Patients Come Second

Working in emergency medicine is a strange place.  One minute it can feel like fighting on a battle field and the next moment it is more like serving on the mission field.  There are times of trauma, tragedy, laughter, and exhaustion.  We care for the sick and dying, the traumatized and the assaulted.  ED clinicians are expected to manage all of this with poise, empathy, integrity, decisiveness, and efficiency.  And, by the way, they can never make a mistake.  This job feels hard because it is hard.  We come home from work feeling like we got kicked in the teeth because we did.  The feelings of fatigue, anxiety, and stress are real.  This job will take every ounce of physical, mental, and spiritual ability that one can muster.

So what do we do to support our ED clinicians?  Do we give them the tools they need when they encounter difficulties.  What resources, mentoring, and guidance is available to physicians and nurses.  Where does one go when they make a mistake?  The reality is, you go to a review board, or court.  Where do you go when you work for two hours to save a kid’s life and they die.  You go home.  You just deal with it.  Who do you talk to when a patient threatens you or physically assaults you?  Nowhere.  Our hospital systems have told staff that we will not refuse care to anyone even if they have threatened or assaulted staff. 

The reality is, there is almost no support available for physicians and nurses when they encounter their own trauma in the workplace.  Our healthcare model of customer service has put so much burden on healthcare providers that it has become unreasonable and unsustainable.  Clinicians are overwhelmed by all the extra requirements of committees, JCAHO standards, documentation, and IT.  People still love what they do but they struggle to provide patient care given the ballooning workload from outside interests with no involvement in the sacred, patient-provider relationship.

Patients come second

Here's the problem.  We put patients first when they should come second.  You can’t expect human beings to function for years under this burden of responsibility with no emotional or spiritual care and not crack.  "Hospitals have missed the point that the best way to improve patient experience is to build better engagement with their employees, who will then provide better service and health care to patients. To put it another way: Patients come second.” 1

I firmly believe that if we applied focus and attention to the care of our staff they would be better equipped to provide excellent, compassionate medicine.  If the hospital organization was designed to provide for clinicians’ needs emotionally and spiritually, the staff could then give focus and energy to patients much more effectively.  If the system prioritized clinicians and what they need in staffing and supplies, they could provide care with excellence and with compassion and empathy.  But we do it backwards.  We put all the emphasis on customer service and customer perception.  

The surveys and measurements are all focused on patient satisfaction and budget concerns.  If these measurements are not satisfactory, it is the clinician’s fault.  We create more protocols and more work for clinicians in addition to an already crushing job.  You get what you measure.  If the metrics are all about patient satisfaction and efficiency, that’s all you’re going to get.  It is actually most important that we get the medicine right.  It is also important that we connect on a human level with our patients and communicate attentive presence, compassion, and empathy.  We should be measuring these things.

This means that our model of healthcare needs to change.  We need to enlarge our philosophy of medicine from simply customer service to the more accurate model of ministering healthcare.  Medicine is the ministering of care from one human to another.  In order to provide this higher level of care, we need to focus on how well our staff is supported.  We need to put resources into the well being of our staff.  

Clinicians who are cared for, supported, and resourced well will provide better patient care.2 In this extensive study at a large urban hospital, the results indicate that “hospital departments that have higher levels of employee satisfaction provide better experiences for patients.” 2 Another study found similar results.  “Patients cared for on units that nurses characterized as having adequate staff, good administrative support for nursing care, and good relations between doctors and nurses were more than twice likely as other patients to report high satisfaction with their care, and their nurses reported significantly lower burnout.”3

If we put the educational, emotional, and practical needs of our clinicians first, they will in turn provide excellent patient care.  They will have the reserves and the resources to do their very best for the people who need them.  We tell moms to be sure to take care of themselves so they can care for their kids.  We tell married couples to put their marriage first even though the demands of family are intense.  We encourage families who are providing care for loved ones to take respite for themselves.  We know that people caring for others tend to do a poor job taking care of themselves.  We need to do this for ourselves and our peers.

Steps Forward

In our emergency department we have started this conversation.  We have developed team lead meetings with nurses, MDs, and APPs who have demonstrated leadership. We meet to talk about burnout, conflict resolution, managing stress, and restoring our vision.  Leaders then communicate these concepts to the rest of the staff.  This begins to create a community of support which in turn creates a culture of excellent, compassionate care.  It’s not perfect but it is a start.  We are beginning to give voice to the clinical challenges everyone is experiencing.  No one understands how hard this job is except the dozens of people who work together every day in the ED.  We need to start turning to each other for mentoring, support, and counsel.  No one is alone in this work.  

We cannot continue to run our staff into the ground with sicker patients in communities that are crushed by chronic illness, opiate addiction, and poverty and then require more standards, more documentation, and more protocols.  We are human beings with limited capacity.  We provide care on the front lines of healthcare to the sickest and most vulnerable.  Hospital systems need to change their focus from patients first, to staff first.  If the goal is well educated, well resourced, healthy staff, the outcome will be excellent patient care with excellent patient reviews.  Let’s start measuring and evaluating these goals.  I suggest that hospitals and physician groups make a regular habit of surveying their own employees in regards to their job satisfaction.  You get what you measure. 

This is going to take some time.  But we can start this change in our own departments. Develop a culture of support.  Develop mentors and leaders.  Mentoring relationships can have a tremendous positive impact on job satisfaction.  This is an investment of time and personal commitment.  Clinicians are encouraged to find people who are perhaps a little older, and definitely a little wiser who can help them navigate difficult clinical events and stressors.  “Finding a suitable mentor requires effort and persistence. Effective mentoring necessitates a certain chemistry for an appropriate interpersonal match. Prized mentors have ‘clout,’ knowledge, and interest in the mentees, and provide both professional and personal support”.4

Make conversation about burnout and stress management common in your department.  Care for clinicians, don’t crush them.  Develop a culture of support and honesty.  Clinicians need to be able to be vulnerable with their frustrations and challenges.  Prioritize the training of mentors.  What are the real objectives of healthcare?  Don’t we really want excellent medical care with genuinely compassionate providers?  We need to consider what it is we really want from our healthcare providers.  If we only measure efficiency and customer perceptions, that is all that will ever be addressed.  We need to make room for measuring clinician and staff satisfaction.  Only by prioritizing and measuring this will we begin to focus our attention on the people who do this difficult work every day.  And if we do this diligently, patients will be treated with the respect, compassion, and efficiency that we all want to provide.

"Hospitals have missed the point that the best way to improve patient experience is to build better engagement with their employees, who will then provide better service and health care to patients. To put it another way: Patients come second."

- Patients Come Second, Spiegelman and Berrett



1Spiegelman, Berrett. Patients Come Second. New York, NY: Green Leaf Book Company;2013.

2Peltier, Dahl, Mulhern. The Relationship Between Employee Satisfaction and Hospital Patient Experience. April, 2009: [3/2017]

3Vahey, Aiken, Sloan, Clark, Vargas. Nurse Burnout and Patient Satisfaction. MedCare.  2004; 42(2 Suppl):1157-1166.

4Jackson, Palepu, Szalacha, Caswell, Carr, Inui. “Having the right chemistry”: A qualitative study of mentoring in academic medicine. Academic Medicine. 2003 March;78(3):328-34.