Question: How will I incorporate and be understanding of persons with different cultural perspectives who come into my practice?
After a PCM presentation highlighting a Chinese naturopath and an M.D. having a mostly Hispanic patient population, I asked myself the question above. Our reading indicated that 70-90% of patients manage their sicknesses outside of the realm of formal healthcare and that our individual cultures play a powerful role in how we care for ourselves. Specifically, our material describes folk remedies that exist in all cultures and which vary tremendously from one culture to the next. So, how can I learn and apply knowledge of complex, culture-based care?
I think the answer consists of two parts: Gaining practical, on-the-ground experience and through independent study. Before I can do either, however, I must realize who my patient population typically will be or could potentially be as I begin to interact with them. I will likely have easy access to this information if I join an existing group practice or hospital. Or, if I begin a solo effort, other local providers or the community composition in the location I select will provide the initial profile.
As a first effort, I will need to read all I can discover concerning the cultures I expect to encounter. Each patient will present with different concepts of family, ideas of social justice, hierarchies among relatives, decision-making authority, folk remedies, and how they will approach their healthcare based on the cultural solutions they are familiar with and of which they are convinced have value. I will need to understand what each patient truly believes will make a difference for them and whether it will truly improve their health. Of course, much of the reading will be found in medical journals – and much of it will not. It may be uncovered in cultural periodicals, stories of persons who live in or originate from those worlds, and articles that describe their practices and beliefs as written by persons who are members of the fold. I will simply have to devote a good deal of my personal time to learning about my patients and until I have a firm grasp of who they are and what they believe will impact their health.
As a second means of learning, I will need to gather information directly from the patients themselves. Since this learning will occur one patient at a time during individual encounters, it will transpire at a much slower rate, but, as I am attentive to each person, I will steadily acquire this understanding. It will require a humble attitude that allows me to hear, and I will have to be open to new ideas and accepting of habits I don’t understand. I will need to inquire consistently as to their ideas and cultural remedies, and seek nonjudgmental compromise as we work together in their plan of care. Indeed, as indicated by Dr. An, the naturopath, some persons believe that the body only heals itself, and we merely need to attempt to get out of the body’s way or remove any impediments to the body being able to heal. And, as long as their methods are not deemed harmful, it may be best to negotiate a treatment plan whereby patients pursue their chosen remedy in addition to any I may deem beneficial or necessary. Possibly, their positive belief and outlook may make a remedy worth pursuing.
As I progress through medical school I will likely gain valuable insight into many cultures and practices. There will always be more to learn. I will continue to seek out new information and clarify my understanding of every culture I encounter. And, as a generous side benefit, my patients will educate me about new cultures in depth, and I don’t even have to purchase a plane ticket. Nice bonus.
Monday, November 2, 2009
Hearing to Heal
Question: How can I communicate with patients so they feel heard, cared for, and cared about?
I consider this question in response to the woman who addressed our PCM class and who told the story of losing her material goods and livelihood due to a husband’s financial dealings and a precipitating stroke. On that particular afternoon, we were hearing how people deal with acute illness and life crisis issues as this woman described the painful interactions she had with busy doctors who left her feeling distant and unheard.
As I listened, I wondered something to myself. What would happen if patients could write their own notes in their charts about how they feel, what their symptoms are, what they think might be wrong with them, and what we (doctors) should do about it? I began to wonder how much of that note a doctor would actually “hear” and take to heart if it were written in that sacred space and whether they would truly believe their patient’s opinions mattered. The truth is we mostly only allow patients to interact with us on our terms and in our official spaces which doesn’t seem to be a way to place them at ease or engender their trust. To do that I believe we must be partners with them in their care and understand them as they present themselves. While we are trained to approach medical problems from an evidence-based perspective, we can never truly have an “understanding-based” perspective until we include in it the expertise that each patient possesses of their own condition and history.
