For the first time EVER, a doctor (general practitioner) asked me, during a relatively routine consultation, what I do for a living. I decided to answer as candidly as possible, which is not easy given my tendency for facetiousness. The exchange went like this:
Me: I am a researcher – an epidemiologist.
GP: Oh, that’s interesting
Me: Do you ask that question to all your patients?
GP: Because I’m interested in my patients and their answer can give me information about how best to treat them.
This was a perfect answer – and has put her up there at the top of my list of most favourite health practitioners of all time!
Firstly, she genuinely did seem interested in her patients. Secondly, she hit the nail on the head: a person’s social position can provide insight into their health and how to improve it.
I have worked on the social determinants of health for many years, so I was very pleased randomly to come across a young doctor for whom the issue of health inequalities seemed an integral part of their daily routine.
Taboos in medicine
My colleagues and I often have discussions with practitioners about how to go about integrating the issue of social determinants in their clinical routines. Perhaps they could ask patients questions about their activities, jobs, or background? Even among clinicians who acknowledge that social determinants are important, the standard reply is that they cannot go about asking such sensitive questions, and besides, there just isn’t time. I have concluded from this that asking people detailed questions about their sex lives is apparently less invasive than asking them about their job, education or social background.
Cultural taboos are partly to blame. In my experience, here in France, people are more comfortable talking about their bowels or sexual activity, than discussing income, property or money. This is quite the reverse among my British or American friends! But this French GP managed to ask the question without any reticence. It seemed a perfectly natural part of her routine questioning with a new patient. Also, her choice of words was clever. The direct translation of her question is “what do you do in life?” an open-ended question the patient can answer as they see fit. Most of all, it carried with it no judgement.
Such a simple question may help doctors in many ways
-A patient complaining of back pain who is a construction worker may not need the same type of attention, treatment or follow-up as the same complaint coming from an airline stewardess or office worker.
-We all have expectations of our health, but this expectation varies over the life span, and importantly, it varies by our social status. People with a higher social status expect better health and are less likely to ‘put up with’ worse health than people with a lower social status (Delpierre et al. 2009). Asking about an individual’s social context may help a doctor to understand what their health expectations are.
-Most of all, asking this type of question outright quite simply gets rid of unsaid assumptions. Some of our day-to-day judgements about one another relate to social status, and once these are more clearly articulated they may be easier to confront or deal with.
To bring this back to research, I was involved in a project on patient/ doctor interactions in general practice in France. The aim was to study whether such interactions have any potential impact on health inequalities. We found that doctors tended to overestimate the general health of their patients when their patient had a lower education level (Kelly-Irving et al. 2011). Also, we concluded that misunderstandings between doctors and patients were more likely to occur when the doctor perceived a social distance between themselves and their patient (Schieber et al. 2013). Both of these findings could potentially lead to a worsening of health inequalities. People from lower social status groups may even experience a double burden – since they tend to have lower expectations of their health AND their doctors might be overestimating their general wellbeing.
By this discussion I do not aim to point a critical finger at general practitioners or indeed any clinicians. The setting of a GP consultation is a miniature version of larger society. In fact, I think these assumptions are quite simply what we all do, every day. We constantly make snap judgments, taking in a huge number of unspoken factors into account. However, if medical practice was to routinely integrate some questions about people’s lives, some of those assumptions and their negative side-effects may be reduced.
Delpierre, C., V. Lauwers-Cances, et al. (2009). “Impact of Social Position on the Effect of Cardiovascular Risk Factors on Self-Rated Health.” American Journal of Public Health 99(7): 1278-1284.
Delpierre, C., V. Lauwers-Cances, et al. (2009). “Using self-rated health for analysing social inequalities in health: a risk for underestimating the gap between socioeconomic groups?” Journal of Epidemiology and Community Health 63(6): 426-432.
Kelly-Irving, M., C. Delpierre, et al. (2011). “Do general practitioners overestimate the health of their patients with lower education?” Soc Sci Med 73(9): 1416-1421.
Schieber, A.-C., M. Kelly-Irving, et al. (2013). “Is perceived social distance between the patient and the general practitioner related to their disagreement on patient’s health status?” Patient Education and Counseling 91(1): 97-104.