had broken a leg, or feared they had cancer. This suggested that it made more sense to organize the hospital around multidisciplinary centers based on those body parts or broad ailments, rather than the old distinctions between surgeons and physicians, Cosgrove argued. He was not sure how this might play out in practice. But in June 2006, the chairman of the hospital’s Department of Neurosurgery stepped down, so Cosgrove launched an experiment.56 The board announced plans to create a “Neurological Institute” that would combine the departments or neurology and psychology (from the world of medicine) with neurological surgery (from the division of surgery), and other brain-linked services as well. “If someone has a headache, they just want to get it fixed,” Cosgrove observed. “They don’t know if they need a neurologist, neuroradiologist or whatever, so it makes sense to put it altogether.”

  Getting someone to run this experiment was not easy. Initially Cosgrove wanted a well-known medical star to lead the institute. The committee duly found a brilliant neurosurgeon who was working at another hospital. But when the proposed candidate realized the unorthodox nature of Cosgrove’s ideas, he backed out. Most high-status surgeons hated working on the same level as medical doctors or psychiatrists. It bucked all the usual medical conventions. “Toby told the search committee ‘Go out and find Nobel Prize level leadership!’ So we were looking for someone with enormous academic credentials,” recalled bearded neuroradiologist Mike Modic. “But it was a disaster.” So, the search committee put Modic himself in charge.57 It was another unorthodox move, since radiologists usually sit well below surgeons in terms of status. But Modic had nothing to lose. So he set about smashing down the boundaries, grouping together all the different types of medical activity and experts that were linked to the brain. “Take the spine,” he liked to explain. “People have been working on the spine for years in separate departments like psychiatry, psychology, imaging, psychiatry, orthopedic surgery, rheumatology, and so on. But we thought we made sense to put all these people together.”

  Cosgrove looked for other ways to redefine the medical map. A special “Institutes Planning Group” was created, with all the top doctors, to create a timetable for reform.58 But as stories about the revolution in the neurology department spread across the hospital network, employees in other departments were becoming scared. Many surgeons feared losing status. Nonsurgeons worried that the reforms would concentrate all the power in surgeons’ hands. “The concern was that the medical departments [like us] would be subsumed under surgical ones,” admitted Abby Abelson,59 chair of the department of rheumatology.

  As fear mounted, some of the doctors asked Cosgrove to scale back the reforms. He refused. He doubled down and announced that the hospital would press ahead with all the planned reforms in one go. He knew it was an ambitious undertaking. By then there were 43,000 people working at the Cleveland Clinic, in different departments, and each of these units had their own mode of treating patients, billing for procedures, and promoting staff. But he also suspected that if he waited any longer, reforms would likely be blocked. “People were getting nervous, they were asking who am I going to report to, who is my boss?” he later explained.

  On January 1, 2008, Cleveland announced its “Big Bang” revolution: twenty-seven new “institutes” were created with labels such as “Dermatology and Plastic Surgery Institute,” “Digestive Disease Institute,” “Urological and Kidney Institute,” Head and Neck Institute,” “Heart and Vascular Institute,” “Cancer Institute.”60 In some sections, the reforms involved nothing more than moving teams into new, joint offices: At the Urological and K
idney Institute surgeons who were skilled in operating on kidneys simply moved their computers into offices next to nephrologists, the medical doctors who worked with diseases of the kidney. In other sections, it was harder to glue the new teams together. “When the reorganization was announced, the rheumatologists were on one floor and orthopedics on another floor. We knew we were all going to work together and went around the buildings for ages looking for somewhere that we could all sit together,” Abelson recalled. “In the end we decided to stay where we are.” But irrespective of where they were sitting, the message delivered to the doctors was the same: surgeons and physicians had to stop thinking about medicine purely in terms of their own specialist field or distinct offices—and start collaborating.

  When the American Board of Surgery and American Board of Medical Specialities found out what was going on, they were baffled and alarmed. These two bodies certify the process of doctor training in America and operate on the assumption that hospitals are always split between physicians and surgeons. They had never seen a hospital that tried to break these boundaries before, and complained that losing these hallowed distinctions would make it hard for Cleveland Clinic to train its doctors. “They were not happy. It took a lot of explaining,” Cosgrove admitted. To placate them, the hospital managers eventually agreed to keep a shadow organizational structure based on the old departments that cut across the multidisciplinary centers. “The outside world is divided up into these specialities and so we had to keep that in play for [training] residencies and things,” Modic explained. Some of the insurance companies that dealt with Cleveland also demanded that the hospital continue to arrange payments along department, not institute, lines. The insurance groups’ computing systems were not flexible enough to cope with this multidisciplinary vision of medicine. That meant the final structure for the hospital was complex, since the shadow departments cut across some of the new centers. But Cosgrove reasoned that this was a price worth paying, not least because this overlapping matrix delivered an unexpected benefit: every time doctors practiced their craft, they were reminded that there was more than one way to define and classify medicine, and forced to move between different taxonomies. A neurosurgeon might be defined as a surgeon, part of that elite tribe. Or they might be just one person working on a brain, on a par with other medical staff who defined themselves as brain experts. It all depended on what perspective you took.