In our lives, we do the best we can with what we’ve got. Our choices may seem strange to others—funny, frightening, or simply stupid—but in the balance of our lives, as we see it, those are the choices that make the most sense.
SIMON AUSTER
DURING MY first few years as an attending physician, supervising a team of residents and medical students on the wards of an urban public hospital several months each year, I was often irritated or frustrated with patients. Almost all were poor, and most were Latinx or African American. Twenty years later I can barely remember what I was upset about, as I don’t have those feelings anymore. I think I perceived many as ungrateful, malingering, or uncooperative. I hid these sentiments during patient interactions, but they did spill over in comments I made about patients with the residents on my team.
Such a negative, judgmental attitude was cultivated during my own training. For instance, as an intern I simultaneously admired and was horrified by a brilliant, charismatic senior resident who sometimes disparaged patients behind their backs. This guy was a walking Harrison’s Principles of Internal Medicine who had authored a paper in a renowned medical journal, so lack of intelligence was not his problem. I remember hearing him describe how he got rid of a patient in the emergency department (ED) seeking to be admitted with a variety of complaints who he believed was malingering. It’s possible the man had nowhere else safe to go on a winter night. This resident recounted how he walked into the enclosed bay in the ED with a nasogastric tube draped casually around his neck along with his stethoscope, and said, “I think we’re going have to use an extra-large catheter today to take a sample of urine from you.” Not surprisingly, the man took one look at the large-bore tube, intended to go down an esophagus, not a narrow penile ureter, and left as soon as possible. As this story was related to us over dinner in the residents’ conference room, everyone laughed.
Looking back, I’m ashamed that I was not immune to such a judgmental attitude. I have, however, since recognized the harm of making negative assumptions about patients and then reacting to them based on those unsubstantiated beliefs. There is of course the indignity, disrespect, dishonesty, and breach of fiduciary responsibility involved in misleading a patient because you judge them unworthy of your services, as in the example above. Less often recognized, however, is that judging also extinguishes thinking. Once we conclude that a teenage girl on her third pregnancy is “irresponsible,” that a patient who doesn’t work and misses appointments is “lazy,” that a patient who continues to smoke despite emphysema is “weak,” or in this case, that a man in the emergency room with puzzling complaints is malingering, we are no longer inclined to find out or even wonder what is really going on.
Once we pass judgment, we cease to exercise judgment. I recall a young couple, struggling to care for a 15-month-old son with congenital anomalies including a cleft palate, who had missed numerous doctor appointments. The toddler had been hospitalized because of failure to thrive. The state authorities (Department of Child and Family Services, DCFS) evaluated the family situation and, along with the inpatient care team, arrived at a plan with the parents that they must not miss any follow-up appointments following discharge. That was a lot to expect, since the child had scheduled visits with a craniofacial specialist, developmental pediatrics, occupational therapy, physical therapy, and general outpatient primary care, among others. Following discharge the family missed just one of them. The resident notified DCFS and then called me to say that “DCFS will probably take the child.” This despite a recent note in the patient’s medical record, just three days prior, documenting that the little boy was doing just fine.
What the resident didn’t do before calling DCFS was contact the family and find out why they missed that appointment. There were possible explanations other than neglect, given the other stresses on the parents. In addition to their young child with complex medical needs, the parents had two other children, the father worked, English was a second language, and the family was quite poor with limited resources for transportation. Furthermore, the resident had not taken into account that a specialist had just evaluated the child and documented that he was thriving. Fortunately, we were able to intervene with DCFS, and the child stayed with his parents and continued to do well.
Physicians can be unabashed about being judgmental. A senior resident in our clinic saw a man with a heroin addiction who had been diagnosed with a lung mass based on a CT scan at another hospital. The resident asked the patient to request a copy of the films and bring them to his next appointment. He returned a couple weeks later without the films, saying that the hospital wanted $20 to print out the images, which he said was money he didn’t have. The resident told the patient that he couldn’t help him until he got those films. When I asked why he didn’t just contact the hospital directly to fax over the reports, he replied, “If that man can’t forgo the cost of a little bit of heroin to pay for those films, his life isn’t worth saving.” When I commented that that was judgmental, he shrugged and replied, “Everyone is judgmental.” Needless to say, we contacted the hospital and got those films.
What does it mean, exactly, to judge someone? Law and religion are the two formalized systems for rendering judgment. In jurisprudence it refers to the determination of guilt or innocence as defined by the rules that govern a particular society. These are laws created by humans for the purpose of maintaining a safe and orderly place to live. A person who violates them is a criminal. In a theological context, a person who commits an offense against a religious law that is believed to come from God is a sinner. Anyone other than a judge or god who judges is simply “judgmental.”
