It’s far more important to know what person the disease has than what disease the person has

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Editor-in-Chief, Chester ‘Trip’ Buckenmaier III, MD, COL, MC, USA.

It’s far more important to know what person the disease has than what disease the person has.  – Hippocrates of Cos (c. 460 BC – c. 370 BC)

Hippocrates, known to every new medical student through the Hippocratic Oath, is considered to be the father of Western medicine. Specifically, he is credited with developing the medical theory that human disease is a manifestation of the natural world and not the result of some superstitious belief or punishment by offended gods. Hippocrates was a keen observer of the human condition, and he and his followers provided many of the first descriptions and symptom associations of chronic human diseases.

As a student of medical history, I often am intrigued by the quotations of historic figures in medicine and how relevant the thinking of those that practiced before us remains in the present day. Certainly it is no surprise to those who frequent this column that I like to introduce these vignettes with a contextual quote from our collective past.

I was recently reminded of this quote from Hippocrates while describing an issue in our present federal system to a senior leader. I was lamenting the fact that the federal “system” has no difficulty in recognizing the labor involved when I am doing a procedure on a patient, but my efforts to communicate with my patients are almost invisible to the system. For example, when I place a continuous peripheral nerve block in a patient for perioperative pain relief (sticking a needle in a patient with ultrasound guidance to place a catheter next to a nerve I wish to block with local anesthetic), I can claim up to 12 relative value units (RVUs) for the effort. As many know, RVUs are a method of determining physician work values and thus compensation in many American healthcare systems.

While we in federal medicine do not get “paid” by RVU generation, it has been accepted as a means to monitor individual provider work output within a particular federal hospital system. Using this classification on days that I am serving as the regional anesthesia section attending (sticking needles in patients all day) I appear to be a highly productive, labor intensive physician (many of my residents are choking on this). In other words, I am generating considerable work for the team that justifies my expense to the taxpayer.

There are other days when I am assigned to serve as the acute pain service attending. These days are spent performing patient rounds where a team of physicians and nurses meets with patients and family members discussing pain issues, providing the patient insight into their pain, and formulating plans to manage their pain. This is the activity where we actually get to know our patients and their families, discuss their needs and desires, and educate them away from their fears and anxiety. We actually spend considerable time talking to our patients–in a needle-free environment. Although this activity takes far more time and effort then the needle procedures we do and is by far our most important function in managing perioperative pain, we receive 0 units for this activity by the RVU system.

A pragmatic taxpayer, looking strictly at RVU generation without the benefit of the previous explanation, would view me as a terribly unproductive physician (you residents should just relax) on those days that I am not sticking needles in people. It is a sad reality of modern medicine that we tend to value doing things to patients but place little to no value on getting to know our patients.

I am not saying that the procedures have no value; on the contrary, much of the good I have done for individual patients in my career has been at the end of a needle. I just wish the good that has been accomplished by talking, teaching, and developing a relationship with my patients was valued as much. While the system tends to have difficulty finding value in talking with patients, the positive feedback I receive from patients comes from that interaction. Rarely do patients express their gratitude for my care when I have a 10 cm needle in my hand.

I recognize that I have been generalizing and have thoroughly oversimplified the overwhelmingly complicated issues of healthcare costs and value. Then again, just because the issues are complicated, does that necessarily mean the solutions need to be as thorny? What if we took a page from the Hippocrates playbook and spent more time and placed more value on talking to patients?

I believe most would agree that physicians are still human, we will “do” whatever it is we get “paid” to do to patients. If procedures and prescriptions are what pays, then procedures and prescriptions, and the businesses that drive those products, will continue to set the medical agenda for this country. I suggest that we strive to find other ways of defining provider labor within our federal system that ascribes equal value on time spent on procedures with time learning about our patients. From my experience with patients in the past 20 years, our value in their eyes could only increase in such a system.

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