There’s no doubt that there is an elephant in the room of American healthcare and it’s efficiency in meeting the needs of our population, especially the most vulnerable. As a clinical occupational therapist and a human-being, I’ve experienced firsthand the gaps and discrepancies that exist within our healthcare model within the United States. The goal is to optimize care, but unfortunately in the process, there is a common experience of low-quality care, disparity gaps, and high emergency utilization rates as a result of the minimization of the needs of both the client and the healthcare service provider. While I am not a trained expert in the business of American healthcare, I am an educated and experienced stakeholder, and so are the clients that I serve. It’s important to talk about the lived experience of both clients and healthcare professionals as their experiences are often a reflection of the quality of our healthcare model and setting, and the gaps that exist within.
Far too often, burn-out and high turnover of the employee and the unmet needs of the client are due the incompetencies of the complex machine that is our healthcare institution.
On a positive personal note, over the past several years of work experience, I’ve had many satisfactory experiences with my employers and educators within public health settings, corporate mental health, and educational institutions with a variety of funding sources. In these domains, I’ve frequently been heard and listened to, and if any concerns arose, they were frequently handled diplomatically and with integrity. While concerns were not always solved with an end result I preferred, the problem-solving process to meet the needs of clients, employees, and the company to the best of our ability was essential to the health of all those working on the team.
Through a consideration of the thoughts, needs, ethical implications and mental health of the employees, ultimately the worker, business, and patient are valued. Such leadership principles are essential for the prevention of burn-out in caretaking professions and the ethical integrity of the healthcare setting. Especially in those environments treating the most vulnerable, such as disabled children, the houseless, and those experiencing complex physical and mental health impairments.
These positive experiences are highlighted to emphasize that adequate leadership is essential, even in difficult work environments. Human-resources departments are critical as they are equipped to handle complex concerns, and they are the engine that works towards improving employee health, through incentives for growth, partnership, retention and success on a larger scale. However, in these institutions, there can also be a practical limit to care quality and ability to meet client needs based on the resources reasonably available.
In 2018–2019, while working in an outpatient federally qualified health center (FQHC) in Skid Row, Los Angeles, I learned firsthand that many of my clients required 24/7 care and support to manage their health and chronic health conditions. Cognitive impairment and living on the street compounded the difficulty of contacting individual’s who lived without a consistent phone or address. Our team of providers did not have the consistent ability to provide the best care possible, despite team meetings weekly to discuss our most vulnerable clients. As a consequence of deinstitutionalization, many adults and older adults require constant healthcare monitoring and shelter that was simply not available to us, and in the rare chance it was available, it was limited and inaccessible to client needs.
In this example, the limits of the state and federal-level institutions involved compounded the stress on both client and provider. While there is no easy solution or answer, these issues are inextricably linked to housing and healthcare policy within the United States.
On the other-hand, in small, private practices I’ve worked in, I’ve experienced various ethical dilemmas in regards to client care and employee burnout, propagated by small-business leadership and limitations. In the Los Angeles area, there are currently upwards to three month-long waitlists to access pediatric therapy in the community, exacerbated by the COVID-19 pandemic and unmet needs of youth and families during the last three years. Some ownership allows such waitlists to be bypassed if a client is willing to pay cash, leading to concerns about the integrity of the system. There are also productivity pressures for therapists which are not regulated by any other entity contributing to burnout and low-employee morale, commonly leading to a “revolving door” of therapists.
This leads to a high turnover, with some children having 4–5 therapists over a period of a few years.
Children are sometimes left confused and feeling neglected, as such turnover, which is sometimes combined with communication restrictions from business owners, can lead to attachment trauma and difficulty for children to process what has happened. For various personal and professional reasons, as well as through consideration of the needs the client, therapists may feel pressured to stay at an unhealthy or unethical work place. Fears of retaliation may linger despite professional concerns regarding employee and client care. New graduates may not believe they have many options without clinical experience. Further, student loans and expenses in metropolitan areas are often too high to endure the opportunity cost for therapists to seek a healthier work environment.
It’s reasonable and somewhat obvious to suspect that a lack of resources and leadership capability (or choice to not invest in those resources to increase profit) is partly behind the various dilemmas discussed. On a basic level it may be unreasonable to expect this to change, as we live in a world of finite resources. However, the systemic variable of which is arguably most easy to alter to improve quality of healthcare is the regulation of profit and productivity, which while it is undoubtedly important and necessary for the functioning of any business and society, does not have a reasonable limit or cap currently.
Unrealistic productivity and pay, as well as a priority on profit, leaves clinicians frequently overworked and in “auto-pilot mode”, with difficulty challenging what is being asked of them. They are encountering wage stagnation not consistent with inflation and education level, leaving a vulnerability to being overworked and underpaid.
Perhaps the whole point of this discussion is to highlight that healthcare workers undeniably require rest, recuperation, and attention to mental and physical health to take care of vulnerable people most effectively — and healthcare is not systemically organized to meet these challenges. At it’s very core, a healthcare model (and a housing model) focused on profit versus people will still help people, but it won’t help everyone, and it certainly won’t help everyone effectively.
While there are many healthcare institutions that are paving way for quality care in this domain, through bridging accessibility, increasing wages, preventative care programs and addressing systemic challenges (Kaiser Permanente specifically comes to mind, especially with the creation of their medical school and it’s goals to combat racism and inequality) the principles of our federal healthcare model still seems to be creating more sick, tired, and desperate people, trying to help sick, tired, and desperate people than it would otherwise. While this is inextricably political, it’s not to create a greater divide or to dismiss the importance of business and financially healthy clinical institutions. This is instead a reminder to stand up for quality care and political activism to help improve the quality of healthcare, locally and federally. We must stand up for unethical practices, and practice conscientiousness in our professional and business roles. If not, we are not active, engaged healthcare professionals.