My wife, Kim, teaches 3- and 4-year-old special-needs children. The children have a variety of conditions. In any given year, her class includes children with autism, blindness, hearing disorders or complete deafness, Prader-Willi syndrome, Down syndrome, cerebral palsy, Cornelia de Lange syndrome and other conditions.
Adding to the myriad problems the children have, they are all poor – very poor. The school is in the inner city, where free lunches are the standard. Many of the children are homeless or living in shelters. Some are foster children; even second- or third-generation foster children. Sexual, physical and emotional abuse are also problems.
There are considerable numbers of single-parent families. Most are single mothers trying to survive. Grandparents are the primary caregivers for scores of the children. It is also not unusual for a child to have a parent in prison.
Kim's classroom is like a nest of busy bees. Teachers, paraprofessionals, social workers, speech therapists, occupational therapists, physical therapists, interpreters and volunteers pass through her room throughout the day, working with the children ... trying to make a difference in their lives.
Early in Kim's tenure at the school, she attended a continuing-education class on understanding poverty. I was fascinated with the information she shared with me. The class had detailed how impoverished people think and react to their environment and circumstances. This was done using comparisons between impoverished, middle-class and wealthy individuals. It is interesting to see how individuals in different classes view various factors in life.1 (Table 1)
Table 1: Perspectives Among Classes On Components Of Life
| Category | Poverty | Middle Class | Wealth |
| Driving Force | Survival, relationships, entertainment | Work, achievement | Financial, social and political connections |
| Food | Is that enough | Was it good | |
| Possessions | People | Things | Legacies, pedigrees, one-of-a-kind objects |
| Education | Abstract and not viewed as a reality | Critical for climbing the ladder of success and making money | Necessary for tradition and maintaining fi nan- cial social and political connections |
| Language | Casual, terse, used for survival | Formal, used for negotiation | Formal, used for networking |
| World View | Sees local setting | Sees the national setting | Sees the international setting |
| Family Structure | Matriarchal | Patriarchal | Depends upon who has the money |
| Money | To be spent | To be managed | To be invested / conserved |
| Adapted from A Framework for Understanding Poverty, by Ruby K. Payne, PhD. | |||
Communicating With Patients Where They Are
So, what does this have to do with chiropractic? We see a variety of people from the three classes in our practices, yet little training has ever been provided to assist in understanding each group's wants and needs. This is especially important in the initial assessment of patients and the report of findings most doctors use. My initial education in the art of the ROF only included making sure the four most common questions patients have are answered:
- What's wrong with me?
- Can you help me?
- What will it take? (procedures and time)
- What will this cost?
Later, I discovered literature that described communications based on the work of Myers and Briggs. Their work identified 16 different personality combinations.2 Understanding the personalities helped me address the four most common questions in a manner that matched the individual patient. This is meeting the patients where they are, not where we are.
Returning to Kim's school as an example, one of the most frustrating aspects of her job is that her children are held to the same achievement standards as 3- and 4-year-olds who do not have special needs. The powers that be have selected a curriculum based on "normal" children, with little thought apparently given to the differences between those children and Kim's children.
A few years ago, Kim's class included a little boy with autism who had never spoken. The child came to school most days hungry and dirty. During a field day near the end of the school year, the child slid down a sliding board for the first time. When the teaching assistant standing at the bottom of the slide caught the boy, he looked up at her and said his first word: Again.
According to the curriculum, this child should know his colors, be able to count to 20 and accomplish other "normal" things. The system expects the child to accomplish tasks they often are incapable of performing and grades the child accordingly. Further insult in this situation is basing a teacher's job performance on obtaining "normal" results with special-needs children.
Kim refers to Abraham Maslow's work when she speaks of this situation. In 1943, Maslow proposed his Hierarchy of Basic Needs theory. The theory states that human motivation is based on five basic needs:3
- Physiological: food, air, water
- Safety: safe from physical and psychological harm
- Love: to love and be loved
- Esteem: reputation, recognition, self-confidence
- Self-actualization: self-fulfillment, achievement
Kim says it is hard to teach children who are lacking in these basic needs. A hungry child living in a shelter with dysfunctional parents has a slim chance of developing self-esteem, achieving and excelling at school. The combination of the child's special needs and their poverty can be overwhelming.
