Sometimes I think my job should not exist. As a behavioral health provider embedded in a primary care clinic there are elements of my work that is a direct result of many health systems transition from patient care to customer service. A change in verbiage may not seem like a big deal. Yet, in postmodern philosophy language literally shapes reality and I believe a simple change in terminology has made a profound impact on the reality of how care is delivered. I find it interesting that with the advances in medicine, it seems that patient outcomes as whole are not improving. Yes, we are living longer but are healthcare customers truly healthier lives? How much has the shift from patient care to customer service impacted the overall wellness of those healthcare providers serve?
Numerous health systems are now focused on market segments or subgroups of current or potential customers for their products (i.e. health care services or goods). The objective of many systems is to define segments with distinctive qualities that allow an organization to target a meaningful and efficient strategy at them (George B. Moseley III & George B. Moseley III, n.d.). There is no doubt that this methodology has been effective in generating revenue. However, it seems very impersonal especially when relationships have been a hallmark of health care for millennia. There are relationships at the core of other businesses as well. Yet, there is a level of compassion in the healthcare professions that cannot be replicated in other industries. For example, I have a good relationship with my mortgage broker, yet it is vastly different then my relationship with my medical provider.
What I have observed in primary care clinics is that patients are scheduled every twenty minutes with a couple forty-minute slots for new patient visits or annual physicals blocked throughout the day. It feels very much like an assembly line and one of the biggest complaints that I hear from patients is that the doctor does not spend enough time with them. As the behavioral provider in that setting, part of my job is to take the time hear what is important to patients the way their providers used to. My availability to “be with” patients allows providers to move on to the next patient and circle back to me for a brief consultation on issues impacting the patients care. To be clear my role as part of the primary care team is much more than that. The primary function of my job is to identify and treat behavioral health conditions that impact the health of patients. My specific role as a behavioral health consultant will be the topic of a different post.
Southcentral Foundation (SCF) a 638 tribal health system based in Alaska has seen a dramatic improvement in patient outcomes and reductions in costs through a renewed focused on relationships. In the late nineties the organization transitioned from a government run facility to a self-governing tribal facility where the Alaska Native people chose to move away from the label of beneficiaries of a federally managed system. Instead they chose to become customers and owners of their tribally run healthcare system. They were no longer just recipients of services; they were also in control of decision making and administration. As customer-owners they are involved in implementing, designing, and controlling their own programs (Gottlieb, 2013).
The core of SCF's shift to customer-ownership is that patients control their health and change only occurs with a foundation built upon relationships. SCF realized that healthcare interventions only impact 10-20% of people's health while the rest is controlled by the patients. SCF providers do not see themselves as the experts driving change. Instead they work with patients as partners on a journey of wellness. This approach has yielded significant results. Since its implementation SCF has cut emergency room visits by 42%, hospital days by 36%, and specialty care by 58% (Graves, 2013).
When you think about it, SCF's dramatic improvement in patient outcomes through a renewed focus on relationships makes total sense. Health care professionals become attachment figures to many of their patients. This is especially true with patients with chronic health conditions. According to attachment theorists' attachment is an innate motivating force. Seeking and maintaining contact with attachment figures is an innate, primary motivating principle in all human beings across the life span (Johnson, 2004). Through the lens of attachment theory patients' wellness does not happen in isolation, it happens in relation to another who is willing to try to understand and validate their subjective experience.
By leaning into their role as attachment figures health care professionals can provide comfort and security to patients, instead of feelings distress because of the belief that they are just another number. Studies have found that the proximity to an attachment figure has a tranquilizing effect on the nervous system (Johnson, 2004). Health care professionals attuning to the attachment needs of patients can be a natural antidote to the anxieties and vulnerabilities of living with chronic health conditions.
Treating a patient like a customer who is a part of a larger market or subgroup devalues relationships. Ultimately it is the authentic relationship between the patient and healthcare professional that leads to better outcomes. It is unrealistic for any health care professional to expect their patients to make substantial lifestyle changes based on a brief conversation or instructions on an after-visit summary. Patients are more willing to make lifestyle changes when they feel heard and more importantly when they feel like they matter as person not as a customer or patient.
To be completely honest there have been times in my career when I questioned why some patients were not responding to interventions. During those times I am grateful that my colleague and good friend Ben Jennings was there to gently remind me that “people don't care how much you know until they know how much you care.” I hope this article can be a gentle reminder to healthcare systems and professionals who are struggling with patients who are not engaging in care to renew their focus on relationships.
George B. Moseley III & George B. Moseley III. (n.d.). Managing health care business strategy (2nd ed.). Jones & Bartlett Learning.
Gottlieb, K. (2013). The nuka system of care: Improving health through ownership and relationships. International Journal of Circumpolar Health, 72(1), 21118. Link
Graves, B. (2013). Lower costs and better outcomes: A system of care built on relationships. BMJ, 347(aug30 1), f5301-f5301. Link
Johnson, S. M. (2004). The practice of emotionally focused couple therapy. Routledge. Link