Forget everything you thought you knew: how your assumptions are impacting the health outcomes of your patients.
Nahkita L. Wolfe
Saturday, September 24th, 2016
Modern health professionals are well versed in the value of person-centred care for their patients. However, the way we are taught to view our patients through a problem-based lens is counterintuitive to this person-centred approach. Medical professionals have learned to consider the diverse sociocultural contexts of patients as a “risk” to their overall wellbeing, rather than acknowledging the unique strengths of all individuals and communities. This focus entrenches assumptions into the way we approach patients of diverse backgrounds. These assumptions and the subsequent expectations that we hold of our patients have been evidenced to serve as powerful self-fulfilling prophecies for an individual’s overall health and wellbeing. Individuals will internalise negative health identities and have poorer health outcomes if health professionals hold low expectations of them based on their sociocultural “risks”. Strengths-based practice recognises resilience and focuses on the strengths, abilities, knowledge, and capacities of all individuals, rather than on their deficits, limits, or weaknesses. It provides a framework for health professionals to better support their patients in achieving their best health outcomes. A strengths-based approach has the ability to shift the broader deficits-based discourse that exists around the diverse sociocultural groups that exist in Australia. Changing this conversation is of immeasurable importance if we are to improve the health outcomes and agency of our patients and mitigate the persistent health inequities that exist within the Australian health system.
As modern health professionals in training, we have been well conditioned to consider all biological, psychological, and sociocultural factors that may contribute to poorer health outcomes in any given patient. We are familiar with the World Health Organisation’s definition of health as “a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity ”. But how does this translate into our practice? High patient caseloads and the sheer breadth of medicine compel us to streamline history-taking processes and problem formation through pattern recognition. We are taught to cluster “risk” factors – to make assumptions about disease, prognosis, compliance, and life expectancy, based upon sociocultural “risks”. We tick boxes. “Now, this is a question that we have to ask everyone, but do you have a history of previous intravenous drug use?”, “Do you identify as an Aboriginal or Torres Straight Islander?”, “Are you from a refugee or migrant background?”, and “Do you live in a rural or remote area?” We turn our attention to “vulnerabilities” and “high-risk groups” without much consideration of the impact of this focus and our subsequent assumptions on individual health identity.
The expectations we consciously or subconsciously hold of our patients, and the language we use toward or about them, inherently impact their health outcomes. In medical school, we are often taught to view our patients through a lens of deficit, by focusing on health problems rather than the opportunities that come from realising patients’ individual strengths. Strengths-based practice can shift this problem-based approach, and is a means of acknowledging the importance of our patients’ environments and diverse sociocultural contexts in the trajectory of their health attainment . Strengths-based practice is an ecological approach to individuals, families, and communities that recognises resilience and focuses on the strengths, abilities, knowledge, and capacities of all individuals, rather than on their deficits, limits, or weaknesses . A strengths-based approach is of immeasurable importance if we are to improve the health outcomes and agency of our patients, and mitigate the persistent health inequities that exist within the Australian health care system. This article will examine the impact of assumptions on patient health attainment and identity, the value and practicality of a strengths-based approach in the clinical setting, and the broader implications of our deficits discourse in the Australian public health arena.
Expectations and health identity
The expectations we hold of our patients can serve as powerful self-fulfilling prophecies for their overall health outcomes and identity. More than once I have heard a doctor use the phrase, “We save smart solutions for smart people”. This approach, however well intended, is damaging. Our clinical decision-making should not be influenced by expectations of noncompliance or assumptions of deficit. This is because health often exists at the nexus of societal expectations and our subsequent internalised perception of self. Essentially, if health professionals have high expectations of their patients, their patients are likely to have higher expectations of themselves, and subsequently experience better overall outcomes. This phenomenon is known in the behavioural psychology sphere as the Rosenthal effect, whereby our interpersonal expectations have been shown to significantly impact the learning, abilities, and health attainment of the subjects of our expectations [3,4]. We subconsciously facilitate “warmer” socio-emotional environments for individuals of whom we have higher expectations . We have also been shown to input more effort into maximising the outcomes of individuals we see as having greater potential . These subtle changes in the behaviour of care providers are internalised by patients and shape the expectations an individual holds of themselves . Negative internalised expectations have been shown to directly lead to poorer mental and physical health outcomes in patients . Internalised expectations may also directly act to motivate or discourage patients in their personal attainment of better health outcomes . Essentially, negative health care provider assumptions and expectations demoralise an individual’s health identity, and this in turn impacts the mental and physical health outcomes of patients [3,6].
