Don't 'due-due' on patients

I have a serious problem with the ubiquitous use of 'due' when talking with patients about what their medical options are. This came up recently when I was given a list of my patients who were ‘due’ for certain services, required if my institution is to receive a financial quality incentive. Typically, ‘due’ shows up in EHR alerts (the diabetic patient is 'due' for their A1c or microalbumin) and quality programs (patients are 'due' for a mammogram every 2 years, a DXA at 65, a pneumovax at 65, even well child visits at set intervals). Clinicians see it and hear it so often, it becomes part of our internal thought process. But it is wrong and harmful. 

Language matters. Framing matters.

The proper phrasing would be 'eligible for' rather than 'due'.

The definition of due is:  owed, expected, required.  It comes from the Latin, debere, to owe, and carries a strong connotation of obligation rather than choice.  Our taxes are 'due' on April 15 and there are legal penalties for paying late or not at all A library book is due on a given date, and there is a fine for lateness. Homework assignments are due on a certain date, and credit is subtracted if they are not submitted or not on time. Payment for my monthly credit card or electric bill is due, and I am subject to punishment if I am late. Payment (such as a co-pay) may be due at the time of service. These are all obligations or requirements, and there is no choice involved. 

Due (in the context of patient care) is a remnant of the paternalistic era of medicine, where the physician decided what was right and the patient followed 'orders' (another term we should be re-thinking in medicine) and was expected to be 'compliant' with the physician's plan of care.

In contrast, eligible is defined as meeting the standards, desirable, meeting qualifications. It comes from the Latin eligere, to choose or elect, and is the appropriate term here. Patient-centered evidence-informed care is the process of providing to autonomous patients the appropriate and balanced information and then helping the patient choose.

Even in something as non-controversial as tetanus boosters every 10 years, it is incorrect to think or talk about patients being obligated or required to have them. Yes, it is recommended by experts and (in my opinion) a good idea, but there is no legal or moral imperative, the patient is not employed by the CDC an d required to follow their advice, and a patient is not a bad person avoiding a debt or responsibility if they defer or decline. They are simply exercising their right as an autonomous adult to make a choice.

What do I mean by the right of an autonomous adult to make a choice?

First, frame this in non-medical terms. Are you obligated to purchase the item Consumer Reports selects as a Best Buy, or are you free to make a choice? That’s a simple way to envision autonomy. It is equally applicable to medical decisions.

Patient autonomy is the first and most basic of the four core principles of medical ethics: the patient has the right to refuse or choose their testing/treatment. (Voluntas aegroti suprema lex.) Patients can only be autonomous if they are given accurate, pertinent, truthful, balanced information with which to make a decision, and are not coaxed or coerced. This is much more than simply not lying to patients. This is informing patients in a way that they can understand and does not (intentionally or unintentionally) make it harder for them to make an independent decision.  The way we phrase things can subtly (or not so subtly) alter the response. Telling a patient something is ‘due’ frames this as a requirement and not a choice, and is inappropriate in any institution that claims to practice patient-centered care and shared decision-making, because it expresses our recommendation as a patient obligation. Telling patients they are 'due' for a service is (in my opinion) disrespectful and poor care.

As I said, words matter. The next time your institution or clinician says you or your patient is ‘due’ for something, push back.



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