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Anesthesiologist Colleen Naglee discusses her article, “We should tip health care workers too.” Colleen reflects on the rise of tipping culture in everyday services and questions why health care workers—who risk violence, burnout, and underpayment—are left out of these gestures of appreciation. She highlights the realities of declining Medicare reimbursements, the dangers of temporary staffing, and the toll of corporate ownership on patient outcomes. With sharp wit, Colleen suggests tipping as a symbolic gesture of gratitude, but ultimately argues for real, systemic change to recognize and support health care workers.
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Transcript
Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Colleen Naglee. She is an anesthesiologist, and today’s KevinMD article is “We should tip health care workers.” Colleen, welcome to the show.
Colleen Naglee: Thank you so much. I’m so glad to be here today. All right, I so appreciate the opportunity.
Kevin Pho: Just briefly share your story and then talk about the KevinMD article for those who didn’t get a chance to read it.
Colleen Naglee: Great. So I’m an anesthesiologist and neurointensivist working at a small academic program, and I recently graduated law school as well. So I’ve really been paying a lot of attention thinking about health care systems and how to improve them, which is, you know, a huge challenge.
Kevin Pho: Yeah. Taking a cue from some of the service industries. You know, if we look around to how service industries are working these days, there’s a lot of dissatisfaction, you know, from everything from Starbucks to Walmart to health care. There’s nothing unique to any of those service industries, but some service industries have taken to tipping as an option.
Colleen Naglee: Yeah. For instead of paying people better or improving their situations and benefits. And I thought it would be funny to see what it would look like if we applied that to health care. Of course, it sounds silly, but, you know, the idea that, hey, we’re a service industry too. Why don’t we apply the same systems that other non–health care systems are using?
Kevin Pho: So in your article, you talk about some of the risks that health care workers face, even though we are part of that service industry. So talk about some of the risks that we face.
Colleen Naglee: Absolutely. So, it’s sad, but violence against health care workers has really been rising in the last couple of years, and it’s one of the most violent industries to work in, which isn’t something that people usually associate with health care. And the laws have been slow to respond to that, where we honestly allow a lot of violence in health care ’cause we recognize our patients are in distress and have a lot of medical issues and psychological issues at the same time. So, you know, thinking about how prevalent it is, most people who work in health care have seen it, and it’s unfortunate. It would be better if we really focused more attention on how to protect health care workers in these situations.
Kevin Pho: So they’re not exposed to the situations at work that honestly no one wants to be involved in. Yeah. How common is it? We certainly hear occasional cases about episodes of violence in medical centers, but it’s been a while since I’ve been in an academic medical center or a large medical institution, so you’re more in tune with it than I am. How prevalent is violence against health care workers—and we’re not just talking about physicians, but nurses as well, right?
Colleen Naglee: Absolutely. So nurses have some of the highest rates of violence, and that’s because they spend a lot more time with patients than most other health care providers. If you look at one study of ER nurses that was done a couple of years ago, 100 percent of the nurses reported violence recently by a patient against them. Not saying there was necessarily harm, but there was at least an attempt to commit violence toward them. And nurses’ aides have the same issue, where they’re seeing a ton of violence. If you look at physicians, it depends often on specialty. So if you’re a physician who works in a psych facility, your risks are very different than someone who works in an outpatient dermatology clinic. We see differences, but compared to other industries, it’s five times more common to be a victim of violence in health care than if you’re a construction worker or, you know, a police officer. And that’s a really notable statistic.
Kevin Pho: So more recently, more and more guests on my podcast have been speaking out and bringing awareness to health care workplace violence. Why has it been traditionally so underreported and kind of swept under the rug?
Colleen Naglee: Oh, well, there’s a lot of reasons, and there have been some studies looking at why people don’t report it. The first is that folks don’t feel that if they report it, it will be taken seriously or anything will be done. And that’s in part because the legal nature is often that we don’t charge these patients with assault. The second major issue is that we recognize that our patients are in a rough situation, right? Many of them have been given medications that affect their brain, many have underlying psychiatric issues, and they’re in pain, along with other psychosocial challenges. So there’s an empathy that patients lashing out in an unhealthy way is somewhat understandable given their clinical conditions. And then you have folks who just say, “Look, this happens every day. What’s the point?” I’m always going to have patients who grab my arm or whatever, and I’m just going to move on because it’s not worth going through that process. So it’s multifactorial for why there’s underreporting, but it’s certainly a sad reality.
