A sharing by Chong Phui-Nah
Judge tenderly, if you must.
–Traci Lea LaRussa
Do you know my pain?
No. I don’t want to start insulin injections. Just let me die! The elderly Chinese woman was struggling with deteriorating diabetic control. I suggested speaking with her son. I don’t want to be a burden to my son!
Slowly, it emerged that her only son had recently been diagnosed with lung cancer and was in remission after treatment, and he was then unemployed. She did not want her medical expenses to burden him. As we discussed her health and what mattered to her, she realized that she needed to be healthy so that she could care for her son. She learned to self-administer the insulin injections, and with the social worker’s help, she eventually found a job as an office assistant.
Commentary
Social factors influence the health outcomes of our patients, especially those with chronic diseases. These include the conditions in which our patients are born, grow, live, work, and age. They contribute towards decisions on priorities, health choices and lifestyle preferences.
Our current care plans for chronic diseases such as diabetes are mostly focused on managing biological and behavioral factors, for example symptom recognition, or diet and exercise advice. Increasingly, however, we recognize that low income, unemployment, poor living conditions, and insecurity impact on health outcomes as mush as poor diet and little exercise.
The drawing depicts the genogram of a young family trapped in its social and financial nightmare. Mum is heavily pregnant and has diabetes, requiring insulin injections. Dad is in prison. The youngest child is an infant, still swaddled. The older children are drawn with downcast faces. The baby is not gonna have a father is a sad commentary on the family’s near-term expectations.
As physicians, we are concerned about the mum’s pregnancy. Diabetes in pregnancy carries its own burdens of dietary restriction, intrusive blood glucose monitoring, increased medical costs, and higher risk of poorer outcomes. On the other hand, the woman clearly has more than her diabetes to worry about.
We need to look beyond “non-compliant” behavior in our patients to the underlying social and economic circumstances that may first need to be addressed.
———A/Prof Chong Phui-Nah
Chong Phui-Nah is a family physician, clinical administrator, and clinical teacher. She is based in the polyclinics and is interested in primary care transformation, behavioral economics, and healthcare innovation.
