What Makes Minnesota’s Mayo Clinic Different?

After working at the Mayo Clinic in Rochester, Minnesota for nine years, Dr. Marc Patterson decided to change his life. In 2001, he moved to New York City to take a job as chief of pediatric neurology at New York-Presbyterian Hospital (NYPH).

This year, Patterson returned to the Big House on the Prairie. “Sometimes I miss New York,” he acknowledges, “but working in a system that actually functions is worth it.

Let me be clear: Patterson has many good things to say about NYPH and Columbia University Medical Center, the uptown campus where the worked.  “I had a great experience, and fabulous colleagues,” Patterson told me. “Moreover, one of the reasons I moved back to Minnesota is because my family is there.”

Nevertheless, Patterson says: “There is a fundamental systemic difference between Columbia and the Mayo Clinic: Columbia is a traditional academic medical center;  [research] that came through the med school provided the money to pay us.  The hospital is a separate entity.  By contrast, at Mayo, the hospital and the medical school are one. It’s an integrated organization.”

What difference does that make?

Patients Trump Research

“At Mayo the focus is on the patient. The needs of the patient come first.  I think one of the Mayo brothers originally said it—and here, that really is the case,” says Patterson. “We also do high quality research at Mayo, and we have a graduate school of medicine.  But research is not the primary focus.

“At most academic medical centers,” he continues, “medical research comes first; education of the students comes second. Clinical practice [caring for patients in the hospital and clinics] is not the priority.”

This isn’t to say that doctors at Columbia don’t strive to give patients the very best care possible. I am a long-time New Yorker, and if I were going to be hospitalized in Manhattan, I might well choose Columbia.

But, at Columbia, “while being an excellent clinician is great, it’s just not as highly regarded as being a brilliant researcher,” Patterson explains. “Here at Mayo, being a superb clinician is the sine qua none—if you’re not able to practice at the highest level, you won’t succeed here.

I have heard the same story from other doctors at some of the nation’s
top academic medical centers.  If you want the money and the glory, you
focus on research. You won’t become a star by being the best clinician,
or even by being a top professor.

At Mayo, on the other hand, stardom is frowned up. “Mayo has been, from
the beginning, a group practice,” says Patterson. “You really have to
be a team player. People in administrative positions understand that
everyone is an important member of the team.”

An Egalitarian Culture

You may have heard that at Mayo, doctors collaborate. But did you know that after their first five years all physicians within a single department are paid the same salary?  During those first years, physicians receive “step raises” each year. After that, they top out ,and “he or she is paid just the same as someone who is internationally known and has been there for thirty years,”  says Patterson. (“Most could earn substantially more in private fee-for-service practice.” he adds.)

“It doesn’t matter how much revenue you bring in,” Patterson explains,
“or how many procedures you do. We’re all salaried staff—paid equally.
This is very good for collegiality, and people working together,” he
adds. “The culture here at Mayo doesn’t encourage egos. There is not
the same cult of personality that you find at other places.”

At Columbia, by contrast, the pecking order is quite clear: even the
furniture on the floor where a physician works tells him where he
stands.  “The floor we were on was perfectly fine,” Patterson recalls.
“But if you walked up a few flights to ENT (ear nose and throat)
surgery, it was a different world—dark wood paneling, different
furniture… These surgeons bring in a much higher return for their
time,” he points out, “and they do some things that require remarkable
skill and training. At the same time, if a psychiatrist spends two
hours with a patient, he may get $200, while all a dermatologist needs
to do is get out the liquid nitrogen…”

The dermatologist can make $200 in a matter of minutes, just by zapping
the harmless crusty brown patches on the back of  a middle-aged patient
commonly known as “barnacles of age.”

That celebrity turns on how much money a doctor brings in hardly unique
to Columbia. “Traditional medical centers are much more hierarchical,”
Patterson notes.

Mayo is the outlier. Its culture is unusual because it is based on “the
very egalitarian ethic of the people who established the place,” says
Patterson, “and the fact that we’re in Minnesota”—a state with a
longtime egalitarian tradition. As a result, “people have the
opportunity to develop skills in whatever they want to do. Our nurses
are superb at doing spinal taps, and they teach our residents.”

“We are starting to make better use of nurse and nurse practitioners
are being integrated into the teams,” he adds. “We also have a lot of
physician assistants here—and they are extraordinary people.

“Turnover is very low. It’s unusual for people to leave here, and when
they do, many like me, wind up coming back.  You would be surprised—we
celebrate many 35 and 40 year anniversaries. That fact that people stay
so long is important to the success of the organization.”

Patterson does not sound as if he’s boasting. He didn’t found Mayo. He
didn’t create the culture. He merely works there—and he is telling me
why he likes it.

At the same time, in fairness I should report that the HealthBeat
reader who introduced me to Patterson was an extremely successful
physician at Mayo for many years, and ultimately decided to leave. The
Mayo Clinic is not Nirvana for all fine physicians.

