What Humans Need

Human Greeting

The telephone is the primary means of accessing the doctor’s office; most calls concern the need for an appointment, prescription refill, or clarification of instructions.² When wait times are long, staff is unfriendly, or needs go unmet,³ the disgruntled patient responds by doing nothing (ie, giving up) or making unintended trips to the office or emergency department.⁴

There is nothing more welcoming to an anxious patient than a human voice on the other end of the line. Too often, a call to the doctor’s office begins with an automated message. But the patient may not know who or what service they need. Long wait times and errant transfers only heighten the frustration. Moreover, an automated system cannot re-assess the need for an office visit or prescription refill. But people in a call center can, especially when they are onsite and integrated into the office flow.

Human Scale

Practices with under 10 physicians have far fewer preventable admissions than do larger practices, especially among high needs beneficiaries.^5,6 Smaller practices are also associated with higher rates of patient satisfaction and accessibility.^10,11

The larger the office, the greater the number of job titles, the more likely that an order will fall through the cracks, and the less likely it will be noticed. Referrals, refills, orders, and messages are all better served by small, organized, and cross-trained teams. The total number of office employees should never exceed their ability to know each other on a first-name basis. And that ability is thwarted when staff turnover is high.

Human Continuity

Greater usual provider continuity (UPC) is associated with better clinical outcomes, lower utilization of urgent care (including hospitalizations and emergency department visits), decreased spending, better patient experience, greater physician wellness, and improved equity in access and utilization of health care services.^5-7

Continuity of care with one’s usual provider is considered a pillar of primary care. Yet the desire for it is conditional. Younger patients with a single, minor concern will happily see the next available clinician. Older adults with multiple problems and a long prescription list want to see “their” doctor, especially when they are ill or worried. But somewhere along the way, the desire for “quick access” subverted the goal of continuity. And did so needlessly, for both goals can be met if there are sufficient same-day slots. Moreover, when continuity physicians see their own patients for an acute illness, they keep their pledge to “be there” for their patients and watch as they recover.

Human Conversation

Diagnostic accuracy is sacrificed when doctors focus solely the chief complaint, because in doing so they overlook critical data.¹² When patients are allowed to tell their story, it provides not only more information, but also builds trust, promotes healing, and secures a connection between the doctor, patient, and health care team.^13-17

There is no substitute for unhurried, nonlinear, and unscripted story telling. It is the way that human beings convey the meaning of life events. It takes time for stories to unfold, time that must be guarded and protected in office visits as well as staff meetings. Conversations expose the frustration and disappointment, confusion and worry that bind us to medicine, but also the small victories, moments of gratitude, and humor that lighten our day.

Human Potential

Office culture plays an important role in our ability to make good clinical decisions,¹⁸ prevent burnout,¹⁹ and adopt improvement strategies.²⁰

Motivation is key to behavioral change. Daniel Pink championed a “science of motivation” in his popular Ted-Talk²¹ and book²² He observes that laborers who perform mechanical tasks will increase their production when offered bonuses. But for those whose job requires even a modicum of cognitive input, monetary rewards can lead to negative results. Pink asserts that professionals are happiest and most productive when they are given some control over their work environment, allowed to master skills, and believe that their efforts are leading to positive change. This closely aligns with Edward Deci and Richard Ryan’s theory of self-determination.²³

In the process of implementing the Patient-Centered Medical Home and confronting the epidemic of burnout, we learned a lot about organization style and practice culture. Clear goals matter. Buy-in matters. Paced implementation, measurement, and feedback matter. But what matters most is a workforce with enough agency, mastery, and purpose to care for the needs of the community.

I know what you are thinking: that an exhausted staff has neither the inclination nor capacity for change. And that our bosses would never agree to take the financial risk. They remind us that economy lies in size, standardization, and the centralization of authority. We must remind them that there is a cost to replace unhappy staff, clinicians, and patients.

An old sage once wrote that “a stitch in time saves nine.”²⁴ Our inboxes are full of the unfilled needs of our patients: for sympathy, reassurance, and guidance. Why not provide it to them up front instead of indirectly through a flurry of prescriptions, tests, and referrals? Just as it takes money to make money, it takes time to save time.

Even if the office never changes, doctors still control certain important aspects of their career. We decide which organization to join. We decide what kind of example we will set in the office. William Carlos Williams reminds us that “the nature of a hello or good-bye, the tone of voice as a question is asked or answered, the private thoughts one has, and the effect they have on our face, our hands as they do their work” still matters to our patients and colleagues.²⁵ Finally, we decide how long we’ll stay. And while sometimes it is in our best interest to leave, patients are always sorry to see us go.