Creating Conditions for Humanity in Hospitals

Why aren’t people in hospitals more attentive to the needs of patients?

In a recent post, Dr. Ashish Jha raises this issue as he relates his own story of coming to an ED with a very painful dislocated shoulder. Unsurprisingly, prompt treatment of his pain was deferred while staff diligently completed registration, sent him for an xray, and waited for a physician to see him.

On the bike path where Jha took his initial tumble, people went out of their way to respond to his injury with attention and concern. But as he lay moaning on a gurney in the hospital corridors, waiting for an xray and not yet treated for pain, people avoided his eyes and even walked by a little faster.

What gives? Why aren’t people in the hospital more empathetic and attentive? Is this a “wonderful people, bad system” issue?

In reflecting on his experience, Jha remarks that people seem to leave their humanity at the door when they arrive at the hospital for work, and posits that we get desensitized to suffering. He notes that some workers were able to “break out of that trap,” and responded to him more empathetically when he directly solicited their help and attention.

“It is the job of healthcare leaders to create a culture where we retain our humanity despite the constant exposure to patients who are suffering,” writes Jha.

Culture change is necessary but not sufficient

Culture is important. Yes I’ll admit that I’m usually a bit skeptical when I hear of a plan to tackle a problem through culture change. In my own experience, this has consisted of leaders trying to “create culture” by describing to front-line staff  what they should be doing, and repeatedly exhorting them to do it. (And maybe giving out gold stars to those who do it.)

This, of course, is never enough. Talking the talk does not mean people start to walk the walk, especially if the walk involves a slog uphill rather than an easier stroll down a path of lesser resistance.

If we – whether healthcare leaders or  just concerned citizens who want to see healthcare improve – really want healthcare workers to demonstrate more compassion and empathy while on the job, then here is what we need to do:

  1. We should take seriously the task of understanding what might be interfering with this compassion and engagement. This means not only studying workflow, but also the behavioral psychology of individuals as well as groups.
  2. We should then be serious about creating the conditions that would allow regular human beings to reliably produce the desired behaviors.

Why it can be hard to help people in the hospital

What interferes with showing compassion and engagement? In reading Jha’s piece, I reflected on my own hospital days. Here are the obstacles that I remember, and the impact on me.

Difficulty meeting the needs of patients and families. I remember constantly feeling that people needed more from me than I could provide. Sometimes they needed to talk for more time than I felt I had available. Or they needed a service or other form of assistance that I wasn’t sure how to get for them.

Especially frustrating was when patients needed something like pain medication on short notice. I have been that doctor very concerned about a patient’s terrible pain. Unfortunately, I discovered that my power to help was quite limited by hospital logistics and workflow: although I could order pain meds right away, the patient could almost never get it quickly. After all, the pharmacy still had to dispense the medication, and the nurse had to administer it.

If you are a conscientious person who wants to help (which I think most healthcare workers are), it’s very stressful to recognize a person’s need and not be able to address it.

Hence, as a coping mechanism, my guess is that many people working in hospitals adapt by learning to “not see” those needs that they feel they can’t address promptly and properly. (Perhaps we might consider this a form of learned helplessness?)

That ED doc that Jha praises for addressing his shoulder quickly? He sounds like a good guy, but it also helps that he had the skills and ability to do something right then and there.

Frustration with workflows and workplace tools. It’s no secret that hospitals and clinics often present a “high-friction” environment for front-line staff. Back when I worked in the hospital, every day involved coping with inefficient workflows that generated various levels of annoyance. There was redundant paperwork. There were computers requiring multiple sign-ins, or repeated sign-ins. There were tasks that took three steps when they really could’ve been redesigned to take one or two.

Along with the expected hassles, one also had to contend with frequent malfunctions in whatever system you were trying to use. A printer out of paper. A computer that mysteriously can’t be logged into. A shortage of staff in a certain department, such that a routine inquiry ends up taking twice as long as usual.

To be fair to hospitals, designing friction-free workflows for clinical staff poses a huge challenge, given the complexity of the work involved and the diverse needs that hospital administrators need to consider. And the nature of life is such that often things do not work as expected.

