Money is the topic most therapists find hard to examine.

The majority of therapists can trace their hangups about money to the fact that they’ve not reconciled two seemingly opposite concepts: profit and service.

For some, service is honorable and profit is evil.

For others in a service-oriented industry like healthcare, making a profit is the natural order of business.

It’s a paradox that can put very sincere, well-meaning people into a state of antagoism that may take many years to reconcile, if ever.

Previous generations planted economic seeds in healthcare that have come to fruition towards the end of the twentieth century. We are now finding ourselves having to deal with the excesses and obsessions that erode the very essence of our professions.

Therapy Is Not Brain Surgery (Thank God)

In 2017 Seattle Times published an expose’ on one of the largest hospital systems in the United States. The Times investigation revealed the high- volume practices of several neurosurgeons at Swedish-Cherry Hill Hospital.

The paper alleged Cherry Hill’s neuroscience program’s approach to the business of medicine enriched the hospital and its star surgeons, sometimes at the expense of the patients’ wellbeing.

The Seattle Times wrote:

“A steady churn of high-risk patients undergoing invasive brain and spine procedures allowed Cherry Hill to generate half a billion dollars in net operating revenue in 2015 — a 39 percent increase from just three years prior. It also had the highest Medicare reimbursements per inpatient visit of any U.S. hospital with at least 150 beds.”

“But the aggressive pursuit of more patients, more surgeries and more dollars has undermined Providence’s values — rooted in the nonprofit’s founding as a humble home where nuns served the poor — and placed patient care in jeopardy, a Seattle Times investigation has found.”

The paper’s investigators blew the whistle on a business approach that maximized reinbursement while trying to improve and save the lives of patients.

Among their findings were:

1.The neurosurgeons were incentivized to pursue a high-volume approach with contracts that compensated them for large patient numbers and complicated surgical techniques.

2. Hospital staff reported that the highly touted surgeons would sometimes do little in the operating room once the patient was under anesthesia, leaving less experienced doctors in training to handle parts of the surgery.

3. There were indications that the high-volume business practice was taking a toll on quality care. Regulators flagged Cherry Hill for lower performance on quality control benchmarks such as blood clots and surgical complications.

4. The increased patient volumes left the support staff overwhelmed by providing one-on-one patient care.

Cast No Stones

Let’s not be too quick to stone the Cherry Hill neurosurgeons and hospital administrators. There are frightening similarities between their business model and the current practices of high-volume therapy practices.

Such as clinic manager salaries tied to staff productivity, unsupervised care being delegated to assistants and techs, and an overwhelmed office staff leading to turnover and burnout.

Let us put down our stones, step back for some self-reflection on what might have led the neurosurgeons down this treacherous path of profit and lack of accountability.

Whether you are a staff therapist, manager, owner or an educator let’s take a look at a few factors the undergird the current productivity-quality care debate.

The struggle between making money and serving others has its roots in Western medicine, pragmatism, and unbridled individualism.


Pragmatism is synonymous with Western medicine, particularly with healthcare in the United States.

Pragmatism comes from the Greek word pragma, which means “business.” The root word has a connotation of practicality, efficiency, and productivity.

Pragmatism is a philosophy and a worldview that assumes that the worth of an idea or action lies in its practical productivity. The value of a thing lies in what it produces.

Things are good if they produce, and what produces the most is best.

The ideals of pragmatism are at the heart of Western culture. It surfaces in America’s healthcare system with the rejection of anything that is not useful, scientific, or efficient.

We can see the dumbing down of rehab to a commodity deliver status via the McDonaldization of healthcare.

This is not to say a pragmatic approach to healthcare has not helped to move our profession forward and make the world a healthier place.

The scientific method and evidence-based practices are essential to providing effective and quality care. But it’s important to recognize the detrimental effects of an overzealous practical approach to medicine.

