Health care value, measured in crayons and chocolate

This post was originally published on the blog Collective Well

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I watched the small baby lay silently sleeping, his little body propped up in a full-sized hospital bed, dwarfed by monitors and machines and bags of medications that looked as benign as pure spring water and yet I knew were controlling most of his bodily functions including this induced sleep. His peaceful demeanor seemed so incongruous to the palpable intensity of everything around him. Despite the alarms, incessant beeping, murmur of voices and general hubbub of the ICU, he went on sleeping, utterly oblivious. In this environment, where every organ’s function is externalized and micro-managed down to each breath and each heartbeat, all medical decisions take on heightened scrutiny.

It is not hard to imagine why functional and technical measures were developed to assess patient outcomes and cost for each of these critical decisions, and how important it is to analyze those metrics to ensure these babies survive the next minute, hour, day.

We can estimate the cost of this baby’s hospitalization, but how do we measure the value?

The astute health care economist Michael Porter and his group have been leading thinkers in trying to standardize patient outcomes as defined as “outcomes achieved relative to costs.”

But in a recent Harvard Business Review article, authors Sullivan and Ellnor argue against focusing on costs when it comes to patient outcomes. They instead placed emphasis on patient-provider relationships.

Patient-provider relationships matter

The authors cite case studies documenting cost reductions and quality improvements in organizations that placed systematic emphasis on nurturing relationships. There are literally thousands of articles spanning decades that suggest strong doctor-patient relationships are critical to good outcomes.

Most physicians are bestowed their medical degree after taking a solemn oath to “treat the patient, not the disease,” echoing the words of the great thinker Hippocrates. His message of humanity at the cornerstone of medicine still resonates.

Medicine has changed much in the thousands of years since these oaths were written. In a room near my patient, another little boy was kept alive by the whirring of a machine that pumped his blood in and out through fat tubing, constantly fussed over by attentive staff. The technology was impressive, but equally impressive was the level of expertise and level of education required of the varied staff and providers who cared for this child. How do we reconcile investing in this kind of care and in ensuring “optimal outcomes?”

I left the ICU and continued on my day, which consisted of a blur of patients, colleagues, committees, trainees, questions, decisions, more questions, and more decisions over and over — my head felt as noisy as the ICU. At the end of the day, I took refuge in the office of a colleague. It was after hours, all of the lights were off in this office suite, and I was the only one there. As I looked around, I noticed the room was carpeted with piles of papers and folders covering nearly every surface, each representing another question asked and decision to be made. Patient needs, committee needs, research needs, trainee needs, regulatory needs. In between these piles, like precious gems glistening amongst rocks and sediment, lay thank-you cards with expressions of gratitude in looping handwriting or earnestly held crayon. Gifts of chocolate (the ultimate expression of thanks if you ask me) were piled on the table.

I thought fondly of similar gifts in crayon and chocolate in my own office, fondly of the patients and families I have the privilege of caring far, and fondly of my colleagues whose dedication from the bedside to the office never lets up. It really is about the relationships, and it goes both ways — the impact the patients and families have on the health care team is as powerful and sustaining as the impact back on the families.

“Value” in health care should take into account both the functional measurements of health and the “value” of investing in these relationships. How do we maximize the supportive potential of these relationships? To me, surviving is only a start, and if we only measure value based on where our patients are, we miss out on seeing how high they can reach. We need to help these children thrive, grow, shine and believe anything is possible.

Gauthier_Naomi 3Naomi Gauthier, MD, is a pediatric cardiologist with a joint Boston Children’s/Dartmouth faculty appointment who practices along the coast of Maine and NH as well as in the exercise lab and outpatient clinic in Boston. She is dedicated to empowering children with congenital heart disease to thrive and rise to their potential, especially as it relates to physical activity, confidence and putting their condition into perspective.


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