High-Value and Low-Value Patients

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    Some patient populations are highly prized in our society while others are very much devalued. This is because American society views some clusters of people as ‘high value’ and others as ‘low value.’ Do you believe that all people were created equally? Do you feel that all individuals are treated equally?

    A handful of readers might have had knee-jerk reactions after reading the title of this piece. Some of you were probably frowning as you muttered to yourselves, “High-value patients? Low-value patients? Who in the hell does the writer think she is?”

    Let me get one thing straight. I’m not the one who assigned values to different clusters of patients. In fact, my personal belief is that all people have the same inherent worth and esteem, regardless of their current situation in life. To be more precise, the greater society in which we inhabit has ascribed different levels of importance to different groups. We sense this disparity when we see how well certain diseases are publicized while other afflictions are simply blown off. We know this gap exists by the types of responses people give when we inform them of our nursing specialties.

    In previous posts I’ve speculated that the prestige of our nursing jobs is strongly tied to the various patient populations with whom we intermingle. To be straight up, society as a whole places an extremely high value on pregnant women (especially if they‘re middle class or higher), the very rich, infants, children, teenagers, healthy young adults, celebrities, thin people, politicians, and very good-looking people.

    To flip the coin, society places a much lower value on the elderly, the overweight and obese, poor people, undereducated people, alcoholics, drug addicts, immigrant migrant workers, the mentally ill, the perpetually unemployed, the disabled, ex convicts, criminals, the developmentally disabled, and the chronically ill.

    So if you are a nurse who works in nursing homes / LTC, jails, prisons, psychiatric facilities, group homes for the developmentally disabled, addictions / drug treatment centers, migrant worker community health programs, chronic dialysis, or free clinics, members of the public will not respond with much interest because you regularly work with patients that have been deemed ‘low value.’ Even many of our colleagues in the healthcare community will think your specialty is a supposedly ‘lesser‘ type of nursing. Some will even ask, “Why don‘t you want to do real nursing?”

    On the other hand, if you are a nurse who discloses that you work in a specialty where you encounter ‘high value’ patient populations on a constant basis (labor & delivery, postpartum, pediatrics, NICU, PICU, reproductive medicine, aesthetic plastic surgery, trauma, sports medicine, the ER, etc.), members of the general public generally respond with a higher level of interest, and your colleagues in the nursing community tend to view you in a more favorable light.

    We see the bias in the amount of attention that certain health problems generate. Type 2 diabetics generally include the overweight and obese, the elderly, racial-ethnic minorities, and other less glamorous groups of people. Does a colored ribbon exist for all the people who died secondary to complications from diabetes? If so, please tell me about it. However, breast cancer has captured the minds of the American public after a young woman from a prominent family lost her battle against the horrible disease many moons ago. Now we live in a sea of pink ribbons.

    To sum it up, some demographic groups are highly valued in our society while others are blatantly devalued. Society views some clusters of people as ‘high value’ and others as ‘low value.’ As much as I believe that all people were created equally, I know in my heart that all individuals are not regarded equally.
    Last edit by Joe V on Nov 30, '13
    annie.rn, hope3456, pseudomonas, and 27 others like this.

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    About TheCommuter, ASN, RN

    TheCommuter is a moderator of allnurses.com and has varied workplace experiences upon which to draw for her articles. She was an LPN/LVN for four years prior to becoming a registered nurse.

    TheCommuter has '9' year(s) of experience and specializes in 'acute rehab, long term care, and psych'. From 'Fort Worth, Texas, USA'; 33 Years Old; Joined Feb '05; Posts: 28,560; Likes: 42,093. You can follow TheCommuter on My Website

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    51 Comments so far...

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    well said!
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    I'm going through two total knee replacement surgeries. They're extremely painful and the rehab is hard work. Recently, a student PT told me I was very brave. Not because I chose to schedule my second TKR several weeks after the first, while the memory of the worst pain and least independence was still quite fresh. But because I had breast cancer last year. Breast cancer was rough, but it didn't require any bravery to schedule the surgery and go through with it -- THAT was pure cowardice. I had cancer; I wanted it GONE. On the other hand, scheduling those two knee replacements so close together in the hopes of using only my 13 weeks of FMLA, THAT was brave.

    Breast cancer is a high value disease, and I was a high value patient. Total knee replacements, not so much. Thanks for an interesting perspective.
    annie.rn, pseudomonas, Christy1019, and 13 others like this.
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    I think part of the problem is that society has a (misguided) perception that breast cancer just happens to people through no fault of their own (which is not always the case as there are lifestyle risk factors) and Type 2 Diabetes is something you do to yourself, so it's "your" fault (again, misguided).

    It's fascinating (and horrifying) that those less financially able to take care of themselves are the ones that are developing diabetes from cheap foods with high fructose corn syrup and high contents of fat because buying fresh food like fruits and vegetables is too expensive. 300 years ago, this was not the case.

    I think this is partly why society places greater value on breast cancer would be placed versus Type 2 Diabetes, even though it's completely misguided.
    annie.rn, pseudomonas, Nola009, and 5 others like this.
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    Quote from Ruby Vee
    Breast cancer is a high value disease, and I was a high value patient. Total knee replacements, not so much.
    I work with total knee replacement patients on a routine basis and your assessment is correct. End stage degenerative joint disease, especially of the knees, is commonly seen as an issue that affects only the elderly or the badly overweight / obese; therefore, people view it as a 'low value' problem that happens to certain groups of 'low value' people.
    annie.rn, pseudomonas, SHGR, and 4 others like this.
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    So true on all counts
    annie.rn likes this.
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    I used to work in a small hospital. As I have gotten older my calling is working with the mentally ill and the elderly. I find those "low value" clients are making me a better person. But by the grace of God go I...
    annie.rn, pseudomonas, Nola009, and 10 others like this.
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    Quote from babyRN.
    I think part of the problem is that society has a (misguided) perception that breast cancer just happens to people through no fault of their own (which is not always the case as there are lifestyle risk factors)
    Wow-I'm sure the people on the forums at Breastcancer.org would disagree with you and Ruby Vee's assessment of breast cancer and the people who have it. I know Ruby has/had it but maybe spending some time reading the posts in the Stage 4 section might change your mind about how brave these woman are.

