Who comes first: Patients or staff?

Behavioral Healthcare’s November 2007 issue profiled “Behavioral Health Champions,” and among them was Lawrence P. Noonan, CEO of A.W.A.R.E., Inc., in Montana and New Mexico. Beyond all of his leadership accomplishments, what really struck me was how he described his most vivid behavioral healthcare memory, which began, “The first day I worked in an ICFMR in Montana, on my first staff break, I was given a choice between helping the resident of the facility who was having an epileptic seizure in the hallway or helping the staff person who was having a seizure in the office.”

Before I complete Mr. Noonan’s quote, imagine what you would do in such a scenario. Or, if you actually have had a similar choice, what did you do? Is this an ethical dilemma like some of those questions designed and used to assess ethical decision making? One well-known mock scenario is whether you would pull a switch that would save five people but kill one, or do nothing and have all six die.

Mr. Noonan continued, “I helped the resident and called for help for the staff member. It was a tough choice.” I can understand why this choice might have been an early example of how his caring for patients was reflected in his actual behavior and a clue for why he received the award.

I’d like to think that I would have done the same thing. After all, as a physician and psychiatrist I was socialized to put the patient first. The American Medical Association’s Principles of Medical Ethics, revised in 2001, emphasizes in its preamble that “a physician must recognize responsibility to patients first and foremost....” If that wasn’t clear enough, Section VIII states that “A physician shall, while caring for a patient, regard responsibility to the patient as paramount.” Perhaps to counter the business and managed care intrusions on the practice of medicine, the 2001 revision places even more emphasis on the patient than the prior version’s preamble, which stated that the principles were only “developed primarily for the benefit of the patient.” Secondary responsibility is to society, colleagues, and self.

When I was an administrator, I developed the Ethical Principles for Psychiatric Administrators for the American Association of Psychiatric Administrators. Although these principles place more emphasis on “responsibility for the well being of the work setting and for the lives of those employed in that setting,” when that conflicted with the needs of patients, patients still needed to come first.

I am not as knowledgeable about the ethical principles of other behavioral health disciplines, but there seems to be a similar sentiment. For instance, the ethical standards of NAADAC, The Association for Addiction Professionals, seem to parallel those of my field. Interestingly, the first ethical principle of the National Association of Social Workers’ Code of Ethics states that “Social workers’ primary goal is to help people in need and to address social problems.” Although it is implied that the people in need are clients, would the staff member in Mr. Noonan’s scenario also apply?
Despite how Mr. Noonan’s decision fit the ethical principles I was familiar with, a nagging doubt persisted. Remember, he said it was a “tough” choice. In fact, the more I thought about it, the more I think it could have been the wrong ethical choice between two ethical goods. Why? Is it heresy to even question the principle of “patient first”?

All these ethical principles say we have some responsibility to colleagues, of course. Who else but us clinical staff to take care of patients? Don’t we all think that the better the staff, the better the care of patients/clients? And don’t all good administrators help us to do better work, or bad ones hinder it?

Logic then takes me to suggest that, just maybe, staff should come first and that, if I had time to think and not just react reflexively to the way I’ve been socialized, I might first try to help the staff member having an epileptic seizure.

I don’t mean that we should come first in a personal, narcissistic sense. Our priority should not be how much money we can make off our patients or how much renown we can achieve. No, I mean that everything possible should be done to help clinicians and administrators become as skillful as possible. I also mean that our own mental health must become a priority. Time to recoup during the day, mental health days off, not putting ourselves in dangerous situations with patients, and continuing education all should be a priority, not grudgingly available because they take time away from patient care.

This line of reasoning also may apply to a topic discussed in Drs. Lori Ashcraft and William A. Anthony’s article “Our workforce’s biggest secret” in the October 2007 issue of Behavioral Healthcare (Maybe there’s something in the air being reflected in different ways in the publication). Drs. Ashcraft and Anthony note that despite the progress of the mental health consumer movement, staff members who have mental illnesses often feel they have to hide their problems (Drs. Ashcraft and Anthony weren’t talking about “peers” hired because of their experiences with mental illness). Why the paradox? Shouldn’t a mental healthcare facility be the place where stigma is at its least? In her letter in the December 2007 issue, Rebecca Cichetti discussed how revealing her ADD and secondary depression in order to get some minor accommodations at the facility where she worked was met negatively. She was traumatized and left the field.

