george-price-i-m-the-captain-of-this-ship-new-yorker-cartoonRick Blaine: Yes. I guess it is too far ahead. Let’s see. What about the engineer? Why can’t he marry us on the train? Why not? The captain on a ship can. It doesn’t seem fair that. Hey, what’s wrong, kid?
Ilsa Lund: I love you so much. And I hate this war so much.

Casablanca, 1942

Being a ship’s captain probably used to be so cool. Dining with the important guests. Yelling commands during exciting storms. Marrying Humphrey Bogart and Katheryn Hepburn types who were tired of that “crazy old war.”

Life onboard a ship has likely been romanticized ever since people traveled from one place to another by boat. Oh, sure, there are stories like Billy Budd and Mutiny on the Bounty but the romance of the sea was always there, at least to those who were not actually at sea.

In an old, old (1960s) Star Trek episode, a computer is placed on the Enterprise and given full command. Kirk is placed on board with a skeleton crew and the computer (remember, it could talk) is given full control. Kirk, accepting of his fate, is even called Captain Dunsel by his colleagues, a term meaning he serves no useful purpose (such as teats on a bull). Just as Kirk finds his peace with the new Star Fleet technology (and, as always, saves the Enterprise), today’s ship captains have done so as well.

The current life at sea is it is a lonely life at best. My department cares for some of the merchant marines who come through Mobile. The large container ships typically have only 12 crewmen and no passengers and are on-board a vessel over 400 yards long. There are likely over 10 different languages among the 12 crew, and so dinner time likely has limited shared conversation. They are with each other at sea for months at a time and as a rule spend less than 24 hours in port. The Captain has the responsibility for keeping this team working in an orderly fashion. Interestingly, the Captains who have come to our office for care seem to like their job. They, as a rule, smoke too much (many are Greek). Not a life I would choose for myself but one that carries responsibility, provides a challenge, offers freedom from direct oversight, and commands respect. A job that is sought after by many. Not one that I’ve met feels like a “Captain Dunsel.”

The role of the physician is now changing in our health care system. The New England Journal of Medicine has posted an article this week about the changing role of physicians. They cite the current situation as untenable and point out that the alternative “usually comprising some combination of alternative sites of care or caregivers, new care processes, and enabling technologies” depends on “two local factors: effective care teams and good management of local operations (“clinical microsystems”).” We have the opportunity to be a positive force  or we can continue to perform poorly and blame others.

Just as there is no “I” in team, there is no team based care without patients. Trying telling this to a Doctor Dunsel. “Our great care,” so the conversation goes, “is wasted on crappy patients.” There has even been a discussion amongst certain academics that we may have a created a super-race of non-compliant patient so self destructive that they can overcome even the best of care.

When trying to sell the benefits of team based care, Doctor Dunsel will tell me “I would love to be a part of a team, it’s the staff/ancillary personnel who are the problem.” Non-physicians’ contribution to care quality tends to be undervalued . The belief is that the great doctoring done by the smart doctor is lost in the incompetence of others. Outcomes measures and benchmarks, therefore, will never work.

So, just like the ship’s captains don’t do a lot they used to (including perform marriage ceremonies), physicians are going to have to come to grips with our changing status and roles. Physicians in the new model will need to “focus on promoting collective action, ceding control to the team, and showing the way by asking others how to get there.” The New England Journal article points out that these changes will be difficult

This model of clinical leadership runs counter to much current practice. [It is]  contrary to mainstream medical training and culture and the current tort environment. In many places, accepting a clinical leadership role brings a loss of status and income as well as disdain from peers.

To avoid becoming “Doctor Dunsel,” we need to embrace the concept of team. Back to the New England Journal article

Without formal authority, the only tool that clinical leaders have is their behavior: what they say, how they say it, and how they model good practice. The choice of language — expressing the team’s purpose in terms of creating value, curing disease, preventing harm, and caring for patients — and even tone of voice are essential leadership tools.

Instead of questioning how we can maintain the status quo, we need to ask the following of ourselves and our peers

“What are we trying to achieve?” “What is the best way to achieve it?” “Are we getting the desired results?” “What can we do to get even better results?” And “are our systems keeping patients safe?”