Yet I believe that there is much that health care reformers can learn
by studying how Mayo operates. This is not to suggest that we should
aim to replicate the model coast to coast, putting golden arches over
every new clinic. There is, after all, a difference between healthcare
and hamburgers.  Healthcare is not a commodity,

A “Firewall” between the Money and the Doctors

Still, there are differences in the way Mayo is organized that are
worth pondering. For instance, there are no “rainmakers” at Mayo,
Patterson explains, because “there is a firewall between the physicians
and the money.  I don’t even know how much Mayo is paid for different
things that I do. I know the billing code, but that’s all. The business
office takes care of all of that.

“I also don’t know which patients are uninsured—and whether Mayo will have to absorb much of the cost of their care.”

Yet—and this is key—although Mayo’s doctors are not worrying about
the dollar value of what they do, they are not more extravagant than
other doctors  in dispensing care.
  Quite the opposite:  Extensive
analysis of Medicare records done by researchers at Dartmouth
University reveals that treatment at the Mayo Clinic in Rochester,
Minnesota costs Medicare far less than when very similar patients are
treated at other prestigious medical centers.

The chart below, from the “Executive Summary” of the 2008 Dartmouth Atlas
is an eye-opener. It shows that when researchers compared how much
Medicare spent  per patient, on very similar chronically ill patients
during the final two years of life at five top medical centers (UCLA,
Johns Hopkins, Massachusetts General, the Cleveland Clinic and Mayo’s
St. Mary’s hospital),  the tab taxpayers paid varied widely,

While Medicare spent more than $93,000 per patient on those who were
treated at UCLA Medical Center, patients at Mayo cost the government
only half as much. As the bottom two-thirds of the chart shows, this is
because, when compared to patients at other medical centers, those at
Mayo spent fewer days in the hospital, saw fewer physicians and were
less likely to wind up in the ICU.

Mayospending

Yet no one would suggest that Mayo scrimps when treating patients.
The Clinic received stellar marks on established measures of the
quality of care, and both patient satisfaction and doctor satisfaction
were higher than at UCLA.

As HealthBeat has pointed out in the past, when it comes to healthcare,
lower costs and higher quality often go hand in hand. Mayo’s patients
are not hospitalized as long as patients at other medical centers—and
don’t see as many specialists—because resources are used efficiently,
and diagnoses are made quickly.

A Fully Integrated System

“Here at Mayo, we can do things in a week that take several weeks to
organize in New York,” says Patterson.  This is because Mayo is an
integrated medical center.

For example, “In New York, each division has its own staff to make
appointments.  If I wanted several specialists to see a patient, I had
to go through each of those divisions. At Mayo, we have a pediatric
appointment office that makes all of the appointments for pediatric
patients.”

Patterson still remembers “the frustrations of the system in New
York…It took a lot of time to get things done. If you wanted something
accelerated, we essentially had a trade and barter system—you would
call in favors. We were always reinventing the wheel, rather than
having a system in place.”

It didn’t help that the uptown campus and the downtown campus of New
York/Presbyterian Hospital have different electronic medical record
systems, “and neither of them is user-friendly,” Patterson recalls,
sounding, just for a moment, a little glum.

How could one hospital have two EMR systems that don’t talk to each
other? “When New York Hospital and Presbyterian Hospital merged in 1997
to form NYPH they had different systems,” he explains. Like many large
medical centers, NYPH is now making major investments in pilot programs
to move information out of “silos” and to “enable easier access to
critical clinical information.” But as this 2008 NYPH presentation observes the project will take not only money, but “time” and “culture change.”

Meanwhile, at Mayo, “We have a unitary medical record and a very
effective IT department,” says Patterson.  “We developed our own
software, and we can we dictate notes—we don’t have to type.” (This is
a boon because, believe it or not, many doctors don’t know how to
type.)

“In the hospital, what we dictate can be transcribed within about an
hour.” Patterson adds. “In the clinic, it’s done by the next half-day.
In the meantime, if someone needs to access your notes, they can dial
in and listen to the dictation.”

Patients, Like Doctor, are Equal –and Many Need Charity Care

Some say that Mayo operates in a bubble that separates it from the real
world. Their may be some truth to this. Certainly, Mayo has created a
very special culture.

But the assertion that Mayo is “different” because the vast majority of
its patients are very wealthy and thus easier to treat than the
patients at most academic medical centers just isn’t true.

The Mayo Clinic in Minnesota sees many local patients.  “And like New
York, we have minorities—just different minorities,” Patterson
explains. “At Columbia, I saw many Dominican patients who lived close
to the hospital in Washington Heights” (a low-income neighborhood that
is beginning to attract middle-class New Yorkers).

“At Mayo, we have Spanish speaking migrant workers” Patterson explains.
(In the 1990s the number of foreign-born Latinos in Minnesota shot up
from 9,200 to more than 62,000).

Surprisingly, Minnesota also is home to many refugees from Africa.
Somalis began flowing into the state from refugee camps in the 1990s,
in part because several well-organized faith-based Minnesota groups
made them welcome, and in part because the economy was strong and jobs
for immigrants who didn’t speak English were available.  Today an estimated
30,000 Somalis reside in the state. “And they are not well off,” says
Patterson, comparing them to the poor patients he saw in New York.

