They were some of the hardest phone calls I’d ever had to make. After more than 25 years of practice, I had to tell patients I’d been seeing for that entire period that I could no longer be their doctor. When I left academia in 1998 for the pharmaceutical industry, I continued to see patients as a volunteer because I wanted to help and connect with patients. As I climbed the corporate ladder, it became harder and harder to maintain my clinical presence. However, that operational (or logistical) difficulty was balanced by richer relationships with my patients. I realized that as a volunteer, I was fortunate to be able to spend more time with my patients (compared to my full-time colleagues), allowing me time to teach medical students, residents and fellows, or to fight with payers over denials for necessary care. For a time, I was even allowed to determine whether to forgive outstanding balances, though that ability was taken away long ago. There was Mrs. Johnson, the first patient I had ever started on a biologic. Her psoriatic arthritis had become increasingly debilitating, and she had been through every small molecule drug in our armamentarium. After her first infliximab infusion, she told me she felt the pain leaving her body as the drug was infused. Over the years, we shared stories of my daughters and her nieces and nephews. Next, there was Ms. Diaz, who had developed juvenile idiopathic arthritis in her early teens and continued to have significant inflammation into adulthood. Her disease was reasonably well controlled with methotrexate and etanercept, which was fine until she and her husband wanted to start a family. We had a long discussion about options and risks, and she eventually had 3 successful pregnancies. Subsequent visits began with pictures, followed by in-person appearances by one or more of her 3 beautiful children. Finally, there was Mr. Wong, who worked as a nurse until he presented with more than 20 swollen joints. When he was eventually diagnosed with seropositive rheumatoid arthritis, it took multiple combination regimens to reduce his swollen joint count to 4. In a clinical trial, this would be a dramatic response. I will never forget when he said to me that with his 4 remaining swollen joints, “I can live like this, but I can’t work with these hands.”

Though there had always been a balance between patient care and paperwork, the administrative responsibilities that came with clinic increased seemingly exponentially. First, there was the new policy that even if patients were 20 minutes late, they had to be seen because “we need to put patients first.” Then, there was the new clinic cancellation policy, which stated, “ALL vacation and personal time off requests MUST be submitted at least 90 days prior to time off requested. ALL work related [sic] requests (service, conferences, etc.) MUST be submitted at least 60 days prior to time off requested. All emergency requests (medical, bereavement, etc.) MUST be submitted at least 30 days prior to time off requested when possible” (capitalized, underlined, and bolded type taken from the original).

One day, I got a message that Mrs. Johnson was not doing well, along with her request that I see her sooner than her scheduled appointment. Knowing she rarely complained, even in the face of active inflammation, I opened an additional slot at 12:30 PM. At 1:05 PM, she was still not in a consultation room. Fuming, I went to the waiting room, only to find Mrs. Johnson sitting patiently. I brought her back and once in the room, she told me she had signed in at 12:20 PM, but that the front desk staff was “chatting.” I spoke to the clinic manager, who shrugged their shoulders and said, “that’s the way it is.” Putting patients first?

By this time, I was honored to have been appointed by the President of the United States to a position in his administration. As part of the responsibilities of my “day job,” I was asked to brief the staff of a senate committee on a clinic day. The clinic administration told me that I could not reschedule my patients because I had not given the requisite 90-day notice. Despite my protestations that (A) this wasn’t vacation, (B) I was a volunteer, and (C) I couldn’t tell the committee staffers I was unable to meet their request because of the clinic cancellation policy, the clinic administrators were unwilling to budge. I finally called the patients scheduled for that afternoon, explained the situation, and unsurprisingly, they were happy to move their appointments. I added a clinic session so they wouldn’t have to wait until my next opening.

The last straw was my accidental discovery that after November 1, 2022, the number of patients scheduled had approximately doubled. When I reached out to the department chair, their response was that revenue was down and we all needed to be more productive. When I reminded them that I was a volunteer, their response was, basically, “tough.” Since my first priority was to the oath I had sworn when I started my role in the federal government, I had no choice but to resign.

