Modules

Indigenous health

Part 3

The case resumes three years later. Clyde tried to take the diabetic medications faithfully, but had less success in controlling his weight and exercising. In the past year he stopped going to the health centre for his blood glucose levels because they always told him it was bad — too high. In the past six months he has been feeling increasingly unwell, with numbness and shooting pains in his legs. He was unable to take a construction job because he felt weak and dizzy. He has been drinking more alcohol as well, and Amy has been worried about letting him look after the younger children. Two weeks ago, Amy noticed a sore on Clyde’s lower left leg that looked infected. She persuaded him to see the nurse.

  • Nurse: Hi Clyde. I haven’t seen you in quite a while. How have you been?

    Clyde: Ah, umm, I don’t know. Umm, I’ve been getting a lot of headaches. My mom doesn’t trust me watching the kids anymore, and I have this … I have this really bad sore on my leg.

    Nurse: Okay, well, let’s have a look at the leg. Oh, Clyde, that looks like a diabetic ulcer. It looks infected. You’re going to need treatment for that. The doctor is coming tomorrow. Uh, let’s see what we can put on there for now.

Part 3, A

Clyde is found to have peripheral neuropathy, hypertension and renal insufficiency, all complications of his diabetes. The physician decides that Clyde needs to go to the medical centre for assessment and treatment so he is flown there and admitted. The resident responsible for his care speaks to his supervisor about Clyde.

As you watch the next scene, look for examples of:

  • Stereotyping
  • Ethnocentrism in a medical culture (e.g., the way we do things is the right way)
  • A “blame the victim” approach
  • Learner-centred teaching
  • Dr. West: So Keith. What have you got for me today?

    Keith: Uh, a young guy named Clyde, 23 years old, came off of the reserve. He was sent down last week. Had trouble getting him admitted.

    Dr. West: No beds in medicine, or was it the weather, or …

    Keith: Um. It was both, actually. Anyway, he is here now because of an infected diabetic ulcer. That was the reason for his evacuation. And of course, his diabetes was essentially neglected, and left untreated for at least three years. So, he has significant neuropathy, hypertension and early renal insufficiency. It’s frustrating it was left so late.

    Dr. West: You used the word neglected. Isn’t there a health station on the reserve?

    Keith: Yeah, but either they didn’t follow-up after his initial diagnosis, or he was non-compliant. Anyway, he got no treatment, and didn’t change his diet. It’s the usual. I don’t think we’re having much better luck up here.

    Dr. West: Why not? Is there language difficulties or something, or … ?

    Keith: No, he speaks English, but I don’t know if I’m getting through to him. I mean, he sits there and listens politely, while I try to explain to him how important and serious taking control of his problem is, and he seems to understand, but then when the ward clerk is looking for him for a test, he’s outside, on the rock, out by the parking lot. The nurses have a hard time finding him. He’s missed his renal ultrasound twice.

    Dr. West: Well, a lot of people have trouble getting used to hospital routine. Aboriginal folks are no different, especially if they are far from home. You know, I’m not really sure how much success you’re going to have if you bombard him with threats of medical complications. He probably knows a lot more about his condition than you realize. Diabetes is a very common condition among his people. You know, you said he’s young. He is probably very frightened, and you may have inadvertently given him the idea that he’s responsible for his medical condition. If you’re going to help him, you’re going to have to gain his trust, and that’s not going to be easy.

    Keith: How do I do that?

    Dr. West: Well, why don’t you try getting to know him a bit better.

Part 3, B

Introduction

In this scene, Dr. West and Keith talk about Clyde. Note the similarity in Dr. West’s approach to teaching to that of the patient-centred model. Analyze the conversation regarding the following techniques and/or styles:

  • Questioning style
  • Listening style
  • Information gathering
  • Information giving
  • Integration of biomedical and psychosocial information
  • Honesty
  • Self-awareness
  • Empathy
  • Dr. West: Keith, how much have you found out about Clyde’s social situation?

    Keith: Well, he lives at home, with several brothers and sisters, and his aunt and her kids. Uh, they live on the reserve. He is unemployed. What else do you want to know?

    Dr. West: How much do you know about First Nations people, in general?

    Keith: Well, there were a couple of lectures in medical school, but, to be honest, I didn’t really pay attention. Um, there is a lot of stuff on the news about land-claims … business like that. That’s about it.

