Tag Archives: dual relationships

Blog: Rural Mississippi—Aftermath of Hurricane Katrina

–Shailendra Prasad

August 2005. I planned on flying back to New Orleans after a conference in Arizona. My wife and son had accompanied me. We watched Katrina grow like a weird reality show—a petulant child gaining weight, becoming unruly. There was talk about this being bigger than Ivan from the year before, even bigger than Camille from 1969. “No,” my friends and patients in Mississippi told me, “nothing gets bigger than Camille.”

Our flights home were canceled. Then we learned our neighborhood was under mandatory evacuation. Evacuation was not foreign to us. We’d participated in four drills during our seven years in Mississippi. “Hurricane parties,” we called them. We’d lock the shutters on the house, secure the garage door, and remove the yard implements that could become missiles in the sixty plus mile-per-hour winds. Then along with our two satchels filled with a change of clothes, our son’s favorite toys, and copies of our important documents we would drive to a safe home, a friend whose home was not in the path of the storm. We’d spend the night playing cards, talking, and waiting out the squall. Usually we could go home the following morning.

We hoped this, too, would pass and called a friend who had a spare key to our house.

“Sounds like a bad one,” our friend said.

“Can you get our hurricane satchels? There are two of them, in the closet in the master bedroom.”

“Sure. I’ll lock up the house too. Anything else?”

“Yeah, put the birdfeeders in the garage. The birdbath too.”

“Of course. Be safe. I’ll be in touch.”

That night in Phoenix I watched the television. Reporters talked about the rain and wind in surrounding areas. Counties in both Mississippi and Louisiana were evacuated. I called every number in my cell phone. No answer at the hospital, the clinic. My practice partner did not respond at his home phone or cell. I could not reach our neighbors or local friends.

Our county, Pearl River, and our town, Picayune, were orange on the weather map. The Internet news pages said nothing more. I could not eat dinner. I continued to make calls. I phoned my dozen sickest patients whose numbers I kept just in case they needed me. No one answered. I worried about my three-year old patient waiting for a renal transplant at Tulane. He’d just gotten a match.

What would happen now? No answer. And there was complicated Mr. Shirley who I just referred to the neurologic unit in Birmingham, Alabama. Would he get there for his appointment? When was that appointment? No answer. Then there was my dialysis patient. Where would she go? No answer. Feeling restless and helpless I walked down to the business center and opened this blog:

Pearl River County Katrina Survivors

This is my attempt to help in the aftermath of Katrina. I work in the Picayune area and have very dear friends in the area. The only precondition to this blog is this—respect your fellow bloggers.

Please blog away to add on to the information on Picayune/Pearl River County,Mississippi.

posted by sprasad @ 8/30/2005 07:54:00PM

By midnight there were thirty posts. I am looking for . . . I am trying to reach. . . does anyone have any information on . . .

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

Dr. Prasad felt an obligation to his patients during Hurricane Katrina. Medicine is rarely something you can walk away from when you leave the hospital or office. Often you carry patients with you – think about them, worry about them, pray for them. In a small town you often see  patients as you run errands at the hardware or grocery stores. This raises the issue about how one sets boundaries. How one cares for his/herself.

Talk with your preceptors and other staff in you clinical setting and see how they manage these challenges. 

Learning to Walk the Healer’s Path

–Erik Brodt

Three minutes and thirty seconds remained in the fourth quarter of the Minnesota Section 6A boys’ basketball final. Showcasing a fake plant step, our All-State point guard sends his opponent to the floor again. Dribbling around the flopping contender, number 5 pulls up and sinks a fifteen-foot jumper to put Cass-Lake up by four. But there is a turn of fate. Floating down from his jump shot, our point guard landed on the foot of another player, twisting his ankle inward and sending him to the floor in agony. Hearts dropped with the crowd’s deep gasp. Silence. I gulped nervously as my time was at hand. I composed myself and strolled onto the court to help our star as thousands looked on.

