Covid or Efficiency Standards?

I keep reading articles about how the hospitals are struggling under the massive patient case load and inability to hire qualified workers. Some hospitals have resorted to utilizing National Guard services (paid for by government use of tax dollars). One common theme that each article points to is the stress of dealing with complicated Covid patients as the primary reason why so many qualified healthcare professionals are leaving the field. 

A virus is constantly being given a lot more credit for destruction and devastation than it deserves. Healthcare people are a tough breed. You have to be tough to see the best and worst of human nature on a daily basis. It is not the typical 9-5 job. These individuals regularly skip breaks to care for ill individuals, perform powerlifting feats in undesirable positions, experience bodily functions and fluids that make the normal person want to retch and then return to repeat these actions the next day. In addition to the physical aspect, deep and personal human interaction occurs (who else do you voluntarily strip down for?). Healthcare professionals see all of the blemishes, regretted tattoos, scars and hear the raw, emotional stories of troubled people. 

I knew deep down that the exodus of healthcare workers (myself included) wasn't simply due to a virus. It was something else. It was something that has been around for several years and only exacerbated by the inability to be prepared for anything beyond immediate needs. Yet, I couldn't quite find the right words to describe it until I took time to listen to someone with a different perspective.  

I recently heard a speech given by an engineer, an outsider to the healthcare world. He described his work and the goals that a business like his strives to accomplish. Efficiency is the gold standard for many organizations outside of healthcare. Utilizing lean techniques, critiquing methods and procedures and cutting back waste are good things to focus on if your goal is producing widgets or selling paper. He described his concern when he learned that these efficiency techniques were being applied to the healthcare world. This explanation triggered a lightbulb moment for me. I remembered hearing about those ideas of lean techniques, productivity measurements and workflow modifications but since they didn't apply to the better outcome of my patients, I simply ignored it. 

Over the years, these efficiency standards, data measurements and reporting have taken over healthcare. You are considered a "good" provider by the number of patients seen in a day versus the patient outcomes. Processes have been tweaked so tightly that the idea of having time between patients for critical thought and evaluation is gone. Crucial face to face communication between healthcare providers to discuss particulars of a patient case is frowned upon and people are being encouraged to simply "read the chart" for any relevant information. Patient disposition is considered more important than having the proper diagnosis. Clicking the right buttons on the computer to ensure maximum reimbursement will keep you out of the bosses' office listening to productivity lectures and threats of punishment. A large patient case load is rewarded financially and verbally. 

An example of the system's move towards efficient and lean processes is that employees rarely utilized sick time. In fact, paid sick leave was rolled into the same bank of time as vacation so that there was no differentiation. You were rewarded with more vacation time if you managed never to be ill. The patients were the ones sick, not he caregivers. Contingent plans were not in place when an employee actually called in sick for the day. A substitute or replacement wasn't allowed or even accounted for because you would have to pay for two people instead of one and that is the definition of inefficiency. Instead, when an employee failed to report to duty due to illness, the remaining employees were told to "make do". This provided valuable information on just how productive the employees could be when staff is cut and provided justification for decreasing staff hours at a later time. The fact that working at decreased staff levels led to increased medical errors as ignored and when impossible to ignore, blamed upon the individual. This policy led to an atmosphere where the employee was discouraged from EVER calling in sick. It was more honorable to show up to work sicker than your patients and hope that you looked bad enough that someone would send you home, rather than face the accusing wrath of overworked coworkers when you returned with improved health. This system worked very well for the company.... until Covid restrictions required employees to stay home and quarantine. A flashlight was shown upon this lean, efficient standard of operation and the results were ugly. The virus received the blame but in reality, it was the lack of backup plans, the protocols of quarantine rules and the inability to be resilient without reserves that caused this issue. 

