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: Clyde, I haven’t seen you in quite a while, how have you been?

    Clyde: I don’t know anymore. I keep getting these headaches and my mom doesn’t trust me to watch the kids anymore. I have this stupid sore on my leg.

    Nurse: Okay, well let’s take a look at your leg. Oh, Clyde that looks like a diabetic ulcer and it looks infected. You’re going to need treatment for that. The doctor is going to be in tomorrow I’d like her to take a look at it. For now, let’s see what I can do for you.

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: Hi, Keith what do you have for me today?

    Keith: A young guy named Clyde, 23 years old. He came off a reserve. He was sent down here last week but we had trouble admitting him.

    Dr. West: Were there no beds available?

    Keith: That’s right. 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 left untreated for at least three years. So, he now has significant neuropathy, hypertension, and early renal insufficiency. It’s frustrating it was neglected for so long.

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

    Keith: Yes, but either they didn’t follow up after his initial diagnosis or he was noncompliant. Anyway, he didn’t receive any treatment and he didn’t change his diet. It’s the usual. I don’t think we’ll have much luck here.

    Dr. West: Why not, are there language difficulties?

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

    Dr. West: Well, a lot of people have a hard time adjusting to a hospital routine especially when they’re far from home. Indigenous people are no different. You know, I’m not sure how much success you’re going to have if you overwhelm him with all of the different medical complications. Clyde probably understands a lot more about his diabetes than you think. It is a very common condition amongst the people in his community. You said he’s young, so he’s probably very frightened. You might have inadvertently given him the idea that he alone is 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: Why don’t you try getting to know him better?

    Keith: Okay.

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, do you have a few moments?

    Keith: Yup.

    Dr. West: So, how much have you learned about Clyde’s social situation?

    Keith: Well, he lives at home with several brothers and sisters as well as his aunt and her children. Umm… He is unemployed. They live on the reserve. Is there anything else you want to know?

    Dr. West: How much do you know about Indigenous people, just in general?

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

    Dr. West: Well, the reason that the land claims are on the news is because Clyde’s people have been systematically kicked off their land. That’s not entirely accurate. They don’t actually consider that they own the land rather that they’re custodians of it. Anyways, the land claims are basically their attempt to get their land back from us but that’s just the tip of the iceberg. I mean, we’re talking about a system of internal colonialism that’s 500 years old.

    Keith: 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: It’s something that they don’t necessarily have now. A lot of the reserves are quite remote. I mean, maybe they have one health nurse working at the health station and then they have a revolving door of doctors coming in and out. Why should they trust us? You’re talking about living conditions that are overcrowded and substandard that’s why diseases like tuberculosis flourish there. There might not be freshwater, they might not even have indoor toilets, and although they have the money to get Clyde down here they didn’t have the money to buy him the proper footwear that might help prevent his diabetic ulcers in the first place. You said, he doesn’t have a job. I mean, you can understand how difficult this must be for them.

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

    Dr. West: There could be a lot of things stopping him. You’re finding this very challenging, are you?

    Keith: I’m afraid so.

    Dr. West: These young residents are good at so many things. They all know the latest treatments and tests which is important, but I also notice that some of them don’t seem to understand that social suffering and economic conditions can have a lot to do with a person’s medical condition. I just wish that Keith could go back with Clyde to the reserve and see how he lives. I remember my first posting to the reserve, I was so full of enthusiasm, I was going to change everything but then I got there, and I was just so busy. The first year I didn’t have time to focus on anything other than medicine. I never got to meet the chief or really even explore the community of the people. 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 months 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: Thank you for seeing me. My name is Keith I’m one of the residents here. Dr. West suggested that we meet and said that you might be able to help me with one of my patients.

    Cultural interpreter: Who is your patient?

    Keith: Clyde, he is diabetic and he’s not doing very well.

    Cultural interpreter: I know, Clyde. He’s had some difficult times lately. His dad passed away a couple of years ago and he’s been helping his mom with the children.

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

    Cultural interpreter: It certainly does. A lot of responsibility for this young man. So how can I help you?

    Keith: Well, he’s also having trouble keeping his sugars down. He doesn’t want to exercise or change his diet. So, I don’t know what to do.

