Learned helplessness is a psychological concept describing when people feel they have no control over their situation. It causes people to behave in a helpless manner and to overlook opportunities for relief or change.
The symptoms of learned helplessness are varied in my practice. I have several patients who've had hypertension, diabetes and high cholesterol for years, but cannot tell me a single medication they take. Some patients do not regularly check their blood sugar despite being on insulin for diabetes and despite having been to multiple diabetes education classes. Others go for months without taking their high blood pressure medications simply because they run out and were not due for another appointment. My medical assistant gets particularly discouraged when, after making all the arrangements and following through, some patients do not show up for their specialist appointments, and return to clinic requesting that we rebook them. Such instances beg the question: Do we, as physicians, "coddle" our patients too much and render them incapable of being drivers of their own medical care? How do we empower a vulnerable population with multiple psychosocial confounders to take control of their own health issues?
Seven months ago I saw a 45-year-old gentleman with high blood pressure and high cholesterol for the first time in clinic. We spent close to 30 minutes talking about his medications, what constituted a low-cholesterol and low-salt diet, and how both his diet and medication were essential in lowering his blood pressure and cholesterol. This patient reiterated all that was discussed and my medical assistant also reviewed the highlights of what had been discussed at discharge. Three months later, he had gained 15 pounds and had even higher cholesterol readings than his first visit. What made the difference was looking him square in the face and asking him: "Do you want to die?"
This patient knew all that he needed to do and we had reviewed resources available to him to help him succeed, but he had not made any progress. In this man's case, asking the direct question made a difference. At his next visit, he had lost 30 pounds and his triglycerides (a type of cholesterol) had gone down from 1,500 to 180. His attitude was also different: He was interested in his numbers and wanted to know what else he could do to get his triglycerides even lower (normal triglycerides should be less than 150).
I've found that setting expectations right at the onset and holding patients accountable is paramount. I tell my new patients with chronic diseases, "You are in charge. I am here to help you by giving you the tools or medications you need to manage your chronic disease but if you don't take control, your disease will control you."
Another example is "Mr. A,' a big, burly diabetic patient in his early 60s who rides a motorcycle and weighed over 300 lbs. We talked about his uncontrolled diabetes and weight when I first met him, and he had resigned himself to the fact that he would be this way for the rest of his life. Mr. A's diabetes was out of control, despite his being on three medications for his diabetes. He was eating a carbohydrate-heavy diet, and frank conversations and talk of insulin didn't seem to make a difference. However a change in my attitude, and my approach, did.
Mr. A has some really good motorcycle stories and is a bit of bragger, so I decided to tap into that. I would stroke his ego a bit and make a big deal of a two-pound weight loss between visits or a good blood glucose reading. Almost a year later, Mr. A is now 20 pounds lighter -- he also shed one of the medications he was on. Now he shows off all the low-carb recipes he's discovering, and actually keeps track of his blood sugar readings.
Part of my role as a physician is to be cheerleader when my patients get it right. In this day of political correctness, we as physicians often try to be nice and sugarcoat things, or we feel it necessary to hold our patients' hands through every step of the way. Yes, medicine is indeed a service industry, but we do a disservice to our patients when we do not empower them to take charge their own care.
Acknowledging patients hurdles and celebrating even small successes help break the cycle of learned helplessness. And sometimes, a good frank talking-to does as well. Effectively engaging vulnerable patient populations in their care is attainable and vital, and will improve health outcomes and contain costs. However, this takes time, and spending time on education is becoming more of a luxury that 15-minute clinic visits cannot afford. Physicians have to become more creative to deliver quality, patient-centered care. Patients in underserved areas are no different, and will surprise you if you invite them to step up to the plate and be active partners in their care.
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