When I finally enter a practice of my own, I will spend much of my time listening to, encouraging, and negotiating with patients as I come to terms with their worlds and seek cures for their ills. Patients can help me do all of these things. One of the ways the woman described above communicates with her doctor is to write notes in advance of her visits, so she can present a complete list of her concerns when she arrives. Her doctor suggested she do this. Of course they aren’t placed in the chart, but, since she has difficulty remembering her symptoms and collecting her thoughts while she is in the room with him, it effectively allows her to feel that she provides all relevant information to her doctor, and she feels like it is an important part of her being heard - of her story being told. The lesson for me is to be aware of what a patient is capable of and aware of how they will communicate with me. I need to find ways, if they are lacking, of being able to communicate well with patients. It can only give me better information to make a more appropriate diagnosis and allow me to have a sense of where patients are at in order to understand them as “whole” persons.
Here are some additional relevant gleanings that I learned from my favorite family practice physician, Dr. Jeff Stoessl at Salem Clinic in Salem, Oregon:
· Sit down
· Don’t stare at the computer when in the room with a patient
· Don’t look at papers, books, or charts except as a quick reference
· Be 110% focused on the patient - nothing else matters right then
· Look patients in the eye when you both talk and listen
· Politely let them know what you are doing – communicate what is occurring at the time
· Allow patients time and space to think
It sounds obvious, but it comes down to a moment-by moment choice. We must choose to care and listen to every patient. We must choose to act in order to make a difference. We must choose not to be paternalistic or arrogant or the keeper of knowledge. We must convey to patients that we have an interest in their lives and that we care for them as whole human beings. Every encounter is a chance to get better at these things. I can’t wait to try them out.
I consider this question in response to the woman who addressed our PCM class and who told the story of losing her material goods and livelihood due to a husband’s financial dealings and a precipitating stroke. On that particular afternoon, we were hearing how people deal with acute illness and life crisis issues as this woman described the painful interactions she had with busy doctors who left her feeling distant and unheard.
As I listened, I wondered something to myself. What would happen if patients could write their own notes in their charts about how they feel, what their symptoms are, what they think might be wrong with them, and what we (doctors) should do about it? I began to wonder how much of that note a doctor would actually “hear” and take to heart if it were written in that sacred space and whether they would truly believe their patient’s opinions mattered. The truth is we mostly only allow patients to interact with us on our terms and in our official spaces which doesn’t seem to be a way to place them at ease or engender their trust. To do that I believe we must be partners with them in their care and understand them as they present themselves. While we are trained to approach medical problems from an evidence-based perspective, we can never truly have an “understanding-based” perspective until we include in it the expertise that each patient possesses of their own condition and history.
When I finally enter a practice of my own, I will spend much of my time listening to, encouraging, and negotiating with patients as I come to terms with their worlds and seek cures for their ills. Patients can help me do all of these things. One of the ways the woman described above communicates with her doctor is to write notes in advance of her visits, so she can present a complete list of her concerns when she arrives. Her doctor suggested she do this. Of course they aren’t placed in the chart, but, since she has difficulty remembering her symptoms and collecting her thoughts while she is in the room with him, it effectively allows her to feel that she provides all relevant information to her doctor, and she feels like it is an important part of her being heard - of her story being told. The lesson for me is to be aware of what a patient is capable of and aware of how they will communicate with me. I need to find ways, if they are lacking, of being able to communicate well with patients. It can only give me better information to make a more appropriate diagnosis and allow me to have a sense of where patients are at in order to understand them as “whole” persons.
Here are some additional relevant gleanings that I learned from my favorite family practice physician, Dr. Jeff Stoessl at Salem Clinic in Salem, Oregon:
· Sit down
· Don’t stare at the computer when in the room with a patient
· Don’t look at papers, books, or charts except as a quick reference
· Be 110% focused on the patient - nothing else matters right then
· Look patients in the eye when you both talk and listen
· Politely let them know what you are doing – communicate what is occurring at the time
· Allow patients time and space to think
It sounds obvious, but it comes down to a moment-by moment choice. We must choose to care and listen to every patient. We must choose to act in order to make a difference. We must choose not to be paternalistic or arrogant or the keeper of knowledge. We must convey to patients that we have an interest in their lives and that we care for them as whole human beings. Every encounter is a chance to get better at these things. I can’t wait to try them out.