A healthcare friend recently mentioned how difficult it was to have a conversation with certain veteran physicians versus the newbies. I knew the individuals mentioned and was aware of their personalities. While never being considered overly friendly people, they were hard-working, intense, thorough and very patient focused in their work. Have their attitudes changed because of the stress of one virus or the impossible productivity standards that are preventing them from performing the job as they feel that it needs to be done? It reminded me that we have a group of new graduates (aka "newbies") that have only known the hospital world within those lean, efficiency protocols. They take great pride in their disposition rates and large caseloads but struggle to place a patient's name with a lab result or condition. They have great tech skills and can document with amazing speed but often overlook patient specific information that can make a difference in outcome. They bust in and out of patient's rooms like a whirlwind ready to check off another patient on the to-do list. They become frustrated when stopped to answer questions and remind me of a restaurant server that is more concerned about table turnover than the actual service provided. They do speak friendlier to their colleagues as they understand that with their help, the patients can be discharged faster. Are they entirely to blame for this behavior when this is how they have been trained? How can they know any better when their whole careers outside of the educational intuition have been focused on rewarding behaviors related to efficiency and ignoring accuracy and compassion? How can inexperienced professionals stand their ground when being penalized for participation in activities that some consider timewasters, such as counseling patients, discussing care with colleagues or asking for advice of more senior staff members?

One tiny virus can cause a lot of problems but this one has earned fame and recognition beyond its capabilities.

      - This virus decreased oxygen levels but didn't shut down production lines and transportation for needed equipment and medications. The reaction of those in leadership shut down the supply lines. 

      - This virus didn't penalize healthcare workers for providing personalized care. The institutions and government agencies penalized providers for providing "unapproved" care. 

      - The virus may have required some healthcare workers to stay home but the institutions have had roughly two years to implement policies to cover for sick employees and haven't made it a priority. 

      - The virus may have spread throughout the population (as viruses naturally do), but it didn't implement the restrictive policies that prevent sick patients from being physically examined by a healthcare professional. The virus didn't force patients to resort to telemedicine and prescriptions without proper testing, the policymakers did. 

    - The virus may have caused patients to cough but it isn't solely responsible for the fear and anxiety that is plaquing society when a stranger sniffles in a grocery store. The media outlets helped to perpetuate that situation with constant, dramatic coverage without proper verification of facts. 

This virus may have caused patients to seek medical care, but it didn't cause the exodus of quality healthcare workers. Most healthcare workers have experienced tougher cases than Covid and persevered. The current working conditions imposed by institutions such as cutting corners, begging for government handouts and bowing to their every request in order to acquire the money, providing pizza instead of proper compensation, demanding unsafe provider to patient ratios, blaming individuals when mistakes happen rather than evaluating the conditions surrounding the mistake and placing compensation over patient outcomes play more of a role in this loss of providers than a virus (especially with variants of decreased mortality). 

The healthcare workers that I see leaving (and trying to leave) are not usually the most productive in the eyes of the institution. The ones planning their exit and running out of the door are those that are being penalized for basic acts of human compassion, such as holding the hand of a dying patient and ignoring the phone calls, taking time to explain procedures and answer questions from scared and skeptical patients or sneaking in family members against policy because they know that the patient needs the touch of a loved one. The ones that are crumbling the most under the pressure being erroneously called "Covid pressure" are the ones who care more about individual patient outcomes than numbers or compensation. They are struggling to find the balance between work demands and the demands of their conscience. Some of these providers are becoming bears to works with, some are succumbing to depression, some are giving up and giving in to the institutional demands, some are bouncing from various locations in hopes of finding better working conditions and many are simply walking away. 

So, the next time that you hear a story of overrun hospitals, ask yourself this question: Is it due to the lack of physical bed space and increased number of patients or because of the decreased number of healthcare providers available?

The next time that you read an article stating that the pressure of one virus, one illness was enough to drive away multitudes of healthcare professionals, be a little bit more skeptical. These are the same people that have treated gunshot victims while looking over their shoulder to see if someone is coming to finish the job. These are the same people that have counseled rape victims. These are the same people that have comforted cancer patients. These are the same people that have exposed child and elder abuse cases. These are the same people that have survived bad influenza seasons. These are the same people that have rallied together in natural disasters to provide care in less-than-ideal circumstances. These are the same people that have put together the grotesque pieces of patients mangled in motor vehicle accidents. These are the same people that have dragged overdosed patients from the parking lot pavement into the hospital to save their lives.

How does one virus have the power to break so many of these people?