Hence, when we say someone is judgmental, we mean that this individual is judging others without any legitimate reason for doing so, often assigning labels such as “irresponsible,” “careless,” or “lazy.” These are critiques of the person, not just their actions. A lazy man is expected to continue to avoid work. A careless individual is expected to remain unreliable. Such judgments diminish a person’s value in the eyes of whoever is doing the judging, as we saw in the case of the resident who didn’t feel the drug addict was worthy of help.
Being judgmental is antithetical to healing for at least three reasons. First, when you judge someone, you are making an assumption about them that may not be correct—for instance, that they don’t take their medication because they are irresponsible, when in fact the underlying problem is that they can’t afford to. Second, once you attribute a behavior to a character trait, you cease to ask questions because you think you already have the answers. Once you decide a patient is just “noncompliant,” you’re even less likely to find out what really accounts for their behavior. And third, to judge another is to assume a godlike superiority that undermines engagement—a form of interaction that can only occur when two people are on a level playing field.
There is also a fundamental illogic behind being judgmental. To judge someone is to believe that they are the primary cause of their actions, which is never the case. An emotionally unstable parent who is negligent did not choose the genes, family they were born into, violent neighborhood in which they were raised or other factors beyond their control that made them an unsuitable caretaker at a particular moment in time. One might respond, “Well, I know other people who grew up in tough, unfortunate circumstances and turned out all right.” But that is missing the point. If they turned out all right, something must have been different, either at the level of their genes or chance factors during their upbringing, such as a nurturing teacher or neighbor, or some other positive influence. The notion that we can somehow rise above our genetic potential and the environment into which we are born and raised is magical thinking. It is a deeply held belief that leads us to pass judgment.
It is hard not to be judgmental unless you let the belief go. For those who need empirical evidence that we are not in control, functional MRI studies demonstrate that the outcome of a decision is encoded in the prefrontal and parietal cortices up to 10 seconds before it enters awareness, that is, before we “decide” to act. One can only speculate about why the fallacy is so deeply embedded in our belief system, but I suspect it’s because we sure feel as if we’re in control. From moment to moment we perceive we’re making decisions about what we’re going to eat, when to take our medications, or whether to rob a bank. The thought that neurons fire based on genetic instructions and all previous life experience up to the present instant is, for many, disconcerting to contemplate. However, if you’re trying to understand or influence another’s behavior, it is essential to appreciate that every action is a reaction to myriad factors, including a person’s upbringing, current environment, past traumas and chance events that collectively make up the context for what you are observing.
Of course, you’ll never be able to fully explain or predict a person’s behavior no matter how well you know them, but social science and psychology research have yielded many insights about correlations. Adverse childhood events (ACEs), including physical or sexual abuse, or incarceration of a parent during childhood, are strong predictors of physical, emotional, and behavioral problems later in life. We also know that concomitant affirming relationships, such as with a caring teacher, physician, or neighbor can mitigate the adverse long-term effects of childhood traumas. To disregard all this information—to not consider a patient’s life context—and to conclude instead that their poor life choices, such as getting pregnant at an early age, simply reflect “carelessness” is judgmental.
Once we recognize that there is a story behind why a teenage patient had three babies at such an early age, and that she didn’t get to write that story—only to live it—we can engage. The purpose of engaging is not to understand why, as even she is unlikely to have a complete explanation, but to understand what to do about it. If the mother just needs a helping hand, you will do what you can to get her the needed services. In the clinic where I work we have special programs for teenage and low-income parents that include home visits and parenting classes. If her mental health is fraying, you’ll treat her condition, if doing so is within the scope of your practice, or refer her to someone who can.
How does one remain nonjudgmental when a patient is harming others, such as when they perpetrate child abuse? In such situations, I find it helpful to think of individuals as accountable rather than responsible for their actions. An abuser may have suffered untold abuse themselves, and aggression may be the only way in which they know how to react to stress and conflict in parenting relationships. In this context they are no more responsible for their actions than a ball is responsible for breaking a window. Nevertheless they must be held to account for their actions in order to maintain a safe and orderly society. Trained and authorized individuals should make a determination about whether the parents will lose custody based on an assessment of the risks and benefits to their offspring.
The shift from thinking about the person to thinking about the consequences of their actions primes us to ask, “What harm might they cause?” and “What can I can do to mitigate that harm while remaining mindful of unintended consequences?” I’ve seen well-intentioned physicians shy away from such questions because they mistakenly thought that asking them was in itself judgmental. A resident I was supervising in the pediatrics clinic decided not to notify the DCFS about an emotionally unstable mother, despite ample evidence that her children were at risk, because she didn’t want to “pass judgment”; she felt the mother was trying hard to be a better parent. In fact, protecting children from parental harm is no different from protecting them from an infection risk or a physical hazard like a busy street. A truly nonjudgmental physician can simultaneously intervene to protect children while striving to maintain a caring, engaged connection with distraught parents. The parents, out of anger, may not initially reciprocate, but the relationship can be invaluable to them in the long run. Not being judged for their failings as parents but supported as they figure out what to do next, enables them to turn to their child’s doctor for guidance rather than finding their way alone.
