Editor in Chief

“When discussing collaboration, people often talk about ‘breaking down silos.’ … ” —William D. Ramsey, MD

by Chester Buckenmaier III, MD COL (ret), MC, USA

July 12, 2019

“When discussing collaboration, people often talk about ‘breaking down silos.’ I object to that terminology because ‘breaking down’ is a negative image that implies destruction or tearing down of silos. Academically, silos represent our areas of expertise. Why would we want to ‘break down’ or destroy such a valuable resource? Rather than ‘breaking down’ silos, we should strive to build large, robust connecting bridges between the silos. Over time these strong bridges solidify the connections between our various areas of expertise and produce a strong and massive structure that can accomplish major goals and produce monumental impact and results.” —William D. Ramsey, MD

This month’s quote is paraphrased from a statement made by William ‘Bill” Ramsey, MD, associate vice president for coordination and logistics and chief collaboration officer at West Virginia University. I was visiting WVU as the director of the Defense and Veterans Center for Integrative Pain Management (dvcipm.org), an organization under the Uniformed Services University as part of a pain research partnership between the two medical universities. WVU had reached out to USU/DVCIPM under the leadership of Clay B. Marsh, MD, vice president and executive dean for health sciences to inquire about the military’s experience with pain and opioids after 19 years of continuous conflict. 

West Virginia has the dubious distinction of being one of the country’s centers of mass concerning the ongoing opioid misuse and abuse epidemic, and leaders at WVU were looking for solutions. From my perspective, the WVU/USU pain research partnership has been an outstanding example of a symbiotic relationship that maximizes the return on taxpayer investment. WVU has benefited from federal pain management products developed in response to ongoing conflict, and the Department of Defense has benefited from the WVU research expertise and use of DoD products within a large, but contained, health system. With the recent opening of the WVU Rockefeller Neuroscience Institute under the direction of Dr. Ali Rezai, I believe this research partnership will continue to benefit West Virginia residents and servicemembers worldwide for years to come.

At this point, I would imagine my readers feel I have gotten lost again in my editorial, but the importance of this introduction as it relates to Bill’s statement will be apparent soon. By any definition, the WVU Rockefeller Neuroscience Institute is a center of medical expertise and knowledge, a silo, if you will, in the finest tradition of allopathic medicine. The RNI brings unique medical expertise from around the nation (and world) and the latest in medical technology and software together in one building. The potential for achieving truly amazing breakthroughs in pain medicine understanding and treatment are evident and already flowing from this medical silo. Dr. Rezai understands that the impact of RNI efforts can only be realized within WVU and the nation by constantly building bridges between the RNI silo and other silos of medical knowledge at WVU and around the country.  Uniformed Services University is the proponent for knowledge of military pain management born of continuous combat trauma and certainly represents a silo of unique medical expertise. WVU’s willingness to reach out and establish bridges between silos of medical expertise, like the one existing between WVU and USU, is exemplary of how modern medicine can progress, become more interdisciplinary and improve the care of patients not just locally but generally in this country. 

The briefest internet search using the words “medical silo” results in myriad articles discussing the need to break down silos to improve coordinated, patient-centered care. This idea has always been unsettling for me. As a board-certified anesthesiologist, I am part of a very important community with specialized training and expertise. I am a member of the anesthesia silo. For most Americans going through their daily lives, the medical silo of anesthesia is of no consequence, even when these folks are interacting with their medical system. This situation drastically changes when a surgical procedure is suddenly indicated. Patients quickly appreciate and demand the expertise derived from the anesthesia silo. Patients also understand that this anesthesia expertise is only valuable if it is coordinated with all the other silos of medicine involved in the surgical procedure (surgery, nursing, physical therapy, pharmacy, medicine, administration and others). In the best health systems, bridges have long been established between these silos of expertise to a point where the interactions between the specialties are seamless and not apparent to the patient. 

I think Dr. Ramsey was wisely reminding us that we should not lament the silos of medicine, rather these concentrations of medical expertise should be celebrated and nurtured. We should become concerned when these centers of expertise become isolated or separated from the larger medical community. Our focus should not be on destroying silos but on building more bridges between silos, both internally and externally within our medical systems. These silo connections should be so common and routine as to be transparent to the patient as they benefit from multiple centers of expertise collaborating with the patient and their interests being the center of effort. This level of coordination and communication is an active process that demands support of health system leaders, administrative resources and constant renewal as bridges break down with personnel movement or specialty parochialism. Whether clinical, research or administrative, federal healthcare leaders should continually be looking for and working toward maintaining established bridges and building new connections between the silos of medical expertise within their institution. To paraphrase Bill even further, “Viva la silos!”



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