Monthly Archives: February 2012

Who lives rural today

Rural counties, especially those located adjacent to metropolitan areas have seen population growth. Challenges arrive along with these new Americans: How do two or three different cultures live together? How does a small clinic with limited resources accommodate different languages and different understandings about health and healing? The diabetic diet looks different from a Mexican diet where beans and rice are staples and different from the farmer of German ancestry who wants his meat and potatoes. Some workers arrive without family, leaving their wives and children back home for the season or several years. Problems such as alcohol abuse, sex trafficking, and violence often accompany this disconnected lifestyle.

 (Excerpted and used with the permission of the authors, published in The Country Doctor Revisited, KSU, 2010)

 The global age with its increasingly diverse communities is now true in many small communities across the US. In Minnesota many communities settled by Scandinavians or Germans now integrate communities who speak such languages as Spanish, Hmong or Somali. Integrating immigrants into a new community takes some planning. Local leaders need to reach out to leaders in the new communities.  Health care settings need to adapt with interpreters, patient education that is appropriate for the cultural values and eventually staff who are from the immigrant community. Health care professionals need education about the beliefs and values of the immigrant community.

 If the community where you are rotating serves diverse ethnic groups, how well has the hospital /clinic reached out and prepared for the different communities? Do not mention the name of your community in your response. Consider the availability of interpreters, patient education materials, diverse staff and the relationships between the hospital/clinic and the community.

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Giving bad news

Selection from Hanging on for Your Life

–Lorence Gutterman

Curled up and bruised, Carter sleeps uncovered on his bed, his sheet rumpled at his feet. Perhaps he shoved it off during a bout of sweats. He has the appearance of being trampled by a bronco. A rodeo rider, he grew up in Minford, a small Ohio farming community.

Carter shuts his eyes and rubs them. He clenches his jaw. “Can you give me something for pain? I hurt like hell.”

The next day I perform the bone marrow biopsy without problems and don’t engage in much additional conversation. Two days later, I muster the courage to enter Carter’s room in the late morning. I sit on the chair next to his bed.  “Are you more comfortable?”

“Sometimes. The nurse said I was screamin’ last night.”

Get to the point I remind myself. “Carter, I have results from your tests.”

“Bad?” he asks.

“You have some serious health problems.”

He frowns at the pain of my words and closes his eyes.

I tell him that the bone marrow biopsy shows Hodgkin’s disease, a type of cancer in his lymph nodes and bone marrow.” He begins to cry. I rest my hand on his shoulder. I continue, “This type of cancer can be treated with chemotherapy. Sometimes the cancer disappears.”

“Forever?”

“Sometimes.” I take in a deep breath, prepare myself for the next part. “But there’s another problem. You have AIDS.” I remain quiet but am unsatisfied that I’ve told him this without a family member or close friend in the room to  comfort him after I leave. Carter turns away from me. I notice how thin his black hair is on the back of his head. In this moment, it’s not important how he got AIDS.

“Does Betsy know?” he asks.

“Not yet. Do you want to tell her or should I?”

“Ya tell her. God, I hope she’s okay.”

“She should be tested for AIDS.”

A slight nod and more silence. There are no right words to fill these spaces.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Giving bad news to a patient is never easy. It’s not easy for the person giving the news and it’s not easy for the receiver.  The best advice is to share the bad news when you are not in a rush and can have a conversation with the patient and his/her family.  In this story, the physician does not do the best job of sharing the diagnoses of cancer and AIDS with the patient. He seems distant and does not take the time to create an appropriate setting.

Sometimes we don’t have a lot of control over the situation in which we are asked to share bad news. Nevertheless, be prepared to return and answer questions. Patients and family members react in different ways and usually have additional questions after they’ve had some time to mull over what you’ve said.

For some tips on how to break bad news see this article in the American Family Physician. As you spend time in the clinic or hospital you will see clinicians who share bad news well and those who don’t do a very good job. Learn from all of these situations.

Watch Lorence read from his selection.

Sometimes patients repulse us…

— Lorence Gutterman

I knock, enter the room, and introduce myself. Carter rolls over to look at me, a grimace on his face. I step back as the musty air of his room reaches me, reminding me of my high school gym locker room. I brace myself and ask him why he became a rodeo rider.

