In health care, we enjoy a unique opportunity to create special relationships with our work. Few enter these professions for practical reasons, and fewer still survive rigorous training without genuine belief in what they might accomplish. And cliched though they may be, the many mission statements which purport the “art of caring” do convey something real.
But to even for the naïve, spending enough time around health care produces a certain perspective. A cold and machine-like structure becomes difficult to overlook — one that’s been engineered to squeeze out dedication in favor of the calculated administration of services.
There are many deficiencies in this system — and they’re growing. Compassion, after all, produces no billable service units. As administrators hand down goals, facilities focused on short-term success game those metrics by reorganizing the ways they care for sick people. Providers, in a climate of acquisition and consolidation among bloated conglomerates, feel powerless to contend with the system around them.
Part of this is our responsibility: we lack ownership of this system and its direction. This barely-recognizable behemoth mutated to serve interests far beyond health itself leaves us wondering how to empower our patients to effect meaningful change, where to find the time to get at the root of their maladies and in a struggle to do work that we can proudly sign our names to.
A craftsman has a direct and personal relationship to his work. As a result, the quality of the product he produces is supreme, unthreatened by assembly lines. But within the confines of this present iteration of healthcare, providers are not craftsmen. Care is fragmented. Each provider must focus on what we can be reimbursed for, regardless of the scope of his training and of what might help his patient most.
In the name of cost-efficiency, the most relational work there could be is growing dispassionate and impersonal. Providers are shortchanged on the privilege to help the person in front of them. Clinics are engineered to maximize profitability and score highly on metrics that distract from real quality of care.
The deleterious effects of this misguided concentration are not easily overstated. Productivity, not quality, has become the measure of a provider’s worth, and it should be no surprise in that paradigm when some quickly refill opioid scripts instead of beginning a long and arduous process that they don’t have time (and insurers won’t pay) for.
It should be no surprise in the same context that patients are walking into our clinics from a culture of rampant consumerism, view their bodies as products and demand effortless solutions to their complaints. Patients, like providers, feel powerless to contend with the system around them. They perceive such limited capacity to impact their own health, and we perpetuate that sense through our own compulsive focus on customer satisfaction and passive engagement.
But insurers pay for office visits, for procedures, for medicines — not for healthy food, or being active, or to quit smoking. This is the most proximate cause of care provision different than what is best for patients, and it exists because of the cultivated dependency on reimbursement dollars faced by hospitals and clinics.
Engaged patients who take ownership of their health aren’t just much cheaper to take care of, they’re much better off. But a hospital makes more money from a patient who relinquishes ownership of his health in favor of passive procedures which cost many times more than sincere, collaborative effort. Behavior change is the highest-value focus there is — and, paradoxically, one that will never generate a dollar of revenue for a hospital system.
Problems like these are pervasive in a self-defeating complex that undermines providers’ opportunities to effect change by overwhelming them with patients, dictating what care can happen and when, and producing incentives that clash with right practice. While these decisions might benefit the balance sheet of one clinic, to our patients, providers, and system altogether — they are destructive.
If we used an equation to predict burnout, we would divide the total impact of the work we do by the volume of work we’re presented with. Right now, everywhere, the volume is too high and opportunity for impact far too low. To fragment care as if it occurs on an assembly line takes away not just the responsibility but the satisfaction of and sense of ownership to help people, replacing them with feelings that we are partitioned from one another and must focus on our assigned tasks rather than care in gestalt. It produces a system of technicians.
As quality slips in a system that pressures services different from the things that patients need most, providers’ effectiveness is limited by a kind of inaction on our own part. We consign ourselves to do our best within the system as it is and accept that its faults are too large and complicated to erase. But this system exists to enable people who take care of patients, not to direct us.
The privilege to contribute to the care of a sick person demands commitment. Clinicians, even excellent ones, who complete visits and bill units and see that as the limit of their responsibility, are enabling the system. The providers who will solve this system’s problems will be those who, beyond their clinical work, engage with the rules of a damaged system and change them to support what is right and sustainable for patients.
The myth of health care is that altruism is exclusive from competitiveness. The hospital system that will thrive in tomorrow’s health care system is the one that identifies synergies between things as they are now and things as they would be in the best possible version of health care, dedicates resources to those areas of overlap, and works towards reorganizing the system around it to better serve patients.
The fragmented nature of care produced by fixation not on ownership of good work but instead on compliance with orders and rules is far-reaching and influences quality, cost, and satisfaction to a high degree. It’s backward: the system exists to support providers and patients, not to direct them. We’re more focused on administering services than empowering patients to achieve health because services — not wellness — are what generate revenue. But the goals of all parties can and should be aligned.
In health care, we have an advantage, and it will help us through a time where another industry might flounder. People are drawn to this line of work by a sense of purpose. We all share in the responsibility to change the rules of this system to enable what we know is right, and it will be providers, not policymakers, who solve these foundational problems.
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