I am a huge advocate of high-value care, which is exactly why I've started questioning who gets to define it. You, me, the insurer, the academic, the boss, or maybe even the patient? Because with time, reflection and a healthy dose of honesty, I'm increasingly convinced we're often talking about completely different things.
In physiotherapy, manual therapy is frequently labelled as low-value care whilst rehab is positioned as high-value care. Case closed, guilty as charged m'lud. I've spent years saying versions of the same thing myself.
Except patients don't seem to have got the memo. They actively seek out experienced hands-on therapists, recommend them to friends, return to them years later and willingly pay good money to see them. And before anyone says it, most haven't been hypnotised by evil clinicians trying to create dependency. They simply value something that perhaps we don't understand as well as we think we do. Which is strange behaviour for something we're told has such little value.
Now before the rehabbers sharpen their therabands, I'm not arguing against exercise. Far from it. Exercise and loading are fundamental, amen to that. But value depends entirely on where you're standing.
From a clinician's perspective, value might mean long-term adaptation. From an insurer's perspective, reduced cost. From an academic's perspective, measurable outcomes. From a clinic owner's perspective, efficiency and utilisation. From a patient's perspective it might be much simpler. I hurt less. I understand what's wrong. I feel reassured. I trust this person. I can play golf again. I can pick up my child again, et cetera.
After 30 years in practice, I've become wary of professions deciding what people should value whilst ignoring what people actually value. Healthcare isn't delivered to populations, it's delivered to individuals, and individuals are wonderfully irrational. They value expertise, confidence, being listened to, touch, feeling understood, yaddah yaddah. The irony is that many of the people defining value have very little skin in the game when it comes to delivering it.
The truth is that something can score brilliantly in an academic discussion and feel utterly worthless to a patient. Equally, something can be dismissed as low value by clinicians whilst being perceived as enormously valuable by the person paying for it.
I don't actually know who's right. I know what many patients value, I know what many clinicians value, and I know those two things don't always align as neatly as we'd like. Maybe the problem isn't value at all. Maybe we're all using different definitions of the word and pretending they're the same.
Who decides?