Kevin Pho: And it’s not just violence against health care workers. There are just so many obstacles that really prevent health care workers from doing the best they possibly could for patients. You mentioned a few in your article: things that could affect staff morale, the takeover of private equity on various services in a hospital. So talk more about some of those issues as well.
Colleen Naglee: Yeah, so, you know, I’ve been in medicine for close to 20 years, and when I think about team-based dynamics, we all perform better in teams. So when you have a consistent team where everyone has a role and everyone understands their relationship to each other, and there’s institutional knowledge about how to do whatever job it is—and this applies to everything: the operating room, outpatient clinics, ambulatory surgical centers—it’s all a team-based approach. Then you take that team and disrupt it by having burned-out providers and burned-out nurses, or by having high turnover of staff because they’re unhappy with their benefits, and you lose that team, you lose that morale, and ultimately you lose institutional knowledge too. It’s hard to underestimate how important those things are for successful patient care because no one can do their job in a vacuum. We all rely on each other. When we can’t rely on someone because we’ve only met them two hours ago, it’s much more difficult to do the right thing.
Kevin Pho: And you also mentioned the impact of declining reimbursements from private insurers and Medicare. That often doesn’t generate a lot of sympathy toward physicians because historically there’s a perception that physicians are among the best-paid professions. But talk about how those declines in reimbursements affect physician morale.
Colleen Naglee: So, you know, we push especially primary care physicians to see patients in shorter and shorter periods of time for less money, and that affects the physician–patient relationship. If my primary care used to spend an hour with me and really understand my issues, they’d know that I’m having difficulties at home and that’s why I’m not taking my antihypertensives. It’s hard to get that in 15 minutes. So we’ve disrupted a lot of those relationships by tying all the work we do to reimbursement instead of the quality of care or the level of patient satisfaction. We tie so much of it to procedural expectations and quick turnover of patient visits. That really diminishes our relationship with each other and with our patients.
Kevin Pho: So what’s kept you going, though? You have a unique perspective, obviously, from that law background, and you’ve been in medicine for 20 years. Where do you see this going? You have, certainly in other service industries, like you said, symbolic gestures like tipping, but in health care that seems a little superficial, and we need more systemic change. So where do you see this leading eventually?
Colleen Naglee: Well, I’d hope that there’s more recognition at a national level that we need to look again at how we provide health care—how do we provide for all Americans, how do we deal with insurance companies and big pharma. I think it’s time for a radical, revolutionary approach to how we do health care. I recognize that every couple of years someone tries to revise how health care is done, but I think we’re overdue. We provide in the U.S. some of the worst care for the amount of money we spend, and I feel like it’s time. I don’t know where the tipping point lies, when we finally say as a country we’re ready to revise how we consider health care, but I would love to reach that point, and I’d love to be part of that solution. I really hope to inspire people to start thinking that there are alternatives and many different ways to deliver health care. If you look all over the world, there are probably better delivery models than what we’re doing currently.
Kevin Pho: So tell us a story about things that you’ve seen in your own medical institution or you’ve heard from colleagues that really moved the needle in terms of health care workers being better appreciated or something that really helped with morale. What have you seen work?
Colleen Naglee: What have I seen work? That’s a great question. I think recognition from the top really matters. When your boss says you do a good job, you’re happy, right? When your friend says you did a good job, you’re like, oh, that’s cool. It doesn’t have to come with money, but I think acknowledging the work that we all do and rewarding people who do a good job is important. I have seen examples where, during COVID, for example, when everyone’s really burned out and unhappy, just an email from my boss saying I did a good job would have meant the world to me. Instead, it’s an email with another protocol to follow. Recognition and acknowledgement of the work we all put in play a big role in our satisfaction. I read once that people leave their jobs for two reasons: money and because they don’t like their boss. I’ve always thought if we put more energy into how we treat each other, we could get a better solution and help each other feel more satisfied with our work every day.
Kevin Pho: That seems like a pretty common-sense approach. We do not see that happen enough, where our superiors, our colleagues, our bosses, or administration simply don’t recognize the work that health care workers do enough.
