Do Clinicians Need Spring Training?

Submitted by Steven Lewis on December 6, 2011 - 18:29

Steven Lewis, President, Access Consulting Ltd., Saskatoon Canada

It begins in February and runs to the end of March. Raw rookies and twenty year veterans, bench warmers and megastars, all of whom have played baseball since their single digits. It’s spring training time, and no one is exempt. The playing field is literally and figuratively level. You come, you drill. Practice, practice, repeat. Over and over, until you get it right.

And once you get it right, do it some more. A ground ball to the right side, between first and second. The pitcher reflexively takes off to cover first base. It is easier if he is right-handed because his follow-through will turn him in the right direction. Lefties must either stop and change direction, or pirouette. If the first baseman has moved to field the ball, keep going. Aim to touch the infield side of the bag with your right foot; the runner owns the rest. Take a curved path so your last steps are parallel to the first-base line to avoid colliding with the runner. Catch the toss from the fielder; if perfectly executed it is like a quarterback hitting his receiver in full flight.

It is rarely perfect. Sometimes pitchers are slow to react and fleet runners beat them to the bag. Sometimes they fail to angle off and collide with the runner. Sometimes the toss forces them to break stride, slow down, miss the mark. Most of the time they don’t need to be perfect – there is a tolerance range. But good isn’t good enough at this level. If you’re good, you can be better. And it’s easy to lose your edge.

There is no such thing as permanent credentialing in baseball. You are only as good as your performance. Yes, great players in a slump will be cut more slack than novices. Managers know that physical errors, though rare (about one every other game), are inevitable, and they forgive them. Mental errors are verboten. You can’t always execute, but you can always concentrate. You train your physical reactions to be automatic so you can focus on the larger patterns of the game.

In spring training, and all through the real season, every player gets coached. Coaches pick up subtle things, like an arm angle, a slightly altered batting stance, inefficient footwork. These are the greatest players in the world, and still their skills are fallible, their deeply ingrained knowledge fragile. They take no shortcuts; they are always roughs in the diamond.

Baseball is a team sport, and players must adjust their skills to complement their partners. The most obvious is the double play combo of shortstop and second baseman. Here precision and timing are paramount and preferences matter. Should the feed be high or low, to the right or left of the bag? Does the shortstop have an average or superior arm (if the former, the second baseman must get the ball to him faster)? In the era of free agency, players rotate among teams frequently, new partnerships must form and long-standing processes must be recalibrated. It is always the same and never the same.

Baseball is a game, and while livelihoods are always on the line, lives aren’t. Health care is more fundamental, and the tolerances are far less elastic. There is far more variation in the human condition and patient presentation than there is in the stitching on a baseball or the trajectory of a fly ball. Both enterprises require highly skilled practitioners and complete mastery of fundamentals.

So it is no small irony that in baseball, professionalism is defined by structure, repetition, coaching, surveillance, and measurement, while in health care, professionalism has largely meant autonomy, independence, and freedom from scrutiny. In baseball, if a pitcher’s control is off by six inches, hitters will whack him all over the park. In surgery, if a surgeon errs by a centimetre, someone might die. Yet, as Atul Gawande recently observed, clinicians don’t have coaches who can pick up minor flaws in mechanics and counsel adjustments.

A surgeon working with new members of an OR team is no different from a shortstop who finds himself with a new second baseman. The newbie might be infinitely more talented than the guy he replaced, but that doesn’t it itself make a better duo. They have to create their own partnership and unlearn the processes that worked in another context but won’t here. They talk, they do, they adjust, and eventually they fuse. It’s the same with new lines in hockey. PDSA, every day.

Maybe clinicians – not just surgeons, but everybody – needs the equivalent of spring training. We can’t send them all to Florida or Arizona every year for 2 months, and there are no exhibition games in health care (though there are cadavers and dummies to practice on, roles to play, cases to review). Everybody can benefit from real-time observation of their work and skilled coaching for improvement. Mastery is fleeting and skills and performance erode subtly. Contrary to evidence and logic, health care assumes that once competent means forever competent; baseball doesn't.

Baseball has it right.      

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