“The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.” – Atul Gawande
I visited a local hospice a few weeks ago. The nurse practitioner I was talking with told me a patient came in a year ago with monitors still attached to their chest from the hospital. When hospice admitted the patient they were removing the monitors as the patient interrupted, “wait, how are you going to monitor me without them?” The nurse paused being struck by the question and said, “we monitor you here with our eyes.”
Similarly, I was visiting a palliative care team in action who were 45 minutes into a conversation with a patient who was not well when a nurse came in to draw blood. The physician turned toward the nurse and said “that test is not necessary right now.”
Both examples shed light on a shared premise: the needs of the patient come first. The Mayo Clinic also shares the same premise as Atul Gawande discusses in his recent New Yorker article. Denis Cortese, the C.E.O. of the Mayo Clinic states, “When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing.” As a result, this premise has improved patient care quality and costs are lower than just about anywhere else in the United States. Their medical communities are not following anyone else’s recipe but they’re organizing through a strong sense of accountability and identification that takes seriously collective responsibility for improving patient care. How are they doing it and why aren’t others rethinking their practices you might ask?
The concept of accountability from a colonist perspective, is concerned with the repercussions for not having followed the rules set forth by a dominant group. Communication scholar Amira De la Garza, PhD however, encourages us to let go of this meaning and look at the word again. Account-ability. The ability to account. To tell a story. So when we are accountable, we are able to tell a story. But in order to know a story, it has to become part of us. It’s not easy. But the hospice nurse’s ability to monitor the patient through their natural instruments – their breathe, the color/temperature of their skin, their words said and not said, the functionality of their body, their weight and their nutrition intake allows them to be harmoniously account-able to themselves and the patient. They rely on others, other rely on them for knowledge about patient care. In a sense, these become their core set of beliefs and values that they become identified to and take on as their own.
Such identifications are important because they help us in making sense of our experiences, organizing our thoughts, reaching decisions, anchoring the self and granting individuals personal meaning. Most importantly, identification is rhetorical; it allows people to persuade and to be persuaded. Identification is not a thing or a product but rather a process. People most often ask ‘what is’ identification rather than ‘what happens’ when people identify with groups, organizations, collectives and to a lesser extent, beliefs, values and goals. The ‘what happens’ question is the one Atul Gawande asks of both the Mayo Clinic and McAllen Clinic. Answering this question allows us to see two very different ways of organizing care. It is not a question of which is better but an opportunity to hold open for a moment, an important possibility for clinical life and care. 
The Mayo clinic, like my hospice and palliative care experiences, is walking to a different drum. Their guiding beliefs and values have created a language and philosophy of care that is extraordinary different from the synchronicity and coherence of dominant medical beliefs, values and norms. In so doing, they are producing a different meaning of care through their understanding of what it means to be account-able and what happens to health care costs, patient care, and physician relations when individuals identify with this set of beliefs and values.
So, we have a choice: are we going to reward the innovators who are trying to build a new generation of care or provide more pen caps at less cost?
What does a philosophy of care built on the needs of the patients look like to you?
What would this clinical practice do for you?
What would it not do for you?
Thanks to kqedquest and OR4N6E for their images. . .
We look forward to your comments!
Carey Candrian
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Ah, the spaces in between. In between visits, in between patient and provider, in between colleagues, in between families. In between forms of clinical care also = old and new schools of medicine, for example.
collaboration and contestation? If we were comfortable with that frame? Perhaps we could get a better understanding of the complex negotiation and understanding of health and the body.Perhaps we would build a new architecture for organizing health and care so all ‘stakeholders’ (read individuals, families, community members, colleagues etc) could connect, re-connect and exist in partnership with each other. 
Communication scholars, Julie Apker, PhD and Susan Eggly, PhD wrote about the 
care, however, is relational and the very things we are training ourselves in like the importance of talk, listening, participation and collaboration, must “count” in other places, like a patient’s bedside.
relationship with their specific doctors that could be considered “connected.” But a sizable minority did not. Steven J. Atlas, MD, lead author and co-director of primary care quality improvement at 