For years, one of my long-standing patients had said repeatedly, “Call me Bill.” My response was always, “Only if you call me Victor.” He could never bring himself to do it. He was one of the first to congratulate me when I received my presidential appointment. He reached out to the department chair, asking them to reconsider. The department chair’s response was that “Dr. Sloan resigned because he refused to do his assigned sessions.” One silver lining to this otherwise unfortunate ending is that we are now on a first-name basis. Bill was scheduled to see me the first week in November, about 3 months after his previous visit. After that difficult phone call telling him that I could no longer be his rheumatologist, he called to reschedule with another rheumatologist and was given an appointment in July, almost 10 months after his previous visit. Putting patients first?

Renowned restaurateur Danny Meyer says that, contrary to the truism that “the customer is always right,” the best way to ensure a great customer experience is by putting employees first (https://signalvnoise.com/posts/262-danny-meyer-hospitality-is-king). In academic medical centers, increasing clinical demands result in decreased time for education and career development.1

Both lay media and medical literature are replete with stories about physician burnout. Prepandemic, burnout rates in academic medical centers in North America approached 50%. During the pandemic, the burnout rate exceeded 75%, with the highest burnout reported by women and early career faculty.2 A survey conducted in 2020 showed that 40% of nurses and 23.8% of physicians intended to leave practice within 2 years, whereas only 12.6% of administrators intended to leave their jobs.3 There was a direct and inverse correlation between feeling valued by one’s institution and an intent to leave.4

In addition, the ever-increasing administrative burden takes physicians away from actually taking care of patients. Tai-Seale and colleagues examined electronic health record transactions in a sample of 471 physicians.5 They found that the physicians were spending as much time on “desktop medicine” as they were on actually seeing patients. The authors noted that many of the nonclinical activities “are of high value to the delivery system.”5 However, devolving more and more administrative tasks onto physicians runs counter to Meyer’s principle discussed above, and will only increase the negative feedback loop of more pressure, more burnout, and more physicians leaving medicine, with an increased burden on those remaining. Putting patients first?

Sadly, because of the pressure and lack of compassion from their institutions, some healthcare professionals even feel the need to take their own lives. Tristin Smith died by suicide in 2023. In her letter to her institution, she wrote: “The staff I worked beside began to go away. In your eyes, these staff were ‘unnecessary,’ but it came at a high cost for the advertised ‘quality care’ provided…by those of us who were left. You asked my colleagues and me what we needed to…improve satisfaction scores, and we told you the truth. But then you sent us to online courses that taught us to just smile more…. You use and exploit us to line your pockets…but when we dare to think we are finally going to get the love and support we deserve, we get a pizza party and free pens for the ‘healthcare heroes.’”6 This sad tale describes an institution that is the antithesis of one that truly values its employees. Real value is not demonstrated by pizza parties, and the focus of these institutions should be on their employees’ well-being first, not on patient satisfaction scores.

If healthcare institutions took a page from Mr. Meyer and made substantive improvements in work environments and staffing ratios (perhaps at the expense of some of the exorbitant executive compensation packages), rather than empty gestures like free pens, perhaps those employees might feel truly valued. If the employees felt valued, that would likely translate to improved patient satisfaction scores, better employee well-being, lower burnout rates, and higher retention. This would truly be putting patients first. Regrettably, despite their protestations that they are “putting patients first,” many, if not most, institutions focus on revenue generation, and whatever initiatives they promulgate place more emphasis on improving patient satisfaction scores as an institutional target, versus implementing meaningful changes to benefit patients. Surely our patients deserve better.

This article is dedicated to all of our patients, for whom quality care should take priority over profit, ever-increasing administrative burdens, and misplaced focus on patient satisfaction scores. I would like to thank Christopher Adams, MD, and Temby Caprio, PhD, for their helpful comments.