What Humans Need ================ * David Loxterkamp ## Abstract Family medicine is a champion of human-focused health care in the context of lasting relationships. What do humans need—those who seek care and those who offer it? Respect, understanding, and kindness. Without it, more money, more ancillary personnel, more time-saving technology cannot lift us from the profession’s doldrums. The author believes that the deep desire to be of help to others can be rekindled in an office culture where the humanity in all of us is honored. Key words: * office culture * humanism * doctor-patient relationship * practice transformation * family medicine Every day and without fanfare, patients are leaving the family practice where I have worked many years. They are transferring to other practices, going to urgent care centers and emergency departments, or simply giving up on the idea of seeing a doctor. Staff turnover is high, and many of those who stay are unhappy and contemplate leaving. Prospective applicants go elsewhere to do other things that better suit their lifestyle or pocketbook. This, of course, is not just a problem at my job; it permeates primary care. And it cannot be solved (just) by raising salaries, hiring more ancillary staff, or investing in labor-saving technology. Four years ago, I left my continuity practice to teach in a nearby residency program. I am now back on a part-time basis. With fewer responsibilities and more time for reflection, I can see how the practice is failing to meet the needs of our patients—and over the years, little by little, how I failed them, too. Primary care is the business of changing lives. Our job is to help acutely ill patients recover, chronically ill patients maintain control, and people who are making self-destructive choices make better ones. It is a human enterprise: people helping people. To do this effectively requires attention to the humanity of our work. What do humans need? Ask them. Patients need to feel acknowledged, respected, and welcomed. Caregivers want a work environment where they can make individualized decisions, improve their skills, and feel like they are making a difference in the lives of others. Not surprisingly, when we care for patients in the right kind of way, we are caring for ourselves, too. Returning to that right kind of way is neither complicated nor expensive. It involves putting people before protocol, sacrifice before ease, common sense before blind obedience, and local wisdom before centralized decision making. The old-fashioned values of service, personal responsibility, camaraderie, and the Golden Rule flourish when the conditions are right. The late Tony Hsieh, founder of Zappos, famously said that “while our brand has come to be known for delivering the very best customer service, the number one priority is actually not customer service. Our priority is company culture, and our belief is that if we get the culture right, most of the other stuff—such as delivering great customer service or building an enduring brand or business—will happen as a natural by-product of our culture.”1 What kind office culture can attract the idealist, retain the hard worker, engage the curious, lead the team, and foster a sense of connection between the caregiver and those they care for? Gauging by the level of burnout in many primary care practices, it is a rare and fragile thing. But not hard to imagine. It comes around to what humans need, especially when they are ill or worried: they want to be greeted by a person, enter an office scaled for intimate interaction, see their own doctor, express themselves in an unhurried and unscripted way, and be trusted to make good decisions about their own health care. The human touch benefits us all, and is supported by the evidence. ### 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. ## CONCLUSIONS The unique physician treats a unique patient, whom he or she comes to understand and care for in a unique way. Doctors, and those who hire them, must trust that age-old formula. What’s at stake here is the basic human desire to help others and to put their good before our own. Success in primary care seldom hinges on the right prescription, the right procedure, or the right algorithm; it is put at risk by the inanimate barriers we have built into our practice. We are a profession of humans helping humans. That is the story of medicine. ## Acknowledgment This essay was written while I was a resident scholar in November, 2022. I wish to thank the Robert Graham Center and the Center for Professionalism and Value in Healthcare for their guidance and support. ## Footnotes * Conflicts of interest: author reports none. * [Read or post commentaries in response to this article.](https://www.annfammed.org/content/21/5/465/tab-e-letters) * Received for publication December 10, 2022. * Revision received April 18, 2023. * Accepted for publication April 25, 2023. * © 2023 Annals of Family Medicine, Inc. ## REFERENCES 1. 1.Logan D, King J, Fisher-Wright H. Tribal Leadership: Leveraging Natural Groups to Build a Thriving Organization. Harper Business; 2011. 2. 2.Nason JC. Telephone Usage at Mercy Hospital’s Primary Care Practices [capstone]. Portland, Maine: University of Southern Maine, Muskie School of Public Service; 2015. [https://digitalcommons.usm.maine.edu/muskie\_capstones/100/](https://digitalcommons.usm.maine.edu/muskie_capstones/100/) 3. 3.LaVela SL, Gering J, Schectman G, Weaver FM. Optimizing primary care telephone access and patient satisfaction. Eval Health Prof. 2012; 35(1): 77-86. doi:10.1177/0163278711411479 [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1177/0163278711411479&link_type=DOI) [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=21685222&link_type=MED&atom=%2Fannalsfm%2F21%2F5%2F465.atom) [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000300417400005&link_type=ISI) 4. 4.Locatelli SM, LaVela S, Talbot ME, Davies ML. How do patients respond when confronted with telephone access barriers to care? Health Expect. 2015; 18(6): 2154-2163. doi:10.1111/hex.12184 [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1111/hex.12184&link_type=DOI) 5. 5.Casalino LP, Pesko MF, Ryan AM, et al. Small primary care physician practices have low rates of preventable hospital admissions. Health Aff (Millwood). 