By HANS DUVEFELT MD
We do a lot of things in our head in this business. Once a patient reports a symptom, we mentally run down lists of related followup questions, possible diagnoses, similar cases we have seen. All this happens faster than we could ever describe in words (let alone type).
And, just like in math class, we are constantly reminded that it doesn’t matter if we have the right answer if we can’t describe how we got there.
So the ninth doctor who observes a little girl with deteriorating neurologic functioning and after less than ten minutes says “your child has Rett Syndrome” could theoretically get paid less than the previous eight doctors whose explorations meandered for over an hour before they admitted they didn’t know what was going on.
Does anybody care how Mozart or Beethoven created their music? Or do we mostly care about how it makes us feel when we listen to it?
We know that stress, meditation and Thai Chi can alter metabolism, immune response and neurotransmission. But do we endorse them based on how many minutes, elements, movements or postures they involve over what their results are?
Of course not!
We also know that physician demeanor can affect treatment efficacy a whole lot more than the number of minutes spent or boxes checked in the EMR. So why are we so fixated with proving the monetary value of our process, instead of the value of our results?
Medicine, at least in the non-procedural specialties, is a relationship based business. If a hostile stranger spends fifteen minutes trying to change your behavior, is that more effective or more valuable than if a trusted doctor, friend or admired mentor mentions the same thing almost in passing?
Of course not!
So why is medicine viewed as an easily quantifiable and standardized endeavor? The manufacturing analogy is outdated; we are more like old-house renovators or art restorers most days, and, on perhaps rare but inspiring and memorable occasions, like composers. We sometimes find ourselves creating something new in the lives we touch and interact with. In those instances we should take little credit for anything except how we were able to awaken the healing potential within our patient.
Health care professes to value outcomes, but we are a long way from doing that. We are stuck in a thick soup of surrogate endpoints and ignorant overemphasis on standardized processes in an era where we are only beginning to understand how genetically different we all are.
Or, are we really suggesting our patients are all 70 kg white males with only one, typical and standardized, medical problem?
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.
Maya Angelou may have said it best: “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
The connection of Social Capital as measured by Trust has been shown to exhibit reverse causality: trust improves health and better health improves trust !
see J. Epidemiology of Community Health 2015 report by Giordano and Lindstrom at
It represents a trail head analysis.
The late Princeton professor and health economist, Uwe Reinhardt, suggested that healthcare quality is a combination of process, outcomes, patient safety and patient satisfaction. While most people would probably consider outcomes to be the most important, reasonable people will differ on how much weight to assign to each factor.
We are also told that between roughly 75% and 80% of all U.S. healthcare costs are attributable to the management of chronic disease including virtually all of my own medical claims. For chronic conditions like diabetes, asthma, hypertension, CAD, CHF and mental illness, patient compliance in taking prescribed medications and following lifestyle recommendations and advice is a common thread that runs through all of those. Unfortunately, that’s something doctors have little or no control over no matter how much they suggest, advise, recommend, or cajole even if there is good personal chemistry and trust between the patient and the doctor.
So, while I get that there is a lot of art in the practice of medicine, especially primary care, based on accumulated knowledge through experience, there is presumably a lot of science too. However, defining quality in healthcare with any precision remains a huge challenge.