organized curiosity

Improving health care through research

Blaming patients

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blameblogWhenever something is wrong in health care, we tend to blame the patient or if the patient is a child, we blame the parents (especially the mother).

Patient blaming takes lots of different forms. One is what I call the psychogenic bogeyman. If we cannot find the cause of a problem, we say it is psychological or “all in your head”.

Now I am not against recognizing the incredible value of psychology. After all I am a clinical psychologist and founded and led for a decade the PhD program in Clinical Psychology at Dalhousie University.

One of my first research studies published in 1983 was on recurrent abdominal pain.  Recurrent abdominal pain was described as pain in children that kept coming back and no known organic cause could be found. It was quite common, especially in girls around 12 years of age.  At the time, it was assumed that the problem was a difficult personality and a difficult family. I was just starting out in my career and this was a great problem to tackle because it was common and assumed to be psychological in nature. I was very disappointed because in this study of 30 children with recurrent pain and 30 children without pain, I failed to find any differences between children with recurrent abdominal pain and children without pain. I had to conclude that we should not diagnose pain as psychogenic unless we had positive evidence.

Unfortunately, people still make what Patrick Wall, a distinguished physiologist in pain, called “a leap to the head,” the tendency to say a disease is psychological in origin just because we can not understand it.

Although we now know that autism is not in any way caused by parents’ behavior, the myth that cold rejecting or “refrigerator mothers” cause autism persists.

How else do we blame patients?

We blame patients for overuse of medical tests and treatments. Even the Choosing Wisely campaign which I have endorsed several times in this blog implies that patients are responsible along with their doctors for unneeded tests and treatments. I think patients can provide a very helpful boost to getting the best care but patients are not the problem.

I recently saw a post in an excellent blog, the Incidental Economist, on a study published in JAMA Oncology about patient requests.  They studied 5050 patient cancer visits by interviewing the doctors right after the visit. There were 3624 patients and 60 clinicians involved. Four hundred and forty or about 9% involved a patient request for a test or treatment. Doctors granted 83% of the appropriate requests. There were 50 requests that the doctors felt were not appropriate and they granted only 7 of these.  That is, inappropriate requests were granted in only 0.14% (7 of 5050) of visits. Here is a graph from the blog.  An editorial in JAMA Oncology “The myth of the demanding patient” argued it is about time we stopped blaming patients for inappropriate tests or treatments.

BlamingPatientsGraph

Another way we blame patients is by calling them derogatory names. Dr. Brian Goldman the host of White Coat, Black Art on CBC radio published The Secret Language of Doctors in which he tells about different terms that have been used for patients.

  • FLK for funny looking kid
  • Yellow Submarine for an obese patient with cirrhosis of the liver
  • LOL in NAD for a Little old lady in no apparent distress

This hostile approach to patients has, in my opinion, declined in recent years but it has been replaced by the “lifestyle blame.” In the lifestyle blame, patients are blamed for their bad choices in not being active or in being overweight.

Adults and children who are overweight may be able to make better choices in their food.

But…

Try and find:

  • Fresh fruit and vegetables in the poor areas of town or in rural areas where many poor people live (there often are not even supermarkets).
  • Places that are safe to walk in poor or rural areas.
  • Social assistance that pays enough to have a nutritious diet
  • Cooking classes emphasizing nutritious inexpensive foods for kids and parents.
  • Physical education time in school that is appealing to kids, especially overweight kids.
  • Time for physical activity if you hold down two jobs to make ends meet.

I don’t mean to absolve each of us for our health choices but let’s be realistic.  Eating well is a lot easier if your income is not below the poverty line. In Nova Scotia child poverty is a huge problem with 22% of children living in poor families. It is a staggering 33% in Cape Breton!

Why do we blame patients?  I don’t think it is because we are bad people. Doctors and other health professionals are no better or no worse as human beings than anyone else. We blame patients because we don’t like to admit when we don’t know what to do or we are frustrated or feel powerless.

We are better off admitting to the limitations of our knowledge and our own feelings of inadequacy than to blame our patients. We, the health professionals and the health bureaucrats, need to realize that in everything we do patients are the reason for the health system; our job is to serve patients. Let’s put an end to patient blaming.

~Dr. Patrick McGrath

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