Our clinical approach to Indigenous patients in Australia offers an obvious example of how health care provider expectations may demoralise an individual’s health identity. At the beginning of any consultation, we are taught to ask all patients if they identify as Aboriginal or Torres Straight Islander. Identification of Aboriginal or Torres Straight Islander descent is essential in creating safety for our Indigenous patients. Too often however, doctors aren’t asking about Indigenous identity in order to practice their (often limited) cultural competencies, but rather to unfold a new list of differential diagnoses, and to remember to ask about smoking, alcoholism, substance use, diet, and exercise. On examination of Indigenous patients, we are also taught to check specifically for signs of cardiovascular disease, hypertension, type-2 diabetes, and chronic renal disease. While such a comprehensive approach to all patient consultations is desirable, our underlying assumptions relating to our Indigenous patients’ health-seeking behaviours, and our expectations for their health prognoses, is problematic. These assumptions are one of the means by which racism is maintained within our health system. As health professionals who work to support others in achieving their best possible health outcomes, we are terrified to talk about racism, or to consider that we might be contributing to its perpetuation in the Australian health system. However, it is important to define what racism in our health system actually means, in order to understand our role in it.
There are three levels of racism that contribute to poor health outcomes for Indigenous people: institutional, interpersonal, and internalised racism [7-12]. Institutional racism is often established in political systems and sustained by the policies of governments and health institutions that discriminate against Indigenous peoples . Interpersonal racism in the health setting occurs when a health care provider makes assumptions about a patient on the basis of their Indigenous identity, or discounts Indigenous beliefs and practices . These discriminatory interactions may be communicated to patients through non-verbal or verbal means, and often alter the course of care for an Indigenous patient [8,9]. Internalised racism occurs when an Indigenous patient accepts the stereotypes of interpersonal and institutional racism, and allows these stereotypes to shape their health identity. Institutional and interpersonal racism are often not intentional, but remain uninterrogated and largely invisible in our health system. Sometimes it is highly visible, but still unchallenged and unchanged. By not acknowledging or confronting the racism that exists within our health institutions, we are reinforcing negative internalisation among Indigenous individuals, leading to negative mental and physical health outcomes [6,8,9]. If a patient is conscious of interpersonal racism, this has been shown to influence their participation in unhealthy behaviours, and directly contribute to the long-term development of cardiovascular disease, hypertension, renal disease, and alter some of the neurochemical processes involved in diabetes [6,8]. The high prevalence of these chronic conditions within Indigenous populations is therefore something that is perpetuated, rather than mitigated, through our current approach to Indigenous health. As health professionals, we must challenge our conventional health paradigms and disrupt the processes that blame such systemic problems on the “unhealthy behaviours” of an entire culture .
By utilising reductionist techniques to simplify care provision for our patients, we are limiting our patients’ ability to attain their highest standard of health, as well as restricting their agency and self-aspiration . An individual’s health is more than the sum of their medical issues – it is also determined by their personal resources. In medical school, we are not taught to identify the inherent strengths of all individuals, but rather to focus on health risks, problems, and limitations. That is, instead of seeing the potential that exists in celebrating the diverse sociocultural contexts of our patients, we regularly view sociocultural identity as a “risk” to overall wellbeing. This deficits-based understanding of health identity and our subsequent interpersonal communication is internalised by our patients, shaping their health behaviour and outcomes. We have the opportunity to change the conversation.
The strengths-based approach
Strengths-based practice is a well-evidenced approach in ensuring people have agency in their own health outcomes and identity. Strengths-based practice appreciates the centrality of people’s environments and sociocultural contexts in the attainment of their optimal health outcomes, and builds upon these strengths to reinforce health identity . A strengths-based practice framework involves six core principles :
- All individuals, families, groups, and communities have strengths, and the emphasis is on these strengths rather than on pathologies
- Communities are an abundant source of resources
- Interventions are built on the self-determination of the patient
- Collaboration is key, and a positive practitioner-patient relationship essential
- Outreach is utilised as a preferred mode of intervention, and
- All people have the inherent capacity to learn, grow, and change.
