Words are powerful. So few symbols can evoke such deep feelings and rouse incredible emotion: “I have a dream.” Language is the achievement that makes us who we are. But while you, I and everyone else employ the same words to communicate shared ideas, what those words mean precisely to each of us — among the many views and opinions that make us unique individuals — can be very different.
I know there are phrases that I interpret, mistakenly, as shorthand for more complex ideas. And I think some bigger misconceptions are affecting all of us more than we might think.
One troublesome word is “noncompliant.” If a patient has been labeled noncompliant, he must not really want to get better. I can belabor the same points ad nauseam, it will not change his behavior. This is, of course, an unfair mischaracterization of any individual – But we’ve all heard it, and we’ve all said it, and we’ve all thought something like this before.
Because we’re motivated to do the most good for our patients but also limited in time and resources, we sometimes make a subconscious egalitarian decision to invest a little less into the care of this patient. We know we can do plenty for the patients who want to get better, so we should focus more on them, to maximize our own impact.
We should erase noncompliance from our collective vocabulary — not in the name of sensitivity, but because using it allows us to circumvent the real issue. When we accept a patient’s noncompliance, we have failed at addressing the root cause of his disagreement with or inability to follow our recommendations.
Another that gets me is “telemedicine.” I know that technology will change health care. Still, when I hear about a telemedicine consult, I picture a clunky and ineffective process that can’t possibly be as good as a provider’s real presence. I am of course wrong here as well: these tools are validated and help expand the reach of specialist providers.
I don’t know where this bias started, just that it’s there, and that it’s not unique. I wonder how I would feel if my family member were evaluated, say, through a screen by a teleneurologist in the ER who has the final say on whether or not to give tPA. I think I’d rather hear that a neurologist evaluated them, and that the best one available was remote. I also realize that this is irrational.
But these are small fries. There are bigger distinctions to make, and they are not semantic.
When do patients become patients and when do they revert to being just people? Aren’t they people all along? Is an individual with a chronic illness still a patient between care episodes? If I’m not sick, do I become a patient when I go for a physical? What about a woman on the threshold of a diagnosis? A man warehoused in a nursing home for social reasons?
We should erase the notion of being a patient altogether, and speak instead about people. This could change how and when we engage with one another, and might even facilitate a more proactive culture of wellness which we so badly need. It might change ideas about responsibility for health decisions. It would absolutely change our biases about where people need to be when they’re engaged with health or medical services.
But for that matter, what is health care? Is it a label for any interaction aimed at improving someone’s well-being? Is it limited to exchanges between sick people and licensed professionals? Is it the sum of services provided within the walls of the health care system? (And haven’t we created those ourselves by defining what insurance pays for?) What about services done in a hospital — by a provider, paid for by insurance — that aren’t necessary in the first place?
When we talk about the health care system, we all more or less mean the sum of experiences between patients and providers, in hospitals, clinics or other designated settings, involving services which are intermediated by insurers. And there are some colossal problems to unpack here.
Imagine that a patient, at her yearly physical, has no complaint beyond that she feels out of shape. On paper, she may not meet the criteria for any diagnosis. Many providers can help her now and can do much more for her today than they could a year later, but they won’t be doing health care — at least not in the way we’ve allowed it to be defined by codes and payers.
Maybe what this patient means is that she feels the symptoms of early insulin resistance, that she’s at risk for and progressing towards developing diabetes, but it’s not her job to know or tell us that: it’s our job to tell her and to do something about it.
Insurance won’t pay for healthy food or exercise education, and that means care of that type happens outside of the health care system. The existence of codes attached to diagnoses on paper literally stops us from doing the right things to care for this person. Paradoxically, a system which is supposed to enable care is now dictating it.
There are too many elderly at home right now deteriorating in functional capacity who we will not know about until they fall and become patients.
Even if we could identify them today and engage with them before injury —thereby preventing a massive and costly sequence that shortens lifespan and creates lasting disability — that would not be the practice of health care.
Would we be providing care to people who need it, at the right time, and in a way that could impact them more than anything we might do after the fact? Absolutely, but not in a way that this system is designed to operate (i.e., receive payment for).
If we started from scratch today and redesigned the delivery of health care, we would never build what we have now. We would never use the words that we do because we would never arrive at these inverted concepts. We might not build a health care system at all, but instead engage with people proactively — often at home, I’m sure. Instead of paying for procedures and hospitalizations, we might create a population budget as we do for education, I can’t say. The important thing is that we wouldn’t impose the barriers that exist now, and we wouldn’t think of people as needing our help only after they become sick and can be called patients.
Nothing became this way on purpose. We evolved in this direction through dynamic societal pressures and adapted to succeed in relation to the payment models presented to us. The language that we use, which has meaning only in this context, connotes very real bias that influences health decisions enormously. We won’t ever stop calling people patients or talking about the health care system, but we should be mindful of the ideas attached to those words, and always question whether the choices we make might be different if we could erase those preconceptions.
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