Colleen Naglee: I think that’s totally true. If you think about our daily lives, how often are you getting rewarded by the health system for the quality of your work? I’m not talking about how many UTIs, but the overall care that you provide. It’s not something that’s hugely focused on. Instead, we focus on throughput and things that are easy to measure—did you get into the operating room on time, did your patients fill out the Press Ganey survey after their clinic visits—rather than thinking more holistically about the care we provide, which is a radically different approach to medicine than how we’ve looked at it for many years. And I mentioned this earlier regarding the impact of private equity, which further increases the focus on objective metrics like revenue and really drives more of a wedge between doctor and patient.
Colleen Naglee: Absolutely. I think that anytime we switch the focus from care to money, you’re not going to be as happy with the way things turn out. It’s great when health systems make money. I’m not against making money; I’m totally for it. I like to have a salary, too. But it’s great when we align that money with things that improve the quality of our care, and I’m not sure that changing to private equity and some of the ways we’re handling insurance and pharmaceutical care are really doing better care. They’re just more financially driven.
Kevin Pho: What kind of advice do you have for your fellow clinicians and health care workers who may be burnt out and not feeling appreciated? Do you have any advice for them in terms of how they can continue moving forward?
Colleen Naglee: Well, that’s tough. For myself, I’ve looked around at a lot of different health systems, and I do think some have much better systems and much better support. I’d say finding a place that’s the right match for you is huge, because if you’re happy where you live and you’re happy with your coworkers, it’s extremely rewarding compared to being dissatisfied. Culture makes a difference, and I’d encourage people to be very thoughtful about the culture. I work with a lot of trainees, and I tell them that they are the ones who will decide the culture of the future, and we should all make a concerted effort to think about what culture we want. So how do I make a phone call to a consultant? How do I talk to a patient? How do I talk to a nurse who did something I’m not super happy with? All of those things are about culture, and I tell trainees that they have to make a decision: Are you going to yell at people when you could be kind? Are you going to create protocols and systems that are good for your patients? If you do, you might be really happy with the results. So constantly be thinking about the effect you have on those around you and the way you can move the needle in the future.
Kevin Pho: I talked about this topic with one of my former guests, and they mentioned the politicization of health information and the current political climate in which expertise—specifically medical expertise—can sometimes be devalued. Are you seeing some of that in your health care system and among the colleagues you talk to? Do you think that also contributes to some of the morale issues in the health care workforce?
Colleen Naglee: Yeah, I think there’s a great distrust among many Americans of health care systems and of physicians. I’d like to write another article on that because I have lots of thoughts on it as well. But I’ll say it does a disservice to all of us, and I think we bear some responsibility for it. By not listening to patients and not taking some of their concerns and their “doctor Google” searches seriously, they’re going to distrust us. So the street goes both ways, but the general distrust of health care workers is tough. When you have a patient and you say, “This is what we should do,” and they say, “I don’t believe you,” I have patients where I say, “I’m sorry, your loved one is brain dead,” and they say, “No, they’re not.” It’s really difficult to get around that. I would love for us to be thinking about how we can engender more trust with Americans and provide better care.
Kevin Pho: How can we do that going forward? Is it simply listening to patients more? What are some ways we can regain some of that trust?
Colleen Naglee: Yeah, I think listening. And I think this goes to the restructuring of health care. If you valued our relationships with our patients more than our procedural skills, then maybe we would focus on that more in training, and after training, and in how reimbursement works. If we gave primary care physicians more time with their patients, they’d probably trust them more. I found a great study once about end-of-life care, which is something I spend a lot of time on, and if you just let the patients talk more in end-of-life conversations, they actually trusted you more and thought you were a better doctor. So listening is really an underrated skill—hearing what people have to say and meeting them where they are. Instead, we meet them where we are, and that’s not always as effective.
Kevin Pho: We are talking to Colleen Naglee. She’s an anesthesiologist, and today’s KevinMD article is “We should tip health care workers.” Colleen, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Colleen Naglee: All right, this is the hardest part. So I’d say think about how it’s time to radically reassess how we look at health care and our care delivery systems. Think about whether they’re effective for both us and our patients, and whether they’re delivering the results we want. If you’re honest with yourself, you’d say the answer is no. Then, you know, we all play a role in advocacy and looking for how we can improve our local environments to make better health care for our patients.
Kevin Pho: Colleen, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Colleen Naglee: Thank you. I really appreciate it.