Are we providing health care, or just delivering health?

As a medical student I have come to appreciate two core goals of health care:

1. Health: The delivery of medical knowledge, assessment or treatment to a patient

2. Care: The compassionate approach to any patient

In my medical training, I have also witnessed clinical medicine practiced across a spectrum of situations.  Taking my time to reflect on these experiences, I am not certain we are meeting our goals.  Too often I have watched a flurry of attendings rush from bed-side to bed-side, witnessed residents spend far more time in front of a computer screen than holding a patient’s hand.

I am not arguing the nature and necessity of our modern system, rather I hope to ask a major question: Do we get so caught up in the delivery of our health care, that we sometimes neglect the care itself?  Are we providing health care, or simply delivering health?

Allow me to frame this in another way.  Have you considered the definition of the word “care”?  One that I rather like defines care as a “watchful attentiveness.”  How often are you watchfully attentive to your patients?  What can be said about the nurses, residents or staff working with you?

At the same time that medical advances allow immediate, efficient, and direct monitoring of patients, these same technologies can so easily disrupt our watchful attentiveness.  New systems, with built in redundancies and alerts have the potential to incentivize complacency and interrupt the patient-physician relationship.  I often overhear residents or attendings say, “Don’t worry about the patient in room 246 until the lab results come back.  There is nothing we can do until then.”  The consequence of this attitude represents a negligence to the value and importance of physician compassion.

Nothing we can do?  What happened to kind words, reassurance, and the offering of a comforting hand?  Sure the electronic record may show normal cardiorespiratory monitoring, no new nursing communications, and no updated lab results – but there still exists a patient, sitting in a hospital bed.  Possibly alone, likely insecure, and almost definitely in need of your care.

Again, I am not arguing that our current system is ineffective in delivering health, nor am I contending the decisions of my peers and superiors.  I have a profound respect for the urgencies and constraints of our modern health system.  But I believe that, in any area of life, self-reflection is necessary for growth.

Somewhere along our medical journey, as we agreed to see more patients then we could handle, and developed advanced technologies that separate patients from caregivers – we may have lost sight of a simple fact.  Fifty percent of our mission as physicians delivering health care is to provide that care to our patients.  To be watchfully attentive over them.  Are we providing health care, or just delivering health?

Aaron George is a medical student who blogs at Future of Family Medicine.

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  • http://healthcareblog.pyapc.com Mark Browne

    Aaron, well said. Although I would disagree that only 50% of our mission as physicians is to provide care. It is a mathematical paradox of sorts that we must strive to provide both 100% health and 100% care. We may not always reach the 100% on the health side, but can always reach 100% on the care side of the equation.

  • http://www.drdarrelwhite.com drdarrellwhite

    Our system of healthcare only delivers “health” if you accept the cold, clinical definition of “health” as “the absence of disease.”

    We, as physicians, are incapable of delivering true “health”. That, young colleague, is the responsibility of your patient. Whether or not she achieves health after your ministrations will be due in no small part to her own actions and choices.

    In the end we do, indeed, deliver healthcare and healthcare alone. We are only as good at delivering “health” as our patients allow us to be.

  • Sherri

    I agree. I’ve been in healthcare for 13 years and I’ve seen how we’ve turned away from the human aspect of it. We provide “customer service” now instead of patient care. We are not selling shoes, we are dealing with sick, frightened people and those that love them. I think it’s time we let business deal with business and we go back to showing concern for our patients and not just “efficiency”.

  • David Lee Scher, MD,FACP,FACC,FHRS

    You are perceptive and on target. We neither are delivering well on health or care. Regulatory requirements, electronic records, practice ‘guidelines’ and technology have removed physicians from their patients. It is for this reason why I recently left medical practice. Unfortunately med students and young physicians will not develop doctor-patient relationships that are meaningful. You will become an administrator over mid level providers, a buffer between them and insurance/govt regulators. This is reality, mobile health will rule healthcare along with computer-derived algorithms. Your best attributes will be to teach providers compassion and the value of a history taking assessment of the patient. I wish you the best of luck, Aaron.

  • http://Kalamazoopost.blogspot.com Tony61

    It’s heartening to hear that medical students are still struggling with this issue, probably something that Hippocrates, Osler and Halsted also considered. The role of physician is changing in many ways: we have to be purveyors of technology like never before, we have to be leaders of teams made up of other highly trained professionals with very different skill sets, but we also have to be concerned about costs and quality and the allocation of time as we always have been.

