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Desigualdades sociales en salud desde la consulta

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Presentación para la mesa sobre estrategias de apoyo a la desmedicalización.
Distrito Sanitario Sevilla.
23/09/2015.

Published in: Healthcare
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Desigualdades sociales en salud desde la consulta

  1. 1. Las desigualdades sociales desde la consulta: la necesidad de enfocar de cerca y de lejos. Javier Padilla Bernáldez Médico de familia y comunidad. MIR Medicina Preventiva y Salud Pública. Hospital de Valme. javithink@gmail.com @javierpadillab medicocritico.blogspot.com
  2. 2. Historia de dos mujeres… Lucía tiene 45 años, madre de una niña de 18, vive con su marido en una casa baja de 2 plantas; trabaja en la banca y en un reconocimiento de empresa le han detectado el “colesterol malo” un poco elevado y la tensión un poco alta (“aunque yo lo que tengo es mucho estrés”), va al gimnasio a hacer step 4 veces a la semana y toma leche desnatada y pan integral “porque ya hay que ir cuidándose”.
  3. 3. Historia de dos mujeres… Vanessa tiene 45 años, madre de un niño y una niña, de 25 y 23 años respectivamente, acude a la consulta cada 6 meses “para hacerse un chequeíto”, aunque nunca ha salido nada alterado además de una tensión arterial sistólica con cifras aisladas en el límite de la normalidad. Su marido está en paro desde hace 2 años, ella no trabaja desde que se casaron; él bebe “algo más de lo normal, doctor”, ella no sale de casa más que para ir al mercado durante 30 minutos por la mañana; a él le han diagnosticado cáncer de estómago hace 2 meses y no le han dado muchas esperanzas, ella es la que habla con los médicos, él no sabe la gravedad; los hijos dejaron de estudiar cuando cumplieron la mayoría de edad y aún viven en casa.
  4. 4. ¿Cuál de las dos tiene más cabida en nuestra consulta?
  5. 5. El punto de partida. Existen dos grandes campos de juego de la desigualdad en salud –visto desde la consulta-: • La influencia de los determinantes sociales de salud en la salud y la enfermedad. • La influencia de los determinantes sociales de salud en nuestra forma de tratar a los/as pacientes.
  6. 6. P R O F E S I O N A L S A N I T A R I O P A C I E N T E
  7. 7. Políticas de bienestar Mercado de trabajo Valores colectivos políticos y culturales Género Marco ético y de construcción cultural de tolerancia a desigualdad Clase social Territorio Factores psicosociales Servicios sanitarios Condiciones laborales Trabajo doméstico y de cuidados Recursos habitacionales Medio físico residencial Medidas macropolíticas ACTIVOS EN SALUD DETERMINANTES ESTRUCTURALES DETERMINANTES INTERMEDIOS Edad Grupo étnico Relacionesdepoder Factores biológicos y conductuales Ingresos y situación económica Marco de determinantes sociales y generación de las desigualdades en salud. Adaptación a partir de Borrell et al (2010). Tomado de Padilla J. López V. FMC. 2015 (en prensa).
  8. 8. Estado de salud físico y mental. Condiciones materiales Condiciones físicas Condiciones psicosociales Condiciones conductuales Condiciones biológicas Renta y estatus familiar Formación y educación Profesión Ocupación laboral Renta Red social Condicionales estructurales y servicios de protección social Bienestar Ruta causal entre renta y estado de salud. Basado en Benzaval et al. 2014. Tomado de Padilla J, López V. FMC. 2015 (en prensa).
  9. 9. P R O F E S I O N A L S A N I T A R I O P A C I E N T E
  10. 10. P R O F E S I O N A L S A N I T A R I O P A C I E N T E Características sociodemográficas no modificables (género, orientación sexual, raza) “El discurso de los profesionales muestra sesgos de género. El más destacable es la creencia de que hay una subjetividad femenina patológica fruto de las características biológicas de ser mujer y no de consecuencias sociales.” Gil García E, Romo Avilés N, Poo Ruiz M, Meneses Falcón C, Markez Alonso I, Vega Fuente a. Género y psicofármacos: la opinión de los prescriptores a través de una investigación cualitativa. Atención Primaria. 2005;35(8):402–7.
  11. 11. P R O F E S I O N A L S A N I T A R I O P A C I E N T E Características sociodemográficas no modificables (género, orientación sexual, raza) ...We chose an obstetrician who hadn’t had a gay couple before…he said don’t bring any of your friends back... when he rang pathology or other services, the same man would say ‘I’ve got the same sex couple’ and when she asked him about that he said ‘oh I don’t know’, leaving the question open about whether he was actually homophobic or simply out of his depth?... Chapman R, Wardrop J, Freeman P, Zappia T, Watkins R, Shields L. A descriptive study of the experiences of lesbian, gay and transgender parents accessing health services for their children. J Clin Nurs. 2012;21(7-8):1128–35.
  12. 12. P R O F E S I O N A L S A N I T A R I O P A C I E N T E Características sociodemográficas no modificables (género, orientación sexual, raza) Características socioeconómicas En los pacientes de clase social más baja…  Anamnesis más biomédica.  Estilo de consulta más directivo.  Menor toma de decisiones compartida.  Menor prioridad en las derivaciones a atención hospitalaria. Verlinde E, De Laender N, De Maesschalck S, Deveugele M, Willems S. The social gradient in doctor- patient communication. Int J Equity Health [Internet]. BioMed Central. 2012;11(1):12. Abásolo I, Negrín-Hernández M a, Pinilla J. Equity in specialist waiting times by socioeconomic groups:evidence from Spain. Eur J Health Econ. 2013
