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Simplifying care: when is the treatment burden too much for patients living in poverty?
  1. Joseph Nwadiuko1,
  2. Laura D Sander1,2
  1. 1Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
  2. 2Department of Medicine, Johns Hopkins Community Physicians, Baltimore, Maryland, USA
  1. Correspondence to Dr Joseph Nwadiuko, Department of Medicine, Johns Hopkins School of Medicine, 5200 Eastern Avenue, Baltimore, MD 21205, USA; jnwadiu1{at}jhu.edu

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It is usually a grand affair when ‘Ms Noelle’ makes it to clinic. The 52-year-old mother with a history of hepatitis C cirrhosis, hypertension, uterine fibroids and migraines has been in our care for over a year. Even so, each visit still brings a new crisis. Today, we found out that Ms Noelle, the caretaker of a daughter with bipolar disorder and nine grandchildren, had just been evicted from her home. She had been without any income for months, and her applications for temporary cash assistance and disability were denied. Ms Noelle maintained a remarkable ability to keep her family protected and fed despite all this, but we have watched as she became the ultimate victim: she struggled to remember her medications, their doses and indications, and her cirrhosis was frequently on the verge of decompensation during appointments she was barely able to keep. She was overwhelmed by even the simplest of tasks, such as completing forms or picking up meds from the in-house pharmacy, despite how much she knew she needed to follow through.

We make innumerable health choices daily. Behavioural economics can help us understand these choices, as well as the logical errors to which all patients are vulnerable. For example, patients may downgrade the importance of future health status in relation to current gratification.1 Individuals are also risk averse in decision-making, valuing losses disproportionally relative to gains, which makes them susceptible to make vastly different treatment decisions dependent on how a choice is presented.1 Further, decisions made in certain emotional states may not translate to behaviour change when in different emotional states (eg, committing to a diet while in a calm state, then succumbing to dessert when stressed).2 These relatively small choices and errors may have substantial effects on health behaviours and health outcomes.

Patients …

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