The Worried Well vs. A Train Wreck

Recently, I commented to another provider at the underserved clinic I'm in, on how much I enjoy the diversity of the patients, the teamwork of social workers and diabetic educators, the creativity needed for low income patients and new immigrants to our country. I've often stated that I wouldn't be as satisfied in a middle to upper class clinic with mostly insured patients with minor ailments. The doctor chuckled and said, "That's true. The worried well are not as interesting as a train wreck." 

I have seen train wrecks. Heck, I've even been one at times. But one of the main differences I see while working with underserved patients is the lack of adequate health literacy, and social or emotional support. After all, in some cultures the word "depression" does not exist. In Romania, for example, depression or mood lability is termed a "neuroendocrine disorder". 

Lack of medical literacy in some underserved populations is fine, except that I've spent most of the last 27 months of my life honing ridiculous algorithms of care into my mind, learning the critical stages and cell receptors and medication classes of Type II diabetes mellitus, for example. The interesting, and rather fun part of medicine in my clinic is that all that savvy medical speak goes out the window. Far far out the window. It has been suggested that teaching medicine, and educating others about their own co-morbid conditions, should be conducted at the 6th grade level, no matter who the patient is. Of course, if the patient is younger than 6th grade, you would adjust accordingly. When working with interpreters and patients with limited English, the grade level also drops a bit because you want to make sure they understand every word. Yesterday, I found myself tapping into my art and illustration background by drawing pictures for several patients, about GERD (gastroesophageal reflux disease), an anterior talofibular ligament sprain (ankle sprain), and constipation! I also found myself acting out charades for several patients, out of my chair, enthusiastically gesturing and grinning--much to their entertainment (or dismay? They were smiling..:-)

And I make lists. I make a small list for every patient. A personal one of all the things we have discussed. I find that, for some patients, this adds another element of genuine patient care. Aside from the drawings, the charades, the personal lists, I have about 10 minutes left to really nail a physical exam and come up with a treatment plan. But I am slowly finding that patients seem more motivated, more adherent to recommendations, more compliant with meds, more trusting, if they feel that the provider is also genuinely interested in them. Overall, I think this extra attention not only saves the health care system loads of money, but also saves the providers and the patients time as hopefully that patient won't have to return to clinic as often. Just yesterday, I spent 1.5 hours on diabetic education with a patient with severe diabetes who arrived gung ho and motivated to change his lifestyle. This was a serious commitment on his part and 20 minutes would've barely afforded him the opportunity to share his expectations and plans, not to mention give us enough time to conduct some necessary teaching points, and also do everything we could to ensure he will succeed. His visit was 1.5 hours. 1. 5 hours = 90 minutes. Assuming he comes in every 3 months to have his hemoglobin A1c checked--at 20 minutes a visit--that 1.5 hour equated to 4.5 visits. That means it may very well have taken him over a year to receive the same information we were able to deliver in that one visit yesterday.  

Structured Support. L. Katers 

For as many reasons as I love the community clinic setting, it is also extremely frustrating to work in a community or under served clinic. Many of the things you want to do for the patients, you can't because you yourself don't have the resources, or the patient does not have the money. You learn to Macgyver many things, and think outside the box, and collaborate with all the other providers on unique treatments or protocols that have been tried and worked for other patients.

The lists I help patients make consist of small, attainable things in order to give them something to accomplish. This goes right along with Albert Bandura from Standford and the idea of self-efficacy. Self-efficacy is essentially building up someone's--child or adult--confidence by giving them first one small task to accomplish and succeed at. The idea is that the more small tasks are accomplished, the person begins developing an inherent confidence and belief that they will, in fact, succeed! The more we accomplish as individuals, the move confidence we acquire that we might be able to accomplish more. For someone with health problems and who is already overwhelmed, these lists can be surprisingly simple: Go to grocery store, make med, apply for one job a week. I have seen the power of of a list for some patients; sometimes they arrive back at the clinic clutching only the list. 

I made my own list today while sitting with a patient who was suffering through a difficult divorce and was struggling with forgiveness, of herself and husband. The list we came up with together, which is also my list today, is positive and present:

- I am present 

- I am beautiful

- I have an open, forgiving heart

- I have the discipline to focus on (work, school, etc)

- I create opportunities to share my gifts every day

What does your list look like, friend?

P.S> Next blog...ECT - electroconvulsive shock therapy, also known as :The Controlled Seizure".

Unbinding Grace

Dear friends, humor me?

First, read these few sentences through. Seek out the quietest place in your house. If it's possible to find absolute silence, go there. Now, sit on the floor, with nothing comfortable underneath you. Lay down if you want. The darker the space the better. It is more accurate, actually, for this exercise, if the room is pitch black. Now, close your eyes. Stay there for a minute?

** 

Now, I want to tell you about Roberta. Roberta is 27 years old and is incarcerated in a correctional facility in Colorado. She is an IV drug user. An addict. She has stolen from friends. She has abused her children. She lies to anyone who gets too near. She has exhausted every social worker within range and refuses to get help or change her ways. She talks loudly and doesn't listen. She will spit on you. She will cuss you out to your face and have no regrets about it. Roberta is a tough, horrible, anxious, and cruel woman. 