Minnesota has a history of active volunteerism regarding immigration
and refugee resettlement, which helps explain why its foreign-born
population more than doubled during the 1990s—from 110,000 to 240,000.

The immigrants include some 60,000 Hmong, an ethnic group that fled
mountainous regions in Southeast Asia. Most of those who settled in
Minnesota come from Laos. Some readers may recognize the Hmong from
Anne Fadiman’s brilliant book The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures.
From his years at the Mayo Clinic, Patterson is familiar with the
cultural divide which make the Hmong difficult patients for many
Western doctors. “They believe in supernatural forces,” he explains.
Nevertheless Mayo treats them—and regularly advertises for Hmong
interpreters.

Like most academic medical centers, Mayo treats a fair number of patients who cannot afford to pay their bills. In 2007 it spent
$182 million providing charity care and covering the unpaid portion of
Medicaid bills—plus another $352 million on “quantifiable benefits to
the larger community” which included “non-billed services, in-kind
donations and education.”

That year, 100,000 benefactors gave the Clinic a record $373
million—enough to pay for the benefits the Clinic provided for the
community, but far from the amount that would be needed cover the
charity care Mayo provided.

Although its $1.6 billion endowment gives Mayo a stable base, it is not
awash in money. In 2007 it operated on a relatively slim margin of 2.9
percent; that year revenues grew by 9.6 while expenses rose by 8.5
percent, “due in part to Mayo investments in patient care and research
activities, as well as information technology infrastructure,” the
annual report explains.

When it comes to serving Medicaid patients, Mayo is generous with its
time and talent. “Here, there is no distinction between Medicaid
patients and other patients,” says Patterson. “I wouldn’t know whether
they are on Medicaid, or have insurance from their employer. The
business office knows that.”

At many academic medical centers, Medicaid patients are seen mainly by
residents in a separate clinic. “At Mayo no one is seen only by
residents. And we routinely spend 90 minutes with a new patent —going
through X-rays, and a complete examination,” says Patterson.  “At
Columbia, we had private offices and a Medicaid clinic, I tried to give
people 90 minutes, but in the clinic, it was hard to do that.”

Those who suggest that Mayo operates in a separate world often assume
that it can afford to be so magnanimous when caring for indigent
patients because so many of its beds are filled with Saudi Sheiks.
Patterson acknowledges that “at Mayo, we do see a number of quite
wealthy people—but that was true in New York too.” Indeed, high-income
patients typically flock to prestigious medical centers like Johns
Hopkins, UCLA, Mass General and New York-Presbyterian.

So when officials at a medical center like UCLA try to argue that
Medicare’s bill are higher when patients are treated in L.A. because
the hospital is treating a different “population” of patients
suffering from and “more complex” and “more severe illnesses,”  this
doesn’t quite ring true. Certainly, it is hard to believe that the
difference is large enough to explain bills that are 80 percent higher.

As Dartmouth’s Dr. Elliott S. Fisher, a co-author of the study comparing Medicare spending at five academic medical centers, points
out:  “We are comparing patients with identical outcomes — all were
dead in two years. So it’s unlikely that differences in the severity of
illness account for the variations we saw.”

It also is  important to keep in mind that, “contrary to popular
assumptions, it’s the volume of services, not the price per service,
that accounts for most of the variation in Medicare spending” observes
Dr. Jack Wennberg, the founder of what is now known simply as “the
Dartmouth research.” And as more than two decades of Dartmouth research
have shown, it is the supply of hospital beds and doctors that drives
volume—not patient demand. When more resources are available, as they
are at UCLA, patients spend more time in the hospital and undergo more
procedures. Yet outcomes are no better; often they are worse.

“UCLA knows it has a problem,” Wennberg confided in an interview last
year. “But what are they going to do—close down beds and fire doctors?
They need that stream of revenue that comes from the beds and doctors
to service their debt.”  So Medicare spends more at UCLA—and some
patients are over-treated.

But Not All Mayo Clinics Are Created Equal

Mayo offers lessons for reformers. Still, it’s not easy to replicate
the success Mayo enjoys in Minnesota.  Not even Mayo can do it.

Over the years, the Mayo Foundation system has grown beyond its
original Rochester, Minnesota site, establishing group practices in
Phoenix, Arizona; Jacksonville, Florida; Eau Claire and La Crosse,
Wisconsin as well as in several other communities in Minnesota and
Iowa.  But when Dartmouth’s researchers examined how these spin-offs
use their resources, they found “surprising” variations.

“Indeed,” the report observes, “the spectrum of approaches to caring
for patients with severe chronic illness ranges from a low resource
input, low-intensity end-of- life pattern favoring primary care to high
resource input, high-intensity end-of-life care relying on medical
specialists. In short, we find no evidence that providers in these
systems use a distinctly Mayo Clinic strategy for allocating resources
and managing chronic illness.”

It is worth noting, however, that at the four Mayo practices that
Dartmouth’s researchers studied, the quality of care turned out to be
either “very high” (LaCrosse and Phoenix) or “above the national
average” (Jacksonville and Eau Claire.)