    I just can't get over your statement though that breast cancer is caused by lifestyle risk factors. Totally ignorant comment. You need to educate yourself about the disease. I'm sure a woman with stage 4 BC would love to have someone tell them that. A lot of woman who have it have no risk factors. Mammograms are not recommended for woman under 40 on a yearly basis yet they have the densest breast. Go visit Breast Cancer.org and see how many young woman have breast cancer who thought they would never get it because they had no risk factors.

    And Ruby, please explain why a TKR takes more courage than having surgery for breast cancer. I'd like to see you explain that comment to someone who has stage 4 breast cancer which is a death sentence because there is no cure for it.

    Wow, I'm just flabbergasted by these two comments. Breast cancer might be a high value when it comes to patients but I don't lump them in the same category as self entitled celebrities or rich people. Cancer patients in general, are very brave in my book. It takes more courage to fight a disease and suffer through the side effects of treatment for a disease that you know might kill you in the long run than it does to have a TKR.
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    Quote from TheGooch
    Wow-I'm sure the people on the forums at Breastcancer.org would disagree with you and Ruby Vee's assessment of breast cancer and the people who have it. I know Ruby has/had it but maybe spending some time reading the posts in the Stage 4 section might change your mind about how brave these woman are.

    I just can't get over your statement though that breast cancer is caused by lifestyle risk factors. Totally ignorant comment. You need to educate yourself about the disease. I'm sure a woman with stage 4 BC would love to have someone tell them that. A lot of woman who have it have no risk factors. Mammograms are not recommended for woman under 40 on a yearly basis yet they have the densest breast. Go visit Breast Cancer.org and see how many young woman have breast cancer who thought they would never get it because they had no risk factors.

    And Ruby, please explain why a TKR takes more courage than having surgery for breast cancer. I'd like to see you explain that comment to someone who has stage 4 breast cancer which is a death sentence because there is no cure for it.

    Wow, I'm just flabbergasted by these two comments. Breast cancer might be a high value when it comes to patients but I don't lump them in the same category as self entitled celebrities or rich people. Cancer patients in general, are very brave in my book. It takes more courage to fight a disease and suffer through the side effects of treatment for a disease that you know might kill you in the long run than it does to have a TKR.
    I didn't have stage 4 breast cancer, and I'm not discounting the bravery of those women who face surgery, radiation, chemo and the knowledge that no matter how hard they fight, they may not win. Or they won't win. That requires more courage than I personally have experienced.

    I will say, however, that once I had the diagnosis of breast cancer and contacted a surgeon, I was "inducted into the system", and things went smoothly. It was almost like a "cookbook." First you do this, then you do that, and then you do something else and as you progress through the steps they tell you what your next one will be. There were care managers and nurse contacts and always a support system. There are breast centers, where all your treatment is under one roof and there's a comfortable waiting room with hot and cold tea, a computer for checking email, TV and piles of magazines. Every patient has an SO with her. There were pink ribbons and people told me how brave I was. I didn't feel brave. I was just doing what anyone with breast cancer would do -- trusting my doctors and getting it OUT of me as quickly as possible.

    The knee replacement I was planning had to wait for the breast cancer treatment, and when I finally was able to consider knee replacement surgery, I was pretty disabled and had flexion contractures of both knees. There's no care manager, no support system and I had to make my own plan. I have better tools than most knee replacement patients to make that plan and those decisions. Knee replacement surgery is painful, and I undertook the first one knowing how painful it was. I'm going for the second with a very clear and recent memory of just how much MORE painful it was than I anticipated, and how much more painful and difficult the rehab is. There are no pink ribbons and no one tells me I'm brave, even though I FEEL brave going through this second surgery with full knowledge of what it entails. There is no "knee center" or "joint center" and the waiting room is uncomfortable and full of people with crutches, canes and walkers who got there on the bus. Very few SOs, but there are a few caregivers. (Paid caregivers). Instead of being treated with caring and sympathy as I was at the breast center, I'm treated with thinly veiled contempt by the office workers and by the medical assistants. I'm old, I'm fat, it must be my fault my knees failed. (Nevermind that the 25 miles I walked a week probably had a lot to do with it.) Joint surgery isn't sexy unless you're going to a sports medicine clinic -- the kind that rapidly referred me away. I'm only a year older than when I had cancer, but now I'm an old lady with bad joints, not a poor soul who got the Big C through no fault of her own.
    annie.rn, pseudomonas, Christy1019, and 23 others like this.
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    Quote from TheCommuter
    I work with total knee replacement patients on a routine basis and your assessment is correct. End stage degenerative joint disease, especially of the knees, is commonly seen as an issue that affects only the elderly or the badly overweight / obese; therefore, people view it as a 'low value' problem that happens to certain groups of 'low value' people.
    Mr. Cynic here - I'd bet that the surgeons who do the joint replacements for a living do value their patients highly.
    As for what others think about those who work with certain patients, and what others think about those patients - who cares? When they start paying my bills, then I will care what they think.
    RLMORLEYOMAHA, Kipahni, poppycat, and 2 others like this.


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