October 8, 2023

Nurses at Kaiser Permanente have just engaged in the largest healthcare worker strike in U.S. history.  The reason reported for their walkout is feeling “burnt out and fed up.”  Wage frustration and high staffing ratios — too many patients per nurse — are noted.  These are symptoms, not the root cause.

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Why are healthcare workers burnt out providing service?  Why are they fed up with the system in which they must function?  Why do so many feel devalued? And why are so many providers quitting clinical care?

The real reason, the root cause or etiology as doctors say, is not money or even working conditions.  It is the lack of psychic reward — the inability to attain self-actualization, the highest on Maslow’s hierarchy of human needs. 

What drives nurses, doctors, and therapists to study and train for many years in order to become caregivers is an immaterial, non-financial but priceless gift: the psychic reward.  For some, preparation to obtain it can extend to 11 or 12 years after college.  (For this author, it was only ten years.)  Then there are incredibly long hours, being on call continuously, and the emotional toll of being responsible for another human being’s life or death. 

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The psychic reward is the expression on a mother’s face when I hand her a healthy child after she brought in a baby dying from a hole in his heart.  The nurse or attendant who sits with a hospice patient holding her hand, humming a familiar tune, does this not for money, but for self-validation.  The psychic reward impels a trauma surgeon to unhesitatingly get out of a cozy, warm bed at 2 A.M. to care for an automobile accident victim.  Over lunch one day, a nurse once said it best: “When my babies [her patients] do well, it feeds my soul.” 

Achieving that emotional high — the psychic reward — requires direct, intimate fiduciary connection between provider and patient.  The patient must place trust in that particular provider.  The provider must feel an overwhelming responsibility for the well-being of that particular patient — not patients in general, but to that one person with name, a face, a family, a mortgage, and a natural fear of illness or death. 

Provider and patient must be voluntarily, closely, and directly connected, with no one and nothing separating them.  Third-party payment structure disrupts direct connection between provider and patient and has taken away autonomy (freedom) from both patient (buyer in market terms) and provider (seller).  Patient doesn’t decide provider.  Patient doesn’t choose medical services.  Patient does not pay the provider for care.  Nameless, faceless, unaccountable government agencies and insurance companies do that. 

Provider doesn’t get the satisfaction of choosing the best care for his patient.  Pharmacy benefits manager decides medications.  Insurance rules, not the provider, determine what treatments are allowed and which are not.  Following Washington-approved benefits packages, health plans dictate where, by whom, when, and even if medical or surgical treatments will be provided.  Providers have all the responsibility but none of the requisite authority.  Without both, there can be no psychic reward.

Without this reward, there are two terrible outcomes.  Each specific patient does not get the best care; the individual gets care by federal guidelines and the cheapest medications.  Patients at large do not get timely care.  In fact, they die waiting in line for care, called death by queue. 

Providers are disconnected from patients by third parties.  Providers have become assembly line workers with no emotional attachment to what — namely, the patient — they are working on.  With no joy of success, providers feel embattled and devalued.  Being blamed for the high cost of care, instantly condemned for any adverse outcome, providers have become the evildoers of healthcare, not each patient’s personal savior.