Chris Froome has done it again. The fourth win of the Tour de France (http://www.bbc.co.uk/sport/cycling/40695072). Well done! Many of us are dedicated, hard working and conscientious but have not won the Tour. So what is there to learn? Froome’s Team Sky has been dominating the Tour this decade, how did they do it.
The Tour is a fairly structured challenge: the route is clear, and it needs to be driven as fast as possible. There are some challenges around the other teams and how they might line up their drivers, but overall it is about the fastest way to get from A to B without coming off the bike.
The secret behind the wins is a man and a principle: Dave Brailsford (from North Wales) and the ‘aggregation of marginal gains’ (http://jamesclear.com/marginal-gains). In oder to win something as complex as the Tour de France, all the ducks need to be lined up. Nothing can be left to coincidence. The team is well rested because it brings its own mattresses. Every driver has exactly the right food. The training regime is exactly the right one. The bike has just the right measures. By increasing performance in every aspect of the race the overall result is stunning.
In the medical world this principle can be summarised in a driver diagram (http://www.ihi.org/resources/Pages/Tools/Driver-Diagram.aspx). This describes what we are trying to achieve (win the Tour de France) and the drivers which affects this outcome (quality of bikes, sleep, food). If the aim is to reduce delays in treating a severe infection such as sepsis (https://sepsistrust.org/) what drivers would affect this? Timely treatment would be affected by poor measurements of the temperature and other vital signs, if medical staff would not be informed of a new fever, if antibiotics would not be prescribed or given too late. All of these are call ‘primary drivers’. If we want to understand why the temperature was not taken we can look at ‘secondary drivers’: was there a thermometer, and did the person who measure know what is a normal or abnormal temperature. We can then provide the right equipment and training. If we quiz our driver diagram hard then we could also see that alternative solutions exist to the problem: instead of giving the thermometer to the nurse, we could also give one to the patient, and if they have had a recent operation or treatment for cancer, then they could measure the temperature. If they would enter the temperature into their smart-phone, then this would inform the doctor …. so suddenly patients are able to drive the improvement in the same way that all the people on Team Sky work to make success happen. In a straight forward problem like giving timely treatment for sepsis this approach might work.
The approach that Team Sky has brought to cycling might not work on its own for a football team like Barcelona. While they will also optimise training, sleep, food their interaction on the pitch is characterised by additional skills. As the opposing site is attacking players need to move across the field, keep an eye on their neighbouring defender, watch where the attackers have got options to pass etc etc. In the old days this was fairly straight forward. Attackers attacked and defenders defended. This all finished with Johan Cruyff took over at the Nou Camp stadium. Cruyff introduced something new that he had learned while playing in Holland: ‘totaal voetbal’, total football. In this system any outfield player who moves out of their position is replaced by a following player. Every player can take every function. Teams play with 10 attackers, 10 mid fielders and 10 defenders and move as one. In human factor research this is called situational awareness. Barca are not the only proponent of this system, but probably one of the most successful ones (https://www.fcbarcelona.com/). The system allows individuals like Lionel Messi to reach their true potential across the whole pitch.
This is a form of team play that is much more difficult to translate. The fluidity of interaction requires highly trained individuals who play a lot together, who know and trust each other. Not easy with shift work, rotating junior doctors, patients who move between wards. New research (https://clinicaltrials.gov/ct2/show/NCT02039297) is trying to provide bed side clinicians with the key information that they need for the decision making on a crowded pitch. And initial results from our VITAL II study suggest that this is a helpful approach to reduce adverse events (https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1635-z).
Patient can easily join a medical Team Sky and ‘drive’ parts of the performance, but where do they fit into the complicated interactions of ‘Total Medicine’?