The variation suggests that it may not be the Mayo “system” that lifts
Mayo’s flagship Minnesota hospital above the tide. Rather, some
observers suggest, it may be the highly egalitarians and collaborative
“culture,” which puts patients ahead of everything and everyone else,
that makes the Mayo Clinic in Rochester, Minnesota  so special.

These are values that can be traced directly back to William Mayo and
Charles Mayo, who, together with their father, William Worrall Mayo,
founded Minnesota’s Mayo Clinic in 1903. The Clinic was one of the
first examples of group practice in the United States. As Doctor
William Mayo explained
in 1905: “The best interest of the patient is the only interest to be
considered, and in order that the sick may have the benefit of
advancing knowledge, union of forces is necessary…it has become
necessary to develop medicine as a cooperative science.”

The Mayos also made it clear that patients’ interests were not well
served if doctors competed with each other. Late in life William
emphasized that in addition to making a commitment to the patient,
doctors must make a commitment to each other:  “Continuing interest by
every member of the staff in the professional progress of every other
member,” would be essential to sustaining the organization’s future.

More than one hundred years later, building a health care system that
adheres to such a collective vision of its mission may be difficult.
Perhaps it can only be done in Minnesota.

Nevertheless, the 2008 Dartmouth Atlas does provide sufficient data to
support the thesis that integrated delivery systems are likely to
provide the most efficient high-quality care. And the report makes it clear
that Mayo is not the only integrated system that stands as a benchmark
for excellent collaborative care. Both Intermountain Healthcare (IHC)
in Utah and the Sutter system hospitals in Sacramento are singled out
for praise.

So the structure of the system is important. But so is the soul. On
that point, I would argue that we should pay attention to the
“firewall” between the doctors and the money at Mayo. Ideally, in any
medical center, the money and the businesspeople should be on one side
of that wall; the doctors and the patients on the other side.  Clearly,
someone has to make sure that the hospital can stay afloat
financially.  But too often, money gets in the way of medicine.

In the end, Mayo offers proof that when a like-minded group of doctors
practice medicine to the very best of their ability—without worrying
about the revenues they are bringing in for the hospital, the fees they
are accumulating for themselves, or even whether the patient can
pay—patients satisfaction is higher, physicians are happier, and the
medical bills are lower. Isn’t this what we want?

28 thoughts on “What Makes Minnesota’s Mayo Clinic Different?

  1. Maggie:
    As a long-time Mayo physician (20 years), I think your assessment is correct. You’re right–staff turnover there is very low. (I left Mayo largely for personal, not practice-related reasons. Beware the Minnesota climate!)
    I agree that culture is paramount, and I have one thing to add about the comparison between Mayo Rochester and the satellites sites that demonstrates this, I think.
    The Eau Claire and La Crosse sites were situations in which Mayo acquired already-existing practices. So the pre-existing culture affected what happened next, I think.
    The larger satellites at Scottsdale and Jacksonville were built from scratch. Mayo Rochester people went down there, including physicians, secretaries, technicians, and others, but the culture that evolved over many years in Rochester was not something that could be recreated overnight.
    Thus the Dartmouth comparisons between Rochester and the other sites represents a clear demonstration of the importance of practice culture and how delicate a thing it can be to recreate. If Mayo found difficulty in reproducing it elsewhere in its own system, it would be even harder to do under other circumstances. But practice culture is still key, I think.

  2. i’d like to see their cost structure. i refer patients to mayo and have the same headaches scheduling appointments as everywhere else. i call bs on that point.
    if they truly take in less money by being efficient and delivering speedier care without excess procedures, and they have more non-paying or lower paying patients, how do they make money? certainly the rent and employee salaries are lower than in ucla, but those things would not lend themselves to reproducibility in other centers.
    they are proposing that doctors never get a raise other than cola adjustments?
    in other words, day one physicians get same as 30 year experienced physicians?
    sounds great for the young guys. i don’t believe it. they can couch it however they want, but there probably are some sort of bonuses or other $ paid to individuals-no extra money for being chief of division? for publishing a lot?

  3. I can answer anonymous’s question about Mayo salaries (assuming things haven’t changed since I left 8 years ago). Mayo has a system of “step raises” that give a starting physican annual increases for, as I recall, 5 years. But then you are at the top of your pay scale and that’s your salary for the duration except for cost-of-living raises everybody gets. Maggie’s right about that.
    Department chairs and section heads do get paid a little more (not all that much more for what they do), but everybody else in the department gets the same pay. (Of course salaries do vary by specialty.)
    Me, I like their system. I liked it so much that I took another salaried job wherein it doesn’t matter how many kids I intubate or central lines I place — I get paid the same.

  4. Yes–
    Marc did mention that admninistrative heads are paid a little bit more.
    He didn’t mention the step increases in the first five years. But that makes sense. I wonder– is the five-year point the point where you are invited to stay permanently?
    But keep in mind that these step increases for the first five years do not make anyone fabulously rich.
    Doctors in most specialiies at Mayo could make far more in a fee-for-service world–as long as they were willing to work as hard as they do and Mayo, and much faster (seeing, treating and operating on many more patients while spending less time with those patients.)
    As I was trying to explain, people at Mayo don’t work for the money.

