The Broken Cash Register

I went to the hospital cafeteria yesterday to grab a quick bite to eat for the first time since I arrived eight hours ago. As I'm standing in line, I notice that the very pleasant cashier – let's call him Joe - is nimbly navigating between three different registers to ring out the customers waiting in line.

I am intrigued and watch intently as Joe smoothly directs some forms of payment to the left, others to the right, and one person to a station behind him. As I arrive at Joe's register, he can clearly tell I've been intently observing him, so, with a sheepish grin, he tells me, "They're broken." Joe clearly gathers by the puzzled look on my face that I don't quite understand what he means by this and goes on to explain. He points to the one on his left and says, "On this one, the credit card machine doesn't work." He then turns to his right and says, "And this other here, the badge-accessed pay deduction system doesn't work." He turns, points to the register behind him, and notes, "With that one, the drawer won't open." With this last one, he further clarifies, with a wink which lets me know he clearly recognizes the depth of my cash register ignorance, "That means I can't take cash there." Ever smiling, he says, "Somethings always broken around here, you know?". I paid eight dollars for my cold sandwich and cup of lukewarm coffee and thanked Joe for his friendly service. I head back to my shared office space and grab a spot at an open computer so I can try to eat a couple bites of this food while attempting to juggle toggling back and forth between putting in orders, triaging which chats and pages to return first, and catching up on a note here and there. Luckily, the open computer I found could load the program I needed in only 10 minutes this time. Some days, it takes a full fifteen minutes. And suddenly, out of nowhere, I am just dumbfounded by how what Joe had said so simply and without an ounce of malice could not be a better summary of our healthcare system - "It's broken."

Shocking news to almost no one: there is a crisis in healthcare. As has been desperately needed for some time, people are finally acknowledging the profound impact of moral injury – which I define as the cognitive dissonance that is caused by the disconnect between the care we physicians and APPs strive to provide and the care we actually can achieve based on existing resources, or, more aptly, lack thereof. As we should, we are talking about how failing to provide our nurses with safe patient care loads and sufficient access to essential equipment and supplies are a few reasons nursing shortages are raging havoc on hospitals nationwide. As we should, we are finally talking about how foolhardy it had been for our hospital leaders to operate under the assumption that we can continue to extract "just a little more" out of our physicians and APPs without devastating consequences. We are now starting to acknowledge that the constant refrain of, If you just work faster, harder, squeeze the resources a little tighter – you know, "trim off the fat" – that we can keep doing just a bit more with just a bit less – are nothing but greed fueled smoke and mirror parlor tricks to keep us spinning in our tracks and constantly off balance while demoralizing our workforce and worse yet, hurting our patients. 

We are hearing loud and clear from all sides about the profoundly negative impact that the "Businessization" of medicine has caused. And yes, despite Mariam and Webster's objections, I have decided that "Businessization" is now a word for this piece. But what I don't think we talk about enough yet is the deeper reasons why some "Businessization" models are wreaking destruction on our healthcare systems. It's not because the goal of a hospital being financially solvent is bad – it's simple math that a hospital must make enough money to pay its workers, keep its lights on, and make improvements to its infrastructure. It's not that money is bad. It's that somehow, along the way, those with the power stopped listening to the people who do the work – the ones who know what is truly needed to succeed and keep our patients safe. These 'frontline workers' are out of sight and out of mind when key financial and strategic decisions are made. Those with the power stopped listening to the nurses, doctors, phlebotomists, pharmacists, therapists, technicians, and countless others, who have said over and over and over that, there are simply not enough bodies to complete the work that needs to be done. And they express shock and dismay when corners get cut, and patients get hurt. They stopped listening when the nurse said the eighth round of duct tape wouldn't hold much longer. They stopped listening to the surgeon who said the equipment was out of date and unable to meet her needs. They have deaf ears for the residents who tell us with desperation in their voices that they are asked to do so much with so little that they don't have time to learn how to be good doctors. 

Instead of listening, they tell our healthcare teammates that if we all just "lean in" a little further, it will fix everything. They ask us to be excited because tomorrow, the newest round of 20-something-year-old healthcare consultants will come to our hospital wearing their sleek business casual threads and let us know, with a very pretty PowerPoint, how we can do our jobs better. They tell us that if we just come back next week with a one-page, 10-point Helvetica font proposal that succinctly outlines the return on investment for that new box of Band-Aids we have been asking for the past three years, they would, of course, be happy to consider that for the budget in the next fiscal cycle. And yet, the most ingenious trick they adeptly accomplished is convincing us that the only reason we don't have enough is that someone else has too much. They tell us that if those nurses would care for just a few more patients or stop taking so many breaks, and those doctors would just admit and discharge a little faster and stop whining about their patient load, things wouldn't be so bad. They tell us we don't need to buy new things because we already have more than enough things - it's just that someone has the things we say we need, and they aren't "sharing." And I am nothing if not fair, so I must pause to give credit where credit is due - it's really a brilliant strategy. It makes us so angry and frustrated with each other that we don't have any energy left to be angry at anyone else. They are quite smart, these men and women in sleek suits.

You're right, Joe, it is broken. It's all broken. And the fact that you come to work every day with a smile despite knowing you must work with broken things that nobody cares enough to fix makes you a hero in my book. And you know what, so are the rest of us.





Clare Mock, MD, CPPS

Associate Professor of Medicine

Director of Patient Safety, Department of Medicine

Division of Hospital Medicine

Department of Internal Medicine

University of North Carolina

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