Pat Jackson was very excited about being invited into a rural group practice in her home state. During her hiring interview, she found the team of physicians, nurses, technologists, therapists, and others compatible with her own commitment to high-quality health care. She told the team how she welcomed the opportunity to attend school in a large city but now was eager to return as a physician assistant to the type of setting she had so enjoyed as a child. The group was impressed with her enthusiasm and the several academic and humanitarian awards she had received during her training.

And so it was a terrible moment for her when with the honeymoon period barely over she misdiagnosed Mr. Sanchez’s symptoms of asthma as a temporary allergic response attributable to the very high pollen count that month. He came into the clinic with the stuffy nose and watery eyes she had seen several times earlier in the week. That Friday evening, she was eager to get out of the clinic in time to serve at a community church supper down the road from where she lived; she was relieved that because he was another pollen sufferer she could quickly send him on his way with a prescription to relieve his respiratory stuffiness. When she asked him whether he had ever had such a reaction before, Mr. Sanchez said “no.” She noted that he may or may not have completely understood her question, although his “no” seemed emphatic enough that she did not think it necessary to call in her colleague who could pose the question to him in his native Spanish. She also knew that he, like many others who came to the area to work the fields during this time of the year, could be faced with allergies he had not encountered previously. But when he was brought in by his foreman 2 months later with obvious difficulty breathing, it dawned on her that maybe she should have probed deeper during his first visit. She was aware that the allergy medication she had prescribed probably would have done him no additional harm but also that untreated asthma can have dire, even fatal, results for a patient. She referred him to the attending physician who conducted tests that confirmed severe asthma. She found herself hesitating to tell Mr. Sanchez or his foreman that she had failed to make the correct judgment 2 months earlier, knowing from living in rural America that acceptance of new young professionals from “away” comes slowly and that word travels quickly. “Why am I hesitating?” she asked herself. “I am an honest person!” Pat knew that had his asthma been treated on the first visit, it would likely not have been so severe now. She concluded that part of her hesitance also stemmed from not wanting to disturb the trust she felt her clinic was building with Mr. Sanchez’s ethnic community, many members of whom had been suspicious of the “white caregivers” and therefore failed to come for care or follow up on prescribed interventions. But even that explanation did not relieve her of a sinking feeling about how she had handled Mr. Sanchez’s situation on that first visit.2

Many issues can be raised in this story, but your opportunity here is to focus on your opinion about how Pat’s mandate to provide a caring response to Mr. Sanchez should have been achieved. Because you have not yet been introduced more formally to the idea of a caring response, we ask you to rely on your everyday understanding.

Reflection

Do you believe that when Mr. Sanchez first came to the clinic Pat treated him with the full attention consistent with your idea of how a caring professional should respond?

Yes____ No ___

Most readers probably can see some aspects of Pat’s situation that could lead to her devoting less than her full professional attention to Mr. Sanchez. If you do, what are they?

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When Mr. Sanchez returned, Pat hesitated to share her misgivings with him or his foreman. In your opinion, do you think her sources of hesitance have sufficient weight to override her concern that she is being dishonest by withholding some information from him when in fact she is an honest person?

Yes____ No ___

Jot down some thoughts about your answer and how they help support your understanding of what a caring response would look like in this situation.

_____________________________________________________________

As in many ethical challenges, you may find yourself seeing two sides of the coin and realize that each has a pull on your moral sensibilities. We will discuss this at more length in Chapter 3.

The patient as focus of a caring response

A caring response does not always mean that you will be able to completely resolve the conflict of claims on you, but it does require you to put your priority to optimizing the positive results and minimizing damage to the patient. What do we mean by a “claim?” A claim is a request made verbally or nonverbally by virtue of the expectations people have of your professional role. It says, “Give me your attention!” You know that your role will involve many types of relationships, with patients or clients and other times with families, professional team members, research subjects, policymakers, or the public. And the list is not complete if you fail to include your relationship with yourself and your own health! Each and every one of the parties you encounter will come with claims on your time, services, expertise, or other type of attention. From time to time, you will find yourself torn between more than one claim on your care, just as Pat did. She understood that her patient Mr. Sanchez had a strong claim on her to be treated with the best attention possible; but still, when she realized she may have been negligent in her treatment of him, some other claims on her also raised their head. For one thing, she knew the value of her clinic’s services in this community and that her presence as an essential new addition on the health care team was a boost to the overall effectiveness of the clinic. She must not compromise that effectiveness. She cared about her colleagues and their heavy workloads, so she felt the need to reflect on the negative effect it might have if their load was increased because she was shunned by patients when the word got out that she was not competent. She was also sensitive to the bigger role of her clinic in providing quality care to a previously underserved Hispanic community in the area and wondered if her admission might undermine their trust in the clinic. Finally, she put into the mix the desire to be caring of herself by honoring her wish to participate in a social event on this Friday night in her newly adopted town. All of this was waging war with her personal value of honesty.

Reflection

Stop right here and think about your day so far. What conflicting claims on your attention have you already faced?

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Conflicting claims are part and parcel of everyday life. But Pat’s professional role helps her to set priorities in relation to Mr. Sanchez. Her primary concern must be the well-being of the patient under consideration. At the same time, Pat’s commitment to honesty, one part of her personal value system, tends to tip the scales in the direction of finding a way to share the information with Mr. Sanchez. This course of action not only keeps the patient in center focus but also allows her personal integrity to be honored. How, when, and where it should be shared requires her to bring other character traits such as compassion and courage into play as she attempts to minimize possible deleterious effects this information may have on him, the clinic, or his ethnic community. She will be wise to engage the services of her colleague who can speak Spanish and comes from Mr. Sanchez’s ethnic group himself.

Patient-centered care

Patient-centered care, or client-centered care, is a term adopted in the health professions’ clinical and ethical literature to emphasize the imperative that professionals keep a focus on the well-being of the whole person. Nursing and medicine have led the way in developing the concept, but almost all health professions have adopted it in principle.3 Entire models of the health professional and patient relationship have been built around this notion, and you likely will learn one or more of them in your professional preparation. The central concept that runs through these models is that patient’s values, concerns, and preferences have moral weight in the everyday clinical decision-making process. Although the terms health care and managed care may have the term “care” embedded in them, they may simply mean dealing with patients in a technical or aggregate sense. For this reason, clinicians and ethicists add “patient-centered” as the orienting point on their moral compass that always brings the focus back to what matters to the patient and what the health professions have to offer.

You can easily see that patient-centered care is highly individualized, tailored to fit each patient. This focus of attention is frequently challenged in an era of clinical specialization and sophisticated medical technology. Clinical procedures often are so specialized that a particular disease, symptom, body part, or biologic system can become the focus of attention. The dehumanizing effect that a fragmented focus has on both the health professional and the patient is illustrated in Figure 2-1.