Monday, June 6, 2011

[1/2] Finding someone (or something) to blame.

When things don't go well, we often look for someone (or something) to blame.  You could say it's almost human to do so.  But that doesn't mean it's the right thing to do, nor does it excuse the finger pointing.

As with most things I blog about, I started thinking about finger pointing and blaming people when I made the mistake of finger pointing and blaming people.

We were in our endocrinology block and our lecturer was pointing out the strong correlation between obesity and type 2 diabetes. Absentmindedly (not an excuse), I remarked "hmm, well it's the patient's fault isn't it?  We suggest lifestyle changes and nutrition changes when we catch them in the prediabetic stage, but they don't do anything about it, and end up with full blown [type 2] diabetes".  

Harking back to an older post, this is when having good friends who will call you out is very important.  One of my close friends got on my case for having such a "blame the patient mentality" (which I don't, but I still deserved to be called out for my comment), and I got to thinking about the "blame the patient" mentality.  

I guess two things need to be clarified:

1. Blaming is just plain silly:
It doesn't do anything about the situation.  It just makes people feel bad and it causes resentment.  All of which are barriers to improvement - which is what we should all be struggling towards.

2. Blaming implies judgement.

No one is ever in a position to judge anyone else.  

2 (addendum): As doctors, our job isn't to judge: it's to heal and maybe even prevent.

But all of those have to be separated from the concept of a root cause.  You always need to search for the root cause.  But it has to be done without blame.

It's analogous to working very hard on something, but being detached from the outcome (as the buddhists and hindus say).  It isn't easy to do, since the work itself (eg. studying for an exam) tends to attach you to the outcome because the outcome tents to be a big driving force (eg. doing well and getting an A).  It is very easy to forget you are working hard because you want to, or because that's what the task deserves.  In the case of medical school exams - it's the idea that some patient in the future may need you to know that tiny detail that could change everything about his diagnosis and/or treatment.

It's similar in root cause analyses.  You work hard to find the root case, and when you get to the "end", it's very easy to try and blame the cause on something.  But it's almost always better to focus on how to deal with the cause.  Dealing with the cause doesn't mean you blame the cause.  In this situation, there's a tiny detail that might make it easier to not blame - to not get attached to the outcome.  The reason you started looking for and analyzing the root cause is to help a patient.

Blaming the patient does not help the patient.

Here's an example: obesity is highly correlated with T2db (type 2 diabetes).  One of the major reasons we have an obesity epidemic is because of the amount of junk food that's (cheaply) available coupled with low physical activity.  Blaming people doesn't do much.  But pointing out that it is something that can be controlled by each and every American is important - we need to empower people to do something about it.  But we have to do it without blaming them.

It is very important to tell our patients that controlling T2DB progression is in their hands.  Weight and exercise will prevent / prolong the onset of T2DB damage.  Contrast that to something like Huntington's disease: the patient has little to nothing they can do to halt it's progress.  So we need to present them with the information, urge them to follow it, but not blame.

I guess my point is it's a very thin line between falling into blaming the patient for something and pointing out these points to improve the patient's life.

I guess it's the difference between

"You have t2db because you are fat.  It's your fault, and you should change how you live"


"Your t2db is probably caused by your obesity.  I can give you some medications for this, but the best way to control and reverse this disease is by lifestyle changes.  But to do that, I'll need your help and your commitment to these changes. I am here to help you through this, so let's talk about what we can do to get you to a healthier lifestyle."

Not judging?  Check
Actually trying to help the patient? Check.

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