My daughter is an aerialist. That means she performs ballet acts in the air usually with silks, but occasionally on a trapeze. Her professional training is in musical theater, but she inherited a romantic attraction to the kind of people who used to travel with circuses. After a recent show in which she performed, I commented that the changeover after her act looked a little clumsy. The stage crew didn’t seem to have a plan for attaching the rope to the silks to pull them out of the way and the karabiner ended up sliding all the way to the ceiling and getting stuck in a pulley.
She explained to me that scene changes in variety shows, with jugglers, sword swallowers, acrobats and the like, are pretty ad hoc, meaning that no one puts much energy into planning the transition between the segments of the show. This, she pointed out, is in complete contrast to professional musical theater in which the adage is, “sloppy set changes will kill a show.” She should know; she spent four years in a serious fine arts conservatory where she learned from Broadway performance artists, among other things, how a tightly choreographed set change can be done so smoothly that the performance can literally proceed uninterrupted as the scene is transformed in front of the audience. In other words, the set changes are as carefully rehearsed as the show itself.
We had this conversation shortly after I had finished a string of consulting jobs with a number of different primary care clinics, including my own, all of which were struggling to ensure that every patient who passed through the clinic would leave with his or her vaccination status addressed. I couldn’t help but be struck by the ways everyday primary care workflows often resemble variety show set changes, and I thought about how they might be made to work more like professional musical theater.
Under the current variety show environment, someone (usually the doctor) tries to remember to address the patient’s immunization status in the midst of juggling all the other issues competing for the limited time in the exam room. A musical theater approach would have the care team reviewing charts before patients arrive and planning who needs immunizations as part of their visit. It would also give patients a chance to update their record with the medical assistant before the doctor enters the room.
With the current variety show approach the doctors and medical assistants are left on their own to figure out how to enter historical immunization dates, since there are usually several places, and consequently everyone does it differently. In a musical theater format everyone would have rehearsed precisely which data entry fields to use for historical immunization dates (and which to avoid as booby traps) so that historical information would be combined with immunizations given in the clinic to produce accurate quality reports and run the health maintenance alert rules-engines.
If a decision is made to give an immunization in the current variety show world, some doctors write their order on a yellow sticky-note or simply tell their MA while others enter it in the EHR with or with or the other codes required to correctly bill for the service. Still others continue to write their orders on the old paper order forms, leaving it to the MA to enter the information into the electronic record. A musical theater company would assure that every provider knows the standard move, and has practiced it to a point that assures successful performance of the order, including notification of the MA.
In a variety show clinic when the MA draws up and gives the immunization there is variation in when (and often even where) the data are entered, which leads to information for reporting being scattered over multiple tables in the reporting database. A musical theater approach would rely on each team member knowing their exact sequence of steps so that the information is always entered in the correct field and all documentation is completed immediately after the vaccine is given so the patient can leave with an accurate immunization record, and the state registry can be updated.
If you’re still thinking that medicine has nothing to do with theater, think again. After all, as medical students we learned a “bedside manner”, along with interviewing skills that allow us to gain the confidence of our patients. We learn to express our empathy professionally and to display a command of information that we may not have at our finger tips. We learn to do this even when we’re tired and hungry and stressed. We are, however, deluding ourselves if we think we are a one-man or one-woman show, or that the others on our team are simply stagehands. The show, in which their role is as important as ours if we want our patients to be properly immunized, is just as vulnerable to sloppy set changes as professional theater. Quality in medicine cannot be separated from the performance. It is not good enough for a doctor to assume that if he just does his job well that that is synonymous with high quality. Our outcomes show us that teamwork and choreography are also required. One of my goals is to help primary care practices move from the ad hoc scene changes more befitting variety shows into a professional plane worthy of professional theatre in which the handoffs are as tightly choreographed as the main scenes under the stage lights.