You can’t spreadsheet a relationship

By Eric Last, DO, Zucker School of Medicine & Department of Writing Studies, Hofstra University

I recently overheard part of a training session for a module in EPIC electronic medical record that’s designed to analyze physician activity. I admit that I didn’t hear the full presentation. But, to me, the clear purpose of the program is to monitor and analyze clinician performance, with the goal of measuring output and productivity, maximizing efficiency, and increasing revenue. This goal strikes a deep and negative chord.

I thought about why the program caused this reaction. I’m a primary care internist. I’ve been practicing in the same community for 37 years, and my non-clinical passion is medical humanities. Beginning in the 1950s, my father-in-law was a GP in this same community. I still care for (a declining number) of people who were his patients, and many more who are their descendants. My undergraduate studies focused on American healthcare policy. I’m currently co-teaching an undergraduate course in medical narrative studies at the university where I studied, and teaching in the medical humanities program at a medical school. My observations are based on the perspective of a primary care doctor, deeply rooted in my community, healthcare policy, and the humanities.

Healthcare in the U.S. is provided in a financialized system. Business principles are applied to a service that should be rooted in compassion, understanding, and ethics. Large healthcare systems dominate a landscape that commingles many components of care, including ambulatory treatment, hospital-based care, diagnostic services, pharmacy services, and the pharmacy benefit management entities that dictate who can get which medicines and at what cost.

My reaction toward the EPIC module is rooted in my belief that our value can’t be measured by the metrics offered, nor by many of the measures used in classic business models. In a large integrated system, the value of care shouldn’t be separated and siloed from the system as a whole.

Because of my background and beliefs, I’m convinced that the value of patient care is rooted in the relationships we build. It’s based on the empathy and compassion we show, and the trust that comes from sincere work. Our value to an organization is obvious when those relationships form the basis of trust in the healthcare system as a whole.

For example, my team and I recently diagnosed a long-time patient with potentially resectable pancreatic cancer. When the time came for a discussion of treatment options and referral specialists, the relationship we’d nurtured turned into trust for our recommendation of the oncologic surgery team within our system. Rather than seeking a consultation at another large healthcare system or a dedicated cancer hospital, our patient received multidisciplinary care from the surgical and medical oncology teams within our own system. It was a win-win—the patient received excellent care, and our system benefitted from expanding and maintaining relationships with the patient.

There are those who will push back and say “Relationships are nice, but they don’t pay the bills. Health systems are businesses that need revenue to survive.” And they’re right. I was in private practice for many years, and am well aware that staff won’t get paid, and the lights won’t stay lit, without income. But perhaps we’re measuring the wrong things. How do you measure compassion, or quantify the value of listening and being present for another human being facing the most difficult days of their life?

The expectation that primary care will be profitable, or merely “break even”, does a disservice to the role we play. We are the face of, and the supporters of, health care systems writ large.

How can we demonstrate our value? We need to maintain our identities, be true to our values, and show sincere caring. Doing so will allow us to cultivate relationships that will benefit our patients, our systems, and ourselves.

To paraphrase the wonderful lyrics from “Seasons of Love” from the musical “Rent”:

How do you measure a doc?
Measure in caring.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.