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.