The phrase “garbage in, garbage out” is used to remind computer science students that a system can only process the data it is given, but this axiom is indispensable in medicine too. After all, without knowing why patients behave in the ways they do, physicians stand little chance of helping them get heathy and stay well.
Following are highlights from an article published in the AMA Journal of Ethics® (@JournalofEthics) by Saul J. Weiner, MD. He is deputy director of the Center of Innovation for Complex Chronic Healthcare at the Jesse Brown VA Medical Center, in Chicago.
Using a hypothetical case of a Spanish-speaking woman with end-stage renal disease who has been missing her hemodialysis appointments, the author explicates the harmful effects of judgmentalism on poor and marginalized patients and the ethical importance of contextualizing patients’ care.
Many patients who are nonadherent are facing economic, logistical or family challenges that prevent them from sticking with a treatment plan. Indeed, their situations might be untenable, and their decisions might be perfectly rational.
One root cause of physicians’ not recognizing this, Dr. Weiner noted, is the failure to investigate.
“A common reason we don’t ask questions is that we think we already have the answers,” he wrote. “When we assume that individuals are behaving irrationally without any knowledge of their situation, we are passing judgment on them. Rather than looking for situational explanations for an observed behavior, we are attributing that behavior to dispositional or personality-based factors.”
In social psychology, this is called fundamental attribution error.
“It amounts to thinking, ‘If you don’t show up for a medical appointment it’s because you are irresponsible or lazy, but when I miss appointments it’s because of traffic or my day care provider calling in sick …’” he added.
Another reason for the misunderstanding is a cognitive bias known as the just-world fallacy.
“Advantaged groups may believe that the world works for those who try hard and do right and hence that those who are faltering have simply made poor choices,” Dr. Weiner wrote. “Even physicians who have overcome great odds are not immune, as they can fall into the trap of thinking, ‘I pulled myself up from my bootstraps; what’s wrong with you?’”
This belief seems to minimize the unease people feel when confronted with evidence that bad things happen to good people. Both fundamental attribution error and just-world fallacy disproportionately affect poor and marginalized patients because they are most likely to appear to be struggling.
Nonadherence should be seen as a red flag that a hidden backstory could explain the patient’s seemingly irrational behavior. Losing control of a chronic condition, not refilling a prescription and missing an appointment, for example, should be seen as clues rather than failings.
“Solving mysteries begins with asking questions, starting from the premise that individuals have reasons for their behavior or are at the mercy of factors that are beyond their control,” Dr. Weiner wrote. “Hence, the antidote to passing judgment is to ask patients questions instead of making assumptions.”
This can help reveal a patient’s life context, which could include competing responsibilities, loss of social support, financial hardship, difficulty accessing care or environmental factors.
“Because contextualizing care is based on the premise that everyone is doing the best they can given the cards they’ve been dealt, it advances health equity,” Dr. Weiner wrote. “Rather than judging patients, physicians partner with them to identify and help address the challenges they face that so often complicate their care.”
The February 2021 issue of AMA Journal of Ethics further explores racial and ethnic health equity in the United States.