Thursday, January 17, 2008

On Decisions and Stumbling Blocks

In my regular perusing this week, I ran across an interesting article. It’s published in the latest JAMA: the Journal of the American Medical Association (January 9/16, 2008) in the column, “A Piece of My Mind.” Written by Ann-Marie Rosland, MD, of Ann Arbor, Michigan, it’s titled, “Assuming the Worst.”

Dr. Rosland writes from personal and family experience. A beloved aunt would perhaps benefit from aggressive care, but a quick decision needed to be made. This aunt had a history of health challenges (and from the description of this aunt, “challenges” seems a more apt term than either “problems” or “issues”), and might well consider aggressive treatment. However, it was not initially offered. From Dr. Rosland’s experience and perspective, it wasn’t offered because of assumptions made by the responsible physician. The physician looked at the patient’s physical appearance, her immediate lab work, and general information from her history, and determined that the patient would not benefit. The physician did not, however, actually speak to the patient to learn about who she was, about her history, her perspective, and her hopes for the future. Because the physician didn’t really know the patient, and didn’t really try to know the patient, the patient was not initially offered all options for treatment.

Dr. Rosland speaks of “attitudinal barriers” to treatment:

Before this, I thought the challenges people with disabilities faced getting medical care were physical barriers: an examination table that doesn't lower, a mammography machine that the patient must stand up to use. But now Jean faced attitudinal barriers: clinicians' attitudes led them to assume that Jean couldn't handle chemotherapy, which they did not confirm before making treatment decisions. Jean had faced unfounded assumptions about her abilities before, but in the medical setting the assumptions seem more dangerous, in both their subtlety and their potential for harm.

Dr. Rosland notes that, “The idea that biased attitudes might contribute to health disparities is nothing new,” and connects this with our experience of assumptions based on race, ethnicity, or economics.

Unfortunately, the situation could be even trickier for people with disabilities. While there is no physiologic basis to assume that minorities will do worse with catheterization, knee replacement, or chemotherapy, it is reasonable to assume there might be medical contraindications to aggressive therapy in someone with physical disabilities. The problem comes when these assumptions are not tested with the individual patient.

Dr. Rosland concludes that, “The responsibility to overcome attitudinal barriers has to lie with those who make clinical decisions and the institutions they work in,” and she notes several initiatives that might provide models. She also “can't help but wonder if changing the circumstances in which we make medical decisions (time pressured, tired, without colleague input) would make us less likely to rely on implicit assumptions.” I can’t help but think she’s right.

Those of us who work in health care see these “attitudinal barriers” all too frequently, and always affecting the way, and the sort of care that is offered. We have our own in-house jokes and acronyms, the most famous and obnoxious of which might be “gomer,” an acronym for “Get Out of My Emergency Room!” Whether it’s an assumption that a patient will be difficult or noncompliant, or that the patient is drug-seeking, if we fail to test out that assumption patient by patient, we risk failing to provide care that would be meaningful and appropriate. If we’re honest, we know we have our biases. Where we fail is when we fail to wrestle with them, to test them, in assessing this patient, this situation, this decision.

When you have the chance, look up this article. It offers us another opportunity to return to the critical factor in medical decisions: the patient right in front of us; and offers it with both clinical and personal authority. For chaplains, trained to “exegete the living human document,” this is an always-timely reminder of where our attention needs to focus. For all of us who work in health care, or in any other field of service or ministry, it’s a call for self-examination: how do we raise “attitudinal barriers” to care, barriers every bit as real and as consequential as the physical barriers we sometimes find easier to see and confront.

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