Jan 23, 2014

Anti-poverty movement, meet the culture of medicine.


The evidence for the burden of income inequality on health is plentiful and convincing, with inequity and its health impact both increasing in British Columbia in recent years. Many voices are calling for attention to poverty reduction and a living wage. But what happens when you add doctors into this conversation?

Progress and challenges both.

Some physicians are at the heart of a growing movement towards addressing poverty’s burden on health as a central social determinant of health (SDOH).  Programs like Rebecca Onie’s Health Leads USA (and a exciting pilot project ignited by ImpactBC called Basics for Health) are entering the landscape. In Ontario, colleagues developed a poverty toolkit, and now Nova Scotia is following suit.

Despite welcome and sincere media attention to this issue, headlines this week are noxiously missing the point by announcing that doctors want to know How much do you make? Although poverty is central to our patients’ abilities to pursue health and treat illness, it’s not about how much patients make. Researching how to address poverty in primary care, I have learned that this practice must be imbued with sincerity, clarity, and evidence. Income figures matter little; what matters is opening the door to the black box of SDOH, uncovering a patient’s barriers to health, and being respectfully present with the powerlessness that often accompanies poverty. The headline suggests an absurdity to the practice of treating poverty in primary care. That absurdity is worthy of attention if we wish to move beyond it to meaningfully address inequities in clinical medicine.

For the last several years, the Canadian Medical Association has made health inequities a priority issue. This is a substantial shift from Dr. Brian Day’s tenure as president in 2007, when the association more openly sanctioned for-profit services in Canadian health care. However, polarized views and motivations persist, more visible than ever before. Doctors are divided between those moving towards addressing inequities by taking on complex patients, and those trying to avoid them. Doctors have a history of cherry-picking patients that began at the inception of Medicare, and continues today. We label patients as “difficult” or “non-compliant”. One reviewer of my research on poverty screening said that the concept made him “uneasy”.

The truth is that our health system discriminates, and this makes addressing inequities hardly absurd, but certainly difficult. It is a consequence of a system in which the demand for doctors is greater than the supply. When there is always a lineup of patients and potential patients knocking at our door, we have little opportunity to wonder, who isn’t knocking loudly enough, or at all? We are attentive to the needs of individual patients, but not to the needs of our practice populations. Among those not in the lineup at our door are the patients with the most barriers who suffer from the greatest burden of disease, and further from lack of appropriate care. We need to look beyond reluctance and absurdity if we want physicians and health systems to broaden their practice of triage to identify the most vulnerable patients and better serve those in greatest need rather than those who are easiest to treat.

I recently conducted focus groups with patients, doctors, allied health providers, students and community advocates together around the table, asking how we can address poverty in primary care. The complexity of the issue became quickly apparent. Doctors feel powerless when they can’t address a problem, so they prioritize biomedical issues and avoid psychosocial ones in a sort of don’t-ask-don’t-tell policy. Patients were shocked that physicians could feel powerless in face of the profound disempowerment of being trapped in poverty, a powerlessness that doctors couldn’t begin to understand, they said. This disempowerment is further amplified by having concerns unacknowledged, or worse, dismissed in favour of the physician’s priorities. Poverty simply isn’t allowed in the clinical encounter, they told us.

Unfilled prescriptions are a good example. The medical profession rarely looks beyond the label of “patient non-compliance” to the common problem of unaffordability of prescriptions (let alone to advocating for a national Pharmacare program that could help mitigate the problem of rising pharmaceutical costs). And yet the cost of medications is just the tip of the iceberg. For a patient struggling to make ends meet, transportation to an appointment, child care during it, time off work to attend a follow-up visit, caregiver burden, and other health system externalities, are significant costs. Because poor patients suffer a greater burden of disease, these costs are higher for those least able to afford them, perpetuating inaccessibility within health care that is embedded in poverty.

Prescriptions are also quick and easy clinical interventions, and can provide both physician and patient with a tempting illusion of treatment and cure. But patients described leaving the doctor’s office often not knowing what prescriptions were for, feeling that their real concerns were not addressed, and deeply “…frustrated. And for a lot of us that have addiction problems, the first thing we do is get frustrated, and turn back to drugs.” Such suffering resulting from a lack of acknowledgment and support isn’t surprising given substantial evidence for the significant and negative impact of perceived discrimination on health. 

In this context, asking patients how much money they make misses the point entirely. However, the absurdity of these words echoes a persistent reticence to address SDOH, in particular by physicians who want to do their usual business, and those increasingly restricting their practice to healthier, wealthier patients. A lack of understanding of our professional obligation as advocates doesn’t mean we should evade this role. To identify patients in greatest need, we must hear the stories of those struggling to make ends meet so that we can deliver appropriate care to them. Asking patients about poverty and treating it with non-judgment is central to that task. As one patient said: “You don’t have to say are you a poor ass, or are you living in a box. You don’t say it like that. I mean doctors are a little more well bred than that… well most of them, anyways.”

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