Friday, October 23, 2009
Another Story of Kindness
When I first realized how sick I was with the flu, I went to the ED for help at 4 a.m., and they kicked me out of school for a week. Good for everyone, I know. But, it meant I couldn't make the test that afternoon, so I emailed my instructor the details of what happened and asked what to do. He said, " This is what you normally need to do, but, don't worry, I've taken care of it for you. You just need to get better. Let us know how things go. Wishing you well!"
And, you know, I did feel better. That was a relief. I had no idea how I could make up a lab exam having 50 structures to identify and that were tagged on the same cadavers that students used every day. A weight had been lifted.
I sent back a status update the next day and advised that my fevers were increasing. He sent back a note jauntily claiming that my quarantine status was a terrific idea and encouraged me that the timing for the illness was perfect in that this was the easiest block for getting caught up. He told me to take care. – I hadn’t realized the block was the easiest. But it really was. The illness was becoming less perilous by the day.
I sent back a note the next day thanking him for the encouragement and letting him know I hoped to be ready to go when they let me back into class. – He replied to let me know that he would allow other options that would permit me to take the test at a relaxed pace and/or at a later date as the illness allowed. He said I could decide when I felt better and to let him know if I was interested in that option. Above all: Try to feel better!
And, so I did feel better. I had options. I was trusted. He believed I was sick and wasn’t a con artist. He believed I was doing my very best, and he wanted the very best from me. He was going to help me do that with every tool at his disposal. Wow. Out of 160 students in that class, he took the time to make sure this one had what he needed. Impressive.
So, the following Monday rolled around. That was the first day anyone was willing to let me come near them. Can’t say I blame them. I was still sick with something. I went in to take the written make-up test. It was handed to me at arm’s length, and the staff was quite gracious as they set up the room for me and started the slides. I finished the test with a minute or two to spare, pages swimming in front of my eyes. At least it was over.
I went into the office, and who was there but our instructor. I had never seen him in there before. He greeted me with a big smile and seemed genuinely glad to see me there. He wished me luck and took the test from me for grading (electronic scan).
I was checking email later that night and up popped an email from the instructor. Apparently, he had graded the test within an hour or so and was congratulating me on an excellent score. I was incredulous. Normally, it took two days for us to get our scores. Then... I get congratulations! – I had no worries about how I did and a boost to keep me going.
And, that’s not all. The next day, he dropped by our lab table to tell my labmates how glad he was to see me back in class on Monday. He gave a robust fist pump and a big grin. He was rooting for me.
Right about then, something clicked. My brain kept telling me to re-evaluate what was happening. I realized something special was occurring. This was no ordinary person and no ordinary act of kindness. This was a person who actively sought out the cause of someone’s pain and worked diligently to cultivate a cure. He was persistent and careful as he tested his remedies. He would not give up until he was certain I had been restored to health.
I realized this was a guy who cared deeply about every single person in our class and who was completed invested in our success. We mattered to him. We really mattered. He truly cared that we learn and that we take away every lesson possible from the experience.
Indeed, he took the time and made a significant effort to create a place that allowed me to heal. He helped me get better. He’s not an M.D. But he’s a healer. He’s the one guy on staff who performed flawlessly during my illness. Without hesitation, I tell you it’s an honor to sit at his feet and learn the healing art of medicine.
Thanks, Dr. Ciment. We’re damn lucky to have you as an instructor.
And, you know, I did feel better. That was a relief. I had no idea how I could make up a lab exam having 50 structures to identify and that were tagged on the same cadavers that students used every day. A weight had been lifted.
