Newtown, CT – August 12, 2016
During the dog days of Summer, we note that some patients are treated like strays year round – A recent blog post in Health Affairs details how the lack of communications skills, especially for the most vulnerable, has a detrimental effect on patient outcomes and likely exacerbates the known disparities between those on Medicaid and those who are commercially insured. And for those who doubt the prevalence of these poor communications skills, consider this interview on the NEJM Catalyst that describes how difficult it has been to institute an organizational-wide communications skills program at the Cleveland Clinic. The effects on patients of not being listened to, having their care dictated to them and their specific needs often ignored has serious consequences, and a first of a series by Kaiser Health News shows the seriousness of those consequences on older Americans. Of course it’s not only some older Americans that can be treated as strays but whole cohorts of patients, such as the ones with mental illness and substance abuse dependencies. Researchers at the Altarum Institute find that this population of patients consumes 40% of all the cigarettes in the U.S. and die from that habit more so than other causes. And in case you’re wondering, most of those patients, when asked, want to stop smoking. It’s just that they’re seldom asked and almost never treated for smoking cessation. They’re the strays that get put away.
What this means to you – The biggest sin many of us commit is to impute behaviors, desires, and thoughts onto others instead of trying to understand and respect what they actually want. Medical ethicists have long talked about this divide between what physicians impute and what patients actually want and express. Even if we can rationalize why those who feel it’s their responsibility to make decisions for those they deem in their care must make those decisions even when the patient verbally or otherwise expresses a contrary opinion, it doesn’t make it right. The patient’s decisions have to be sacrosanct and yet they rarely are. Many of us struggle with these same issues when, for example, dealing with an ageing parent that may have dementia. “Dad/Mom never wanted to live like this, not knowing who they are or what they’re doing.” That, of course, starts opening the door to ending people’s lives because we impute on them feelings, thoughts and needs that aren’t necessarily theirs. Think about it, have you ever met a stray dog that wants to be euthanized? More commonly, at least in the mental health and substance abuse population, it leads to maintaining and even encouraging a smoking habit when the patient wants to quit, and it ends up killing them. Or it can lead to debilitating hospitalizations that leave the patient far worse off than they were coming through the door. It’s not surprising that this affects the more vulnerable because they are much more likely to be the ones on whom much is imputed. Just consider what you imputed about the last homeless or “crazy” person you walked by. We can and must be better. We can and must do better.
Francois de Brantes