While strengths-based practice has not been formally implemented in the medical system, analysis of its feasibility in the social work setting may inform its rollout across the broader health sector. There are three developmental stages of health professional learning: socialisation, internalisation, and identification . Socialisation involves health professionals learning how to enable a strengths-based dialogue among their colleagues, so that their colleagues may then develop the knowledge and skills to empower others . Internalisation in this context is the process whereby health professionals internalise strengths-based principles in order to counter any barriers to enabling patients to see their strengths . Identification involves the recognition of tacit assumptions about patients, and the impact of these assumptions on health provider practice and their patient’s cultural context of empowerment . To shift our deficits-based approach to health care in Australia, health professionals must first be socialised to the concept of strengths-based practice, before we can then internalise its importance, and address any negative expectations we inadvertently hold of our patients.
The language we use to converse with our patients is often a product of the expectations and assumptions we hold of them. Paradoxically, our expectations are shaped by the broader public health discourse and problem-based learning that is indoctrinated into many doctors throughout their training. The rigidity of our health and medical education systems that institutionalise this deficits-based discourse make it difficult to universally adopt strengths-based practice across Australia. However as health professionals, we are still able to begin shifting this conversation and challenging the assumptions that we usually accept of our patients. Indigenous peoples in Australia are well versed in the power of strengths-based practice, and have identified three crucial ways we might enable positive change and start shifting our health discourse away from a mindset of deficit :
- Create safety: enable a space and process for robust discussion.
- Challenge mindsets, habits, and conversations: take responsibility, find courage, and lead by example.
- Co-create transformative pathways: engage with community groups to develop change and spread the word to engage in a national dialogue.
A deficits-based health discourse extends beyond interpersonal interactions of doctor and patient. As health professionals, our opinions are respected and hold legitimacy in public health discourse. How we talk about people matters because it plays a major role in shaping the public dialogue, and subsequently assists in setting a national health agenda for our politicians to action. We should be engaging in strengths-based health rhetoric and promoting the wellbeing of all individuals, rather than focusing on their limitations. As a result of our privilege, we have a duty to amplify the voices of individuals and communities who are working hard to shift our national dialogue to a narrative of strength, resilience, and opportunity.
Changing the conversation
Over recent decades, an emerging theme in the public health discourse has been a focus on health disparities between your “average Australian” and specific sociocultural groups. Arguably, this well-intentioned advocacy has been successful in fostering the next generation of compassionate and socially conscious health professionals. Many of my fellow students would attest that they entered their medical degree because they saw it as an effective means of helping people they perceived to be marginalised in our society. This motivation is exciting and provides fertile ground to generate unprecedented change to the inequities that persist in the Australian health system. But the fundamental assumption that our current deficits-based medical curriculum will enable us to effect positive change for marginalised groups is flawed. We assume that a medical degree, taught through problem-based learning, will provide us with the knowledge, skills, and sensitivity to offer the help that is needed. However, without realising the strengths of all individuals and communities, we are missing out on an enormous opportunity to celebrate resilience, reinforce positive health identities, and improve health outcomes for all.
Attention to sociocultural determinants of health has allowed us to raise awareness of persistent inequalities in our health system. However, focusing solely on deficits is detrimental to the broader narrative of the diverse sociocultural groups in our society. Drawing back upon the example of Indigenous health in Australia, large health promotion campaigns have been incredibly valuable in shedding light on the inequalities that persist between Indigenous and non-Indigenous Australians. These campaigns have also ensured that Indigenous health and education remain on political agendas, and they have secured funding for important programs. However, these awareness-building education and health promotion strategies have inherently focused on the “gaps” experienced by Indigenous people, and are an ineffective substitute for a whole government commitment to address the broader social determinants of health and shift our discourse away from deficit . If we constantly emphasise life expectancy “gaps” in our public discourse, without closely examining our role in the discriminatory policies and practices that maintain these “gaps”, we will only perpetuate the inequities that exist between Indigenous and non-Indigenous Australians. By continuing to allow deficits to eclipse individual strengths, we are doing our patients, their communities, and our broader society, a colossal disservice.
Our health discourse does not exist in a vacuum. As modern health professionals, we have an obligation to celebrate the individual strengths of each of our patients, and a duty to use our respected voice to shape the rhetoric that currently marginalises the diverse sociocultural groups that exist in Australia. So challenge expectations, transform mindsets, and check your assumptions at the door – together we can ensure better health outcomes for all.
Scott Gorringe, for his patience, persistence, resilience, strength, and friendship.
Nicholas Fava, for his invaluable assistance in proofreading this piece.
Conflicts of interest
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