But, there is something else I know about Roberta. Her kids, 3 and 7, have been taken away by the courts. They were all she had and now she says she has nothing to live for. But, there is more. Her mother died giving birth to her. From as far back as she can remember, she can't recall one single person saying "I love you". No one ever told her she was good, or beautiful or smart or loved. Instead, Roberta went through her childhood meeting fists with her face, being raped by her father and uncle until the age of 15, when she finally ran away. She was abused to such a degree that she had 3 abortions by the time she was 17, dropped out of high school, and took up with a boyfriend, 20 years her senior, who also humiliated, abused and assaulted both her and her children. She had no job, no credentials, few skills and absolutely no hope or faith for herself or her children to live in this world. 

**

Now, I want to meet you back in that dark room. Perhaps you've been there 5 minutes or so. Uncomfortable, restless, waiting to get back to your life, your good life. There is a restless wind coming in through the screens. Perhaps a dog is yapping out in the neighborhood, the leaves are rustling in the trees. Block that out. Just for a few more minutes. Close your eyes, feel the weight of all of that darkness. 

**

Roberta continued the chain of abuse she experienced as a child. Her children were subsequently   abused. By her, her family, her boyfriend, and the system. Those children were now in their own dark room. With no way out. Perhaps they would end up incarcerated as well. The cycle to continue. Roberta had no way of stopping something that began for her 27 years ago. 

There is an organization I worked with years ago that focused on helping women just like Roberta. Kerry Kurt is the founder and executive director for Unbound Grace, a non-profit organization established by Kurt to facilitate healing and transformation from wounds left by childhood neglect, domestic abuse and trauma through the use of personalized programs involving the arts, the natural environment, physical challenge and the workplace. Unbound Grace uses a three phase program to help motivated women in Denver Women’s Prison gain the skills necessary to obtain and maintain employment that will pay a living wage and support a healthy lifestyle after their release.

Unbound Grace carried out the last of these three phases by partnering with Outward Bound, an  outdoor leadership and wilderness program. Outward Bound (OB) is a phenomenal organization and at the epitomy of "wilderness therapy". If a participant arrives at OB and feels confident and excited about their life, then the OB instructors make sure to "shake up" that person's life a bit, maybe put them in a few uncomfortable positions. The goal would be to quite literally throw them completely out of their comfort zone. But if a participant already has a shaky life, someone like Roberta, and is living not in their comfort zone but instead in their panic zone, then the goal of OB is to give that person a safe place to be. The goal is to offer the wilderness and all of her charms as a safe haven. And also to utilize self-efficacy and give that participant small tasks that he or she can accomplish to begin gaining self esteem and confidence. Roberta was a perfect candidate to experience the power of wilderness therapy. 

**

Are you still with me? Are you still in that dark room? Are you still wondering when or if I will free you and you can get up and go back to your life? Well, one of the main discussions that comes up often for me in the line of work I'm interested in is: WHY help someone like Roberta? She is a felon. She has broken the law. She has hurt and victimized people, including her own children. Why not forget about Roberta and instead put that time and energy into helping her victims? 

The reason we help someone like Roberta is this: She has also been in a dark room, as I have put you in now. But unlike each of us, she has been there her entire life. She was born into that room with no comforts, no love, no warm touch, no affection and no one to love her. Nothing. The room is so dark she has never been able to find a way out. No one, not ever, has attempted to crack a door in the room for her. By doing the kind of work that Unbound Grace does--thinking and participating in healing outside of the box--and that persistent social workers and health care providers can do, is open a door. Just a crack. 

A few things Roberta, and many of my patients I see in psychiatry with similar backgrounds, have taught me, are:  

- We all need the light turned on from time to time. And we all need to turn that light on for others. 

- Having time to sit with pain causes you far less suffering than if you repeatedly try to run from it. 

- The wilderness alone is therapy; if you take the time to look up, birds still fly overhead. They still fly overhead. But, you have to look up! 

- Through Outward Bound I've learned that challenging oneself with ones biggest fears causes you to become bigger, and less afraid of the smaller things. Also, the best way to make instant friends is by trusting them to hold you steady as you hang by a rope over a raging river. 

- Lastly, women are strong, we are nurturing by nature and caretakers, but if put under enough pressure, we all crack. And the underneath part of our hard shells is soft, and vulnerable and so exquisitely beautiful. 

**

I haven't seen Roberta in several years but I remember the spark in her eyes when the door was finally opened for her, just a crack. When she began to have faith and courage in herself that she could live this life, not merely survive it. When she began to gain the skills necessary to overcome her abuse and also steer her children down a different road than she had walked. When she began to see options.  

Feel free to get up now, shake out your legs and arms, breathe in a sigh of gratitude for your own health and life, and venture out to enjoy this beautiful day. Both Roberta and I thank you for reading this. 

“Live frugally, unsurprised.” – Rebecca Carson – OB Instructor Extraordinaire