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.
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| 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".
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