    Dr. West: Well, the reason the land-claims are in the news is because Clyde’s people have been systematically kicked off their land. No, that’s not entirely accurate, because they don’t consider that they own the land, rather they are custodians of it. Anyway, the land-claims are their attempt to get their land back from us, and that’s just the tip of the iceberg. You know, we are talking about a system of internal colonialism that’s over 500 years old.

    Keith: Yeah, but all I’m trying to do is give him the best medical care he can have. That’s something they didn’t have 100 years ago.

    Dr. West: Well, they don’t necessarily have it now. Most of the reserves are remote. There may be a nurse at the health station, and then there is a revolving door with white doctors coming in and coming out. I mean, why should they trust us? You know, we’re talking about housing conditions that are substandard and overcrowded. That’s why diseases like TB flourish there. And, you know, there is no clean water. There is no indoor toilets and they have money to send Clyde down here, and yet, they can’t have money for proper footwear for him that might prevent diabetic ulcers. He can’t even get a job, so you can really see how difficult it must be for him.

    Keith: I know, I know, it’s terrible, but, what can I do about it? I mean, I don’t understand why he can’t just take care of his health. I’ve … I’ve told him to exercise and eat right. What’s stopping him?

    Dr. West: There is lots of stuff stopping him. This is really a challenge for you, isn’t it?

    Keith: (nods) Yeah.

    Dr. West: These young residents are so good at some things. Well, they all know the latest tests and treatments, which is important. But, I also notice that they don’t seem to understand that social suffering or economic conditions can have a lot to do with a person’s illness. I just wish that Keith could go back with Clyde to the reserve and see how he lives. (laughs)

    On the other hand, I remember my first posting to a reserve. I was full of enthusiasm. I was going to change everything. And when I got there, I asked to see the chief. They looked at me like I had three heads. There was 50 charts and a room full of people. I was so overwhelmed that first year, I just didn’t have time to do anything other than medical things. I didn’t even get to meet the chief. It’s … it’s complex.

Part 3, C

  • A physician’s view on medical training

  • Even though I got a good education as a medical student I don’t know that I was taught cultural sensitivity as well as I could have been. In terms of how it incorporates into your practice of medicine. And I suspect that as a medical student I was far more concerned about, you know, learning how hypertensives work, and what the doses are and not killing someone with the wrong medication than to understand that actually practicing medicine has more to do with the social interaction between two people than simply knowing what the right thing to do is from a medical standpoint. If you don’t understand why the person is how they are, you’re never going to be able to treat them.

    Their previous experiences, their family of origin, influences that process so much and yet I think that when I was going through medical school I was far more focused on what are the criteria for identifying a diabetic rather than understanding that getting them to follow a diabetic diet will certainly be influenced about what types of foods they eat, and that if you’re really going to be able to be effective you have to know that.

    It’s just sometimes I think I didn’t pay attention to the right things and I only appreciated it six month after I was in practice so that then I caught on and thought, oh, yes, this is the stuff that I need to know.

    It wasn’t that it wasn’t offered, I think that with so many things, until you have the experience, you don’t know what you don’t know. And then I think oh, yes, I remember that, I should have paid more attention to it. Because that’s what I use every day.

The case continues

Introduction

Dr. West suggests that Keith talk to the hospital’s Indigenous interpreter.

  • Why does she do this?
  • If she knew anything about Clyde’s life, why did she not tell Keith herself?

Analyze this conversation. For instance, note the difference in worldview in Keith’s first statement and that of the interpreter.

  • Keith: So, Dr. West suggested that we meet, uh, that you might be able to help me with one of my patients. Um, Clyde has diabetes and he is not doing very well.

    Cultural interpreter: I know Clyde. He has had some difficult times lately. His father died a couple of years ago and, you know, he’s helped out his mother with the younger kids. You know.

    Keith: Oh, I didn’t realize that. That must make things a lot harder for him.

    Cultural interpreter: Ah, yes, it certainly does. A lot of responsibility for a young man.

    Keith: Yeah. Well, he’s also having trouble keeping his sugars down. Um, and he doesn’t want to exercise, or change his diet, so …

    Cultural interpreter: He doesn’t want! How well do you know what his life is really like? You know, maybe he can’t. How well do you really know Clyde?

    Keith: I … I guess I don’t.

