Quality in Primary Care Open Access

Patients may increase health care providers’ workload. Those patients are labeled as “bad patients”, stigmatized by the general population and have some specific characteristics: homeless, drug addict, alcoholic, unobservant, marginal group, invalid, violent, run away.1-4 With those patients, health care providers may change the care to reduce the increased workload they feel.5,6 However, those characteristics don’t take into account personality (moaner, uncooperative) and the variability of behavior of a patient from one day to another. In our opinion, the theory of allegiance7,8 seems an appropriate way to explain the following case.

Based on observations in an emergency ward for two weeks in November 2010, this paper reports the case of Simon, a homeless 59 years old, and the care he received from health care providers. In that November, the weather was cold and Simon came every evening, around 9.00 p.m. asking for food and a bed for the night. All health care providers in that emergency ward knew that and ordered dinner for Simon, even before he arrived. They also had made a deal with Simon: they would give him dinner and a safe and warm place for the night and Simon had to take a shower and stay calm and cooperative. This was a part of activity for the team.

Like most people, Simon has good days and bad days, changing his behavior from cooperative to uncooperative. Based on this, health care providers act differently toward Simon. Sometimes Simon was cooperative: when he arrived at the ward, he sat on a chair, patiently waiting for the nurse to call him, went to take a shower, and followed the nurse to a bed. Those days, all health care providers were aware of Simon and nice to him. They went to see him, pretended to do some medical tests and took the opportunity to have a chat with Simon. They were considerate of Simon. Their aim was to break his isolation and loneliness: “he doesn’t really need medical tests, but at least he talks a couple of minutes with some people”.

But one evening, Simon arrived drunk and requested dinner and bed “I want to eat and my bedroom”. Consequently, health care providers stopped being considerate and became cold: “sit and wait till we call you for the shower”. Simon was disagreeable and refused the shower. Then, health care providers raised their tone and reminded of the deal: no shower=no meal and bed. Simon became insistent, refusing to act as the staff requested. That night, Simon slept on a chair in the waiting room and had a piece of bread for dinner.

This case illustrates the importance of the behavior of the patient in the adaptation of health providers’ activity. When Simon is cooperative, people are more considerate with him; he has a real dinner and sleeps in a bed. When Simon is uncooperative, people are cold and he sleeps on a chair with only a piece of bread for dinner. As it was the same patient, the difference from health care providers does not depend on a difference between patients. It is not a difference observed between a drug addict patient and a non-drug addict patient but between cooperative and uncooperative behavior from the same patient.

These observation are according to studies of Gangloff 7,8 about the norm of allegiance. He defines this norm as the social valorization of the individual which keeps him from questioning the social system in place. Allegiant people follow rules, orders and hierarchy. On the other hand, non-allegiant people are rebellious, questioning and refuse to follow rules. Allegiant people are valued by others. Among teachers, “ideal” students are those that preserve the environment from questioning and rebel students are rejected.9 Once a child is categorised as rebel, teachers judge he has difficulties at school. According to Pygmalion effect, educators act based on that impression, and propose that a student go into a specialized class.

In a same way, when Simon is cooperative, so allegiant to the medical system, health care providers are considerate with him. But when Simon in non-cooperative, thus rebel, health care providers are less patient. However, while previous research defines difficult patients and activities through stigmatized characteristics, allegiance may be a better predictor of the relationship between health care providers and patients and the variation of their care cure. To confirm this hypothesis, it would be also interesting to observe patient care without stigmatized characteristics with allegiance and rebel attitudes.

References

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