February 18, 2020
It’s all about the patient. Well, unless that patient has been to particular hospitals for treatment and is having trouble paying the ensuing bills. Then it’s about the hospital and collections agents and wage garnishments and such.
For this approach to providing care, the Lown Institute, a nonpartisan think tank advocating for bold healthcare ideas, honored a group of what they clearly consider rapacious hospitals with the ignominious Shkreli Award. Martin Shkreli, as many will remember, is the widely reviled “pharma bro,” hedge fund manager and CEO who acquired the license to an anti-parasitic drug and promptly raised the price from $13 to $750 per pill. He currently resides in prison.
“Nonprofit hospitals are meant to not only provide health care services, but to contribute to community health and wellbeing,” reads the Lown Institute web site. “But many hospitals have ruined countless families’ financial security and livelihoods, by suing thousands of patients for unpaid medical bills. Some hospitals go as far as to garnish their wages and repossess their assets.”
Sure, hospitals should be paid for the services they provide, but that simple axiom crumbles when one looks closely at the complexity and contradictions built into healthcare, e.g., “… the widespread acceptance at the top of health care organizations that being ‘business-like’ is a virtue…,”says Vikas Saini, MD, the president of the Lown Institute and a Harvard-trained cardiologist.
It’s not enough that some patients are subjected to the inherent indignity of testing and hospitalization, for which no one is at fault. They must also endure the humiliation of looking like deadbeats in a system that won’t identify actual costs or provide affordable care. In a nutshell, they’re not permitted to retain their basic dignity.
And it’s not just the patients. In large numbers, doctors are also questioning their choice of profession. According to a recent survey of physicians by Medscape, roughly half across generations would take less money to claw back more free time. Across healthcare settings, physician burnout is worst in large organizations, where almost half say they’re spent. Roughly 22 percent say they’ve had thoughts of suicide.
What are we to make of these survey results? In many ways, it’s clear that doctors are struggling, overwhelmed with bureaucratic tasks, diminished by the tedium of patient data entry, exhausted from long hours, bewildered by a perceived lack of respect. Once motivated by the idea of a rewarding, respected professional life, many now search for the dignity they expected after the long slog of education and training.
The common thread, then, among doctors and patients? Dignity.
Indeed, the word has more purchase in healthcare than most other scenarios because dignity is so necessary. In a lot of other situations, simple courtesy will do. When dealing with lives, nothing less than dignity is acceptable.
And is dignity something that can be achieved by those in the business of healthcare? Yes. Yes, it is. In fact, dignity in the right hands actually becomes a business strategy.
“The part of healthcare that stands out to me is the humanity of the experience,” says Dr. Joseph Alvarnas, senior medical director for employer strategy at City of Hope Medical Center. “We are born, we struggle, we experience joy, we celebrate and, in time, we die. Yet, we find ourselves in a system for which humanity isn’t the principal goal.”
The challenge, of course, is how to translate dignity into something applicable to a healthcare environment. According to a hospital turnaround study referenced in the Harvard Business Review, ensuring dignity in healthcare means giving people responsibility, autonomy, a voice.
“In the early phases of implementation, the researchers found that employees contributed most to the change initiative when they believed that doing so would increase their control over their work and work environment,” writes Monique Valcour in HBR. “When they followed up three years after implementation, they discovered that the employees contributing most actively to the shared leadership program also expressed high trust in management and perceptions of fair treatment.”
That control improves satisfaction in a work setting feels intuitive, unsurprising, even while it illustrates a tension that endures in almost every work environment.
Might the same approach prove valuable with patients? In a word, yes, but patients tend to define dignity more broadly and individually than members of a work team.
According to a study of the Dignity Care Intervention, patients identified dignity with the way the care team responded to the illness, how the illness directly affected the patient, and how the illness impacted other relationships. Providers can assist directly with some of these concerns and only tangentially with others, but they can empathize and be aware in all instances.
Ultimately, ensuring the dignity of all involved in the healthcare dynamic requires personalization—that we see one another, acknowledge the other person’s existence and collaborate to meet specific needs. But in achieving that goal, something we currently consider essential might have to be minimized.
“Short-term efficiency lets us check off a lot of items from our to-do lists, but we never actually connect with our colleagues, and therefore never really tap into each other’s fullest capacity to contribute,” writes Glenn Llopis in Forbes. “Long-term efficiency results when we deliberately honor each other’s dignity and build relationships that ultimately lead to better ideas and more fruitful results.”
In healthcare, short-term efficiency means more tasks done, more patients seen, more tests performed more revenue generated. If this were manufacturing, short-term efficiency would be a perfectly acceptable measure of success.
But it isn’t manufacturing.
None of this is to say that the efficiency-focused measures of success in healthcare are invalid. It’s just that they’re not MOST valid, and they’re a poor measure of healthcare quality. In many ways, it feels like every segment of healthcare, including healthcare IT, has wandered away from this reality.
How do we make dignity the animating principle in healthcare? Create buy-in among participants, focus on both autonomy and responsibility, and above all show respect for the individual.
Speaking last year at the Leadership in the Age of Personalization Summit, anthropology professor Scott Lacy recalled his time in the Peace Corps in Mali, west Africa. After he arrived, the local elders gathered round to decide what Lacy would do. Resembling a game of telephone, the elders spent 45 minutes going from person to person, each passing on information and adding their own perspectives and opinions.
“I kept thinking: Come on, time is money! Can’t we just have a conversation?” Lacy explained. “But that’s when the seed of what I was learning was planted. Looking back on that, it wasn’t about short-term efficiency. They were doing inclusive decision-making that included some back and forth, it included some affirmation words, it included a blessing, and everybody got to add their own layer … We established a consensus and a relationship that day.”
Ultimately, it’s difficult to list the specific processes of a dignity-focused organization. It is not, however, difficult to identify organizations that are not sufficiently focused on preserving dignity. To paraphrase Justice Stewart: Dignity-focused organizations are not easy to define, but also not hard to recognize.
Having trouble getting members of the team to really invest in collective goals and shoulder vital objectives? Find ways to create autonomy, personal investment and responsibility. Empower them to care for their own dignity, and in the process get a firmer grasp on your own.