One medical educator wrote me in response to the podcast, “How a small change in what you say can improve your patient education.” She thanked me for giving a ‘name’ to the problem that is a deficit perspective.
She pointed out the tension between approaching a patient focused on the problem, and approaching a patient holistically. As an educator, I appreciate that tension.
Providers also face shrinking time to forge relationships with patients, pressure to adhere closely to ‘what works,’ and accountability requirements that eat into their time (and may even contradict their professional judgment).
There’s no time to mess things up with a deficit perspective.
So what is a deficit perspective?
I have addressed deficit perspective before, relating it to
- Seeing patients as empty ‘containers’ to be ‘filled.’ Passive recipients. Not people with lives, thoughts, histories, or resources.
- Maintaining a focus on what a patient doesn’t understand, or doesn’t do; what a patient’s situation lacks; what his or her community can’t provide.
It can also refer to a focus that’s limited to negative results, effects, examples, depictions, or instances.
I’ve been keeping an eye on deficit views in education for more than a decade, and I know they can emerge in research, practice, and policy. Here’s how I have seen some deficit views show up in the health sector.
Deficit perspective in research
Two separate research reviews—one on rural health, and one on sexual minority youth of color–each make similar points:
- the research in their field has been characterized by a deficit perspective
- this has harmed the field, and potentially those who work in it as well as the patients being served.
One is titled From ‘problem-describing’ to ‘problem-solving’: challenging the ‘deficit’ view of remote and rural health. This study found that the tendency of “embedding a deficit perspective in research has stereotyped rural and remote health as poor environments to work in and as inherently problematic.”
A second literature review, of health and well-being of sexual minority youth of color, found that “research with SMYoC has been framed by a lingering deficit perspective, rather than emphasizing normative developmental processes or cultural strengths.” The authors point out several gaps in the research base as a result of this perspective, and “highlight areas for future research focused on minority stress, coping, and resilience of SMYoC.”
Some studies have found a deficit view in everyday practice.
This study, about how dentists perceive poverty and people on social assistance, found that the dominant perspective was a deficit one, in which
“Dentists explained poverty by individual factors and emphasized individuals’ negative attitudes toward work and lack of capabilities.”
Significantly, “The results suggest the individualistic-deficit perspective impedes the care relationship between dentists and poor patients.”
The authors of this paper on health systems suggest that “Health system leaders and front line clinicians are prone to interpreting health literacy as a patient deficit.” They remark that it is “too easy to frame the problem as one that resides in the patient—that they have to develop certain skills, become more literate, be better able to navigate, use health services, and understand and follow orders.” They maintain this perspective is “implicitly reinforcing paternalism.”
Deficit perspective in policy
And, there’s policy.
This three-year empirical study was on the impact of a set of ‘healthy school’ initiatives in the UK. The authors find these policies
“position the body as being in deficit, unfinished, or at risk and, therefore, in need of rescue from conditions, ‘risks’, over which individuals or populations have increasingly less control.”
The combined effect of official and unofficial policies is in defining “what body size, shape, predisposition and demeanour is and ought to be, and how, for those who do not meet these ideals, there is treatment, repair and restoration.”
In the face of these policy pressures, “many [young people] not only take drastic action to lose weight and become ill but also become seriously depressed.”
Why does this happen?
As providers, you have a ‘problem’ focus when you meet with a patient. This is part of what the medical educator at the start was talking about. You’re there for the complaint, the illness, disease or injury.
You get to hear many things about what is ‘wrong’ with your patients.
I am not saying this leads to a deficit perspective. But it does seem to exert quite a lot of pressure toward seeing patients as collections of problems to be solved.
That’s on top of the reasons we all have for tending to favor people (and worldviews) that reflect us.
But that’s just common-sense!
One way to think about a deficit perspective is having its roots in an ethnocentric bias.
This is our tendency to take for granted our own linguistic and cultural practices.
Our cultural position leads us to celebrate particular virtues. That’s all well and good.
Until another tendency kicks in: the tendency to describe something different from us as something less than us.
You could liken this to going to a new town, or even a new restaurant: we often judge it according to what it doesn’t have that we’re used to having.
We focus on perceived weaknesses based on what we think is (or should be) normal, basic, fundamental, what it ought to be.
My way or the highway. This is the ethnocentric bias.
And its effects are exponentially stronger when there is a marked power difference between the people involved.
This was the big kerfuffle in anthropology in the early-to-mid 20th century. Unknown lands tended to be judged by western European standards. The language and customs of these ‘new’ groups were not considered on their own terms, but rather were seen in reference to the ways of the dominant group. Where the anthropologists tended to be.
I’m not sure how I could scientifically prove that a deficit perspective is a waste of time. But it seems reasonable to assume that it’s, at best, naïve and counterproductive.
Here’s how to begin to be aware of a deficit perspective
Turning away from a deficit perspective means being able to take some blinders off, in terms of what normal looks like.
This in part means: what you tend to take for granted that ‘normal’ people do in terms of reading, language use, learning, keeping healthy. What you would consider ‘normal’ displays of intelligence, concern, curiosity, commitment, and so on.
I won’t be the first to encourage you to place patients’ complaints in the larger context of their personhood and their lives. This includes the ways they use language. And the ways they learn. Especially when these are not the ways you learn, or use language.
You have more options.
What can you focus on instead?
- Resources! All patients come to you with extraordinary linguistic, cultural, and intellectual resources. Just not the same resources as you. Or as other patients.
The idea is to help people be healthier and live longer. So you need as many resources as you can get. Acknowledge the resources (including the richness of language and culture) all patients bring to you. These resources might be overlooked or altogether missed–because of the pressure to be looking for something else.
2. Reflection! Self-reflection plays a crucial role in this process.
Make explicit to yourself how you name and define ‘normal.’ Really tease these meanings out. Have standards, but be ready to look closely at what yours are, and at what it means to hold those standards rather than others.
We all can overgeneralize and rely on stereotypes – and sometimes (often?) we do this without noticing. Some dangers may come when the differences are perceived as deficiencies on which further action is based.
If you are interested in taking your language use seriously, why not start with your metaphors? This workshop shows you how to break down the metaphors you use, understand their cognitive and affective aspects, and evaluate them in use. On demand, right on this site.