Still, it all added up to a fair drain on one’s energy and attention, and made it harder to provide patients and families with attention when they needed help.

Inadequate levels and reserves of energy. Compassionately interfacing with patients takes energy, especially if pain or emotionally intense issues are at hand. If one is worn out by earlier encounters, or by a long workday, it becomes much harder to muster the energy to engage with those who need us.

And of course the energy one can bring on any given day is powerfully influenced by the overall balance of exertion and regeneration that one experiences over weeks and months. Long workdays stacked back-to-back (as experienced by many hospitalists) take their toll. Young children at home, or other significant obligations outside the hospital, can also reduce one’s energy at work.

On the flip side, certain activities help people regenerate and restore their energy. Adequate sleep, exercise, and close relationships with friends and family are sustaining staples that are needed by all. Plus everyone tends to have some favorite soul-nurturing activities that help recharge the batteries.

For physicians in particular, the problem is that residency tends to leave people with little time to recharge. We form our habits as doctors during a time of chronic stress and fatigue.

And even after residency, many physicians end up with chronically intense work-schedules. What effect does this have on their ability to be compassionate and responsive to patients and families?

My own experience has been that when I work long hours, it feels much harder to give people the support they want. I still try to do it but I suspect I do it less well. I also know that when I’m tired I make an extra effort with patients but then have much less patience with other members of the healthcare team. (And then when I come home I’m short-tempered and crabby with husband and kids; not necessarily a problem for hospital and patients but concerning to me.)

Enabling humans to show humanity

Cultural expectations within institutions and groups are powerful. We do take our cues from peers and leaders. But it’s hard to follow the cues when surrounded by pervasive stressors and obstacles. In fact, it can be demoralizing to be told to do something when your leaders don’t seem to be making enough of effort to enable this doing.

As healthcare leaders take on the important task of making hospitals more responsive to the needs of patients and families, I hope they’ll consider the following:

  • People don’t like being faced with situations that they can’t fix, or that they feel will be a huge time/energy suck to fix.
    • Make it easier for them to do the right thing.
    • Recognize when you are asking them to do something that is a big time/energy suck.  Try to give them more time. Realize that they’ll have less energy afterward for efforts that are cognitively or emotionally demanding.
    • Provide communication and empathy training. Without explicit training, people often don’t realize that patients and families appreciate sympathy and attention, even when you can’t solve the exact problem at hand.
    • Frictions in the workplace add up to material stress and depletion of energy.
      • Reducing these frictions can enable workers to be more responsive to the needs of patients (and colleagues).
      • Adapting to changes in the workplace — such a new computer system or workflow — does create a drain on staff’s energy and attention. Ideally, this is temporary but poorly designed changes often create permanent energy drains.

Be mindful of the overall energy and stress levels of your workers.

  • Workers who are already experiencing chronic stress and fatigue will have difficulty becoming more attentive to patients’ needs.

Now, if you told me that healthcare leaders already know all this, I wouldn’t be surprised. If you’re in a leadership position, it’s really part of your job to learn about managing human capital.

The trouble is that for the leaders of a hospital, addressing the obstacles that I experienced in the hospital feels costly to them. It takes time, energy, and money to reduce workplace frictions. And managers are generally very reluctant to reduce a person’s workload in order to free up cognitive and emotional energy so that the worker can then be more responsive to suffering patients, or even adapt to new technology for that matter.

In principle, these investments in nurturing one’s human capital should pay off down the line: more satisfied patients, less worker absenteeism, better teamwork among colleagues, and possibly even fewer hospital errors and better health outcomes among patients and staff.Will healthcare leaders find a way to walk their own uphill path, and really make it possible for their front-line staff to do better work? I hope so.

Leslie Kernisan, MD, MPH, has been practicing geriatrics since 2006, and is board-certified in Internal Medicine and in Geriatric Medicine. She is a regular THCB contributor, and blogs at GeriTech.

15 replies »

  1. Patients can, and do, fire doctors for whatever reason they wish: insufficient humanity, body odor, bad haircut.

    But that implies that we still think the doctor works for the patient, not for The Man.