Avoiding judgmentalism doesn’t mean you won’t initially feel anger toward a patient who has harmed someone else. What matters is whether you can begin to engage with them anyway, responding to whatever happens during the interaction in the present moment rather than to past behaviors you probably haven’t witnessed. When a student responded judgmentally to a situation of an abuser and Simon challenged him, the student asked, “How can I not listen to what is in my heart?” Simon replied, “By remembering that everything that is in your heart is going through your brain.” While judgmentalism is driven by a noncognitive, emotive response to another individual, it is only our rational mind that can intervene.
Judgmentalism is an insidious process working in the background to degrade many routine clinical interactions as well, even when a patient hasn’t caused anyone harm. It seems particularly prevalent among physicians in response to obese patients. For an unannounced standardized patient study I was conducting, we hired several actors, one of whom just happened to be overweight. He had the frustrating experience of physicians focusing on his weight rather than listening and responding to whatever else he brought up as a part of his script. He said he felt badgered by many of them to the point of having trouble hiding his irritation. The physicians’ judgmental attitude so preoccupied them that they were unable to provide effective care.
It’s hard to say if physicians are more judgmental than other people. I do think physicians are particularly judgmental of themselves, which in turn shapes how they respond to others. We self-obsess over all sorts of things, as if that does any good. A rather judgmental medical student was chastising himself while confiding to Simon that he watched a lot of Internet pornography, prompting Simon to ask, “What do you think is wrong with that?” The student replied, “Well, it’s sinful!” Simon said, “So you think you may be doing something wrong in the eyes of God?” “Yes,” the student answered. Simon concluded, “Why don’t you let God deal with it? If he’s unhappy, he’ll punish you.” The student smiled and said “Thank you.” The message implicit in the question was liberating: If you can’t come up with any reason why your behavior is wrong except that it’s sinful, then why beat yourself up over it?
Simon’s point is that judging ourselves is as fruitless as judging others. God can judge us, according to certain religious tenets, and we may be judged in a court of law, but regardless of whether we feel that we or our patient is a bad or lazy person, we should focus instead on the consequences—if there are any—of specific behaviors and what we are going to do to address them.
What makes us judgmental? I think it is hubris, which may be particularly prevalent among those who have the good fortune of becoming physicians. To judge is to forget one is not God. Who are we to decide that someone could have done better despite the cards they were dealt? And just as we tend to overlook the misfortune that leads individuals to self-defeating lives, we may discount the luck that enabled us to succeed. Instead we chalk up our achievements to hard work, resilience, intelligence, and our great personalities. But where did those come from? Once again, we must acknowledge that we too didn’t pick our great genes, the economic advantages and/or nurturing family, friends, or community that enabled us to make it this far. Some of us were successful against great odds, perhaps because of an unusually resilient genetic makeup or chance events that worked in our favor. Whatever the reasons, they weren’t ones we got to choose.
Hence, giving up the belief that people fail in life because of their own self-inflicted behaviors without acknowledging that those behaviors are the product of factors beyond their control, also means giving up the belief that we are personally responsible for our own successes. It can be a painful trade-off but well worth it. It enables us to forgive ourselves and forgive our patients, so that we can relate to them with a sense of shared humanity, collectively swept along in the river of life. And when we see them stumble, rather than judging them, we can think, “There but for the grace of God go I.”
Questions for Reflection and Discussion
1. Can you think of examples of judgmentalism affecting patient care, like the one described in which a physician called child protective services before finding out why the family missed just one of many appointments, risking separation of a child from struggling but caring parents?
2. Can you think of an example in which you didn’t ask a question because you made an assumption about a patient’s motivation (for example, that they are not taking their health care seriously) when, in fact, there may have been some impediment, such as cost or fear, that got in the way of their following the expected care plan?
3. If you were caring for a patient who you learned was a registered sex offender, how might that information affect the way you relate to them? What if you also saw a note in their chart indicating that they are “drug seeking”? Would you be predisposed to dislike them? If they had significant long-term health care needs, would they be at risk of getting less attention from you as their physician than you give to other patients? If so, what could you do to correct that deficiency in the consistency of the quality of your care? If you learned that they had been sexually and physically abused as a child themselves, would that change your perspective?
4. How do you react to the epigraph at the beginning of this chapter that, essentially, we are all doing the best we can with the cards we’ve been dealt? Do you agree? If not, what are your objections? What are the implications of your point of view for how you as a doctor might relate to and care for a patient who engages in self-destructive behaviors, including not following your evidence-based recommendations?