  13. 13. P R O F E S I O N A L S A N I T A R I O P A C I E N T E Características sociodemográficas no modificables (género, orientación sexual, raza) Aspectos clínicos del paciente Características socioeconómicas  Diagnósticos psiquiátricos.  Obesidad.  Toxicomanías.  Discapacidades.  … Lawrence D, Kisely S. Inequalities in healthcare provision for people with severe mental illness. J Psychopharmacol. 2010;24(4 Suppl):61–8. 12 Russell N, Carryer J. Living large: the experiences of large-bodied women when accessing a general practice services. J Prim Health Care 2013;5(3):199-205
  14. 14. P R O F E S I O N A L S A N I T A R I O P A C I E N T E Características sociodemográficas no modificables (género, orientación sexual, raza) Aspectos clínicos del paciente Características socioeconómicas INTERSECCIONIALIDAD Crenshaw K.Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics". University of Chicago Legal Forum 1989: 139–67
  15. 15. Los factores que median en el trato inequitativo.
  16. 16. P R O F E S I O N A L S A N I T A R I O P A C I E N T E Características sociodemográficas no modificables (género, orientación sexual, raza) Aspectos clínicos del paciente Características socioeconómicas Falta de sentido de control Problemas en la comunicación
  17. 17. P R O F E S I O N A L S A N I T A R I O P A C I E N T E Características sociodemográficas no modificables (género, orientación sexual, raza) Aspectos clínicos del paciente Características socioeconómicas Falta de sentido de control Problemas en la comunicación Lo que conocemos (y lo que no) Universal <-> concreto El cuerpo y la persona Charon R. Narrative evidence based medicine. The Lancet 2008;371(9609):296-7
  18. 18. P R O F E S I O N A L S A N I T A R I O P A C I E N T E Características sociodemográficas no modificables (género, orientación sexual, raza) Aspectos clínicos del paciente Características socioeconómicas Coincidencia médico-paciente (raza, enfermedad, clase social…) Falta de sentido de control Problemas en la comunicación Incapacidad de generar empatía
  19. 19. P R O F E S I O N A L S A N I T A R I O P A C I E N T E Características sociodemográficas no modificables (género, orientación sexual, raza) Aspectos clínicos del paciente Características socioeconómicas Coincidencia médico-paciente (raza, enfermedad, clase social…) Falta de sentido de control Problemas en la comunicación Incapacidad de generar empatía Social Class as Culture: The Convergence of Resources and Rank in the Social Realm (Association for Psychological Science, 2011)
  20. 20. ¿Qué nos toca hacer –además de cambiar visión-? Ni socializar lo médico ni medicalizar lo social. • El domicilio como la forma inmediata de hacer salud comunitaria. • ¿Quién es esa persona a la que llamamos trabajador/a social? • La utilidad de diagnosticar con códigos Z.
  21. 21. ¿Qué nos toca hacer –además de cambiar visión-? Contextualizar para relativizar responsabilidades • Explorar estructura de cuidados familiares en mujeres obesas vs consejo breve anti-todo (tabaco, grasas, sedentarismo, dulces,…). • ¿Es la persona capaz de decidir hacernos caso o no?
  22. 22. ¿Qué nos toca hacer –además de cambiar visión-? ¿Tenemos ley de cuidados inversos en nuestra consulta? • Auditar cribado de cáncer de cérvix en función de nivel educativo (oportunista en consulta) • Auditar HbA1c según red sociofamiliar y nivel de instrucción.
  23. 23. ¿Qué nos toca hacer –además de cambiar visión-? ¿Y si hacemos un “cribado” de pobreza en nuestra consulta? • “¿alguna vez tiene dificultades económicas para llegar a fin de mes?” (S98% E64%) • De recetar medicinas a recetar recursos  conocer primero esos recursos  mapeos. Ontario College of Family Physicians. Poverty. A clinical tool for primary care in Ontario. Ontario: Ontario College of Family Physicians, University of Toronto. 2013.
  24. 24. 1. Dos ámbitos de desigualdad: 1. En el desarrollo de los estados de salud. 2. En el trato dentro de la consulta.
  25. 25. 1. Dos ámbitos de desigualdad: 1. En el desarrollo de los estados de salud. 2. En el trato dentro de la consulta. 2. Importancia de la Atención Primaria como puerta de entrada de la desigualdad
  26. 26. 1. Dos ámbitos de desigualdad: 1. En el desarrollo de los estados de salud. 2. En el trato dentro de la consulta. 2. Importancia de la Atención Primaria como puerta de entrada de la desigualdad 3. ¿Qué es tener una visión de desigualdades en la consulta? 1. Ni socializar lo médico ni medicalizar lo social. 2. La mirada a la comunidad a través de la mirilla de la consulta (Turabián). 3. La Ley de cuidados inversos en nuestra consulta. 4. ¿Preguntamos por la pobreza en la consulta?
  27. 27. Las desigualdades sociales desde la consulta: la necesidad de enfocar de cerca y de lejos. Javier Padilla Bernáldez Médico de familia y comunidad. MIR Medicina Preventiva y Salud Pública. Hospital de Valme. javithink@gmail.com @javierpadillab medicocritico.blogspot.com

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