In a Dec 2009 blog post, I wrote that too many patients with end-stage renal disease (ESRD) are waiting for a deceased donor kidney. They would have a much shorter wait and experience better outcomes if they could find a live kidney donor. I am currently working with Harvey Mysel and the Living Kidney Donors Network to set up a program in Seattle to provide training to patients to give them the tools and the confidence to find a donor.

Part of my effort includes learning as much as I can about working with patients. I have plenty of experience in public speaking, having been a market research consultant. But in that case the audience consists of highly driven business executives. I have some experience working with disadvantaged populations, having been a volunteer tutor in an adult literacy program. But I do not have any experience working with medical patients. How does one instruct and motivate kidney patients who are quite ill? Even more concerning to me, can I effectively work with patients who have behavioral or emotional problems that make me uncomfortable? What about physical appearance? The leading causes of kidney failure are diabetes mellitus and hypertension, both of which are highly correlated with obesity. Will I consciously or even unconsciously blame overweight patients for their disease? Hopefully, just knowing I have a potential bias may help prevent me from allowing it to affect my ability to help.

While pondering this, my wife forwarded an article entitled “How clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research” that appeared in Philosophy, Ethics, and Humanities in Medicine Jul 2010. It is a review of 141 articles on how clinicians form moral judgments regarding patients and how those evaluations affect empathy, level of care, and the clinician’s own well-being. Just reading the list of references to the article is an eye opener. Below are some selected quotes from the article.

“The paucity of attention to moral judgment, despite its significance for patient-centered care, communication, empathy, professionalism, health care education, stereotyping, and outcome disparities, represents a blind spot that merits explanation and repair… Clinicians, educators, and researchers would do well to recognize both the legitimate and illegitimate moral appraisals that are apt to occur in health care settings.”

“[T]he treatment of medically unexplained symptoms… varied by patient ethnicity, physician specialty, the spatial layout of the clinic, and the path sequence of patient contact with physicians and ancillary personnel.”

“[N]urses judged dying patients by their perceived social loss, often giving ‘more than routine care’ to higher status patients and ‘less than routine care’ to the unworthy. People dying from a Friday night knife fight, or the adolescent on the verge of death who has killed others in a wild car drive, have their own social loss reinforced by an ‘it’s their own fault’ rationale.”

“The patients and physicians were able to gauge whether the other liked them, and that perception predicted whether they themselves liked the other. Physicians liked their healthier patients more than their sick patients, and healthier patients liked their physicians more. Physician liking predicted patient satisfaction a year later.”

“Poor patients belong to outgroups of particular interest in healthcare. Public hospitals serving these groups comprise only 2% of acute care hospitals in the United States but train 21% of doctors and 36% of allied health professionals. Primary care physicians serving poor communities are often troubled by what they perceive as their patients’ inadequate motivation and dysfunctional behavioral characteristics.”

“One of the factors that may prevent clinicians from triggering moral appraisals is interest, often equated with curiosity… Good teachers have stressed the value of curiosity for clinical care… ‘One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.’”

“Once a stimulus–or perhaps patient, for our purposes–appears beyond one’s comprehension and ability to manage, interest wanes. These appraisals mediate individual personality differences in curiosity and the experience of interest… [W]e can use interest to self-regulate our motivation. When intrinsic motivation lags, we can activate strategies to engage our interest and thereby remain motivated for the task.”

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