In the depths of winter, America was shocked by the video of a young, bruised and confused woman being discharged from a Maryland Hospital – alone into the cold night, wearing nothing but a thin hospital gown and socks. Hospital security officers dropped her at the nearby bus-stand and then briskly wheeled away the chair in which they had brought her out, deftly avoiding the questions of a concerned citizen who bore witness to this inhumane act. Most healthcare workers in the U.S., physicians and nurses, allied health professionals, and janitors alike felt a wretched sadness watching the video, recognizing as they did another sign of the sickness that ails the healthcare system today.
As our culture has become increasingly more consumeristic, healthcare has become increasingly more commercialized. A “provider interaction” has become a commodity; and hospitals have become the factories producing that commodity. This has shifted the balance of power from healthcare providers to professional managers. This change, ostensibly done to provide doctors more time to practice their art, instead has insidiously but surely changed the culture of our healthcare institutions.
The daily-lived values of our institutions have changed from the core values of medicine – caring, compassion and empathy for the patient, to more corporate values of productivity metrics and profits. What was to be a properly balanced socio-economic model for hospitals has gone tragically wrong. The goal was efficacy – efficient and effective patient-centric care. However, the disproportionate focus on efficiency, achieved by applying industrial engineering and productivity standards to patient care, has compromised effectiveness. More importantly, this has eroded the core of patient-centric care – compassion and empathy. That the CEO of the Maryland hospital insisted that the patient was provided appropriate medical care, even as he acknowledged the failure of humanity and compassion, sadly demonstrates that compassion and empathy are no longer the core values of healthcare.
While the application of industrial standards is necessary in certain arenas in medicine to control waste and cost, the pervasive cultural shift, especially at hospitals and long-term care facilities, is problematic for patients and caregivers alike. The human element is essential to the health of the chronically ill patient, where illness erodes the psyche as much as the body. For caregivers and healers, this change in culture puts personal and professional core values of compassion and empathy at conflict with the daily “lived” values of productivity metrics, causing an erosion of the sense of self, disillusionment, and detachment from work. Increasing levels of internal conflict and disenchantment ensue, causing mental and eventually physical illness for the care-provider. And, our healers are now sick. Depression rates for physicians are soaring at 40 percent. Medicine ranks among the professions with the highest rates of suicides, especially for women; we lose a physician every day to suicide in the U.S. The numbers are not much better for nurses. Many healthcare providers are simply leaving medicine.
Those who continue to stay at work suffer disengagement and burnout, which has reached epidemic proportions at 52% among physicians. The mounting pressure to meet efficiency goals has redirected time and attention from patient care to achieving productivity metrics. With this pressure, time has all but evaporated to thoughtfully consider treatment options, let alone have compassion and empathy for patients and for co-workers. The resultant loss of trust and cooperation with colleagues causes increasing discord and friction, further undermining healthcare quality by eroding the second absolute bulwark of healthcare – teamwork. This loss of teamwork is largely invisible. The huddle of local teams remains intact, but the looser multispecialty network of disconnected specialties that work together to ensure the care of a patients with complex illnesses is broken. No longer is there time to discuss and engage a subspecialty colleague, to review the imaging with the radiologist or the slides with the pathologist to accurately diagnose. Now, work is simply daily toil. It only needs to be logged as complete, so the patient can be passed down the assembly line.
As a result, things get overlooked, sometimes causing severe harm. In fact, it has been shown that Ebola patient zero was misdiagnosed at least in part because of a failure of communication involving some combination of nurse, physician, and the electronic health record. Caregivers put increasing effort into preventing these mishaps by shifting administrative and clerical effort to afterhours. They engage in pajama time and date nights with medical records to meet the “recording metrics” imposed by organizations. But, that only makes them more exhausted, and they return to work even more cynical and hardened the next day. They no longer have the ability to be caring. They cannot care for themselves, let alone patients or co-workers.
A cultural change is needed to return caring to healthcare. The Faas Foundation, established in 2005, has partnered with the Yale Center for Emotional Intelligence, and Mental Health America (MHA) to study these destructive cultural dynamics in the workplaces, including at hospitals. They are helping to reorganize healthcare institutional culture, to make workplaces safe and healthy for providers, so that workers can be caring to patients. To do this, administrative, physician and nurse leaders need to agree on common cultural values for their institutions and prioritize caring and compassion as a forefront value. They need to model caring, compassion and empathy for their own workforce, so that the members of their organization recognize these as true core values of their work-lives.
As Chris Argyris, the noted expert in organizational learning stated, behaviors modeled implicitly by leaders in daily interactions become tacit behaviors in organizations more easily and pervasively, than do the behaviors that leaders say they value but do not model daily. Organizations need to invest in and care for the emotional wellbeing of their workforce, to ensure that caring can return to healthcare.
Vinita Parkash is Associate Professor of Pathology at the Yale School of Medicine and a student at the Yale School of Public Health. Andrew Faas is the Founder and CEO of the Faas Foundation and the author of “From Bully to Bull’s Eye – Move your Organization Out of the Line of Fire’.
They are Public Voices fellows with the OpEd Project.