2014; 33(9): 1680-1688. doi:10.1377/hlthaff.2014.0434 [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6OToiaGVhbHRoYWZmIjtzOjU6InJlc2lkIjtzOjk6IjMzLzkvMTY4MCI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvNS80NjUuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 6. 6.Casalino LP, Ramsay P, Laurence C. Baker LC, Pesko MF, Shortell SM. Medical group characteristics and the cost and quality of care for Medicare beneficiaries. Health Serv Res. 2018; 53(6): 4970-4996. doi:10.1111/1475-6773.13010 [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1111/1475-6773.13010&link_type=DOI) 7. 7.Edwards P. Bigger practices are associated with decreased patient satisfaction and perceptions of access. Brit J Gen Prac. 2022; 72(722): 420-421. doi:10.3399/bjgp22X720521 [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYmpncCI7czo1OiJyZXNpZCI7czoxMDoiNzIvNzIyLzQyMCI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvNS80NjUuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 8. 8.Loxterkamp D. Small is beautiful: health care with a human face. J Am Board Fam Med. 2021; 34(2): 264-265. doi:10.3122/jabfm.2021.02.210014 [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMzQvMi8yNjQiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzUvNDY1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 9. 9.Yang Z, Ganguli I, Davis C, et al. Physician - versus practice - level primary care continuity and association with outcomes in Medicare beneficiaries. Health Serv Res. 2022; 57(4): 914-929. doi:10.1111/1475-6773.13999 [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1111/1475-6773.13999&link_type=DOI) 10. 10.Mittelstaedt TS, Mori M, Lambert WE, Saultz JW. Provider practice characteristics that promote interpersonal continuity. J Am Board Fam Med. 2013; 26(4): 356-365. doi:10.3122/jabfm.2013.04.120306 [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjYvNC8zNTYiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzUvNDY1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 11. 11.Loxterkamp D. The lost pillar: does continuity of care still matter? Ann Fam Med. 2021; 19(6): 553-555. doi:10.1370/afm.2736 [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTkvNi81NTMiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzUvNDY1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 12. 12.Nendaz MR, Raetzo MA, Junod AF, Vu NV. Teaching diagnostic skills: clinical vignettes or chief complaints? Adv Health Sci Educ Theory Pract. 2000; 5(1): 3-10. doi:10.1023/A:1009887330078 [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1023/A:1009887330078&link_type=DOI) [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=12386472&link_type=MED&atom=%2Fannalsfm%2F21%2F5%2F465.atom) 13. 13.Novick DR. Sit back and listen: the relevance of patients’ stories to trauma-informed care. N Engl J Med. 2018; 379(22): 2093-2094. doi:10.1056/NEJMp180963 [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1056/NEJMp180963&link_type=DOI) 14. 14.Groopman G. Why storytelling is part of being a good doctor. The New Yorker. Published Jul 25, 2022. [https://www.newyorker.com/magazine/2022/07/25/why-storytelling-is-part-of-being-a-good-doctor-all-that-moves-us-jay-wellons](https://www.newyorker.com/magazine/2022/07/25/why-storytelling-is-part-of-being-a-good-doctor-all-that-moves-us-jay-wellons) 15. 15.Lown BA, Dayron R. Lost in translation? How electronic health records structure communication, relationships, and meaning. Acad Med. 2012; 87(4): 392-394. doi:10.1097/ACM.0b013e318248e5ae [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1097/ACM.0b013e318248e5ae&link_type=DOI) [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=22452913&link_type=MED&atom=%2Fannalsfm%2F21%2F5%2F465.atom) [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000302143200008&link_type=ISI) 16. 16.Barrier PA, Li JT, Jensen NM. Two words to improve physician-patient communication: what else? Mayo Clin Proc. 2003; 78(2): 211-214. doi:10.4065/78.2.211 [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.4065/78.2.211&link_type=DOI) [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=12583531&link_type=MED&atom=%2Fannalsfm%2F21%2F5%2F465.atom) [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000180791800009&link_type=ISI) 17. 17.Robinson JD, Tate A, Heritage J. Agenda-setting revisited: when and how do primary-care physicians solicit patients’ additional concerns? Patient Educ Couns. 2015; 99(5): 718-723. doi:10.1016/j.pec.2015.12.009 [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/j.pec.2015.12.009&link_type=DOI) 18. 18.Shackelton R, Link C, Marceau L, McKinlay J. Does the culture of a medical practice affect the clinical management of diabetes by primary care providers? J Health Serv Res Policy. 2009; 14(2): 96-103. doi:10.1258/jhsrp.2009.008124 [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1258/jhsrp.2009.008124&link_type=DOI) [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=19299263&link_type=MED&atom=%2Fannalsfm%2F21%2F5%2F465.atom) [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000265267400007&link_type=ISI) 19. 19.Edwards ST, Marino M, Solberg LI, et al. Cultural and structural features of zero-burnout primary care practices. Health Aff (Millwood). 2021; 40(6): 928-936. doi:10.1377/hlthaff.2020.02391 [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1377/hlthaff.2020.02391&link_type=DOI) 20. 20.Scammon DL, Tabler J, Brunisholz K, et al. Organizational culture associated with provider satisfaction. J Am Board Fam Med. 2014; 27(2): 219-228. doi:10.3122/jabfm.2014.02.120338 [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjcvMi8yMTkiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzUvNDY1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 21. 21.Pink D. The puzzle of motivation. TED. Aug 25, 2009. [https://www.ted.com/talks/dan\_pink\_the\_puzzle\_of\_motivation?language=en](https://www.ted.com/talks/dan\_pink\_the_puzzle_of_motivation?language=en) 22. 22.Pink D. Drive: The Surprising Truth about What Motivates Us. New York, NY: Riverhad Books; 2009. 23. 23.Ryan RM, Deci EL. Self-Determination Theory: Basic Psychological Needs in Motivation, Development, and Wellness. New York, NY: The Guildford Press; 2017. 24. 24.Williams WC. The Doctor Stories. New Directions; 1984. 25. 25. Ben Franklin. Poor Richard’s Almanack. Peter Pauper Press; 1980.