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choices

This past week my five days as the attending physician on service went incredibly fast but also consumed a lot of my time, and more importantly, my psychic energy. During the week, I was faced with many choices.

Just as patients and families have a choice in where to go for their health care needs, and what to request, providers also have a choice in what kind of healthcare to provide and how deeply to care about the value of that care to the patient. Quality health care may be judged by the absence of obvious errors. But valuable health care is judged by the extent to which the physician and other members of the team have considered the wide variety of possibilities, and have approached the delivery of care in an empathetic, patient-focused, yet evidence-based way.

The decisions we grappled with this week ranged from deciding how far to go to evaluate a chronic intermittent problem in an adolescent girl who had been seen in the emergency department many times in the past. She  had an unusual finding that often occurred during her prior visits, and had never been addressed. By evaluating this finding, I believe we have taken a step toward improving the quality of her life considerably. We could have just sent her home again, without an answer because this finding was unusual and nearly inexplicable. But we persevered, got an appropriate specialist involved, and established a plan by which she could go home safely. Her mother was extremely grateful that we took her seriously, and spent the time and effort required to consider the issues seriously and try to address them.

Other decision points surrounded evaluation of a number of infants with poor weight gain or demonstrated weight loss. While there are many possible causes of failure to gain weight in infants, most of the time we find a cause that is not specifically related to a medical issue significant enough to explain the weight loss. We could have said: "we didn't find a cause for your baby's inability to gain weight" and sent these babies back to their pre-admission environment. However, that would not be right for the infant. One of the prerequisites for being able to discharge a patient is having addressed the underlying cause of the problem. If we haven't done that, we have done nothing.  So even if that cause is not strictly medical it needs to be addressed. And that takes time. And that is sometimes uncomfortable for all of us, since we have to deal with issues that don't have a simple answer.

Yet other patients presented problems with no obvious underlying cause. Why does this person have X? Many would take the approach of just treating the symptom, whether that is fever, or pain or respiratory distress. So while it is important to address the symptom that brought the child to the hospital, it is not of value unless you search for and address the cause of that symptom. For example, if you have a high fever I will treat you with an antifever medication while I search for a source of infection or other reason. If I just gave you an antibiotic, I might hide the cause and we would likely never know why you had that fever. The same clearly goes for pain. Lots of people present to emergency departments with pain. Treating the pain with medication may provide  symptomatic relief. That is useful, but again, not valuable unless we can find the true reason for the pain, and address that.

You get the idea. Some of my patients this past week had problems that were relatively easy to diagnose and treat. They got better and went home. Many, however (more than is typical) had complex or subtle problems that did not declare themselves. These were wonderful patients from whom our medical students and residents could learn. Mostly they learned the art of listening, of asking appropriate questions, and of patience, in finding an answer that would lead to the ability to provide a valuable health care experience for both the patient and the family.

I would love to hear about your experiences in health care--providing valuable healthcare, or receiving it. Or, times when you didn't receive what you perceived as valuable. Tips for our health care providers (and especially our learners) in what they can do to make your healthcare experience more valuable would be particularly welcome.

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