Unwittingly, we set the stage for blame.
Greta needs a liver transplant. How long has she been an alcoholic?
Taylor has an STI. Did they use protection?
Anjali's HbA1c is through the roof. Has she been following the dietitian's recommendations?
Anton has lung cancer. Did he ever stop smoking?
As clinicians, our first thoughts in response to these scenarios are automatic, well intentioned, and necessary. Connecting the dots between risk factors and disease is part of our job. We know, for example, that having unprotected sex increases the risk of STIs and that smoking can cause lung cancer. This is invaluable information, and in talking with our patients, it would be irresponsible if we didn't make those connections.
That being said, elucidating the relationship between risk factors and disease also creates a challenging dynamic. Even as we do our best to empower patients with the information they need to take control of their health, we're simultaneously shouldering them with the burden of individual responsibility. Certainly, we have good intentions. We want to prevent disease whenever possible, or at least mitigate its impact -- but unwittingly, we're also setting the stage for blame.
The Natural Instinct to Blame Is Ultimately Counterproductive
Sooner or later, our patients' health will inevitably deteriorate, and when it does, we take the next best step. We see if we can get Greta on the transplant list. We make adjustments to Anjali's medications. Meanwhile, we lament that the decline in their health was likely preventable. If only Greta had stopped drinking sooner. If only Anjali had taken better care of herself. What we don't realize is that such thoughts imply the patient is to blame for their condition. Usually, it's not that we're blaming the patient intentionally. Rather, our neural pathways that link risk factors and disease are so robust that those associations, and the conclusions we draw from them, are simply second nature.
However, the narrative of blame (whether implicit or explicit) is fundamentally at odds with our calling to care for our patients. Richard Gunderman, MD, PhD, Chancellor's Professor at Indiana University, , "...to blame the patient when health is lost may be to fail to offer care precisely when it is most needed." Blaming patients doesn't only affect patients though; it also has a negative impact on us as clinicians. Subconsciously, we assume that blaming a patient for their deteriorating health will absolve us of our own inability to prevent an unfavorable outcome. However, in shifting responsibility to the patient, it keeps us focused on the decisions they made that were outside of our control. Therefore, it's an inherently disempowering defense mechanism. Although in the short term it can help obscure our own vulnerability to disease and make us feel a little safer, in the long run, it fuels our frustration and exacerbates our sense of despair. It's a natural response to that which is outside of our control, but ultimately, it's a counterproductive coping strategy.
We've Taken Some Steps to Move Away From Blame
Blaming patients is nothing new. From to , blaming patients for their symptoms, for contracting a disease, and/or for not complying with treatment, is more common than we'd like to admit.
There is good news though: we have admitted it. We've even acknowledged that blaming patients causes real harm, and as a result, we've made some meaningful changes to the ways we approach patient care. For example, instead of trying to convince a patient to stop smoking by shaming them, we've learned to use motivational interviewing, a framework that's grounded in compassion and respect for patients' autonomy.
In other words, we've already had plenty of practice with accepting the fact that our ability to influence our patients' decisions is limited. We do our best to inform them about the relationship between risk factors and disease; then, they go back out into the world and continue living their lives. They make their own decisions, they take certain risks, and they do what they need to do in order to make it through each day. There's no doubt that our patients' decisions can impact their health, but systemic factors also play a significant role. In recent years, we've grown in our understanding of the importance of social determinants of health, and we've realized that we need to take into account the ways in which everyone is a product of their environment.
But, we must admit, we haven't fully put an end to blaming patients. The next time we determine that what ails a patient was preventable, may we guard against the instinct to blame. As we continue learning to accept the things we cannot change, may we have compassion for ourselves and for our colleagues. As we face another day, may we have the fortitude to continue doing the best we can.
Shannon Casey, PA-C, is a physician assistant and former assistant teaching professor in the Department of Family Medicine at the University of Washington. She writes at .