Earlier this year, I completed a medical rotation in Africa. It was an amazing, eye-opening experience. While I expected it might be difficult to acquire newer, more expensive medications and procedures, I had anticipated that, given limited resources, there would be some rationale in deciding which medications and procedures would be available. I was deeply mistaken in this assumption.
During my time abroad, I watched several patients with heart attacks pass away because there was no thrombolytic (clot-busting) therapy. Thrombolytic medications are inexpensive and have been around for more than 50 years. The low cost of these medications combined with the high rates of coronary heart disease makes it puzzling that the hospital did not have thrombolytic medications.
Instead, the hospital was building a cardiac catheterization lab. While catheterization can produce better patient outcomes than thrombolytic therapy for heart attacks, it is significantly more expensive and good outcomes require skilled interventionists with experience performing a high volume of catheterizations. In a country with few trained cardiologists (not to mention interventional cardiologists), this latter resource is essentially unobtainable.
This was just one example of many puzzling choices that I saw during my time abroad. Others include the presence of CT and MRI machines as well as ventilators but an inability to acquire basic labs including serum bicarbonate levels, arterial blood gas levels or reliable culture results. To me, it seems that, in a country with high rates of communicable diseases, reliable culture results are more important for patient outcomes than an MRI.
While the leaders of the institution had chosen to invest in the most modern technologies instead of finding the greatest value for their funds, I want to make clear that this decision is not unique to those in developing countries. In fact, we in the United States do this all the time as well.
We often fail to ask if the new, fancy technology will make the biggest difference in patient outcomes. Has increasing the use electronic medical records improved care coordination or quality of care? Is a 10 Tesla MRI machine meaningfully different from a 3 or 5 Tesla machine?
Sometimes it is the simple, low-cost changes that make the greatest difference in patient outcomes. Antimicrobial foam outside every patient room. Rotating ICU patients every two hours. Removing unnecessary central lines.
We are a rich country, but we do not have unlimited resources. We also need to seek the greatest value for our money. We need high-value health care.
The idea of high-value health care has been around for several years but has gained increasing traction as our country begins to recognize that even we have finite resources. The New England Journal of Medicine and Harvard Business Review recently collaborated to create an online forum to help health care leaders identify ways to increase the value of health care.
The Institute for Healthcare Improvement has long been a proponent of value. Its website contains several resources for identifying ways to achieve high-value health care. Of particular interest is its 5 Million Lives Campaign that focused on specific actions that would prevent 5 million incidents of medical harm in hospitals over a two-year period.
As future health care providers in the current health care climate, we will be asked not only to practice evidence-based medicine but also high-value medicine. It is important that we know what actions provide the most value in ensuring patient safety and improving patient outcomes. Now is as good a time as any to start learning.
Elaine Khoong is a medical student. This article originally appeared in The American Resident Project.