    I would like to think that when your attending said not to “worry” about a certain patient until the labs were back, he/she was merely teaching about time management, but your concern is noted.

    Your post is well done, and we physicians need to continue to be the constant examples to our colleagues that the primary mission will always be patient care.

  • Keisa Bennett

    Thanks Aaron. I’m posting on my residency’s Facebook page to remind patients a good reason why rounds sometimes go long. It’s because we’re doing the right thing by sitting down, touching the patient, answering questions, building trust and empathy. Becoming better humans.
    Glad you’re looking at being a future Family Doc – we need you.
    Keisa, Family Medicine, Kentucky

  • Hexanchus

    I think this is a very astute analysis and commentary!

  • Phil

    I could “care” for that pt lying in bed lonely and scared or I could be in ED admitting my next AMI pt and delivering “health”.
    It’s all about best management of limited time.
    I have to work where the Venn diagrams don’t overlap. If someone else can do the job that I am doing I am not making the best use of my skills.
    -PC, MD

  • Kevin

    “What happened to kind words, reassurance, and the offering of a comforting hand?”

    An attending once told me, “If [whatever you're doing] is something your mother could do, you probably shouldn’t be doing it.” She meant that non-clinical tasks should be relegated to someone lesser trained. Her argument had to do with the realities of time-management on a busy ward. I agree, to a point. The physician is the scarcest resource, and his/her time should be managed with that in mind. It certainly does ignore the “care” aspect of health care.

    Many doctors just don’t have a personality that conveys compassion/concern, but are nonetheless highly competent. What should we do with them? I personally don’t think we can teach this (all we’re doing is teaching acting…think about it).

  • DrDutch

    Young padawn, re-post your thoughts in 10 to 15 years, and update your reflections on the compassion which doctors need to exhibit, and how effectively you accomplish this task.

    First off, your essay is eloquent. Your comments echo the ideology that is the young student. These thoughts will change with time, age, experience, as noted in the above replies from others in the profession. A few comments-

    1. Delivering care which is “compassionate” means different things to different people, and is an interplay between the doctor and the patient. What to me is “compassion”, to my nurse may be “over-the-top”, and to the patient “not enough”. You cannot control other peoples’ perceptions.

    2. “Compassion” cannot be taught. As a faculty member, I can speak for an hour on my thoughts about being a caring physician. The student will either be able to take those thoughts and apply them to his/her own practice, or not. Again, based on thought #1, a person’s own opinion on his/her own “compassionability” will play the largest role in how he/she shows empathy during clinical practice.

    3. Not everyone is “touchy-feely”. Not everyone wants to hold a patient’s hand. Not everyone wants to know about the social aspects of a patient’s life. These do not imply that the doctor cannot correctly diagnose an acute MI, or reconstruct a fractured femur.

    4. Apathy is the specter that lurks in the recesses of everyone’s mind, whether they want to acknowledge it or not. Seeing what we see, working the amount of hours we work, having to answer and argue with to non-physicians (administrators, insurance, politicians) about how we administer our care becomes tiring. In years gone by, front-line soldiers suffered from “battle fatigue”. Physicians are no less subject to the untoward emotional effects of the career than anyone else. Safeguarding onesself against apathy is a constant challenge.

    A final thought, as this was given to me by a nurse during my med school years- for you, the patient is another child with an earache. To that parent, it may be the worst moment of his/her life. Take the extra second to show you care about them- that is what the parent will remember – not the diagnosis itself so much, but how you, the doctor, treated them as person.

  • Goerge paterson

    You are very bold to criticize your whole profession with only a student’s worth of experience. I would never think to criticize my colleagues this way.
    What you say may be true. But for you to have the confidence to boldly state with basically no experience by comparison to your colleagues, is laughable. You should learn respect, loyalty to your profession, and humility.

    • kelvin

      @George,Boldness is what gets us ahead in life being complacent will get you nowhere buddy.Remember a Prophet is never liked by his own People.I work in the medical field and have seen that Doctors have lost the Compassion that they once had.Patients are a Customer or commodity and that is not the way its supposed to be,i have witnessed first hand dr’s who do not acknowledge the patient and juts get straight to the point…no introduction and are left asking….was that the doctor???

      • Hexanchus

        Kelvin,

        I agree. I don’t believe the OP was criticizing the doctors as much as he was the system that they operate within. There are definitely major problems in the health care delivery system, and it takes those with the insight to recognize that and the courage to step up and advocate for change to solve them.

        What I really believe that doctors have lost is their connection to the patient. This needs to change.