“Three minutes and thirty seconds!” she shouted as I threw myself into my disaster gown. “Estimated time of arrival, three minutes and thirty seconds!”

My hands quivered cold with sweat as my fingerprints formed though my  latex gloves. Confusion rested on my shoulder. I didn’t know what, but I could feel something horrible happening. That day, now eternally etched into my mind, had begun as a splendid day. Each step was light, walking between medicine clinic and the women’s health wardto visit a laboring mother and evaluate a baby I had delivered in the morning.

Wearing a wide grin of connection and accomplishment, I fought to contain the giddy chuckles of becoming a doctor. When all is well, being a doctor is bliss. Pulling the hospital door, it didn’t budge. Puzzling. Why was our rural hospital locked in the middle of the day? My pager sounded, I was needed in the ER immediately. March 21 will never be another day to me. No day will.

As a third-year medical student I performed a nine-month rural clerkship at North Country Regional Hospital in Bemidji, Minnesota. I chose Bemidji to be close to my family and the three largest Minnesota Chippewa Reservations. I am Anishinaabe (Chippewa) and it was the perfect opportunity for me to invest in the Native community during medical school. Little did I know how profound an impact the experience would have on me, especially on the afternoon when a young man entered Red Lake High School, shooting thirteen people and killing eight, including himself.

Reprinted from The Country Doctor Revisited (Kent State University Press, 2010) with permission from the author.

As a medical student completing a 9-month clerkship in a hospital near the Red Lake reservation, Dr. Brodt cared for the victims of a tragic shooting. It was particularly challenging because he had spent summers with his grandparents on the reservation and knew many of the victims and their families. Triaging and treating the patients injured in this kind of disaster is difficult for any health care provider. Because Dr. Brodt knew the families, it added another layer to the calamity. Because the community had just celebrated the men’s basketball team competing in the state finals, the community’s elation quickly crashed with the tragedy.

In earlier posts we have talked about the blurring of boundaries that occur in small communities. Our patients are often our friends. This is both positive and negative. Together the community mourned, but as a nurse or doctor that day, Dr. Brodt and his colleagues had to put their feelings aside and do what needed to be done. I often think of it as pushing a hold button on my feelings so that I can do the A,B, Cs–airway, breathing, cardiac . . . Once the work is done, I release the hold button.  In his essay in The Country Doctor Revisited, Dr. Brodt reflects on how he and the community struggled to heal from that tragic day.

As physicians we witness the best and worst of times in the lives of our patients and the communities we care for. In order to stay healthy ourselves, so we do not become jaded and cynical, it is important that each of us figures out how to care for ourselves. We may see some colleagues turn to alcohol, drugs, too much work or other behaviors that keep them from facing the real issues. Life is filled with good times and bad times and ultimately we have very little control.

LIFEprayerDEATH

–Kathleen Farah

“I prayed for you”

she said.

“I prayed every day you would have a healthy baby.”

I did.

She sat across the aisle from me at church you know,

Exchanged greetings of peace and watched my pregnant belly grow.

We prayed.

Tall in my white coat I stood before her in shivering snowflake gown.

My eyes and hands observed the tumor her right arm birthed had grown.

I sighed.

Too few weeks later I kneel beside her in her home hospice bed.

“I pray for you”

I silently said.

Words and tears are blocked by “professional boundaries” in my head.

I silently cried.

“I pray you have a peaceful death.”

She did.

Dr. Farah explores professional boundaries, prayer and expressing emotions with patients. As we have explored in other posts (Onime) dual relationships are common in rural areas. Our patients are our friends, and expect to be. We may see them at church and at the grocery store. Close relationships increase compassion, but may also bias us in our care for patients. Being close to a patient may make us more compassionate in giving bad news, but may make it harder to help a patient make decisions about their care because we have our own opinions and hopes as their friend.   What have you seen on your rural rotations?

