On (not) blaming patients

Should doctors blame their patients?

(edited version published as a debate piece on Pulse Today)

Working in Hoxton in one of Hackney’s most deprived wards, where the high rates of alcohol and drug abuse, cigarette smoking, domestic violence, child abuse and all kinds of other criminal behaviour may give me more reason than many GPs for finding fault and blaming my patients, I would like to argue, briefly, that blame is not helpful.

One doctor whose patients have more reasons than most to be on the receiving end of blame is Gwen Adshead, consultant psychiatrist at Broadmoor hospital. The violent crimes her patients have committed put our patients’ ordinary misdemeanors into perspective. She describes the dividing line between good and evil in an inspiring presentation for the Forgiveness Project.

There is, I think, a distinction between blaming someone and holding them responsible. Blame implies a finality, “You’ve bought this on yourself and you’re on your own now.” As doctors, we are bound to work with patients who may be blameworthy, but they may also be vulnerable and so it is not good enough for us to cast blame when we could be helping them take responsibility. This is what Adshead does by helping her patients move on from a position of “it wasn’t me, it was my illness”, to ‘it was me, but it was an old me and I want to engage with a new me”. Understanding why patients behave the way they do and engaging with them and helping them take control is hard, therapeutic work and it is part of doctoring. But this takes time and energy that many of us feel we are desperately lacking.

Adshead’s patients like many of our own patients are no strangers to blame, fuelled by media and political rage against the poor, the obese and now immigrants with HIV for being a burden on the NHS and the economy. Blame and shame are internalized and the harshest criticism is often self-imposed.

We should also be concerned by how blame affects us because blaming others is both symptom and cause of our own unhappiness. When we are overwhelmed we tend to blame our patients for demanding too much, but consultations where our patients are blamed leave both parties feeling miserable. Refusing to blame patients is a way of showing compassion for our own distress.

It is interesting, but unsurprising that one study of GPs who work in challenging areas found that,

Doctors were motivated by the belief that helping a disadvantaged population is the ‘right thing’ to do. They were sustained by a deep appreciation and respect for the population they served, an intellectual engagement with the work itself, and the ability to control their own working hours (often by working part-time in the field of interest). In their clinical work, they recognised and celebrated small gains and were not overwhelmed by the larger context of social disadvantage.

I recently reviewed some qualitative papers that looked at parents’ experiences of consulting with sick children. Parents were acutely sensitive to accusations of timewasting and hated being made to feel stupid for consulting either when their child was not sick enough to be worthy of the doctors’ attention or so sick that they had left it too late. The conclusion I drew from the papers was that what parents wanted from doctors was not just reassurance, but confidence. It was of little use to know that their child was OK at the doctors when what they wanted was the confidence to know that they would be able to cope with a sicker child later on. Giving confidence is empowering and empowering parents helps them take responsibility. Humiliated parents are disempowered and leave anxious and upset. The next time their child is unwell, they seek help elsewhere in the hope that their fears won’t be belittled or dismissed.

It is frequently claimed that there should be no rights without responsibilities driven by a steady rhetoric of the powerful telling the powerless how to behave. But it is with power that responsibility lies. The powerful can access what they need or desire through force, wealth or contacts without resorting to rights. Rights are to protect the powerless and are therefore unconditional. When we talk disparagingly about ‘the entitled masses’ or ‘rights without responsibilities’ we miss this important distinction. Our patients need empowerment not blame. The right to compassionate, empowering care is unconditional. It is at the heart of why the NHS is so precious. And if the NHS is to be sustainable for the future, patients and professionals need to be partners, not enemies.