Browsing for articles on the concept of the ‘good patient’ I came across an article by American Asset Protection Specialist entitled ‘Get Rid of Bad Patients’. In it he listed 5 types of patient who should be fired. These included:
- Problem patients who complain, are negative or abusive.
- Patients who miss appointments, fail to pay bills and fail to take care of their health.
- Patients who are self-obsessed.
- Patients who cost a lot to treat and take up time (old and chronically ill/disabled).
- Patients who watch TV every day and are thus more likely to sue.
After each group came the words “Get rid of them”. Once these patients were removed the practice would be more profitable and less stressful. Although an extreme example, set in a context without a universal healthcare system, the categorisation of patients as ‘good’ and ‘bad’ has been around for a long time and is still very evident amongst healthcare professionals and policy makers. What makes this categorisation different from early references to ‘heartsink’ patients, who also elicit negative feelings, is the profit factor.
As far back as 1960’s articles were appearing in nursing and medical journals categorising patients as good or bad. Whilst profitability was not a factor in the early UK based studies, utility, ease of treatment and moral judgements about deserving and undeserving patients were key criteria. Jeffrey (1979) found that A&E patients were categorised by the clinicians treating them according to a set typology, good patients were ones who: allowed doctors to practice the skills needed to pass professional examinations (i.e. those with unusual conditions); allowed staff to practice chosen specialisms; stretched the resources of the staff and department. Bad patients (‘rubbish’) were those who: attended A&E unnecessarily; were drunk; had taken overdoses or were homeless. Interestingly, characteristics that made patients ‘good’ were condition specific whilst characteristics used to categorise patients as rubbish were person specific.
In 1982 Kelly and May reviewed the literature and argued that patients are not categorised as good or bad based on any inherent characteristics in them or their behaviour, but as a result of their interaction with healthcare professionals. They further argued that much research in this area is empirically, methodologically, epistemologically and theoretically suspect, and yet these categorisations continue to be used by healthcare and policy professionals and reported in research papers, and patients are still categorised either overtly or covertly and treated accordingly.
In our recent work on the understanding and practice of patient-centred care in dentistry bad or difficult patients were those who chose not to engage (whether due to dental anxiety or depression), or engaged too much (asked too many questions, came with too much information, were demanding, took up too much time). And yet, as highlighted in a previous post ‘Taking responsibility for our health’, NICE chairman David Haslam, has recently recommended that patients should educate themselves and enter the surgery aware of the treatment options available and willing to assert their right to the best available treatment. Following this NICE logic, a ‘good’ patient is one that is informed, educated, confident and assertive. This ties in with the literature on empowerment and the expert patients that has emerged from research and practice around long-term conditions, but contradicts the reported views of healthcare professionals in ours and other studies.
What is apparent from looking at the research in this area is that categorisations of ‘good’ and ‘bad’ patients are context and healthcare professional specific. Professional rhetoric is around good patients and bad patients (and how this is characterised in terms of those who accept the passive medical model and do what doctor says, and those that don’t) whereas policy rhetoric is about good patients and bad professionals, where good patients are those that hold professionals to account. In this context, the patient is used by professionals to legitimise their exalted expert position, and is used by state (through policy) to undermine that exalted expert position.
But where does this leave patients? The advice that they receive is contradictory and the characteristics that they are required to display vary by location and encounter. What unites these categorisations and the judgements that are made is the idea of culpability. In the American example in the first paragraph patients who are old, poor, chronically ill, challenging, or at home during the day are ‘bad’ patients. Other studies refer to those with self-inflicted health problems, those who fail to look after themselves, those who don’t make enough money to pay for care, those who fail to engage sufficiently and those who engage too much and are demanding. All of these are deemed ‘bad’ patients. In almost all of these examples (with the possible exception of age and some long-term conditions) there is an assumption that patients have a choice and that they therefore should take responsibility for the person specific components of the situation that they find themselves in and retain culpability, whilst deferring to professionals, for the condition specific components. This call for personal responsibility, inherent in health policy from 1980’s onwards, precipitates a judgement of culpability and leads to representations in the media of bad, irresponsible, undeserving patients and the calls for alcoholics to pay for hospital treatment or those who miss appointments to be removed from treatment lists.
Such rhetoric makes it possible for us to make moral judgements about who deserves treatment and who does not. Furthermore it is invariably the most socially vulnerable who are classified as undeserving. This is particularly dangerous when coupled with current rhetoric around a funding crisis in healthcare and welfare and the need for rationing. It fundamentally damages the foundations of a universal healthcare system which proclaims to be ‘free at the point of use according to need and not the ability to pay’, perhaps even suggesting an alternative formulation around the notion of “free at the point of use according to need and the ability to take responsibility for personal failings at the point of clinical need.”