What we value in society and in healthcare
While I’ve been using locums work as an opportunity to job-hunt, I’ve also recently learned a lot about what makes my workday pleasant and satisfying, or profoundly unpleasant and soul-crushing. Obviously in order to support longevity in my overall career, the former must outnumber the latter, and by no mean degree. While interviewing, I’ve deliberately selected for smaller hospitals in smaller communities, despite enjoying bigger and more challenging anesthetics, and now I feel like I’ve uncovered the why behind that preference. What follows will be a plethora of gross generalizations, but bear with me: smaller hospitals tend to attract people who are less focused on production and efficiency metrics and more focused on quality, not necessarily of the equipment or the facility, but of the staff and the patient experience. The intimacy of the environment, and even sometimes the self-evident resource limitation, both prompts and requires more effort on behalf of each member of the care team to execute their duties well on behalf of the patient. Make no mistake, the team and teamwork matters as much or more than anything else. Medicine has long resisted this truth, preferring to seat responsibility at the feet of the individual at the top of the command hierarchy, usually the doctor, but the more recent data on “compassionomics” and civility bears this out (and if there’s hard empirical data, the concepts might finally be worthy of more generalized attention). This is why the myriad closures of small, grassroots, local hospitals is problematic - not just because it creates more obstacles to care in that patients must travel farther to access the health system (which it does), but because the prioritization of efficiency and productivity in this particular arena has a measurable decrement on outcomes because we have diminished and devalued the teams at the root of the care proffered.
It’s encouraging, then, that newer research is shedding some light on what both patients and doctors have known and felt for decades, if not centuries or eons: that one cannot effectively scale up the fundamentals of human connection, and that in the arena of care and caring, that connection matters, no matter how it’s named. Now that we’ve found ways to measure it, we can start to question how to reverse the trends of treating doctors like identical widgets and patient suffering like a resource whose extractive value is measurable in dollars. By focusing on the demonstrable value of the softer sides of medicine, there are movements to combat on the one side burnout and moral injury and resultant practitioner workforce attrition, and on the other hand the populist backlash against expertise in a scientific establishment that has for too long been too cozy with most callous and visible profiteers (big pharma, massive health insurance conglomerates, private equity). Shocking as it is and yet should not be, it turns out that patients heal faster and live longer with less pain and suffering and a higher degree of functionality when they are treated compassionately by their caregivers. On the flip side, teams charged to maintain a pinnacle of efficacy because literal lives hang in the balance perform measurably worse when led with tactics like intimidation, belittlement, gaslighting, humiliation, and micromanagement. Intimacy is a requisite condition to create the emotionally connected space in which effective communication and shared decision making flourishes, to the great satisfaction of the people on both sides of the drapes or at the bedside.
One of my favorite learning methodologies has always been case reviews of less-than-ideal outcomes, usually in the setting of morbidity and mortality conferences or root cause analyses. When first introduced to me in training, the inclination was to blame individual failures of performance due to some remediable deficit with the right education or additional training. As my career has progressed, the tenor of those conversations changed, at least in some systems, to discussions of swiss-cheese models and how better to shore up the system to catch errors that are, unfortunately, inevitable, before they result in patient harm. It is hard to overstate how impactful I personally found this approach, or how dramatically it contrasts with how we train young doctors to expect total agency and to assume total responsibility in the highest stakes game one can possibly play, gambling with the lives of others. Since the concept was introduced to me, it has come to color more and more of my thinking: how did the system encourage the individual to behave this way in this circumstance, and how can the system be altered to support different (hopefully better) behavior in a similar future circumstance? Seen this way, individual acts are the center of an onion which peeled outward reveals a series of environments that are alterable to support the individual in correct autonomous decision making. For instance, supporting an individual who is synthesizing a significant amount of complex data into a diagnosis and then choosing the appropriate clinical action might look like making sure that they are as well-fed and well-rested as possible with enough time in between shifts to attend to their personal and familial obligations. It might look like using electronic means to flag data that is unexpected or unusual. It might look like creating a culture where ancillary members of the care environment are empowered to communicate openly, share ideas, and draw attention to neglected avenues of thought. And in fact, many of these environmental contributors are already being recognized and addressed on manifold levels.
What I don’t think has been very well addressed, perhaps because it does not lend itself well to discrete interventions, is the way in which our entire nominally scientific, market-based economics of value, with its emphasis on utility and efficiency, conspires to devalue real and important contributors to health outcomes, and to exacerbate the worst behavior of some individuals. Currency is in modern society a surrogate measure of value, and in healthcare we pay according to standard production metrics, without modifiers for the connection, compassion, or intimacy of the caring relationship. If success (and by extension, failure) is only the result of individual competence, expertise, and agency, and the application of those attributes with maximum utility and efficiency results in the highest salaries, there is little room left over for self-reflection, much less compassion, collaboration, or teamwork. Megalomania and sociopathy abound, and we all suffer. Even the most recent administrative emphasis on “quality” has missed the mark and instead come to mean more of only slightly different productive metrics - reduced infections and hospital readmissions and adherence to normative algorithms, etc. The marginal nod to the human aspect of our work comes in patient satisfaction scores, which are often attributed to the so-called attending of record, but who could possibly be satisfied feeling vulnerable in a system that wholeheartedly dismisses compassionate connection as a means to ameliorate suffering? If those scores are then abysmal, despite our best efforts, perhaps that just reflects the inevitable tension that results when what the system values and compensates for is so far divorced from what would actually make us feel better, faced with our own frailty, humanity, and inevitable death: genuine compassionate human connection. As a doctor, I would rather be a healer than a scientist, as blasphemous as that may sound in the ivory towers of medical training programs full of burgeoning, eager physician-scientists. The cognitive dissonance created by this tension within our economic valuation of medical practice is on some days almost unbearable, and I would argue a larger contributor to my own personal career frustration than basically any other single factor. I seek out small hospitals because in the intimacy of a familiar, collaborative team I can more effectively pretend the supremacy of my values and carve out a little bubble of compassionate care supported by our shared humanity.
