Association for Academic Surgery (AAS)

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Modern Applications of Causal Attribution in Medicine

Bernard Weiner’s theory of social behavior posits that we respond to events by judging its cause, leading to the assignment of responsibility, emotional reaction, and the ultimate response (Weiner, 2006). When Dr. Ernest Codman, a graduate of Harvard Medical School in 1895 and an advocate for improved patient outcomes, presented the concept of morbidity and mortality conferences in the early 1900s, he lost staff privileges at Massachusetts General Hospital for attempting to evaluate surgeon competence. An initiative to improve patient outcomes, a universal goal of a hospital, was met with punishment and offense. This was presumably for the horrific idea that a blame game was about to be instituted, instead of an objective way to evaluate physician error and improve the health of patients.

Morbidity and mortality conferences are now ubiquitous across modern surgical training centers, both academic and community, general and subspecialty. The interest lies in exposing errors that could have been committed by anyone, and to do what is best for the patient. On an individual level, causal attribution can be seen in feedback for both residents and attendings, varying from objective corrections free of insinuation to improve future care, to blameful accusations, assuming negligence or intent to cause harm. Cultures vary by institution, but the modern paradigm now uses quality improvement models to identify systems processes, including training, communication, and environmental pathway changes, to enhance relationships and improve patient outcomes.

Similarly, provider-patient interactions can be dictated by causal attribution. When providers care for ‘noncompliant’ patients, the blame can be put on the patient for not taking prescribed medication or not losing weight as instructed. The shared goal of enabling the patient to reach his or her potential through optimized health and wellness is no longer the focus when blame is involved in the discussion. Weiner’s theory finds that when causes of actions are perceived to be within individuals rather than social or economic environments, reactions will be far more punitive, whereas the recognition of factors that may not be within the individual’s control yields the context for a more therapeutic relationship. Mutual understanding can come with recognition of unsafe surroundings preventing an active lifestyle, lack of access to unprocessed foods, fruits, and vegetables resulting in low diet adherence, poor health literacy and intimidation by the healthcare system resulting in lack of medication adherence, and stressors without resources for decompression resulting in comfort food reliance and thus poor weight management. Recognition of these factors can provide patients with the relevant and appropriate resources to improve their health; relegation of poor outcomes to patient obstination can leave both patient and provider feeling frustrated and unfulfilled.

Just as Dr. Codman’s morbidity and mortality conference was initially dismissed, so too has the education of physicians to recognize interactions where patient factors may not be recognized, preventing care from progressing. While physicians recognize that disparities exist, few believe that disparities occur often and even fewer believe disparities are likely to occur in their own clinical setting, endorsing patient factors, rather than system or provider factors, causing disparities (Taylor, 2006). For the universal goal of better patient outcomes, investigation into healthcare disparities is far from an accessory, it is a necessity. Uninsured patients have twice the risk crude mortality than insured patients after similar trauma, the great equalizer within surgery (Haider, 2008). A landmark report from the Institute of Medicine in 2002 found that after adjusting for health insurance, stage and severity of disease, income, education, comorbidities, type of healthcare facility, black and minority patients receive statistically fewer procedures and poorer-quality medical care than white patients (Nelson, 2002). This IOM report found that unconscious bias by health care professionals contributes to deficits in the quality of care, a phenomena created by an international history fraught with colonialism that persists today through social, legal, political, and cultural structure. Differences in mortality between black and white patients are estimated to account for the premature death of 260 black patients every day (Levine, 1999).

The list of unequal treatment and outcomes experienced by patients of different gender identities, racial groups, sexual orientations, geographic locations, and access to resources, is unending. Though gaps in health disparities can seem Sisyphean to close, so too were the health challenges of every decade, every generation. The eradication of polio, the creation of sterile technique, the development of heart transplants – every specialty has seen an insurmountable challenge surmounted, a novel, untried practice now commonplace and standard of care. The beauty of medicine is that it lies both within and untouched by the spheres of political, legal, and social systems. From the moment a patient encounters the healthcare system, every member of the provider team is aligned to the same goal of doing what is best for the patient. It is not within our scope of practice to assign blame when a patient arrives at the trauma bay with a stab wound after an altercation, it is not an emotional burden for us to carry whether a patient deserved a certain outcome as we are not the moral arbiters, merely the workforce with the skills necessary to help that patient achieve the best possible outcome.

 

References:

  1. Haider, Adil H., et al. “Race and insurance status as risk factors for trauma mortality.” Archives of Surgery10 (2008): 945-949.
  1. Levine  RS, Foster  JE, Fullilove  RE,  et al.  Black-white inequalities in mortality and life expectancy, 1933-1999. Public Health Rep. 2001;116(5):474-483.
  1. Nelson, Alan. “Unequal treatment: confronting racial and ethnic disparities in health care.” Journal of the National Medical Association8 (2002): 666.
  1. Taylor, Stephanie L., et al. “Racial and ethnic disparities in care: the perspectives of cardiovascular surgeons.” The Annals of thoracic surgery2 (2006): 531-536.
  1. Weiner B. Social Motivation, Justice, and the Moral Emotions: An Attributional Approach. Mahwah, NJ: Lawrence Erlbaum;2006.
Connie Shao, MD

Connie Shao, MD

Connie Shao, MD is a general surgery resident at the University of Alabama at Birmingham (UAB) where she is also obtaining an MSPH. Originally from Michigan, she completed her undergraduate degree at Washington University in St. Louis where she majored in Biomedical Engineering before attending the University of Chicago Pritzker School of Medicine. Her research is in health services, focusing on improving equitable health engagement among patients via clinical outcomes research.