I sent back a status update the next day and advised that my fevers were increasing. He sent back a note jauntily claiming that my quarantine status was a terrific idea and encouraged me that the timing for the illness was perfect in that this was the easiest block for getting caught up. He told me to take care. – I hadn’t realized the block was the easiest. But it really was. The illness was becoming less perilous by the day.
I sent back a note the next day thanking him for the encouragement and letting him know I hoped to be ready to go when they let me back into class. – He replied to let me know that he would allow other options that would permit me to take the test at a relaxed pace and/or at a later date as the illness allowed. He said I could decide when I felt better and to let him know if I was interested in that option. Above all: Try to feel better!
And, so I did feel better. I had options. I was trusted. He believed I was sick and wasn’t a con artist. He believed I was doing my very best, and he wanted the very best from me. He was going to help me do that with every tool at his disposal. Wow. Out of 160 students in that class, he took the time to make sure this one had what he needed. Impressive.
So, the following Monday rolled around. That was the first day anyone was willing to let me come near them. Can’t say I blame them. I was still sick with something. I went in to take the written make-up test. It was handed to me at arm’s length, and the staff was quite gracious as they set up the room for me and started the slides. I finished the test with a minute or two to spare, pages swimming in front of my eyes. At least it was over.
I went into the office, and who was there but our instructor. I had never seen him in there before. He greeted me with a big smile and seemed genuinely glad to see me there. He wished me luck and took the test from me for grading (electronic scan).
I was checking email later that night and up popped an email from the instructor. Apparently, he had graded the test within an hour or so and was congratulating me on an excellent score. I was incredulous. Normally, it took two days for us to get our scores. Then... I get congratulations! – I had no worries about how I did and a boost to keep me going.
And, that’s not all. The next day, he dropped by our lab table to tell my labmates how glad he was to see me back in class on Monday. He gave a robust fist pump and a big grin. He was rooting for me.
Right about then, something clicked. My brain kept telling me to re-evaluate what was happening. I realized something special was occurring. This was no ordinary person and no ordinary act of kindness. This was a person who actively sought out the cause of someone’s pain and worked diligently to cultivate a cure. He was persistent and careful as he tested his remedies. He would not give up until he was certain I had been restored to health.
I realized this was a guy who cared deeply about every single person in our class and who was completed invested in our success. We mattered to him. We really mattered. He truly cared that we learn and that we take away every lesson possible from the experience.
Indeed, he took the time and made a significant effort to create a place that allowed me to heal. He helped me get better. He’s not an M.D. But he’s a healer. He’s the one guy on staff who performed flawlessly during my illness. Without hesitation, I tell you it’s an honor to sit at his feet and learn the healing art of medicine.
Thanks, Dr. Ciment. We’re damn lucky to have you as an instructor.
Something Different
Here's a poem I wrote the other day.
Healer
I hurt so much
And fear so deeply
That I am all undone
When she arrives in pain
At the very least
Do not harm her further
When she brings the shattered pieces of her life
In her hands
Do not jostle her
Or squeeze her hands so tightly
That you cut them
As the jagged pieces
Dig into her flesh
Choose differently
Ask her to place the pieces
On the table between you
And seek to discover
The source of her pain
And the healing that need be done and
Create
The place where healing can occur
Allow the science to work its magic
As you pour yourself over the broken pieces
Causing peace and love
To flow over the shards
Of her cup
And allow them to mend
So she might fill her cup
Once again
Healer
I hurt so much
And fear so deeply
That I am all undone
When she arrives in pain
At the very least
Do not harm her further
When she brings the shattered pieces of her life
In her hands
Do not jostle her
Or squeeze her hands so tightly
That you cut them
As the jagged pieces
Dig into her flesh
Choose differently
Ask her to place the pieces
On the table between you
And seek to discover
The source of her pain
And the healing that need be done and
Create
The place where healing can occur
Allow the science to work its magic
As you pour yourself over the broken pieces
Causing peace and love
To flow over the shards
Of her cup
And allow them to mend
So she might fill her cup
Once again
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