    Cultural interpreter: So how well do you know how Clyde lives? Does he not want to exercise or maybe he can’t? How well do you really know Clyde?

    Keith: I guess, I don’t.

    Cultural interpreter: So, can I share with you what Clyde’s life is like on his reserve?

    Keith: Please.

    Cultural interpreter: So, on Clyde’s reserve it’s not always easy to access healthy food, fruits and vegetables are really expensive.

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 I’m Dr. West. I work with Keith, would it be okay if I spoke with you for a few minutes?

    Clyde: Yeah, yeah sure.

    Dr. West: Okay. Now, you have been here for 10 days now. Yeah… A long way from home.

    Clyde: Yeah.

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

    Clyde: No.

    Dr. West: No…

    Clyde: I just want to go home.

    Dr. West: That’s what we want for you too. Can I ask, how’s access to your reserve at this time of year, I think it’s spring thaw?

    Clyde: Well, you can’t always get in, planes can’t always land because of the ice everywhere. My mom is up there all alone with the kids right now. She needs my help.

    Dr. West: I can see you’re really worried about her. Have you had an opportunity to talk to her at all since you’ve been here?

    Clyde: No.

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

    Clyde: Yeah but she doesn’t have a phone.

    Dr. West: Okay, is there anyone else that we can contact that could get a hold of her for you?

    Clyde: Yeah, yeah you can call my auntie.

    Dr. West: Okay I’ll have Keith get that information and we’ll see if we can make that happen for you today.

    Clyde: Okay, okay.

    Dr. West: So, it looks like we should get you out of here sooner rather than later especially with the thaw. I see that your ulcer is improving and your diabetes is a little bit better.

    Keith: Yes, that’s correct.

    Dr. West: Okay, now once you get back home you’re going to have to take a couple of pills a day. You’re also going to have to see the nurse at the health station every week and you’re going to have to see the doctor when they come in. Are you going to be able to do that?

    Clyde: Yeah. Yeah, yeah, I can do that but only if I can go home.

    Dr. West: We’re going to get you home. Okay. We’re going to see if we can make that happen in the next day or so. I’m going to get Keith to talk to the nurse up at the health station and they can make a plan.

    Keith: Yeah, I’ll get right on that.

    Dr. West: Do we have your permission to contact the nurse?

    Clyde: Yeah, yeah.

    Dr. West: Okay, all right then we are going to get things arranged as soon as possible, all right?

    Clyde: Okay great, thanks.

    Dr. West: You’re welcome.

    Keith: Dr. West, can I talk to you for a minute? I’ll be right back. Dr. West, I don’t understand you’re letting him go? What are we going to do about his follow up and his diet and exercise plan and his renal disease?

    Dr. West: Well, the monitoring should be able to be done long distance.

    Keith: Yes but…

    Dr. West: I don’t think that the hospital is the place for Clyde to make his lifestyle changes at this point. I mean, he’s probably going to have a lot more success once he’s back home in his community and he’s surrounded by family and friends where they’re either going to support him or they’re going to be a barrier to him. Does that make any sense?

    Keith: I think so.

    Dr. West: Okay. Now, I know you’ve been gathering a lot of medical information about what’s been going on with him. Why don’t you try getting a little bit more information about his educational history or his past employment history, those kinds of things are really important when it comes time for you to work with the health nurse up at the reserve to come up with a plan.

    Keith: Okay, I’ll do my best.

    Dr. West: Okay.

    Keith: 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 Amy? I heard Clyde was at the hospital?

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

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

    Amy: My cousin has one on her reserve. She thinks I should start one here too. She says it’s good.

    Christine: Yeah but what is it exactly?

    Amy: The ladies go walking 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.

    Christine: That does sound great. It would be good for a whole community to get people walking. It’s the best thing for diabetes. Maybe we could use the kitchen in the community center and offer cooking classes.

    Amy: Yes, that does sound great but I don’t know how to get it started. Do you think you could help?

    Christine: Sure. We’ll talk to the nurse. She probably has a bunch of good ideas how to tell people and if Clyde sees other young people walking I’m sure he’ll start walking too.

    Amy: (Starts sentence in Mohawk) my friend. I knew you could help.


 

Next: Conclusion

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