"A rising tide lifts all boats..."

According to popular belief, John F. Kennedy first used the phrase, "A rising tide lifts all boats" in a speech in 1963.  Actually, according to his speechwriter, Ted Sorensen, Kennedy first noticed the phrase at the New England Council and liked it so much that he used it over and over on a number of occasions.  The phrase is commonly used to defend free-market principles and refers to the idea that a strong, healthy economy benefits everyone. 

I have been thinking about this phrase a lot in the last couple of weeks.  Most academic medical centers are working on their budgets for the next fiscal year (the academic calendar usually starts around July 1st, so many academic medical centers start the new fiscal year on that date).  It is a well known fact that a relatively small number of medical and surgical specialties generate a positive margin (remember, margin = revenue - expenses).  For example, the surgical specialties and a few medical specialties (e.g., cardiology, oncology, neonatology, intensive care) usually generate enough margin to cover the expenses of some of the medical specialties that do not generate sufficient revenue to cover their expenses (e.g., primary care and endocrinology).  In fact, it is frequently true that one or two subspecialties generate a significant proportion of the total revenue for an academic medical center.  However, here is the important point to keep in mind - many of these so-called high revenue programs rely upon some of these less profitable specialties to help provide quality care. 

One of the great things about having highly specialized care at some of these hospitals is that they provide excellent care that leads to outstanding outcomes.  But that benefit can come at a great cost - care is so fragmented that any particular patient in the hospital may have a number of different teams providing his or her care.  Medicine has truly become a team sport.  I have worked in one of these highly specialized fields for most of my medical career, and I once took care of a patient who had 10 different medical and surgical specialties participating in her care (I actually counted them, and I think we had almost every medical specialty, with the exception of dermatology and adolescent medicine, covered!). 

Patients today require (indeed, they rightfully demand) that their providers work collaboratively together to provide excellent care.  But it goes beyond just patient care.  In today's academic medical center (and I suspect the same is true for any health care organization), all of the medical and surgical specialties need to work collaboratively together to provide high-value care.  No one medical or surgical specialty can do it on its own.  We are all tightly linked, and we are only as strong as our weakest link.

So what do I mean when I think of the phrase, "A rising tide lifts all boats"?  It's pretty simple actually.  Each and everyone of us needs to be successful - we are all in it together and we cannot do it alone.  Rather than trying to justify a particular request (a capital investment or any other investment of resources) with a phrase, such as "We generate 25% of the hospital revenue", the specialties that generate a positive margin need to understand that their success, both in the short-term and the long-term, is going to depend upon the success of all the other specialties, even the ones who don't generate enough revenue to cover their own expenses.  Just imagine.