  5. Maggie:
    If things haven’t changed, the point when you are asked to stay permanently is at 3 years. This brings up another interesting difference between Mayo and many “academic” medical centers–they don’t pyramid junior staff. In other words, every new hire is assumed to have a permanent slot. If they need 1 person for a slot, they hire 1 person, assuming they will do a good enough recruiting job to get the right doc. So the transition at 3 years to permanent staff happens for most, something that greatly relieves the stress for a new doc just out of residency. Unlike the model at many centers, they don’t hire 2 young docs, let them scramble with each other, and then sack one of them when promotion/tenure time comes.

  6. every physician at every academic center and most physicians in general don’t work for the money, if you ask them.

  7. Chris and Anonyous:
    Anonymous: I definitely thin you are right: most physicians don’t work for the money.
    If a person is bright enough and diligent enough to get through med school, he/she could find many far, far easier ways to make a large amoutn of money.
    But I do suspect that for many doctors, how much they make, compared to other earn doctors, affects their self-esteem. This is simply how they have been conditioned–and unfortunate because those doctors who earn the most are not necessarily the best.
    What I like about Mayo is how manages to erase “money as a measure of your worth” from the equation. (See Chris Johnson’s most recent comment above, and my comment here:)
    Chris:
    You wrote: “every new hire is assumed to have a permanent slot. If they need 1 person for a slot, they hire 1 person, assuming they will do a good enough recruiting job to get the right doc. So the transition at 3 years to permanent staff happens for most, something that greatly relieves the stress for a new doc just out of residency. Unlike the model at many centers, they don’t hire 2 young docs, let them scramble with each other, and then sack one of them when promotion/tenure time comes.”
    This seems to me very important, and, interestingly, the exact opposite of the way Jack Welch (often seen as the master of corporate management) ran things at GE.
    Welch purposefully pitted employees (and divisions of employees) against each other. This was his idea of “motiviating them.”
    Rather like letting pit bulls get a taste of blood.
    When we finally look back at what happened to corporate America from 1980 to ?? I think we will realize that Welch was one of the world’s worst, and most vicious, managers.

  8. how do they have time to give all those talks? the ones in my specialty must be gone from mayo conservatively 40 working days a year. who is taking care of the patients then? maybe they slot three physicians instead of two in other practices? also what is their plan for addressing student loan debt in young physicians?

  9. I certainly agree about the importance of the collegial and collaborative culture at Mayo vs. other academic medical centers. I would be curious, however, to see to what extent Mayo’s revenue mix among private insurers, Medicare and Medicaid compares to other AMC’s. Does Mayo have more privately insured patients in its revenue mix than other hospitals or not? Also, how much of Mayo’s revenue comes from investment returns on its endowment plus philanthropy and how do those revenue sources compare as a percentage of total revenues to other AMC’s? At the same time, providing more appropriate and less intensive care and getting patients out of the hospital faster should, in theory, allow for more throughput which could largely offset less revenue per case than other AMC’s who treat more intensively may realize.

  10. Mayo Clinic for all?

    Maggie Mahar waxes eloquent on the Mayo Clinic, and contrasts their care and outcomes compared to other health systems in the country.
    While true that they provide higher quality care at lower costs, this is partly due to scale and the fact that the May

  11. Barry–
    Mayo is known for doing a great deal of charity care.
    The point is that there are many other prestigious
    hostipals with large endowments and many donors. But they tend to use the income differently–rather than investing it ins superb health IT and patient care, they spend it
    on things that can be seen, and will help draw doctors who care for affluent patients –or that will draw in lucrative business (cath labs–which lead to more angioplasties.)
    A few years ago, a study showed that Mahyo is the only academic medical center in the country that doesn’t adverstise. Word of mouth brings it patients–and its happy to take patients who can’t get the care they need elsewhere, whether or not they have insurance.
    Other presitigious medical centers often shun the poor.
    If you want more info on Mayo’s financial, see the link to their annual report in the post.

  12. You clearly point out that the doctors at Mayo are a highly self selected group – willing to live in an undesirable location, willing to take lowered pay with no future raises, willing to not ever be a “big shot”. What makes no sense is why you think this is something that can somehow be generalized to the entire US health system when it is clearly attributable to a minority of people who end up in places like Mayo. It’s like saying Harvard law grads who take low paying public defender jobs out of pure altruism do a great job so surely learning from them is the key to improving the legal system… no, it’s just that in any profession there is a small group of people who aren’t driven by the things most human beings are. Expecting the other 95% of humans to start acting like them is just bizarre.

  13. Maggie:
    I agree with everything you described about Mayo, but would echo what Chris said about culture and, as Bob says, resist the temptation to generalize from the Mayo experience.
    I was in a leadership role in a very highly regarded large group practice with a very similar salary structure to Mayo’s. I know this because we had a former Mayo physician in the group. In many ways the system worked well. However, we had a recurring problem with the best docs feeling (and being) overburdened relative to many of their colleagues. The ones who went the extra mile for their patients or referring docs were rewarded by more patients, more referrals, longer hours and later nights. The ones who did their jobs competently and protected their time weren’t as busy, but were paid the same. The result was that many of the top docs moved on, slowed down or burned out. The system continued to do fine, but without the commitment to excellence that also defines Mayo. There’s a lot more going on in Rochester than paying on salary.