  2. EHRs are the care directing devices. They are impediments to care, from the nonsense sign ons to the meaningfully useless drop downs, and their sheer disruption in enabling a consultant to determine how a patient got to where it is today, after weeks in the hospital.

  3. How did you witness the difference? Did someone say specifically this is why a treatment would or would not be done was related to their medical coverage?

    Most hospital staff do not even know what kind of insurance you have, or whether you have any at all. Physicians and private contractors have to know because some testing will only be covered if certain diagnoses have been written or certain pre-testing has been done. They want to get paid, so of course they’re going to know what they need to do in order to get paid for the work they do, as would any contractor or other service provider.

    Too many people go for emergent care and expect to be treated like they see on television, rather than what is practiced in the ‘real world’. Dr. House, Dr. Grey, Dr. ‘McDreamy’ or whoever you watch are getting paid too… unfortunately, the billing and insurance part of health care is only dramatized when there is a romantic involvement in someone with healthcare coverage marrying someone who doesn’t in order to get special testing or treatment that otherwise wouldn’t be available.

    Not everyone gets a private room with a waterfront view… sometimes you get the one with no windows, with a roommate, in the center of the building, but you’ll get the same care, the same compassion, and the same treatment as everyone else. (Sorry your expectations were higher.)

  4. I’m glad you enjoyed. As far as I know, only in truly exceptional circumstances are doctors fired for treating patients callously. Generally, pretty bad behavior has been tolerated in doctors, esp if they bring in lots of revenue to the hospital.

    Not sure what you mean re navel-gazing. I don’t think you can mandate humanity at a leadership level; hospital administrators & leaders need to try to create conditions for it to be more possible.

    But of course patients can and should say something if they’d like to see improvement, and they should also attempt to take their business elsewhere if they’re able to.

  5. This sad but I’m sure it happens. I myself felt I didn’t usually know what kind of medical coverage people had per se, but some patients certainly look more likely to be on Medicaid.

    I think as providers we’d like to treat people equally regardless of socioeconomic status, but of course we are humans and prone to all kinds of unconscious (or sometimes conscious) biases which will affect how we treat people. To overcome this, we would need to make an effort. To make an effort, we need time and mental energy…just what is lacking in most hospital settings.

  6. Not sure which care directing devices you’re referring to. A well-designed device in principle should help. In practice, many care directing devices do indeed suck up our attention and energy, so unless they are providing a lot of clinical benefit, not clear that overall they are improving care.

  7. I am an ER nurse in a large urban hospital and I see this every day. The problem isn’t that the staff lacks compassion, or that they intentionally ‘tune out’ people who are suffering… it’s a systemic problem with more than one contributing factor:

    1. ER nurses can treat pain with elevation, ice packs, etc. but we’ve learned pretty effectively that people don’t want that kind of compassionate care… they want narcotics… and until they get them, people can be extremely rude. This isn’t true for every patient, but it’s true of enough of them who have NO physical signs of distress at all, that even though we’ve been taught that “pain is exactly what the patient tells you it is”, there are so many patients who can go from laughing and joking with friends on their cell phones to moaning and carrying-on when the nurse arrives that we’ve become somewhat desensitized to people in distress (because of your fellow patients who abuse the system and have made us that way).

    2. ER nurses cannot give you narcotics or other medications without a physician’s order, and while pain is a ‘vital sign’ we’d like to treat early on, most physicians will not give orders for any medications until they’ve examined or at least talked to you. The hospital where I work has 50 ER beds. Each physician has about 17 patients at one time, and if we’re busy with stretchers in the hallways, it can be closer to 25. If the physician is treating a patient with a life-threatening condition, you are going to wait until s/he is done with stabilizing that patient before you’re going to be seen…. and until you’ve been seen and assessed by a physician or PA, you’re not going to get anything for pain. Compound that with the fact that you’ll be seen next in order of severity of illness or complaint in most cases… and while a shoulder dislocation is a legitimate reason to visit an ER, you’re going to have to wait until the person who needs to be put on a ventilator can breathe, or until we’ve stopped doing CPR on the patient down the hall.

