Thursday, March 06, 2008

The Soft Bigotry of Low Expectations of Patients

The 'soft bigotry' phrase was often used by President Bush in his campaigns with reference to education (it's not clear where the phrase originated). However, I think the phrase also applies to healthcare professionals and how they interact with their patients. The notion of discrimination in healthcare is not new. However, I was surprised to find myself carrying these biases in a recent patient encounter.

The patient was an elderly male from a minority group. At first glance, he seemed to be a nice enough gentleman, but perhaps from one of the lower social strata. I don't think I made any conscious judgments about the patient as my preceptor began describing various treatment options. My preceptor tried to explain the options to the patient in terms the patient could understand. However, I was surprised to hear the patient respond with the technical terms for the procedures (terms that, frankly, I did not know myself). My attending could not hide his surprise as well. He gave the man a puzzled look, to which the patient replied, "Last time, you gave me a booklet about my condition. I read it."

Well, duh. Why should we have expected any less?

At first, I'll admit that I just found this amusing and was glad that the patient was so invested in his own health (and, I still find this fact reassuring). However, my narcissistic side soon started to reflect on my own visceral response to this exchange. Why had I expected this patient to be any less interested in his own health than the most well-to-do appearing patient? I suppose to some degree we cannot help our prejudices, and should strive to mitigate them and certainly never act on them. I cannot tell what exactly led me to have low expectations of this patient (his race? his age? his speech patterns?); regardless, these low expectations surely would shade whatever treatment decisions I would make. Perhaps, were I the physician, I may subconsciously choose to be less aggressive with his treatment, or not describe the options as fully. I certainly hope that I treat all my patients the same, but such pre-formed expectations are hard to dislodge if one is not even aware of them.

So, how should we change these low expectations? Clearly, the long-term solution requires social change in terms of education, healthcare delivery, and cultural attitudes. But, for now, perhaps a more modest systemic solution is necessary. I believe that the low expectations I had were formed partially due to repeated interactions with patients and families who were unaware and ill-informed about their diagnoses. To change this, the healthcare system should adopt a uniform standard for informing patients about their diagnoses, especially for major/chronic illnesses like cancer or diabetes. There is already a precedent in place: all children's vaccinations require a Vaccine Information Sheet that explains what the vaccine does and the associated benefits and risks. Why not expand this system to all disease conditions? Perhaps there is some roadblock I am not aware of, but it seems like this would be within the realm of possibility. Such a standardized system would greatly shift the expectations doctors have regarding their patients. Of course, some patients will still be poorly informed, but at least there would be a basis for educating our patients. Perhaps, by educating the patients, we may broaden our own perspectives as well.


  1. You weren't sure were the phrase "soft bigotry of low expectations came from.

    Though Michael Gerson a former speechwriter for President Bush takes credit for coining the phrase that I believe the President first used on July 20, 2006, the former U.S. Secretary of Education Rod Paige used the term in a speech before the Commonwealth Club of California on March 12, 2003.

  2. Thanks for the info! I find it ironic that that quote orignated with Secretary "Roderick" Paige, but maybe that's just me.



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