      • DrDutch

        Using personal anecdotes to indict an entire profession does no one any good. I’ve seen idiot med students who were more pompous than the most arrogant doctor I’ve ever encountered, nurses who annually make the new interns job a nightmare, and midlevel practioners who were in over their heads but couldnt recognize it. I’ve also met a-holes at the post-office, as restaurant servers, clerks at the bank, and mechanics. Does that mean all of the people who work in these worlds are bad? No.

        There is also a fine line to walk as a student. There are times where you think you are correct, and sometimes you are. But there is a hierarchy in the medical world, and respect for that hierarchy is needed. To see the big picture takes time and training.

        Again, the OPs opening comments are reasonable. But we need to be cautious at judging the behavior of others.

    • Aaron George

      I have to offer some defense here, Goerge.  Your point is well taken, and I assure you that criticism is the furthest goal in my mind.

      I’m not criticizing my profession, I’m critiquing the health care “system”.  Those are two very different things.  Ask any health care leader today – they want the nurse or janitor to speak up when they notice a fixable error or an unsanitary practice.  Without these voices speaking up, the problems may go unrecognized – or worse – unfixed.  That is the nature of our system. 

      I have the utmost respect for my profession.  That is EXACTLY why I take the time to post blogs such as this.  It is because I care so much and am so loyal and committed to the future of medicine.

      Best,
      Aaron George, OMS-IV

    • Aaron George

      I have to offer some defense here, Goerge.  Your point is well taken, and I assure you that criticism is the furthest goal in my mind.

      I’m not criticizing my profession, I’m critiquing the health care “system”.  Those are two very different things.  Ask any health care leader today – they want the nurse or janitor to speak up when they notice a fixable error or an unsanitary practice.  Without these voices speaking up, the problems may go unrecognized – or worse – unfixed.  That is the nature of our system.  

      I have the utmost respect for my profession.  That is EXACTLY why I take the time to post blogs such as this.  It is because I care so much and am so loyal and committed to the future of medicine.

      Best,
      Aaron George, MS-IV

  • Alan

    It seems like this piece is moving in the right direction, and earnestly written to boot, so well done. But is there such a need to for axiomatic definitions? It seems laughable enough the public discourse is framed around notions of “health care,” when in fact, what is intended is merely third party reimbursement of the costs of disease management and/or prevention.

    For example, “1. Health: The delivery of medical knowledge, assessment or treatment to a patient.” To an outsider, this definition strikes the ear as detached and hyper-clinical, really, the antithesis of what I would look for in a good physician. Think through the logical implications of this definition. Is there any situation in which more “health” would not be preferable to less? Is health a commodity to be imparted externally? If so, then isn’t more always better? What then of self-limiting conditions, does the definition leave any role for this occurrence? This definition delineates the role of the patient as the prospective and presumably passive recipient of knowledge, assessment or treatment given as from on high. Without belaboring the point or coming off as overly churlish, perhaps one might consider whether this definition is broad and encompassing, or unduly circumscribed and framed predominantly in terms of interpersonal power relations. To paraphrase a saying, we internalize our definitions and our definitions can come to define our outlooks and behaviors if we believe them–so choose carefully.

  • Terry McFarlin

    Dr. Kevin:

    Where I live in Tennessee, they let patients die in the ER., my husband recently had a stroke, as a nurse assistant, I know the signs of a stroke when left side paralysis take over and confusion sets in. When the ambulance picked him up they said it was a panic attack. No it is a stroke.

    When taken to the ER in Bedford County, Tennessee. They let him set overnight with no tests, no MRI, just blood work. The next day I checked him out AMA and took him to Vanderbilt. The nurses made him walk to the elevator and down to the car outside where I was waiting.

    When we arrived at Vanderbilt, he was seen within 30 minutes and had an MRI done. The neurologist came in to talk to him, and verified that if medication had been given within the four to eight hour window factor of a stroke, he would not have went through this. The MRI had shown a blood clot had passed to the right frontal lobe of his brain.

    Now as a student in pastoral ministries, he has had to drop his classes, he cannot drive, he is confused and very slow. Dyslexia seems to have set in. This is all because our doctors in this town do not listen to patients or wives of patients. It IS, “WAIT” till you die?

  • Terry McFarlin

    Dr. Kevin:

    Where I live in Tennessee, they let patients die in the ER., my husband recently had a stroke, as a nurse assistant, I know the signs of a stroke when left side paralysis take over and confusion sets in. When the ambulance picked him up they said it was a panic attack. No it is a stroke.

