November 18, 2014

From Subhuman to Substandard

When is a patient not a patient?  When he’s a piece of shit.

A recent article on Slate described an acronym, SHPOS, used among some medical professionals to identify a certain type of patient.  It stands for “subhuman piece of shit,” and this is what it means:

A SHPOS becomes a SHPOS when a health care worker hates him.  The term is known to physicians everywhere, passed by word of mouth from resident to intern to medical student. Psychiatrist Abbey Strauss described the phenomenon in a 1983 paper: a patient who is “childlike, unreliable, occasionally arrogant, demanding, insensitive, self-centered, ungrateful, non-compliant, and wrongly motivated.” Strauss describes a type of SHPOS who might be called a “difficult patient.”

Sadly, many mental illnesses cause behaviors exactly like this, especially the more serious ones.  Yes, med compliance is a problem with the mentally ill, as well as others.  Yes, some of these people appear “self-centered” and “ungrateful” because when the pain is overwhelming enough, you just don’t have the ability to worry about what other people feel and think.  Doctors are seeing them at their most vulnerable.  They don’t know what they’re really like or what horrors lurk in their brains that they can’t control.

That’s why we treat such things with therapy and/or medication.  These are people who go to their doctors for help, not to be judged as “subhuman pieces of shit” because of the nature of their illness.  One wonders if the same term is applied equally to elderly dementia patients, because there is no fundamental difference.

It stands to reason that the worst cases are going to wind up in hospitals.  And that means that doctors and nurses can be exposed to some pretty awful things, including random and sudden violence.  The safety of medical personnel is critical, but so is the safety of an out-of-control patient who may be on drugs or suffering from psychosis.  Both need protection, and if anyone is hurt, it’s a tragic situation.

I have nothing but concern and sympathy for anyone who has to be exposed to the dark side of the brain, whether it is someone else’s or one’s own.  I don’t want to downplay or excuse violence in any way.  It requires a serious response.

Labeling the patient as subhuman is not it.

And for non-violent patients, any possible justification for viewing them in such a way decreases dramatically.  If they are upset or have trouble understanding or complying with treatment, that does not make them subhuman.  It makes them all too human.

It’s understandable that doctors and nurses may think such things.  They’re human too.  They deal with a ton of pressure, long hours, possible physical danger, and a lack of appropriate appreciation.  But the fact that it goes so far as to result in dark thoughts being shared openly among them is problematic.  It isn’t professional, and there is too great a risk that it will result in substandard care.

The author, a psychiatrist, gave an example of a cocaine addict who had come in for a meeting to discuss treatment.  He wanted to go to rehab, but his insurance denied it.

The patient found this difficult to accept, understandably, but rather than make the best of what he had to work with, he lashed out at the women in the room, the social worker and myself. He spoke to us with absolute contempt. He attacked me particularly as an unethical, uncaring, and lazy psychiatrist whose only agenda was to save the hospital money. His remarks were so unexpectedly and inappropriately hostile that the team was taken aback and took several minutes to collect itself and terminate the meeting.

While being berated, I was aware of my heart pounding, and of the effort it took not to retaliate verbally and physically for this assault. I maintained my self-control, but at a cost. For days I ruminated over the event. I imagined that my struggle to contain my own anger had damaged my cardiovascular health. I felt humiliated in front of my colleagues and unmasked as a weak person not competent to manage difficult patients. I thought of my parents’ pride when I became a doctor, and imagined what they would think if they knew about my actual daily experiences.

She glosses over the patient’s very real, very serious problem (for which he desperately wanted help) in favor of focusing on how this situation affected her emotionally.  The dismissiveness in which she said, “rather than make the best of what he had to work with” and the absence of compassion for what the patient went through makes me wonder if he didn’t have a legitimate reason to refer to her as “uncaring.”

Do I fault her for having those raw emotions?  Absolutely not.  I sympathize with her plight.  If someone is verbally abusive with me, I have much the same emotional reaction.  Although frankly, if those in the mental health field cannot tolerate an occasional verbal tirade, it seems to me that they may have chosen the wrong profession. It comes with the territory.

I do have to give her some credit for her blunt honesty, however.  It takes courage to present oneself in a less than favorable way, and bringing this topic out in the open is enlightening.  But this would be so much more powerful had she been able to present it with a greater degree of insight and understanding once the incident had passed.  Or if the article had in any way addressed this from the perspective of SHPOS patients and expressed concern over how their treatment might be compromised.

Articles like this have the power to cause patients to question themselves.  It’s not just about the mentally ill.  It’s not just about the people who actually become violent and abusive.  It’s also about anyone who is going to worry that daring to disagree with or question a doctor could earn them the SHPOS label and substandard care as a result.  Whether that's true or not doesn't matter.  The fear alone has the power to shame them into not seeking help.  Or, in the case of those who experience a total loss of control in psychosis or substance use, to feel demeaned and confirm to them their deepest fears: that they really are worthless human beings.

My husband is this way.  He was almost certainly given the SHPOS label by medical professionals.  In the long years before his diagnosis of schizophrenia, the Dude self-medicated with drugs and alcohol and spent time in jail, like so many people with the illness.  In psychosis, he becomes verbally abusive in a way that would be unthinkable if you saw him properly medicated and relatively clear-headed.  Add addiction to the mix, and you have a volatile combination.  He was just a badass drug addict to medical professionals, and he was treated as such.  This is one reason he went so long without a diagnosis or treatment, which led to years of terrible and unnecessary suffering.

This was crushing to whatever measure of self-esteem the Dude had left after having been bullied and treated as worthless by his classmates growing up.  And that’s the biggest tragedy.  Here is a man who is unusually polite and well-mannered, respectful, devoted, loving, articulate, and one of the most objectively intelligent people I’ve ever met.  Yet he can’t believe those things about himself.  He judges himself based on the things he has no control over.

The fear that medical professionals may agree with his assessment of himself makes things so much worse.  Were they affected by their interaction with him in the past?  Perhaps, but then they went on to the next patient while he went home to live with his pain every minute of every day.

The SHPOS label serves no purpose and has no defense.  It helps no one, and there are healthier ways to deal with stress caused by dealing with difficult patients.  Repeating, “it’s just the illness talking” sounds like a helpful place to start.  It's what I often have to do, so they can too.  Anyone who throws around the label SHPOS needs to understand that they aren’t only diminishing their patients’ humanity.  They’re diminishing their own.

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