Continuing Keith’s education, Dr. West models patient-centred behaviours in talking to Clyde. Again, analyze this conversation and note the non-verbal behaviours of all three.

  • Dr. West: Hi Clyde?

    Clyde: Yeah.

    Dr. West: Hi, I’m Dr. West. Keith and I work together. Would it be alright if we talked to you for a few minutes?

    Clyde: Yeah.

    Dr. West: Okay. It’s okay if I sit down?

    Clyde: Yeah.

    Dr. West: Thank you. So, you’ve been here for how long? Ten days?

    Clyde: (nods)

    Dr. West: Yeah, it’s a long way from home, isn’t it?

    Clyde: Yeah.

    Dr. West: Do you have any relatives here in town?

    Clyde: No. I just want to go home.

    Dr. West: Well, that’s what we want too. Uh, tell me, what’s the access like up to your reserve this time of year. I know it’s spring thaw.

    Clyde: You can’t even get in. Planes can’t land ’cause ice in the water everywhere. Hm, my mom is all alone up there with the kids. She … she needs help.

    Dr. West: I can see you’re really worried about her. Have you talked to her at all since you’ve come here?

    Clyde: No.

    Dr. West: Would you like to have a conversation with her if we could arrange it?

    Clyde: Yeah, but …

    Dr. West: Okay.

    Clyde: … she doesn’t have a phone.

    Dr. West: So, is there somebody we can contact that could get a hold of her?

    Clyde: Um, you could call my auntie.

    Dr. West: Okay. Okay, I’ll get Keith to get that information, and we’ll try to make that happen today for you.

    Clyde: Okay.

    Dr. West: Okay. Well, it’s obvious we have to get you out of here sooner than later because of the spring break-up. Your ulcer is healing and your diabetes is a little bit better. You’re going to have to take a couple of pills every day. And you’re going to have to see the nurse every week at the health station, and the doctor when she comes in. Are you going to be able to do that?

    Clyde: Yeah, I could do that … but only if I go home.

    Dr. West: Oh, you’re going to go home. We’re going to arrange that in the next day or two if at all possible. And, I will have Keith talk to the nurse up at the health station, just to arrange a plan for you. So, can we get your permission to talk to the nurse?

    Clyde: Yeah.

    Dr. West: Okay, alright. So, we’re going to get everything arranged as quickly as we can.

    Clyde: Okay.

    Dr. West: Okay.

    Clyde: Yeah.

    (in the hallway)

    Keith: You’re letting him go? What are we going to do about a follow-up, and his diet and exercise plan, and his renal disease?

    Dr. West: Can’t the monitoring be done long-distance?

    Keith: Uh …

    Dr. West: I don’t think the hospital is the place for Clyde to make his lifestyle changes. I think we’ve both seen that. He’s probably going to have a lot more success among his own people, where they’re either going to help him or they’re going to be a barrier to him. Makes sense?

    Keith: Yeah.

    Dr. West: Okay. So, I know that you’ve been getting a lot of information about what’s going on with him. Try to get a little bit more about his educational background and his past employment history. Those kinds of things are going to really help you to work with a nurse to create a plan for him.

    Keith: Okay.

    Dr. West: Okay.

    Keith: I’ll do my best. Thanks.

Clyde returns to the reserve and takes up his life helping his mother with the younger children. Spring weather improves and a few weeks after his return, Amy calls on her friend Christine, who is the community health representative.

  • Christine: How are you doing Amy? I know Clyde was at the hospital.

    Amy: Yeah, but they let him come home. He’s been taking his pills and he feels a bit better. I wanted to talk to you about a walking club. Do you know what that is?

    Christine: Not really. I know they have one in the city.

    Amy: My cousin started one on her reserve. She thinks I should start one here. She says it’s good. The ladies walk together every day, and sometimes with the kids. And once a week they get together and learn new recipes so they can cook better food. They even made a cookbook. Maybe if Clyde sees me walking, he’ll walk too.

    Christine: That does sound good. It would be good for our community to get people walking. It’s the best thing for diabetes. We could use the kitchen in the community centre to have cooking classes.

    Amy: That’s good. I don’t know how to get it started. Could you help me?

    Christine: Yeah. We’ll talk to the nurse. She probably has a lot of really good ideas about how to tell people too. And if Clyde sees other young people walking, maybe he’ll start walking too.

    Amy: Yeah.


 

Next: Conclusion

Continue