“My uncle and older brother rode. I wanted to be like ’em. Doc, you want to try it?” He laughs through his obvious misery as he pushes himself into a sitting position, his reedy legs now dangling beneath the flimsy, gray-checkered hospital gown.

“I’m too chicken to sit on a bucking horse,” I say and place my chair a safe distance from him. Not so far away to be rude, but I need some space.

“Man, what are ya’ afraid of? Thought Docs could do everythin’.” His grin changes to a frown as he crosses his legs.

“Believe it or not, doctors get scared.” What would my colleagues think of me, admitting vulnerability?

Carter shuts his eyes and rubs them. He clenches his jaw. “Can you give me something for pain? I hurt like hell.”

“Of course. I’ll talk with your nurse.” I quickly leave the room to find his nurse who is counting tablets and putting them into a tiny paper cup. I ask her to increase Carter’s dose of morphine. I reenter Carter’s room. The odors have not changed. I return to my chair, the cracked vinyl squeaks.

“Hey Doc, ya gonna get me feelin’ better?” He has returned to lying down.

“I’ll try. Can’t promise you though. Could you control the bronco the first time you sat on it?”

He tries to prop himself up on his right elbow. “Doc, ya never can control that animal.”

“Kind of like your fever, until I know more about you,” I say fidgeting with his chart.

“Those shakes last night, damn! Bounced me around more than any bronc.”

“Fever caused your shakes.” I stare at the plastic bag filled with clear liquid hanging on a metal pole on the corner of his bed. Its slow drip is hypnotizing, calming. I decide to get to know him before I start quizzing him about risks for AIDS. Taking a sexual history has never been a comfortable task for me.

(Excerpted from Hanging on for Your Life and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

In this selection the author appears repulsed by this patient. It may be the patient’s profession, it may be the smells of illness, it may be the patient’s personality. We are human, we all have reactions to patients. My toughest patients are those who are morbidly obese and come in with complaints related to their excess weight. Obese patients are hard to examine. My feelings are real, I can’t get rid of them. The important thing to remember is that I cannot act on my feelings. I need to recognize them, then set them aside and figure out how to meet the patient where he or she is. Likely the obese patient is embarrased about their weight and has been the recipeint of cruel comments. I try to find some empathy for that patient.  Partnering with a patient demands figuring out what if feels like to walk in their shoes–that saying may be cliche, but its a good place to start. Empathy can help me put my repulsion aside. This is part of professionalism. We may have unsavory feelings, but we don’t act on them.

Sometimes to let off steam, we may joke with colleagues and co-workers about a patient or the situation. Be careful about this. You never want to do that in a location where the patient or his/her family/friends might over hear you. Humor helps us to cope, but eventually you need to set it aside and return to a position of empathy.

The author also talks about being scared. Feelings of fear are human too. Sometimes we are afraid and we need to ask for help. However, sometimes we need to set our fear aside and do what needs to be done.

As you spend time in clinic and the hospital you will see health professionals who are empathetic and kind to some of the most difficult and repulsive patients. Watch them, ask them how they do it.

Home Visit–sometimes your patient makes you laugh

The Brothers

–Ann Neuser Lederer

I go to visit two brothers,

one eighty-eight, the other past ninety.

Scoured and shaved and smiling for the nurse.

Shoes shined, pants pressed and belted,

plaid shirts buttoned to the neck.

Past ninety takes his teeth out

when I ask to look in his mouth,

then he goes to bite me.

Both brothers chuckle.

This morning, says the young one,

he told his brother

while changing the diaper:

You’re just like an old cow now.

I have to clean out your stall.

The brothers laughed and laughed.

The older brother adds:

My brother’s a funny guy.

He don’t say much,

but then

he comes out with something.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

It is important to like what you do. Some days are drudgery, that’s life, but most days your work should make you happy.  If not, reconsider what you are doing.  It’s important to take the time to find the delights–the experiences in your day that make you smile.  Nurse Ann Lederer shares a home visit poem with us about two brothers.  Watch Ann Lederer read her poem.