As patient satisfaction plays an increasingly important part in medical care, a physician’s understanding of diagnosis-related stigma is critical for the alignment of physician and patient when a patient has a stigmatizing diagnosis. Neurosurgeons may have had the experience of feeling that they have competently addressed the medical issues, but the patient is dissatisfied with the clinic visit. These situations can be handled more productively with an understanding of diagnosis-related stigma that may impact a patient’s experience, often before they have entered the neurosurgical clinic. While neurologic diagnoses overall are less stigmatizing than other diagnoses, neurosurgeons will frequently encounter patients with stigmatizing diagnoses, whether or not these diagnoses directly impact the neurosurgical diagnosis or treatment plan. A few of these diagnoses are considered below; also outline some strategies to use in these situations.
Obesity
Obesity is one of the most highly stigmatized conditions, stemming from a belief that obesity is a personal failing rooted in behaviors such as inactivity or overeating. People seeking treatment for co-occurring conditions such as back pain and obesity often have have experienced stigma from healthcare workers, significant others and even themselves long before presenting for neurosurgical evaluation. These experiences can lead patients to avoid accessing healthcare resources and may exacerbate maladaptive coping, such as overeating. In the neurosurgical clinic, linking obesity to a patient’s pain symptoms or candidacy for surgery can be perceived as stigmatizing by the patient.
The impact of obesity-related stigma can be mitigated through team-based care including medical weight loss to deal with weight preoperatively. Offering concrete medical solutions such is both highly acceptable to patients and recognizes obesity as a medical condition with a treatment. Empathic communication and the use of non-stigmatizing terms is also helpful for minimizing the perception of obesity-related stigma.
Pain
Historically, chronic pain was felt to be related to some form of hysteria or psychosomatic disorder. The stigma associated with “pain of no obvious origin” continues today. Patients who present without evidence of the cause of their pain are often dismissed and met with suspicion by healthcare workers. Documentation of “drug-seeking behavior” or “pain inconsistent with injury” perpetuates these stigmatizing beliefs to others through the medical chart. Despite a thorough examination, patients who are given undefinitive results begin to doubt their own perception of pain. The stigmatization of pain, either enacted by others outside or internalized by the patients themselves, can increase pain-related disability. In the neurosurgical clinic, this is encountered when a patient’s symptomatology has no identifiable radiographic structural correlate. When these patients/situations are deemed to have no surgical treatment, patients may question the validity of their own symptoms.
Empathic communication in this situation is critical; in addition, referral to a comprehensive pain center messages that other non-surgical treatments may be of benefit.
Substance Use Disorder
Stigma surrounding substance use is driven by perceived patient culpability, stereotypes and public fear; this may lead patients to delay treatment or conceal their substance use history from providers. In addition, these feelings can lead to increased drug use, overdose and maladaptive behaviors for the stigmatized individual. Substance abuse can delay and hinder treatment and recovery efforts; in neurosurgery, this can be seen in spinal infections from unsafe injection practices.
The impacts of stigma regarding substance use disorder in healthcare settings manifest in decreased treatment of symptoms and patient non-compliance due to poor relationships with the healthcare team. Team based care involving psychiatry and pain management is critical for treatment of pain and withdrawal symptoms. In addition, utilization of non-stigmatizing terminology (“clean”/”dirty”), and normalization of SUD as a serious illness, rather than a moral failing, are also helpful.
Smoking
With the “denormalizing” of smoking over the years, smoking has become less acceptable and increasingly stigmatized. Tobacco use leads to poorer health outcomes and the public health initiative to denormalize smoking is undeniably positive. However, the stigma associated with smoking can lead to avoidance or delay in care and contribute to underreporting/concealing of smoking history to healthcare providers. In the neurosurgical clinic, this is most commonly encountered during discussions regarding spinal surgery and fusion, where the requirement for smoking cessation can be seen as arbitrary or stigmatizing to patients.
While smoking cessation is critical pre-operatively, explanation of the need for smoking cessation shows patients that medical care is not simply being withheld arbitrarily.
