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Sunday, March 28, 2010

How do Haitian patients' expectations resemble those of American patients?

My trip to Haiti was satisfying, the people remarkable, and though many things about Haiti were very foreign, there were some definite and unsettling areas of similarity between the patients I saw there and those I see in the US.

I expected to see people with horrible and potentially curable injuries and infections, and thought that bringing antibiotics would be exceptionally useful. Instead, I found that most people were very healthy, and that they had complaints that didn't correlate with any physical findings of ill health, and which certainly were not life threatening. Many of these discomforts appeared to be related to various forms of overuse, such as headaches related to carrying five gallon buckets of water on their heads for long distances, and pelvic disorders related to having many babies.  In general they were disappointed if I didn't have a drug or a test for their particular condition, and many were unconvinced or under-impressed with my explanations for their symptoms. I saw quite a bit of obesity and hypertension, and the hypertension was not treatable other than with instructions for lifestyle changes, since the vast majority of people could not afford a medicine that they would have to take daily, and I would feel uncomfortable prescribing one and being unable to monitor any blood tests or regular blood pressure readings.

So the general problems were related almost entirely to lifestyle and the patients wanted to get out of a doctor visit some sort of resources, be it a test or a pill.  The test or the pill had value, and since I was doing work for free, this was a chance to get something for nothing.

Now, not all of my interactions were of this type, and there were people glad of an explanation, also people for whom a consultation or a medication had real value, but most of my patients really did not need a doctor and seeing me did not particularly improve their health.

In the US this same dynamic is at work. People pay for insurance, or in the case of Medicaid, insurance is paid for them, and they wish to get value out of the resource outlay.  Tests are great, medication are great, all have intrinsic value, even if I, the doctor, don't see it that way. Unlike in Haiti, where very little is available in terms of medication and testing, in the US we spend huge amounts on both of these things, encouraged in many cases by the wishes (or presumed wishes) of our patients.

In Haiti, medical care and medications are available, to a limited extent, but though they are very inexpensive, they are outside of the means of most Haitians. In the US, procedures and medications are also available, but also cost more than most American's can really afford.

After a day of consultations in Haiti, examining people in a dark concrete room which was about 95 degrees and rarely giving them what they were expecting, my helpers and I decided that the whole process would have been much better if people had been expected to pay something, anything, even one goud (equivalent to a few cents). The patients would have self selected more appropriately and would have valued the interaction more. The same is true, I think, for American patients. I believe that having a real sort of contractual interaction with a caregiver focuses the interaction more effectively and gives it more value. I think the very fact of a medical appointment being paid for by insurance, as necessary as it has become, removes this important defining feature from a medical encounter.

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