    3. We really do see people who will hurt themselves or fake symptoms in order to get medications or sedation and they clog up ER’s and make the wait times longer. Just this month, we’ve see the same patient at least twice while I was working who ‘shops’ emergency rooms in order to get pain medication and sedation for his ‘dislocated shoulder’. He is well known to at least 3 emergency departments in the city. We know this for sure because we’ve hired physicians from those hospitals who are now seeing the same patients they saw elsewhere for the same complaints. (And that’s just one example… I assure you, there are many many more… ask any fireman or 911 ambulance crew if they have any ‘frequent fliers’ and they’ll know exactly what you mean, can probably give you the patients names… and know exactly where they live because they’ve been there so many times.)

    4. Someone else posted something about the EHR “becoming a disease” and distracting the hospital staff, but I assure you, when used correctly, it significantly shortens the length of time it takes for an experienced nurse to treat your pain once something has been ordered. Much faster for me to be able to glance at any computer and be able to see if my patients have any medications ordered than the way it ‘used to be’.

    5. Yes, we have to get you registered first.. because we have to know who you are in order to move you through the hospital system. The only way to decrease that time is when we’ve all got computer chips that we can wave in front of a monitor to ‘register’ ourselves for treatment. Until that happens, you’re going to have to wait on the person who’s entering your information, having you sign the paper that gives us permission to treat you, the paper which tells you that we’re not responsible for your valuables, the paper which allows us to bill your insurance, and the paper to inform you that we’re a ‘smoke-free’ facility. Thank your fellow patients for all the forms and legal documents you have to complete before you can be treated because somewhere a lawyer decided all that was necessary, not your nurse or doctor.

    6. Cultural changes are not the problem, it’s over-crowded emergency rooms that are full of ‘not emergency’ patients. It’s too few primary care physicians who can’t schedule time for patients to be seen sooner, so they feel like their only option is to go to the ER. It’s raising generations of people who think a missed menstrual period and vague low back pain for several days is a reason to call 911. It’s the psychiatric patient who checks into the ER saying he’s suicidal because it’s raining outside and he’s cold… and the culture that we’ve created that says anyone who comes in and says they are suicidal is going to get a room in the ER before the patient with chest pain. (And then that psych patient is going to tie up that ER bed for up to 72 hours or until such time as they’ve seen and been cleared by a psychiatrist… and not all hospitals have psychiatry available). It’s the patient who has had 10 ultrasounds, 25 CT scans and 50 xrays for abdominal pain in the past YEAR who causes the delays because they “know” something is wrong and won’t get a primary care physician, so they use the ER like one instead.

    I know that I come off as a little off-colored and cynical in this reply, but I really do love being an ER nurse. I love that I can help people who need care, who need compassion, and who need treatments and procedures that are actually emergencies. I care about the people I see every day. I am happy to drive and hour in order to do this job every day and know that after almost 10 years, I am really good at it and I literally do help save lives every day. I will happily help pull beads out of children’s ears or noses, do chest compressions on your grandmother to help her heart pump after it stops, and I will be more than happy to treat the pain associated with a dislocated shoulder as soon as possible.

    (Also, know that the physician may need to wait for an xray in order to decide the best course of medications to treat your pain. Would hate to have you react poorly to a pain medication and then be unable to use sedation in order to fix your shoulder if it is really dislocated. We don’t make you wait out of spite, or because we don’t believe you, but sometimes we do wait for your safety.)

  8. I enjoyed reading this. My immediate reaction is: is a doctor ever fired for treating a patient with insufficient humanity?

    If not, then this is all navel- gazing–a vague preference, not a real requirement.

  9. Just out of curiosity, do you work in a hospital? I’d be curious to hear about this issue from the point of view of someone giving the treatment.

  10. Sad to say, I have witnessed the difference in treatment at hospitals based on the medical coverage you have. That said, there is still a coldness by a lot of hospital staff. I can understand getting desensitized but people notice that and it needs to be addressed.

  11. Is this a joke? Nope. You are my straight man/woman!

    You probably do not read how the user unfriendly idiosyncratic EHR devices have become the disease attracting the attention of the health care professionals, while the real patient lies in neglect.

    Just the new way of electronically automating medical care.

    I gues you would agree that these new unproven care directing devices are toxic, no?