What We Do vs. Who We Are

Unfortunately, in a pragmatic society, we can only feel good about our work and ourselves when we are producing and contributing to the bottom line. Measurable results are admired and rewarded.

Human acts of kindness and emotional support, which are difficult to quantify, seem unimportant or undervalued.

In an algorithm-driven society, artificial intelligence is valued more than emotional intelligence.

Kai-Fu Lee, ‘Oracle of Artifical Intelligence’ was shaken to his core by a cancer diagnosis before realized there are certain jobs that won’t be replaced by robots.

“These jobs require compassion, trust, and empathy — which AI does not have. And even if AI tried to fake it, nobody would want a chatbot telling them they have cancer, or a robot to baby­sit their children,” Lee writes.

When we receive more recognition for the numbers we produce rather than who we are and the lives we transform our work and job satisfaction takes a nose-dive.

An out of control pragmatic business approach to healthcare is at the core of the productivity–quality debate.

Each of us will need to come to terms with the achievement of career goals, professional identity, and organizational loyalty in order to negotiate limits to our daily schedules.

Unbridled Individualism

As therapists feel more pressure to produce, we begin to fatigue; we eventually lose our motivation as we move towards cynicism and burnout.

To escape, we imagine ideal work settings where we have all the time we want to help our patients. We long for a utopian work-life balance.

Some of us dream about being our own boss to be finally free from the constraints of company policies and benchmarks.

There is nothing inherently wrong with pursuing meaningful work and making a living. What is at issue here is an excessive preoccupation with our private worlds while being blind to the reality of others.

For most of us, it is our inner world that seems massively real. Other people’s lives and the needs of our society are not as authentic. We can easily fall into the trap of seeing our patients and employers as a means to an end.

There has been a constant movement towards individualization and self-fulfillment in virtually every area of American life. Expectations of therapists are not immune to excessive individualism.

The Ideal Therapy Job

In today’s culture, the ideal therapy job is to have the ultimate paycheck, a schedule filled with ideal patients, opportunities to develop your clinical skills, a perfect boss who will mentor you, and support staff that takes care of all the hassles.

When our narcissistic desires are left unchecked, we lose contact with the bigger picture and double down on our private worlds. We lose touch with reality beyond ourselves which contributes to impersonal patient care and job dissatisfaction.

We can become so preoccupied with achieving our personal goals that we fail to recognize and appreciate the reality of our patients and the organizations where we work.

Our employers are under tremendous pressure to deliver quality care through the people they lead while keeping their eye on revenues and expenses. That’s their reality.

To escape the snare of self-obsession we all need to see our interdependence upon the community around us to do our work and to find fulfillment.

No Easy Answers

So, how many patients are too many?

Beneath the question of how much is too much is the ever-present anxiety that something else is going on.

The great paradox of our time is that for many of us,

Our schedules are full yet we are unfulfilled.

We are busy and bored at the same time.

Most of us have incomes that make us rich by any world standard, but we have poor self-worth.

What’s a therapist to do?

Socrates spoke of the futility of living an unexamined life. We are living at a time where sober reflection and resolute perseverance are necessary.

Whether you are a worker or boss, I encourage you to step away from our pragmatic, data-driven; work to the point of exhaustion; healthcare system to regain your perspective.

I recommend taking a personal retreat to examine your beliefs about money and service. I know for some of you a time of solitude and silence is unsettling. (An University Of Virginia study found that people would prefer an electrical shock over being alone with their thoughts.)

Make time to reflect on your calling and your connection with other human beings.

Recover your center.

Rediscover your purpose.

Reconnect with your community.

Michael Hyatt’s approach to Living Forward can be a good place to start. For those of you who want to include a spiritual dimension, Creighton University’s Online Retreat may work into your busy schedule.

Learn to operate and communicate with others from your true center as you pursue meaningful work while setting boundaries on how much is enough.

I’d like to hear about how you reconcile money and service. Please comment below or email me or click here if you want to chat about it.