  14. One other thing that makes being a Mayo staff member interesting is the generous trip allowance. When I was there, every consultant (their name for a staff physician) got 18 working days to attend meetings, give talks, etc. This was apart from vacation. Not only are you paid for these days, your trip expenses are covered. That’s a huge perk, one that keeps you sharp and involved in your specialty.
    I also should mention that, although a consultant’s salary doesn’t rise over time, one’s vacation days do. So that is one perk of being there for a while. But so-called “trip days” are equal.
    In my opinion, the whole Mayo culture in general does not encourage “tall poppies.” So if you want to be a big shot, you will be unhappy there.
    Another thing that adds to the job satisfaction is that, as Dr. Patterson said, the allied health folks, from the desk clerks to the lab folks, are extraordinarily efficient. This makes the “hassle factor” low from the doctor’s perspective.

  15. Bob , David, and Chris–
    Thanks for your comments-
    Bob —
    As a former academic I know many, many people who are willing to accept relatively low pay while doing something that they love. (When I started out in academia, pay was extremely low. If I had taken my Ph.D. in English and gone out into the private sector, I could easily have doubled by salary.)And the university was filled with people like me.
    My son is now an academic. In today’s world, he could easily earn three times what he makes now. He was actually offered several very lucrative jobs in the business world when he graduated from college–before he went to grad school. But when he interviewed for these jobs he realized he wouldn’t find his potential colleagues (the other people being interviewed) and bosses as interesting or congenial as the faculty and students he works with now He loves teaching.
    Finally, I now work at a non-profit foundation with some very talented people.
    Why do we choose to work here rather than in the business world, in the financial world, or in management in the corporate world?
    As one of my young colleagues who did a stint in the business world (after graduating from Harvard) and before coming to the Foundation) puts it:
    “I decided I would rather be poor than bored.”
    And we’re not priests, nuns or missionaries. There are people out there who make huge sacrifices to help the world –for example doctors who commit many years to working with “Doctors Without Borders.”
    By contrast, we all have very comfortable lives doing work we find very stimulating working with people we generally like and respect.
    So, no, I don’t think we represent 5 percent of humanity.
    A great many people– from artists to people who choose to spend many years in government, education, academic medicine, or the non-profit world–earn much less than they might otherwise earn, know that they will never be “big shots” –and feel badly for people who are “driven” as you put it, by money, or their need for status, celebrity and a huge heap of toys.
    Based on my life experience, I’d say that, if we’re not in the majority, we represent at least 40 percent of the population.
    Btw, I also don’t think of Minnesota as an “undesirable location.”
    But, then, I like cold weather.
    David–
    I understand what you are saying about Mayo’s culture; this is what makes Mayo work, and it took many, many decades to build. I agree–just putting doctors on salary wouldn’t do the trick.
    You need to attract a group of like-minded people. My impression is that at Mayo, no one wants to be seen as a slacker; everyone wants to hold up his end of the load.
    Conceivably, if you had had some sort of probabtion period (lilke the first three years at Mayo) after which a doctor was or wasn’t asked to stay, you might have been
    able to weed out the docs who were competent, but not willing to go the extra mile, and eventually have built a practice comprised entirely of the “best docs.”
    Of course, after being asked to stay, some docs might have slacked off . . but peer pressure and cultural pressure might have made them begin to feel that they didn’t belong . .
    These things–building a “culture” or a community– are very, very tricky. There’s no rule book.
    But it sounds as if, at the very least, you built a fine organization–even if you don’t feel it achieved a commitment to excellence equal to Mayo’s. In our broken health care system, that is quite an accomplishment.
    Moreover, I think that if, over time, people study the “firewall” between the practice of medicine and the business at Mayo and the way Mayo chooses to use its surpluses (investing so heavily in information technology— something that helps patients)–other hospitals could learn something.
    The firewall between the business and the practice of medicine reminds me of the firewall that used to exist in journalism between the publisher and the people who sold ads on the busines side of the organization, and the reporters and editors on the other side of the wall. Henry Luce, founder of Time Inc., felt strongly that the two should be kept separate. (He referred to the two halves as church and state.) They were always on separate floors of the building..
    On the business side, the publisher and ad sales people worried about what readers wanted to read–but they didn’t direct the editorial content of the publication. Those decisions were made by editors and reporters who were less concerned with what people Wanted to read than what they Needed to know.
    A few publications are still run that way–and they are the very best. (Barron’s was run that way during my first years there.As a result I could write anything that was true. We didn’t worry about offending advertisers-or readers who owned a particular stock.)
    I also wonder how much Mayo pays its very efficient clerical staff, lab clerks, etc. I suspect that, after adjusting for local cost of living, Mayo pays its clerical staff more than most academic medical centers, while paying its administrators as well as its doctors much less. (When you are talking about wages on the lower steps of the income ladder, I do think paying more will attract the sharpest, most energetic people. What I don’t believe is that people who earn $800,000 will do a better job than people who earn $250,000. Or that CEOs who earn $3 million work harder than–or are smarter than–CEO’s who earn $1 million. In fact, reserach shows that the highest-paid CEOs tend to be not as good. They’re just there to line their own pockets.)
    Chris’ description of how Mayo makes more vacation days, rather than more money, the “perks” you accumulate over time also sounds very sane–and something that could be dullplicated.
    Dangle more and more money in front of people’s noses, and you may well motivate them to run harder, and harder but you also encouarge them to work harder than is healthy.
    Give them more vacation time —more time off from the often stressful job of being a physician– and you probably wind up with happpier physicians who are better able to help their patients.
    Many European countries figures out a long time ago that more vacation time is more valuable than more money. They think we’re crazy, the way we work outselves to death.
    Again, I’m not suggesting that anyone can “clone” Mayo, just that we can learn from it in many ways. . .And again, it’s not the only place that has achieved such a commitment to excellence and efficiency. The DArtmouth reserach talks about Intermountain in Utah, and a couple of other places that serve as “benchmarks” of higher quality and less waste.
    We’re going to be developing more large multi-specialtly salaried practices in this country, and so we should try to understand how the best ones are run.
    Finally, Chris–thanks again for the insights into Mayo . . . someone should write a book . . ,
    Things like the vacation days instead of bonuses probably seem natural to you–hardly worth mentioning–but to me, it’s another example of a very intelligent cultue.