How Socioeconomic Variables Influence Patient Compliance
While most of us do not deal with the impoverished special-needs children as Kim does, there is some overlapping of the situations and principles here. Patients enter with a variety of physical conditions, but they are also dealing with the factors unique to their socioeconomic class. In the case of the impoverished, they may be hungry, unsheltered and dirty.
During our initial contact with the patient, we often use a one-size-fits-all report of findings. This is not meeting the patient where they are. During the report, we often jump quickly from the patient's condition to a period of time two and three months down the road, and even further down the road to wellness care.
For the impoverished patient in survival mode, they simply want the pain to stop: Help me in the here and now. In their life situation they cannot think two to three months into the future or consider lifelong wellness care. This is one of the reasons patients disappear even after receiving the doctor's best report of findings.
Every patient should receive the information necessary to make an informed decision. The appropriate treatment is "the appropriate treatment" and should be recommended, but the information and treatment can vary. We cannot frame each patient's circumstances in a manner that seeks solely to have every patient commit to a 30-visit treatment schedule and a lifetime of wellness care.
I know doctors who refuse to accept a patient unless they agree to follow every aspect of the doctor's recommendations. One hundred percent compliance is hard to obtain from the majority of patients. Failing to consider individual circumstances and ultimatums further limits the patient. Yes, there is a point when some patients must be dismissed from care, but these are the exceptions, not the rules.
"Special-Needs" Patient Care
Patients who fail to complete treatment plans are often referred to as bad patients. We are attempting to hold some patients to a standard they are not equipped to meet. We often tell patients what we want, not necessarily what they need or can undertake.
We are obligated ethically to inform the patient accurately of their diagnosis and the appropriate treatment; but we are also obligated to meet them where they are. This approach can help the patient accept chiropractic care to the best extent possible for them.
Our traditional method of reporting and recommending care to patients is based on what we feel represents the ideal follow-through by a patient. This often drives patients from lower socioeconomic classes away. They feel the doctor is not addressing their concerns, which are immediate. Once they leave, they are not likely to return.
If a patient is met where they are in life, providing education gradually during the initial stages of care and not necessarily all during the report of findings can help the patient move to the next stage of care without feeling pressure. It is hard to educate the patient if they leave seeking someone else who has the insight to meet them where they are.
We cannot grade a patient based on what practice management has determined to be the normal or standard; nor can we judge a doctor solely on their ability to get patients to complete a 30-visit schedule and become lifelong wellness patients.
Table 2 details reactions I have observed from patients in different classes since developing the awareness that social class can impact patient behavior. The point is not to recommend only the care a patient might be able to afford. Appropriate recommendations must be made with an effort to understand the patient's reaction to the recommendations based on socioeconomic class.
Understanding the four major questions, the 16 personality combinations and socioeconomic circumstances are all valuable in patient communication. Understanding provides us the opportunity to work with our patients, meet them where they are and fulfill our mission to provide quality health care.
Table 2: Reactions And Feelings Of Different Social Classes To Health Care
| Category | Poverty | Middle Class | Wealth |
| Feelings About the Doctor | Often a necessary evil | Advisor, healer | See as an equal or less, a provider of a service |
| Pain | Just make it stop now | Wants relief, but is concerned about assur- ing that the pain does not return | Wants relief and some- times a guarantee that the pain will not return |
| Health Care Cost | Wants the minimum care at the minimum cost and cannot continue care unless another party can assume the cost | Willing to pay a fair rate/fee schedule that is primarily covered by some form health care insurance. Wellness will be considered, but it is diffi cult to comply | Willing to pay beyond the cost and point of necessary care if convinced preventive measures and wellness plans are worth the additional cost |
References
- Payne RK. Framework for Understanding Poverty 4th Edition. Texas: aha Process Inc., 2005.
- Kroeger O, Thuesen JM. Type Talk; The 16 Personality Types That Determine How We Live, Love and Work. New York: Tilden Press, 1988.
- Kreitner R, Kinicki A. Organizational Behavior 9th Edition. New York: McGraw-Hill and Irwin, 2013.
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