    When taken to the ER in Bedford County, Tennessee. They let him set overnight with no tests, no MRI, just blood work. The next day I checked him out AMA and took him to Vanderbilt. The nurses made him walk to the elevator and down to the car outside where I was waiting.

    When we arrived at Vanderbilt, he was seen within 30 minutes and had an MRI done. The neurologist came in to talk to him, and verified that if medication had been given within the four to eight hour window factor of a stroke, he would not have went through this. The MRI had shown a blood clot had passed to the right frontal lobe of his brain.

    Now as a student in pastoral ministries, he has had to drop his classes, he cannot drive, he is confused and very slow. Dyslexia seems to have set in. This is all because our doctors in this town do not listen to patients or wives of patients. It IS, “WAIT” till you die?

  • Anonymous

    Aaron,

    Great article. I would suggest you drop the term health care in favor of ‘practice of medicine’. HC is now more a government / political term than meaningful to physicians. The pressures placed on current practice have dramatically changed the seasoned clinicians. If you truly believe what you wrote in your article I would also suggest you fight the government getting between you and your future patients.

    Much success in your career.

    • Anonymous

      “Health care” is, in fact, what each of us does–or fails to do– each day to promote and to guard our own health.  That includes good nutrition, regular exercise, plentiful sleep, not smoking, etc.  Nothing else comes close to our own daily health care in determining the quality of our lives and independence.  “Health care” is therefore much more than a “government/political term.”  I agree that physicians do not provide health care–each of us must do that for ourselves–and that “practice of medicine” is an appropriate phrase to describe physicians’ contributions.  Until we fully embrace that true health care is what we do each day for ourselves, we will continue to be dependent on an inefficient, impersonal, medical business that is bankrupting our country and frustrating physicians and the general population alike.

      • Anonymous

        I’m sorry you feel so negatively about our system of health delivery.  However, inefficient and impersonal are terms I apply to entities such as the DMV and other governmental agencies …… not our system of health delivery, except for the government intrusion.  I suggest you re-think your position regarding the delivery system bankrupting the country.  The system provides a valuable service that helps maintain our citizen as productive members of society.  There are countless government agencies or programs that produce nothing and have have spent trillions of tax dollars for that result.  Other unintended consequences of those programs that impact health delivery is the explosion of an underclass, increased drug use and other risky life-style choices.  So, I agree that the country is charging towards bankruptcy.  Let’s point the fingers where the blame belongs and begin to reverse the awful trends we’ve seen in government programs and policies that have impacted all of us ….. including health care.

  • Leader1776

    Aaron,

    Great article. I would suggest you drop the term health care in favor of ‘practice of medicine’. HC is now more a government / political term than meaningful to physicians. The pressures placed on current practice have dramatically changed the seasoned clinicians. If you truly believe what you wrote in your article I would also suggest you fight the government getting between you and your future patients.

    Much success in your career.

    • healthcareobserver

      “Health care” is, in fact, what each of us does–or fails to do– each day to promote and to guard our own health.  That includes good nutrition, regular exercise, plentiful sleep, not smoking, etc.  Nothing else comes close to our own daily health care in determining the quality of our lives and independence.  “Health care” is therefore much more than a “government/political term.”  I agree that physicians do not provide health care–each of us must do that for ourselves–and that “practice of medicine” is an appropriate phrase to describe physicians’ contributions.  Until we fully embrace that true health care is what we do each day for ourselves, we will continue to be dependent on an inefficient, impersonal, medical business that is bankrupting our country and frustrating physicians and the general population alike.

      • Leader1776

        I’m sorry you feel so negatively about our system of health delivery.  However, inefficient and impersonal are terms I apply to entities such as the DMV and other governmental agencies …… not our system of health delivery, except for the government intrusion.  I suggest you re-think your position regarding the delivery system bankrupting the country.  The system provides a valuable service that helps maintain our citizen as productive members of society.  There are countless government agencies or programs that produce nothing and have have spent trillions of tax dollars for that result.  Other unintended consequences of those programs that impact health delivery is the explosion of an underclass, increased drug use and other risky life-style choices.  So, I agree that the country is charging towards bankruptcy.  Let’s point the fingers where the blame belongs and begin to reverse the awful trends we’ve seen in government programs and policies that have impacted all of us ….. including health care.

  • http://twitter.com/BAlmustafa Bader Almustafa

    Nice article.
    I agree. However, I guess that we deliver some medical services, few of us are able to deliver care. Both the systems of service delivery and medical education are highly accused for that..