The Ladder Is Broken: What a Millionaire Cashier Teaches Healthcare About Keeping Its Healers
Tony Barzar spent almost forty years as a cashier at Costco. He recently retired with more than a million dollars in his 401(k) — and he never once held a supervisor title. According to a Wall Street Journal profile this month, he’s one of many thousands of hourly Costco workers to reach that milestone.
When I read his story, I didn’t see a retail anecdote. I saw an indictment of how healthcare designs careers — and a glimpse of what it would look like to design them for healers instead.
The number behind the story
Costco’s turnover after the first year of employment hovers around 7%. Compare that to nursing, where the national RN turnover rate climbed to 17.6% in 2025, reversing the prior year’s improvement. And the cost gap is staggering: analysts estimate losing a front-line retail worker costs an employer about $10,000. Losing one full-time registered nurse costs a health system more than $60,000.
Read that again. Retail solved retention economics before we did — and their downside risk is a sixth of ours.
The reflexive explanation is wages, and wages matter. Costco has long paid above its industry, recently raising its top hourly rate and adding vacation for its longest-tenured people. But if compensation were the whole story, healthcare’s rising wages — RN advertised salaries have grown 26.6% faster than inflation over four years — would have fixed our turnover problem already. They haven’t. Something structural is broken.
The ladder problem
Here is healthcare’s quiet design flaw: we have built a career architecture that moves only in one direction — up and away.
Want more pay? Take the manager role. Want more influence? Leave the bedside. Want recognition? Trade the work you were called to do for work someone needs done. We convert our finest clinicians into reluctant administrators, and in doing so we send an unmistakable message to everyone who remains: staying in your role is settling.
There’s research underneath this failure. Amy Wrzesniewski’s work on job orientation shows people relate to work in one of three ways: as a job (focused on pay), a career (focused on advancement), or a calling (focused on meaningful contribution). People with a calling orientation show higher satisfaction, greater resilience, and stronger commitment — and healthcare is full of them. That’s the design flaw in one sentence: we’ve built career-orientation architecture and imposed it on calling-oriented people. The ladder assumes everyone wants up. Healers want in — deeper into the work they were called to. This is also why rising wages haven’t rescued our turnover numbers. Pay addresses the job. Advancement addresses the career. Neither addresses the calling — and the calling is what walks out the door.
I’ve watched this happen across my years leading a health system, and I suspect you’ve watched it in yours. The nurse whose hands and judgment were irreplaceable at the bedside, now buried in scheduling software. The physician whose presence calmed entire units, now presiding over meetings. We call it advancement. In The Healer Revolution, I argue that a revolution without return isn’t a revolution at all — it is merely extraction, taking and taking until nothing remains. The career ladder is that failure rendered as an org chart. Extraction at the scale of a shift produces burnout. Extraction at the scale of a career produces resignation letters.
The revolution is a return
In The Healer Revolution, I make an argument that sits underneath everything I believe about healthcare culture: the most important word in revolution is not revolt. It is return.
A revolution, in its original sense, is a cycle that completes. The heart contracts and relaxes. The planet orbits and comes back. The healer pours out — and must be restored before the next rotation begins. Sustainable healing cultures aren’t built on heroic depletion. They’re built on completed cycles.
Now look at the career ladder through that lens. The ladder is a cycle that never completes. It is linear, one-directional, always away. It tells the healer that renewal isn’t found in returning to the work — only in escaping it. That’s not a career path. That’s a slow-motion exit strategy, and our turnover numbers are simply the ladder working as designed.
Tony Barzar’s forty years at a register are the opposite: rotation after rotation in the same role, honored and renewed each time around. His career was covenant, not transaction. His organization never asked him to leave the work to prove his worth.
What destination roles look like
The good news is that this isn’t theoretical, and healthcare is already testing it.
Influence without authority. Costco created “culture coach” roles so long-tenured hourly workers train new employees without becoming their bosses. Readers of The Healer Revolution will recognize this immediately: it’s a Fire Keeper — someone given formal standing to protect and perpetuate the culture itself, without a manager’s title. I argue in the book that this role is part of the essential rigging of any sustainable healing culture, and that maturity is a characteristic, not a job title. A forty-year cashier can carry more culture-shaping authority than a district manager — if the organization builds a structure that recognizes it. Intermountain Health’s Saint Joseph Hospital in Denver did exactly that after losing many of its most experienced nurses: it rebuilt mentorship around group models led by nursing professional-development staff and peers rather than managers. Retention of new nurses reached 97% by early 2025. Fire Keepers, formalized.
Investment that returns. FMOL Health in Baton Rouge originally budgeted $11 million for workforce initiatives — then its CEO approved nearly five times that after his CHRO made the case. RN turnover now sits below 10%, well under the national average. As their CEO put it, when people know they’re genuinely cared for, they stay — and, in turn, they take care of patients and communities.
Honoring the whole arc. Systems like Luminis Health and Cottage Health are using flexible scheduling and phased retirement to keep veteran caregivers engaged longer — capturing decades of institutional wisdom before a wave of retirements walks it out the door.
Notice what unites these examples. None of them asked their best people to climb. All of them made staying a destination.
The engagement dividend
There’s a second layer most leaders miss. Press Ganey’s latest analysis of more than 2.6 million healthcare workers found that hospitals in the top quartile for employee engagement are 4.2 times more likely to earn top patient experience scores. Disengaged caregivers are 2.6 times more likely to leave, and turnover at low-engagement organizations runs 24% versus 15% at highly engaged ones.
One finding haunts me: employees who don’t respond to engagement surveys leave at nearly twice the rate of those who do. Disengagement doesn’t announce itself with complaints. It announces itself with silence. The healer who has stopped telling you what’s wrong isn’t at peace — she’s already halfway out the door, because the system gave her no reason to believe staying would be honored.
This is why retention, engagement, and patient experience aren’t three initiatives. They’re one cycle. When healers are restored and honored in the roles they love, patients feel it. When the cycle breaks, patients feel that too.
Three questions for every healthcare leader
- Can your best clinicians grow in pay, influence, and recognition without leaving patient care? If the honest answer is no, your ladder is your turnover strategy.
- Do your most experienced people have a formal way to teach — without becoming someone’s boss? Mastery that can’t be passed on dies with the retirement party.
- Are you measuring the cost of the ladder itself? Not just turnover — count the great practitioners you’ve converted into mediocre managers because management was the only way up.
Rig the boat
In The Healer Revolution, I offer healthcare a different metaphor for the forces working against us. Entropy — the chaos, the churn, the relentless pressure — is the wind. You cannot stop it, and every leader who tries is fighting a law of physics. But a well-rigged boat doesn’t fight the wind. It uses it. The same force that destroys an unrigged vessel propels a rigged one across oceans.
Destination roles are rigging. The Fire Keeper with formal standing, the mentorship that flows from mastery instead of management, the career that deepens instead of departs — these are the structures that channel decades of tenure into propulsion instead of watching it blow out the door.
A cashier retiring a millionaire after four decades at the same register is proof that an organization can rig the boat. If a warehouse retailer can build careers worth staying for, surely the institutions entrusted with healing can do the same.
The healers are already here. The wind is blowing. Let’s build the rigging that lets them stay.