Dr. Farah also explores expressing emotions with patients. Crying with and for a patient is not a bad thing as long as we can step back and be in our doctor role when we need to be. The ability to move from one role to another is often called compartmentalizing. This allows us to switch between roles. For example, in a crisis, I need to put my feelings aside so I can think clearly and make decisions about what to do. Feeling sadness or happiness for and with patients is also quite human and shows that we care. Grieving the loss of a patient we were close to is normal and healthy.  As a physician we are privileged to walk through the best and worst of times with patients. It is important to learn how to distance ourselves from some of the intense emotions, otherwise the roller-coaster ride of highs and lows is exhausting and draining. However, not taking the time to feel the feelings at all can lead to cynicism and burnout.

Dual relationships

–Godfrey Onime

The yellow-, red-, and green-striped gift bag containing the present lay on my office desk among the stacks of charts and assorted papers. Curious as to the sender, I looked at the card that came with it. “Oh no, not again.” It was from my patient Ms. Emalee, next on my schedule. Among her myriad medical problems—diabetes, hypertension, obstructive sleep apnea—was intractable knees and back pain for which she used narcotics chronically. On her current visit I’d planed to perform a random drug test, to ensure she was actually taking the medications and that she did not use illicit drugs. But now the gift, although this was far from her first—she often brought fruits, baked goods and other presents for everyone in my clinic. After she learned I got married and hinted she was looking for “something special” for me, I’d entreated her not to worry. She had looked at me as if I were from a different planet and then declared I was “like family now,” adding “you better believe you getting something from me, don’t matter you snucked off ‘n’ got married without telling no one.” Now I wondered: What if her test results indicated a problem? Would her act of kindness make it difficult for me to do my job, such as refusing to prescribe further narcotics or even discharging her from my practice?

 The question of boundaries with their patients is one issue that small-town doctors face. Often for lack of convenient alternatives, country doctors not only have to take their friends on as patients, but their patients quickly establish themselves as friends. It seems to challenge the reader to consider that in small towns, where privacy is shunned and familiarity with neighbors prized, maybe physicians’ closeness with their patients is exactly what they need to render care with true understanding and deep compassion.  

 When I entered Ms. Emalee’s room, she looked up at me expectantly and asked if I liked her present. I told her I had not opened it. Sensing her disappointment, I quickly added that I was waiting to get home, before opening it with my wife. The explanation seemed to satisfy her. “Smart man,” she said, “I’m sure she’d love it.” Ms. Emalee’s knees and back still hurt, but her pain medications were helping. No, she did not have significant side effects from the medications, such as constipation or drowsiness. I also asked if she ever sold her pain pills, but that seemed to annoy her. “You keep asking me that foolish question every time I comes here and I keeps telling you no, I does not sells my medicines. Don’t you even trust me?”

I apologized, but reminded her it was the law and my job to ask. At the conclusion of the visit, I told her I’d like a sample of her urine for a random drug test. “Whatever you say, doc,” was her sarcastic reply. Then she informed me they were having a birthday party for her mother—who was also my patient (as were her two sons, a daughter, a sister, and brother-in-law). Her mother was turning eighty. Her family would be greatly honored if my wife and I could come. Not sure how to respond, I promised to get back with her.

(Excerpted from Who We Are—Synopsis, The Country Doctor Revisited)

Boundaries between physicians and patients are usually different in rural areas than in larger metropolitan areas. Students are often caught in a double bind when they learn in medical school that physicians cannot be friends with their patients, but see in rural areas they usually are. As Dr. Onime states, “Patients often quickly establish themselves as friends… and that closeness may be what is needed to render care with true understanding and deep compassion.”  What do you see as the benefit and downside of “dual-relationships” –friend and doctor to the same person?  How do the professionals on your rural rotation negotiate this? Physicians often feel like they live in a fish bowl, especially in small towns where everyone knows everybody’s business. How do your preceptors draw the boundaries? Some professionals relish being the heart of the town and others prefer much more privacy. Imagine yourself as a small town practitioner, what would you do?