Three Reasons Why Patients Can’t Come First

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“The patient must come first!” Medical Tradition

It sounds right. It’s not.

Unfortunately, over the course of my career I have seen way too many of my colleagues sacrifice themselves on the alter of “the patient must come first.” If we want patients to receive the very best care, they can’t come first. It is time for us to rethink this and I believe that there are some principles from the international disaster response world that you will find helpful.

Problem 1: Sleep deprivation impairs executive functioning

In 2000, Williamson and Feyer published an article that got the world’s attention. The title of the article is: Moderate Sleep Deprivation Produces Impairments in Cognitive and Motor Performance Equivalent to Legally Prescribed Levels of Alcohol Intoxication. They discovered that 17 to 19 hours without sleep was equivalent to a blood-alcohol level of .05%. Response speeds were up to 50% slower, and accuracy measures were significantly worse. After longer periods without sleep, they discovered performance levels that were equivalent to a blood alcohol concentration of 0.1%. In most states, a level of 0.08% is considered legally drunk. Yet, in most training programs, it is considered a badge of honor to go without sleep. When we are exhausted patients can receive less than optimal care.

Problem 2: Impaired interpersonal relationships erode purpose

As Baumeister (1995) stated in his often quoted article1, people have a strong psychological need to belong (emphasis mine). Decreased connectedness can lead to symptoms of anxiety, depression, grief, and loneliness. When we put patients first and neglect relationships with our family and friends, it can be all too easy to withdraw and lose sight of our underlying, motivating purpose. In his famous TED talk, “Start with Why", Simon Senik stresses that at the core of our motivation is the "why" we do what we do. When we lose sight of our “why” we can easily become detached from our patients.

Problem 3: Neglected teams disengage

Not only do we neglect ourselves but, when we put patients above all else, we tend to neglect our teams. Morale can suffer. Engagement can decline. A "safe culture" can be nearly impossible to maintain.

How I almost killed my team in Haiti - Lesson learned

It was a very chaotic situation when we first arrived in Haiti after the earthquake in 2010. My team was tasked with getting Kings Hospital in Port-au-Prince back online. There was debris everywhere. There were long lines of patients outside waiting to be treated. The crush injuries were horrific. We had orthopedic surgeons and anesthetists who were some of the best in the world at disaster surgery. Inside the hospital, most of the supplies were now on the floor. The rooms were a mess. We rolled up our sleeves and got to work. We had a clear objective: take care of the long line of patients that desperately needed our help. We were motivated. After several hours of work, the operating suites were ready for business and we started performing surgeries.

It was not until the second day that I realized my error. I was horrified. As I went around the outside of the building, I discovered that the operating suite was cantilevered out approximately 20 feet. Over half of the operating suite jutted out from the building. When I looked carefully, I discovered that there was a crack approximately 1/2 inch wide that ran up the side of the operating suite on the outside of the building. It would not have taken much for the entire operating suite to fall off the front of the building. We had to evacuate the building. I met with structural engineers from the United Nations and we were able to build support pillars under the structure to give it more support. Eventually, we were able to return to the operating suites and start taking care of patients once again.

I could have killed my team. I could have killed the patients. I could have killed myself. I made the mistake of putting the long line of desperate patients first. I violated one of the prime rules of disaster response: safety first. The command structure that we use for disaster response is very similar to the command structure the fire departments use. As the Incident Commander, it is my responsibility to assure that we are safe until I delegate that responsibility to a safety officer.

If I put patients first, before my safety or the safety of my team, I risk the entire team. If I lose my team, we lose the ability to care for the patients. There is no place for blinded heroics in disasters. If I truly care about the well-being of patients, I need to take care of myself and my team.

Call to Action: Self-Care + Team-Care is the foundation for great Patient-Care

As we consider the importance of safety, self-care, and team-care, we need to consider two different perspectives. We need to look at it from the perspective of the individual and what we can do to take care of ourselves and our teams. We also need to look at it from the perspective of the organization and what the organization can do to take care of their individuals and their teams. It makes no sense to drive people so hard that they no longer have the time to take care of themselves and each other.

So where do we go from here? I would suggest the following three steps as a starting place:

1.) Don't compromise on your sleep. If you compromise on your sleep it increases the risk of errors, and it also makes you less efficient.

2.) Block out time in your schedule to connect with your friends and family. I would suggest doing this at the beginning of the week or even perhaps at the beginning of the month.

3.) Start doing daily huddles before the shift begins to check in with your team. Take a few moments to connect with them and care about each other.

4.) As I've written about previously, remember that we can't change the organization until we get involved.

What are your thoughts?


  1. Baumeister, R. F., bulletin, M. L. P., 1995. (n.d.). PsycNET. Psycnet.Apa.org ↩︎
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