When Poverty and Unemployment Are Misdiagnosed

by Maggie Mahar

“I diagnosed ‘abdominal pain’ when the real problem was hunger,” admits Dr. Laura Gottlieb in a wonderfully candid Op-ed that explains why physicians so often fail to recognize poverty as the true cause of what appears to be a physical disease.
“I confused social issues with medical problems in other patients, too. I mislabeled the hopelessness of long-term unemployment as depression, and the poverty that causes patients to miss pills or appointments as noncompliance. In one older patient, I mistook the inability to read for dementia,” writes Gottlieb who is a Robert Wood Johnson Health and Society Scholar at the University of California, Berkeley, and the University of California, San Francisco.
“My medical training had not prepared me for this ambush of social circumstance,” Gottlieb adds. “Real-life obstacles had an enormous impact on my patients’ lives, but because I had neither the skills nor the resources for treating them, I ignored the social context of disease altogether.” (Many thanks to HealthBeat reader Dr. Rick Lippin, who called my attention to Gottlieb’s superb Op-ed.)

The patient who suffered from abdominal pain was only 8 years old. “I had known and adored Jeremy's family for several years,” Gottlieb confides. “So when the sandy-haired, good-natured 8-year-old came to see me in my clinic with abdominal pain, I bent over backward to find out why his tummy hurt. I poked and prodded; did tests of his urine, stool and blood; and took X-rays, over the course of several months. When those tests came back normal, I did more. I had trained at a top medical school and gone on to one of the best residencies in my specialty; in Jeremy, I thought I had identified a real clinical mystery. But in the end, the mystery was not a best-seller: It turned out that Jeremy's family couldn't afford to buy food.
“It had never even occurred to me to ask his mother about how much food there was in the house.”
            

Medical Care vs. Health Care -- Broadening the Focus of Family Practice Gottlieb laments that her medical training at Harvard had not prepared her to identify the “ambush of social circumstances” that makes many of her patients ill.  In a piece published in the Journal of the American Board of Family Medicine, she elaborates:  “As doctors for a low-income, largely uninsured clinic population, my colleagues and I are bombarded daily by the social determinants of health. Our patients lack access to employment and safe housing, suffer violence and discrimination in their communities, and experience hopelessness . . . The evidence continues to mount that these social factors have wide-ranging health effects.”

*snip*

 . . . But Huddle claims, “this attempt at incorporating political responsibilities into professional norms is relatively recent” and “has not so far been strikingly successful.” He admits that “various professional organizations have recently declared a duty to advocate to be part of medical professionalism and physicians may acknowledge such a duty when responding to surveys,” but he insists: “most physicians do not engage in advocacy activities.” In fact, “they engage in other community and political activities less often than do others with similar levels of income. In a 2004 survey, just 25% of U.S. physicians claimed to engage in political activity on local health issues beyond voting. Medical trainees may not even acknowledge social justice or advocacy to be among their professional responsibilities,” Huddle concludes, with some satisfaction, citing a 2007 study which appeared in Medical Education.

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