  16. could we see a link to that study that showed mayo was the ‘only’ academic center not to advertise? where is it that they are not advertising and others are? national/international news magazines? national news papers?
    have you ever visited the mayo? it seems to me that if you have had the chance to go visit it as a patient or visiting a patient, you would walk away impressed with their commitment to service, the sheer number of patient touches that occur by various people to make sure things go well.
    and if you had to design a system to support that infrastructure, you would see there is no way (at least that i can see) to make it financially viable through clinical $.
    how many cath labs are they running? how many electrophysiology labs? how many operating rooms? how many endoscopies? how many mri machines do they have? the denominator of the population they serve is hard to know given they serve as a tertiary referral center for the world.
    dr johnson alludes to the generosity of the mayo in allowing people to go on paid educational days, 18 days, essentially what other practices view as cme. but in fact, many practices allow their physicians to take at least five to ten days of paid cme leave when they are employees as a perk. when partners, some take more, some take less, depending on their priorities as it can cost them in the form of lost revenue.
    i wonder how much $$$ comes to mayo from hosting the cme activities? is that money directed to supporting patient care activities? what about speaker fees generated from the thousands of talks given? book and patent revenues?

  17. Anon–
    I really don’t make these things up
    Here is the link to the medical journal article on advertising by academic medical centers.
    http://archinte.ama-assn.org/cgi/content/full/165/6/645
    Where do they adversite?–Newspapers, you name it (122,000 newspaper ads in 2002 alone.
    Regarding your other specific questions about how Mayo manages to stay afloat financially, please see the link to its annual report in the post

  18. “Our study should be interpreted in light of several limitations. First, because we limited our analysis to the 17 medical centers named to the US News & World Report 2002 honor roll of “America’s Best Hospitals,” our results may not be generalizable to other institutions. Medical centers with less name recognition may rely more on advertising to attract patients and may use different marketing strategies. Second, we specifically limited our investigation to newspaper advertising. While we recognize that other forms of consumer-directed marketing (direct mail, magazine, outdoor, radio, or television advertising) might differ in content or character, this is the mode of advertising most commonly reported by the marketing departments of the centers we studied. Finally, like all content analyses, ours involves subjective judgments”
    from the article, only one of 17 academic centers (a far cry from all academic medical centers), and only discussing advertising in newspapers (not as likely to be fruitful for mayo as medical journals for the source of their referrals).
    also, i am afraid i lack the expertise to evaluate the quality of the financial report to see whether their claims are likely correct? sorry about that, i truly wish i did have the expertise to do that.
    what do you think of the mayo clinic’s completely scientifically unsupported executive physicals? how do you balance that concept against the thought that they provide cost effective care?

  19. Maggie, Maggie, Maggie! Your post read like a puff from the Mayo’s Public Relations department. When the people at the Mayo aren’t walking on water they and the Mayo have just as many peccadillos as common folks and organizations. To learn about some of them them you should read the posts by Mayo Clinic employees on the “Rants & Raves” section of the Rochester Craigslist. Or go to http://www.Mayinfo.com (a site run by an ex mayo employee). Another website where you may see the other side of the Mayo coin is page 13 of http://www.mayovictim.com

  20. David-
    I can’t help but wonder:
    are you an ex-employee, or
    maybe a physician at another instiution.
    I have found that doctors at other instiutions are sometimes very eager to put down Mayo. Something about the place is threatening.
    I don’t see “Craig’s List” aa a terribly reliable source of scientific information on hospital quality. I’m more impresed by the unbiased Dartmouth Reserach as well as what doctors who practice or have practiced at Mayo have to say.
    Because Mayo has a such a high reputation, it is bound to be a target.