So if shame and stigma are even higher among mental healthcare staff, a quarter of whom have mental illness (based general population data), we surely aren’t getting the best we can out of our employees.

There may be a parallel to this dilemma in the lives of everyday normal families. Children’s needs usually are a priority for one or both parents. Yet it takes a supportive, agreeable, and loving partnership to provide the best child rearing. Therefore, the relationship with the partner should still be the first priority even after children arrive. Dedication to the child at the expense of nurturing the relationship and needs of each parent will likely backfire at the expense of the child’s development.

Think back to Mr. Noonan’s example. If the staff member was having a dangerous seizure that turned out to have a bad outcome because he was neglected in favor of the resident, how many residents would be adversely affected over a long period?

Certainly, we are not going to be exposed to many ethical dilemmas like this over our careers. And, most certainly, the priority of our work is to indeed help those we serve. But we have to help ourselves first to do that as well as we and the organization can.

In Behavioral Healthcare’s October 2007 issue, Editor-in-Chief Douglas Edwards asked how we thought the situation of shame and stigma in staff who have mental illness could be changed. Simple, I say: Put the well-being of the staff first and everything else good will follow!

H. Steven Moffic, MD, is a Professor in the Department of Psychiatry & Behavioral Medicine, as well as in the Department of Family and Community Medicine, at the Medical College of Wisconsin. He has spent most of his 20-year career developing and leading behavioral healthcare systems, ranging from community mental health centers to capitated managed care contracts.

Sidebar
Lawrence P. Noonan’s response

In making his hypothetical choice, Dr. Moffic experiences the same mental tug-of-war I did when faced with the dilemma of whom to treat first: the patient or the caregiver. It’s not unlike the ethical predicament of the physician ordered to treat the wounded soldier so he can return to combat quicker. Practically speaking, more information might have made the decision easier. For example, knowing the severity of the patient’s and caregiver’s seizure (i.e., how life-threatening or the organic cause) certainly would influence a decision about whom to treat first. If the staff member’s seizure were more life-threatening, and we knew that, we might treat him first, as a fireman might try to rescue the person most in peril in a burning building. In making my decision, I didn’t have that information. I followed a code of ethics that has become part of my makeup. My instinct was to treat the client first.

The National Association of Social Workers’ Code of Ethics says, “Social workers’ primary responsibility is to promote the well-being of clients. In general, clients’ interests are primary.” There are exceptions. A social worker’s responsibility to society or specific legal obligations may, on occasion, supersede the loyalty owed to clients. But those exceptions don’t apply in my case. Religiously maintaining a consumer-first philosophy is the only way to meet consumers’ needs and let caregivers know our priorities. I have found that people who work in human services feel better about an administrator who keeps the consumer first, particularly if he/she consistently applies this philosophy.

But back to the case in point. I could have justifiably and in good conscience based my decision on whom to help first on the same precepts medical doctors use, although they weren’t running through my mind at the time. According to the Association of American Physicians and Surgeons’ Principles of Medical Ethics, “The physician’s first professional obligation is to his patient, then to his profession. His ethical obligation to his community is the same as that of any other citizen.”

I would make the same choice again—and encourage people who work in our organization to adopt the same mentality when giving care. The rule is that the consumer, the client, the patient come first. Certainly, the employee comes next in any consideration, and that consideration is close to that given the consumer. I often tell employees that while consumers come first, employees are a close second because we must have a quality staff to provide our services. What we primarily provide to consumers are people who can help them with the challenges in their lives. Housing, offices, vehicles, and all the other resources we need to provide services are secondary to having a quality staff implementing plans and helping meet consumers’ needs. The goal of any good human services administrator is achieving and maintaining the right balance, and it’s the mentality that should rule any business. In their book A Passion for Excellence: The Leadership Difference, Tom Peters and Nancy Austin offer this advice: “First, take exceptional care of your customers...via superior service and superior quality.”

In human services, too often the providers within an organization take on the role of consumers. Their needs sometimes become so important that there’s a tendency to direct resources toward them instead of consumers. We try to direct our resources toward consumers and, in fact, have made it a guiding principle in our organization. That principle grew out of my experience. Lawrence P. Noonan is the CEO of A.W.A.R.E., Inc., providing mental/emotional healthcare, developmental disability services, family services, and housing assistance in Montana and New Mexico. In 2007, he was named a Behavioral Health Champion by Behavioral Healthcare magazine.