• Subjective vs. objective value in health care

    In assessing “value” in health care, there’s a bit of tension among the experts. Some emphasize satisfaction, others quality metrics. It’s subjective vs. objective. Which way is best?

    I’ve been mulling this over for some time, and will begin to write about it—not in a fully formed way, but by conveying a few responses to articles as I read them. This post is about the excellent 2013 NEJM piece by Lisa Rosenbaum.

    Using the famous “illusion of attention” gorilla study by Daniel Simons and Christopher Chabris as an analogy, Rosenbaum says what I noted above, “[v]alue in health care [] depends on who is looking, where they look, and what they expect to see.”

    When I consider which is best, subjective vs. objective notions of value, I am reminded of optical illusions in which one can see different images depending on how one looks. One can flip between them, but it’s hard to see both images in the mind’s eye at once.


    Do you see a young or old woman?

    Like seeing either the young or old woman (or flipping between them), both aspects of value seem to have merit. Your subjective experience matters and is valid, not least of which to you. It’s your body on the line! But your care is also financed with my dollars (through taxation or collective premium funds, or both). I don’t want you to spend it on objectively “bad” or “lower value” care. It’s my money on the line!

    The wedge between these two views is similar to Rosenbaum’s observation that “[t]he value narrative effectively splits patients and physicians into separate teams.” Focusing on physicians invites objective measures. They’re the product, in a way. Like the specs of a car or phone, it’s natural to want to know what we’re getting for the price.

    Focusing on patients invites subjective considerations. They’re the customer, in a way. (Ignoring third-party payment that complicates that notion.) And we all know it’s darn near impossible to make a fully objective decision about almost any product. Often it comes down to, “How does it make me feel?” (This is the basis of most marketing, whether it works or not.)

    Rosenbaum tells the story of Mr. W who is “crippled by worry” over the possibility he has heart disease. He won’t be satisfied until he receives the test that rules it out. There is no such test and cardiac imaging, among other types of imaging, is among the services that are overused. Objective metrics suggest that more testing might do more harm than good. Subjectively, will this satisfy the patient? When considering tests and procedures for which there is no clear evidence of benefit or harm, the answer is harder still. When things are vague, do we bias toward or away from treatment? How much weight do we give satisfaction?

    One recent study showed that patients who present to the emergency department with abdominal pain are more confident that they have received good care if they undergo an abdominal CT scan than if a physician simply examines and reassures them. In the case of back pain, for which imaging is frequently used and we have outcomes data and guidelines to inform decisions, two studies have shown that patients who undergo magnetic resonance imaging, even when it is not medically necessary, are far more satisfied with their care than those who do not. [Links added.]

    On the other hand, there is also evidence that what patients really want is to be listened to, for their concerns to be understood and taken seriously. That suggests the route to patient satisfaction might not be an imaging study, a procedure, or a pill. Perhaps a thorough conversation is what the patient really seeks. When it was explained to Mr. W why additional testing wouldn’t be helpful (but some other things might), he replied with relief, “No one has ever explained any of this to me before.”

    To the extent that (subjective) satisfaction and (objective) evidence-based care align, the apparent conflict between the two evaporates. It’s not likely this will always occur or that getting it to do so where possible is easy. There’s likely room for both notions of value. Getting them to work in concert may require clinicians and patients to communicate differently, which takes time and effort. It sounds simple, but it’s a big challenge.


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