Wednesday, September 10, 2014

Helping Those Who Won't Help Themselves: The Role of Personal Responsibility in Medicine

Give a man a fish, or teach him to fish.
It is a well known secret in medicine:  many of those we care for are unconcerned with their own care, as evidenced by their revealed preferences.  "What medications are you on?" the physician asks.  "I don't know, doc," comes the reply.  "Why are you on carvedilol?"  "I don't know."  "What was your last HgbA1C?"  "What's that?"  We have encouraged physicians and other professionals in the healthcare system to take responsibility for every aspect of patient's care to the peril of patients' own interest and investment in their care.  How often do you enter a room and find a patient researching their illness and its treatment, rather than surfing the internet or watching TV?  Is your patient more concerned with the timing of the next dose of antibiotic or the next dose of dilaudid?  How often do your patients keep detailed records of their past medical history?  Why does the intern or resident or PA or NP schedule follow-up appointments for patients, rather than the patients do it themselves prior to discharge?  Why must so many patients be coaxed out of bed and working with physical therapy?  The actions of patients reveal their preferences.  Those who are invested in their own care take responsibility for it and are knowledgeable.  Those who would rather watch television than work with physical therapy reveal other priorities and preferences.

All the hubbub about healthcare and health disparities has entirely glossed over the role of personal responsibility and accountability in medicine.  Some may find it inexcusable that many patients have so little investment in their own health care, expecting instead that the government, their insurance company, and the healthcare system at large allows them to abdicate their own personal responsibility without consequences.
(I am not here referring to people who are unable to care for themselves, but rather those who are perfectly capable but who shirk the responsibilities.  If you cannot accept this and wish to accuse the author of "blaming the victim" read no further.  Yes, the victim of disease is being blamed for any lack of personal responsibility that is contributing to poor health.)

If there is a lack of personal responsibility in medicine, there are several important implications that we should be concerned about.

The first is that there simply is no substitute for an invested patient.  No amount of effort on the part of physicians and the healthcare system can serve as surrogate for a patient's own dogged interest in and participation in their care plan.  I will not belabor this point further, because I consider it self-evident.

As a corollary of that, it may well be that there is decreasing marginal utility of healthcare investment in uninvested patients.  That is, a unit of effort expended on an invested patient leads to X improvement in outcome, whereas that same unit of effort expended on an uninvested patient leads to an improvement that is <X by some function.  Thus, to maximize utility the physical therapist should spend more time with the invested patient who is almost convalescent and ambulatory, and less time with the bedridden patient who is a non-collaborator in their care.  This will not sit well with people of certain political and philosophical persuasions who will cry foul and accuse the utilitarian of begetting and abetting healthcare disparities.
(It also stands to reason that some proportion of the effort invested in uninvested patients is wasted effort because it has less utility.)

The second implication has to do with the burdens placed on healthcare providers and the untoward downstream effects on healthcare that trying to use "the system" as a surrogate for personal responsibility foments.  I know a very overworked provider who has begun telling patients that he will no longer negotiate on their behalf with their insurance companies.  He will write the Ambien prescription, but if Aetna will not pay, that's not his problem.  "That's between you and your insurance company," he tells them.  And perhaps it should be.  Why do patients expect that he should pay an office worker to spend 10 or 20 minutes on the phone to argue with their insurance company so that they will not have to pay out of pocket for Ambien ("Ambein' Delirious") or negotiate on their own behalf?

The intern and his resident spend three hours admitting a "train wreck" and "frequent flier" who is a non-collaborator in his care and is non-compliant/adherent.  While they are so engaged, several other patients must be neglected.  Moreover, many years of taking care of patients who do not take care of themselves begins to wear on the psyche of those house officers, making them jaded and causing compassion fatigue.  "Why do we work so hard to take care of this guy when he doesn't care enough to take care of himself?" is a question that is asked only behind closed doors and whose rhetorical answer provides little solace.

As a final implication I'm going to posit that compassion fatigue may result because of the moral weight of helping those who can, but will not, help themselves.  Many Americans have a moral belief that people have a responsibility to take care of themselves, and that the exertion of effort on your own part makes you more deserving of the help of others.  (Surely you can think of many examples of this in your everyday life - if not, perhaps you should move to a less gentrified neighborhood.)  Symbolic affronts to this brand of morality happen frequently to the RNs, when a perfectly capable person pushes the call light and asks the RN to get the Sierra Mist that is in reach if the patient were to reach two feet to the left.   Or the patient who is capable of getting to the bedside commode but prefers that the nurse clean them up in bed.  Another implication may be that the healthcare system, by not requiring people to do things for themselves (such as make follow-up appointments, negotiate with their insurers, educate themselves about their illnesses and be knowledgeable about their past medical history) engenders moral hazard - that it encourages indifference, because of the expectation that others will take care of your problems.

It has become unpopular to complain about or even discuss the failure of patients to take responsibility for their own health.  But a discussion of healthcare outcomes, disparities in healthcare, value in healthcare, and changes in the healthcare landscape require that we consider it.

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