I read with interest the research report by Weiner et al.1 that PCPs experience moderate or extreme stress in caring for complex patients, particularly due to unmet social and financial needs. They conclude by advocating for “implementing interventions to address patients’ unmet needs.”
As a PM&R doctor with 30 years of experience caring for complex patients, the findings resonate. I also fear that the report does not go far enough and could have unintended consequences of further marginalizing an already marginalized population. The problem is not the patient but the healthcare system.
Complex patients, as “people whose combinations of medical, behavioral health, and social challenges result in extreme patterns of healthcare utilization and cost,”2 are not going away. A disproportionate number have publicly funded insurance. Many are people with disabilities. The cost of NOT addressing the problem is also great.
I would suggest reframing the clinician experience from stress to “moral injury,” or being “unable to provide high-quality care and healing in the context of health care.”3 Many practices discourage accepting these patients due to poor reimbursement; interdisciplinary teams and resources required; lack of knowledge and training, and sense of futility. Complex care patients are “hot potatoes,” bouncing around, belonging nowhere.
But the onus should not be on the individual clinician to fix the problem, nor should the patient be blamed. These are structural problems that require structural solutions. Structural competency “calls on healthcare providers not only to recognize how institutions, markets, or healthcare delivery systems shape symptom presentations but also to mobilize for correction of health and wealth inequalities in society.”4 There are meaningful solutions being developed that require a societal and organizational commitment.5 It is time to hold them accountable.
Weiner J, et al. Primary care physician stress driven by social and financial needs of complex patients. J Gen Intern Med. 2019;34(6): 818–9.
Hasselman D. Center for Health Care Strategies Superutilizer Report. October 2013. https://www.chcs.org/media/FINAL_Super-Utilizer_Report.pdf. Accessed 25 Jul 2019.
Talbot SG. Dean W. Physicians aren’t, burning out.’ They’re suffering from moral injury. Stat. 2018. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed 25 Jul 2019.
Metzl JM, Hansen H. Structural competency: Theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014; 103:126–33.
Humowiecki M, Kuruna T, Sax R, Hawthorne M, Hamblin A, Turner S, Mate K, Sevin C, Cullen K. Blueprint for complex care: advancing the field of care for individuals with complex health and social needs. www.nationalcomplex.care/blueprint. Accessed 25 Jul 2019.
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Kirschner, K.L. Physician Stress Driven by Complex Patients. J GEN INTERN MED 35, 2470 (2020). https://doi.org/10.1007/s11606-020-05806-1