Substituting Alliance for Alienation: Supporting the Human Side in Changing
Health Care
Harold J. Bursztajn, MD
Joy Kosta
Harold J. Bursztajn, MD consults nationwide
as a medical decision analyst, clinical ethicist, and forensic psychiatrist.
He is senior faculty member at Harvard Medical School and co-Director
of the Program in Psychiatry and the Law at the Massachusetts Mental
Health Center. Joy Kosta is an organizational development and human
resources expert. She designs projects and trains interdisciplinary
teams to implement customer service improvement initiatives in the
health care field. She is active at the national and Vermont state
levels in Businesses for Social Responsibility.
Lead-in. Business and health care disciplines are merging
together more than ever. Each practice has its common maladies and strengths.
This article addresses how professionals, practitioners, and patients
can avoid common maladies and benefit from applicable helpful responses
by building alliances to replace alienation.
Introduction. The dramatic degree of change and uncertainty
in today's health care market affects providers and patients alike. The
human experience for providers and patients, both maladies and "cures" (helpful
responses and actions), have strong parallels. By focusing on the commonly-held
experiences and possible adaptive responses, providers and patients together
can better influence and shape the outcomes they experience and the future
direction of models in health care.
Being revered as the customer. As available dollars
with which to pay for health care can no longer be considered "limitless," many
providers now regard their patients as customers, and therefore try to
win and retain business by distinguishing their customer service quality.
Patients have come to expect excellent customer service from their health
care providers. If caregivers (i.e. doctors) are expected to deliver
individualized, empathetic, "can-do" problem solving service
to external customers (i.e. patients), then they should experience the
same level of service as internal customers from their own service providers
(e.g., HMO's). This involves looking at the interaction skills of staff
and the service systems throughout the organization that either frustrate
or enhance good service. Organizations that overlook this parallel are
asking the near impossible of their staff, and may unknowingly invite
or help to create staff turnover, loss of patients to other providers,
and general alienation of staff and patients alike.
Supporting natural reactions to uncertainty. For many
health care providers, acknowledging the uncertain future in their field
and job is difficult. Will their company go out of business or be acquired?
Will jobs be downsized? How will future health care costs be paid for?
Will their organization survive financially, only to experience the worst
possible effects of "over" managed care? Some providers and
caregivers acknowledge and face these uncertainties, as unsettling as
they are. Others may try to deny it, get angry or depressed about it,
or fantasize that a magical solution will appear. These are classic reactions
to the threat of sudden change affecting one's well-being. It is usually
easy to recognize these anxious reactions to uncertainty when observing
patients' reactions to sudden change in their personal health circumstances.
It is at such times that people isolate themselves, instead of building
and relying on trusted relationships and teamwork to help support and
coach them through uncertainty and change. Organizations that do not
respond constructively to such isolation and anxiety can find themselves
facing the maladies of employees who show up for work in body but not
in spirit, and, in the extreme, employees who litigate on charges of
alleged wrongful discharge or alleged work stress, disability, or sexual
harassment (even when there is none), or in malpractice lawsuits filed
by patients.
Building trusting alliances. Management often asks employees
to "leap" to a change in routine and behaviors without a clear
picture of what the change entails and what their role can be, and without
reassurance that management will be reliably supportive. Employees and
patients understandably fear uncertain outcomes, and may "freeze" with
the difficulty of finding solutions and making choices based on the best
information available. At this point, health care professionals and patients
need reassurance and patience from supervisors, physician executives,
and clinicians in order to face uncertainty, assess probabilities, make
decisions and active choices, and anticipate outcomes before leaping
into a change. This type of therapeutic management response can apply
constructively to organizations' survival strategy in the health care
market, their day-to-day operations, and treatment plans chosen by provider
and patient together.
The benefits of modeling and unity. A convincing method
of persuasion toward belief in a concept or value is to create a model
which demonstrates that, since it works for you, it can work for others.
In order to continue extending the benefits of trusted alliances with
patients, caregivers should experience those same benefits (e.g. through
co-workers and organizational behavior) that they are asked to create
and demonstrate for their patients. A genuine effort toward such modeling
might involve employees and patients participating in meetings that periodically
revisit values, mission, and strategic planning. Such efforts can build
unity and enhance ethical practice while deepening the human experience
of cooperation in facing challenges and creating opportunities in the
future of health care. They can also prevent both employment related
and malpractice litigation at the root, by supporting the human side
of change and substituting alliance for alienation.
The role of forensic psychiatry in preventing lawsuits. When
all else fails, and claims arise which call for an administrative, pre-litigation
response, an external forensic psychiatric and medical decision analysis
consultation can be helpful. This type of independent, objective, and
comprehensive investigation can help keep administrative response within
employment and quality assurance guidelines. It can also be helpful toward
mediating conflicting perspectives within what is, in effect, an expert-mediated
alternative dispute resolution forum. And, if litigation ensues, this
type of investigation can also provide evidence of good faith, pre-litigation
efforts at dispute resolution via expert input. It can also serve to
educate all concerned regarding the uses of alliance to address the alienation
which can be expected in the midst of change in health care organizations
and delivery.