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.
Many of the children are not toilet trained when they first arrive. Many have minimal vocabularies or have never spoken at all. Many are considered special needs just because they do not speak English. A significant number of the children are immigrants, with more than 11 languages and cultures represented in the school.
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
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
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