I read an interesting article recently that recommended changing the Triple Aim in medicine to the Quadruple Aim. Let me provide a little background. Don Berwick and colleagues first described the Triple Aim as a way to optimize health system performance. (I know this sounds painfully dry, but bear with me.) It proposes that health care institutions pursue three performance parameters: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of health care. This sounded brilliant and has been widely accepted and implemented. This apparently has had the unintended consequences of increased workplace stress for physicians and their teams as well as quality reductions and cost increases. This is one of those situations where something sounds reasonable and practical on paper—a win-win as they say—and then in practice it fails miserably. How could this be? The Triple Aim didn’t take into account a fourth factor, which is the well being of the people implementing the first three aims. Physicians and their health care teams started experiencing burnout, which in turn threatened the viability of the first three aims. The whole system is then at risk of collapse. So the Fourth Aim delineated in the article involves improving the work life of those who deliver care.
I find it so completely fascinating that the concept of the Triple Aim never took into account that the folks implementing the three aims might have actual feelings and needs. This strikes me as an essentially corporate way of approaching medicine. The thing is—patients are people. Doctors and their staff are people. We all have feelings and needs. For everybody to be happy and functional a certain understanding of this balance is necessary.
I recently taught a workshop on mindfulness for physicians, and this need for harmony and balance in the workplace was palpably evident. Under the current system, doctors are not happy people. We all go into medicine with altruistic goals. We want to help people. We want to have meaningful and enduring relationships with our patients. We want to do the right thing. We don’t want to sacrifice our own well being and the well being of our families in the process. That is often what happens.
Mindfulness is not the panacea; it is not the cure. It is the means to recognition that the Fourth Aim is important and should be honored. It must be honored or our whole health care system is at risk. In my humble opinion.
Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Millwood). 2008; 27 (3):759-769.
Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med 2014; 12:573-576.
Dr. Heather's musings about medicine, mindfulness and life.
Heather Krantz, M.D.
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