A Doctor’s Life-Changing Discovery

For the past decade at least, most health care organizations have had a “patients first” initiative. While it seems intuitively obvious that the customer of the health care organization should come first, this initiative, when pursued without a deep understanding of the care process, can result in unintended negative consequences that can lead to burnout for physicians and nurses.

The most serious consequence is a negative reaction from caregivers (the doctors, nurses, technicians and assistants) who are already stressed out, feeling over-scheduled, overburdened and underappreciated. The thought of being asked to do more, particularly by an administrator who is perceived as not understanding the realities of patient care, can leave the caregivers feeling as though no one “cares” about them. This is a recipe for burnout.

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And if this is the way a patients-first program is implemented, the caregivers are right. Are patients first — or second?

One result of this concern is a movement called “Patients Come Second” in order to ensure that caregivers’ needs are being properly addressed up front. I have deep concerns about this as a tagline.

In my five-plus years as CEO at Sutter Gould Medical Foundation, I started most meetings by asking, “Who is the most important person at Gould?” It was gratifying to hear almost everyone respond that the patient is the most important. After all, without patients, we would have no reason to come to work, no opportunity to fulfill our professional or personal goals, and no revenue to pay our salaries. Clearly, the patients are the most important.

Then I would ask, “What is the most important thing we do?” Everyone would agree that taking care of our patients was most important. I would then explain that the most important thing that happens in our work is the healing interaction between a caregiver and a patient. And caregivers included anyone who directly interacted with a patient, whether on the phone, at a check-in desk, in the exam/hospital/procedure room, or anywhere else. Every interaction gave a caregiver the opportunity to reduce pain and suffering, relieve anxiety, provide solace, and promote better health. In other words, it’s an opportunity to put patients first.

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While I have had tens of thousands of healing interactions with patients over the decades of my career as a family physician, when I was CEO I no longer directly cared for patients. My role had changed. It was my job to support the caregivers to ensure that they had everything they needed to provide the best possible healing interactions, with every patient every time.

So while the patient is the most important person, the caregivers need the most support from management. This is a crucial distinction. The “who comes first?” question has to be answered differently depending on the role of the person who is answering.

For caregivers, the patient must come first — for the reasons noted above. Patients are the reason for our work.

But for administrators, the caregiver must come first. Patients are still the reason for our work, but as administrators we don’t take care of the patients directly. We provide care indirectly through our frontline caregivers. So our job is to take care of our caregivers with as much commitment, concern, and compassion as our caregivers have for their patients. It is our responsibility.

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People often ask me if I miss taking care of patients. I do. And I have experienced a lot of what I miss by truly caring for my frontline providers and for everyone who supports them.

The “quadruple aim.” There is a movement developing that is adding to the so-called “triple aim” (great care, great service, equity). It’s the goal of a great workplace experience — and is coming to be known as the “Triple Aim + 1” or the “Quadruple Aim.” It is right on. Caregivers strive to holistically address patients’ physical, psychological, and social needs to promote overall wellness.

Administrators should do the same for caregivers. This is the key to preventing physician burnout.

Lean management done right creates an organizational culture that supports caregivers. And it’s what “respect for people” is all about.

Paul F. DeChant, M.D., is deputy chief health officer with Simpler Healthcare/IBM Watson Health in California. He provides executive coaching and thought leadership on the prevention of physician burnout. During his tenure as CEO of the Sutter Gould Medical Foundation, the organization achieved Consumer Reports’ highest overall rating of 170 medical groups in California for two years in a row, while physician satisfaction rose to the 87th percentile. This piece appeared on PaulDeChantMD.com and is used by permission.