  21. Wow! And I can’t help but wonder, based upon: “The lady doth protest too strongly” what your motive or incentive was to write the piece . I’m not a doctor Maggie. Further I’ve neither been nor am I an employee of the Mayo Clinic. And how on earth did you extract the notion from my post that I was “eager to put down the Mayo.”? As for the “unbiased” Dartmouth Research, I know that you are sufficiently worldly to appreciate that there is no such thing as “unbiased” research. To relate it to your discipline it’s called “reading between the lines” and to mine it’s called the Heisenberg Principle. I wonder who funded the Dartmouth Research project?
    As for your point about Craigslist. Are people’s postings to it any less credible than the postings to your blog? At least posters to Craigslist have to register and be confirmed and many of the posters to the Rochester list are actual or former employees and patients. I don’t think you went to the links I gave. If you had you would have uncovered some of the Mayo Clinic’s skeletons.
    You don’t think Craigslist worthy so how about the “Wall Street Journal”? Is that credible enough for you? If so this link will take you to WSJ article where the Mayo Clinic tries to slap a patent on a common remedy for sinusitis:
    http://lists.essential.org/pipermail/ip-health/2003-April/004683.html
    Or is the U.S. Dept. of Justice credible enough for you? If so this link will take to the DOJ website where you can see where the Mayo Foundation were fined $6.5 million for misusing a federal grants program to line their own pockets:
    http://www.usdoj.gov/opa/pr/2005/May/05_civ_292.htm
    Here’s an article from “City Pages” by Beth Walton about the way the Mayo Clinic has (mis) treated a boy and his family (when you get to the page you’ll have to scroll down a bit):
    http://www.citypages.com/2008-05-14/feature/mystery-illness-fells-young-man/
    Take off your Mayonaise obscured glasses Maggie and go to the sites I list above and in my previous post. Also set your computer to call up Mayo Clinic references. You’ll get an unending stream of Mayo Clinic public relations waffle but along with patient horror stories you’ll find others ranging from allegations of a Mayo Clinic doctor selling drugs from his garage, another traveling many miles seeking sex with an under age girl, a surgeon photographing a patient’s genitalia with a cell phone during surgery and another who enslaved a young woman from abroad.
    Again Maggie, I’m not trying to put down the Mayo. I’m sure they so some sterling work. My point was that just as with any other person or institution they have skeletons in their closet. But the Mayo does hide them particularly well – just look at the size of their Risk Management and P.R. (Dept of External Affairs) departments.
    Thank you for publishing your blog and allowing others to offer differing viewpoints.

  22. As a patient of Mayo in MN I want to add that even the billing department is efficient and professional. Our insurance companies have paid better than they do with other providers, without us having to do any further work after turning it over to the business office. Mayo is also very patient while we and they wait for the insurance companies to pay up. Quality from top to bottom.

  23. Thus the Dartmouth comparisons between Rochester and the other sites represents a clear demonstration of the importance of practice culture and how delicate a thing it can be to recreate. If Mayo found difficulty in reproducing it elsewhere in its own system, it would be even harder to do under other circumstances. But practice culture is still key, I think.

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  25. Great article and comments. I trained at mayo, left to work somewhere else with a completely different culture, and am now considering returning, for many of the reasons mentioned above- the team work model, patient first mentality, egalitarian pay structure, and the benefits of self selection of physicians who choose lower pay and frigid climate to work in a more effective, congenial and efficient environment. But one factor that has not really been mentioned, which I believe explains why mayo Rochester cannot be effectively replicated anywhere else (even by mayo itself) is the support staff (nurses, technicians, secretaries, porters, etc.) which is drawn largely from the local community of Olmsted county – a community that for generations has grown around the hospital and is entirely in tune with mayos mission to provide the best patient care possible. There is really no other major medical center that can draw upon a more dedicated local talent pool.

    • Anonymous–

      Thanks for commenting.

      Yes, Mayo in Minnesota is unique. It’s a culture that has
      grown and developed over many years. What you say about the
      local pool of workers rings true.
      Next time I write about Mayo, I’ll mention that.
      But I also think that other hospitals can study and learn from the Mayo model.
      The egalitarian culture (same pay for everyone in a given specialty) and the
      emphasis on patient care (while research is more important at many hospitals)
      is something that the accountable care organizations of the future might
      learn from.

  26. Maggie, Good article, And comments. I think you are too emphasize on “fire wal”l than culture and surrounding community.

    Fixed salary is everywhere, including communist country. It tends to slow down regular people, less work same salary. I have first hand experience as patient family in Kaiser and as employee in semi isolated structure in medical practice. When we are facing shortage of health care workers, “unhealthy working hours” might be needed just to carry the load.

    I wonder what is the insurance mix in Mayo, compare to inner city hospitals, percent wise, not by pure number of indulgent patient.

    • James

      The comparison of Mayo to other hospitals is based on looking at very similar patients in terms of
      age, disease, whether there any co-existing chronic conditions, etc.

      So the culture, surrounding community and % of indigent patients doesn’t matter.

      A great deal of evidence shows that when doctors work on salary, the quality of care is higher.