I watched Ken Burns film “The Mayo Clinic: Faith—Hope—Science” on my local PBS station the other night. As I watched, I remembered when I was in second grade my physician-uncle had given me a book on Will and Charlie Mayo as boys. And I remembered finding Doctors on Horseback in my physician-grandfather’s library—the story of William Beaumont and his patient Alexis St. Martin particularly impressed me. All of which got me to thinking about heroes.
Certainly, the Doctors Mayo and Dr. Beaumont were all trying to improve the art and science of medicine, and in that time and place individual effort was all that was possible. But Mr. Burns showcased several individual patient stories intertwining interviews with Mayo surgeons and physicians who had cared for them. While most of the stories were of a heroic nature, all the physicians stressed their place as members of a team—none claimed heroic status for themselves. And very little mention was made of the prosaic, non-dramatic, daily work of patient care—it would not have made very good television. (Atul Gawande has noted that incrementalism is what characterizes most good medical practice, even though the compensation system still rewards the physician who takes the heroic approach as opposed to the one whose skill is tolerating uncertainty.)
The film also discussed how the Doctors Mayo went about getting a hospital to do surgery on their patients. They approached the Catholic Sisters of St. Joseph order and asked them if they would build and staff the hospital. As was pointed out several times, when the Mayo Clinic converted its assets into a foundation, the lawyers wanted copies of the original deal to review and include, only to be told there had never been more than a handshake between Dr. Mayo and the Mother Superior. (It needs emphasizing the heroic nature of their donation of the ownership of the clinic and all the assets they had tied up in it, but that did not get as much air time.)
This contrasts with a recent news story about the people of Immokalee, Florida, a medically underserved area of Collier Co., Fla., and its resident physician, Dr. Beau Braden. The town is located forty miles inland from Naples and has no hospital. “So when he proposed opening a 25-bed rural hospital to serve the 50,000 people who live in the farming community of Immokalee and the nearby planned community of Ave Maria, people rallied to the idea. They envisioned a place where mothers could give birth and sick children could get 24-hour help.” But their effort was opposed by a large hospital system in Naples in the Certificate of Need hearings. They raised several specific concerns but concluded this was a “a project doomed to failure.” While the original request for a certificate of need was approved, the hospital has appealed, and legal costs are rising. I highlight this not so much to argue for people in white hats or black hats, but to point out how complicated and bureaucratic the process is now, compared to times past.
The Mayo Clinic was the first example of a multispecialty medical group in the United States, a structure many subsequent groups, including mine, have copied. Key to all these efforts is the notion that doctors who band together for patient care can do a better job than any one of them could by themselves. In other words, the model is distinctly not heroic, even though Will and Charlie Mayo have heroic roles in their institution’s memory.
Hospitals have been buying up practices, but often find they can’t manage them, so once again, national physician practices (NPP) are reappearing. I was serving as my Clinic’s medical director when PhyCor, a first generation NPP, was making its move. Our administrator and I met with them at the headquarters in Nashville but realized what they were offering was a way to raise money in the capital markets, but at the cost of a 15% tax on revenue in perpetuity. They proposed to increase our efficiency and productivity enough to cover that tax. We thought it unlikely that PhyCor could do either and decided we did not need that deal. In contrast to PhyCor, which was working with multispecialty groups, the current generation of groups are usually either single specialty or closely aligned specialties.
Dr. John Birkmeyer is Chief Clinical Officer for Sound Physicians, which focuses on hospitalist services. He notes the current generation of NPP are either aggregators or innovators. The aggregators strive to make money by spreading administrative overhead over more physicians and finding ways to improve physician productivity—in other words using scale as the driver of profits. Of course, such a strategy assumes the groups being acquired have not already maximized productivity and/or have major cost-inefficiencies. Efforts to drive revenue through concentrated market power have not played as well as it has for hospitals.
The innovators, on the other hand, are betting they can produce more cost-effective practices and drive revenue from newer “value-based” contracts. Of course, they are assuming the knowledge of how to drive down costs in one location are applicable or can be applied in other locations in a timely and efficient manner. Since medical care, like politics, is decidedly local, this is an unproven assumption that depends heavily on the quality of small unit leadership.
The Ken Burns film raised the question in my mind: Is the age of medical heroes over? In the sense of one doctor and one patient versus the four horsemen of the Apocalypse, the answer is undoubtedly yes. But the Doctors Mayo were individualists, striking out on their own path, doing things the way that made sense to them, refusing to “go with the flow.” In that sense, there is still a need for “hero” organizations—those that are committed to doing things better, more humanely, and in ways that bring value to their patients and their communities. The rampant bureaucracies of government and large healthcare corporations makes this every bit as challenging as the feats of the Drs. Mayo. But I remain hopeful that somewhere, sometime soon, some maverick organization will prove it is possible to prosper financially while providing good, patient-centered care and treating its physician provider and its employees humanely. There has been a lot of talk about the “Triple Aim” and the “Quadruple Aim,” both of which focus on physicians. What we need is a new “Triple Aim” that recognizes the need to balance clinical, financial and human needs to create a healthy healthcare organizational environment. Maybe that is what it takes to be heroic in the present age.
30 September 2018
 Hammontree, Marie. Will and Charlie Mayo: Doctor’s Boys. The Childhood of Famous Americans Series, No. 87. (NY: Bobbs & Merrill, 1954.)
 Flexner, James T. Doctors on Horseback: Pioneers of American Medicine. (NY: Viking Press, 1937.)
 Gawande, A. The Heroism of Incremental Care. The New Yorker, 23 January 2017. Accessed online 18 January 2017 at http://www.newyorker.com/magazine/2017/01/23/theheroism-of-incremental-care.html.
 Healy, J. A Rural Town Banded Together to Open a Hospital. Its Foe? A Larger Hospital. 5 September 2018. https://www.nytimes.com/2018/09/05/us/rural-florida-hospital.html.
 Birkmeyer JD. Aggregators, Innovators, and the Resurgence of National Physician Practices. 16 August 2018. https://catalyst.nejm.org/resurgence-national-physician-practices-npps?
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