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The difference between “health care” and caring

In his 1996 book The Lost Art of Healing, Dr. Bernard Lown called attention to what he saw as a disturbing trend in medicine – the erosion of trust and reciprocity between doctors and their patients: 

“Healing is being replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures. Doctors no longer minister to a distinctive person but concern themselves with fragmented, malfunctioning biologic parts.”

Not only was our abandonment of listening in favor of tests and procedures making medical care more impersonal, it was making it more expensive and less efficient, Lown noted. Taking an unhurried personal history is often the most cost-effective way for a doctor to diagnose a patient, he wrote. But doctors no longer have time for such luxuries, with increasing pressure to fill their schedule with more patients and mounting administrative burden.

It makes sense that giving doctors more time to develop a trusting relationship with patients would lead to improved health and savings from fewer unnecessary services, better medication adherence, and prevention. But we don’t have hard proof of these benefits – until now. 

Economist and a primary-care physician at the University of Chicago Dr. David Meltzer has spent the past few years conducting the first randomized clinical trial comparing two models of care for high-risk Medicare patients: A standard model in which patients have both a primary care doctor and a hospitals, and a new model of “comprehensive care” in which one doctor provides both inpatient and outpatient care.  

There are a few obvious benefits of the comprehensive care model: The 30-minute clinic visits allow doctors to ask patients more questions than in the standard 15-minute visit, and having the same doctor make hospital rounds gives them a strong base of knowledge and familiarity with which to conduct hospital care.

Kim Tingley from The New York Times spent four months observing 90 doctor-patient interactions in Meltzer’s comprehensive care clinic. She found that doctors spent what seemed like an inordinate amount of time on talking to patients about elements in patients’ everyday lives. But these seemingly trivial matters often held the key to making a patient more comfortable, discovering what was making a patient sick or distressed, or even preventing a health emergency.

In The Lost Art of Healing, Lown recounts how a casual, unhurried conversation with a patient revealed that his symptoms were not due to underlying heart problems, but stress over his estranged daughter. Discovering the real cause of his symptoms saved the patient from going through a battery of unnecessary tests and procedures. 

Meltzer’s research reveals that this extra time with patients pays off in both health outcomes and cost. Patients in the comprehensive clinic reported feeling more satisfied with their physicians and rated their mental health significantly higher, compared to patients in standard care. Clinic patients had 20% fewer hospitalizations after a year compared to patients receiving standard care – that’s $50,000 at least that Medicare doesn’t have to pay for each patient that avoids hospitalization. 

Clinic patients had 20% fewer hospitalizations after a year, saving at least $50,000 per patient.

And the clinicians, most of whom had come to Meltzer disenchanted from their previous experiences, were more invested and satisfied being able to spend more time with patients. This newly found relationship is not easily defined in survey metrics; it’s priceless. As Tingley writes:

“Perhaps the explanation for patients’ allowing me to witness these conversations was as simple as wanting, even at their most vulnerable — perhaps especially then — to be seen and heard, and that this was also precisely what they prized in Meltzer’s doctors. What both doctors and patients were after, it seemed, was not just an assignation of ‘value’ but of meaning.”

We need to prioritize nurturing and strengthening the doctor-patient relationship, for the sake of the health of patients and clinicians, as well as the sustainability of the health care system.