An Even More Modest Proposal

How many of you remember being presented with Jonathan Swift’s ‘A Modest Proposal’ in English 101? It was a not so subtle satire of 18th century British treatment of the Irish, in which he hyperbolically –and anonymously- suggested that the Irish might be able to ease their economic distress by selling their children for food to English gentry. It was clearly so outrageous and inflammatory that it was intended to make the readers see how wrong the then-prevailing treatment of fellow human beings could be. To alter, in other words, the perspective, and facilitate the shift to a different world view. To allow people to see what they had hitherto ignored and perhaps make them want to improve it.

My own modest proposal is less preposterous and certainly not satirical, but it does fly in the face of what we in the richer nations have come to expect and accept: only the use of professionals in our health system; and discount: the adjunctive use of non-professionals to help with some aspects of that care. It was engendered by a segment in an October 2016 PBS program and has intrigued me ever since: http://www.pbs.org/newshour/bb/can-ordinary-citizens-help-fill-gaps-u-s-health-care/ The idea that health care is becoming increasingly expensive and that even with universal coverage, there are still a lot of gaps that are unlikely to improve even with the addition of more doctors and nurses. Training and equipping them is expensive, and still does not usually solve the problem of their accessibility to those most in need –the poor and disadvantaged in our societies.

Professionals are viewed as part of a power structure that is often alien to a population all too frequently ignored, isolated and denigrated by the mainstream. Issues of cultural safety frequently play a role in this –lack of understanding and respect for cultural or economic disparities may make them unwilling to engage with professionals until the problem is untenable or even irremediable. Prejudices don’t need to be stated; they are too often felt. So the idea that there may be bridges into this demographic –keys, however counterintuitive, that could unlock barred doors- is worth exploring.

The idea of using trained volunteers to talk to those in society that are often ignored until in extremis is certainly not new. Think of the ‘barefoot doctors’ working in rural villages in China, for example. Or, ‘In sub-Saharan Africa, community health workers have long formed the backbone of health systems, filling in gaps where doctors and nurses are in short supply.’ The key concept for the acceptance of these para-medical workers, of course, was the relative lack of other facilities and professionals to fill them.

So why should we, in our relative affluence, consider the use of non-professionals? Especially here in Canada where, in 2003 at least, there were 2.14 doctors and 9.95 nurses per 1000 population? Perhaps in Malawi, where there is 1 doctor per 50,000 people (2004) the need is more readily apparent, but Canada…?  Well, it seems to me that the gap is not so much one of professional numbers as engagement. As one of the patients interviewed in the PBS program said of the volunteer that talks to her about her severe diabetes condition: ‘With your doctor, you don’t really want to say what you eat, so I’m able to tell her like, really, if I’m not going well, or, you know, if I sneaked and cheated. I tell her the right things, and she helps me.’

In other words, the volunteer is not attempting to take the place of the doctor or nurse and give medical advice, but is acting almost as a translator of patient concerns that are not verbalized in front of the doctor or nurse. We sometimes forget the power discrepancies on display between doctor and marginalized patient.

The addition of trained community volunteers should not be seen as a threat to the professions, but rather as a helpful, and essential, adjunct to expand the reach of healthcare beyond its present boundaries. Nor should it be seen as creeping multi-tiered medicine with the poor being relegated to substandard care –swept under a carpet where they can be safely ignored until they become seriously ill and show up in Emergency Departments across the land -an expensive way to provide health care, not to mention wellness-promotion. It is simply not cost-effective, no matter the system.

The volunteers can be used to penetrate the layers and develop relationships with people who otherwise might not seek help until they had no other choice. Help them to know when to seek professional advice. Check to see if they are following whatever recommendations were given; make sure they take their medicines as directed. Emergency care is expensive and its facilities limited; timely, early intervention is both preferable and, ultimately, more humane. I know that our Social Service is already doing a sterling job in this regard -especially in our larger cities- but they are stretched pretty thinly nowadays; I would think they might appreciate a little help. Doctors and nurses in the various walk-in community clinics or in smaller towns could suggest clients who might benefit from some additional help, and the word would spread from there… As I have suggested, there are layers within layers to penetrate in a neighbourhood.

And if we agree that the volunteers would be better prepared and more useful if they received an appropriate basic training course to equip them for what they are likely to encounter, why not fund this? For that matter, why not pay them? Or am I being naive?

It’s a modest proposal, though… Isn’t it?

 

 

 

 

 

 

 

 

 

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The Medical Student

She was not old for a medical student I suppose, although her face spoke of experience far beyond her years. But how do you measure age in a profession that cherishes the wisdom and equanimity that so often accompany Time’s passage? No, she was not old, but nor did she possess the naïveté that so often colours the awkward period of youth; she was, in a way, just Maria: confident, inquisitive, but neither gullible nor easily swayed from an opinion once she had weighed the evidence.

Short, with straight brown hair to match, she was dressed in what I would call an unobtrusive fashion –not meant to draw attention to herself but to enable her to emerge from the shadows with dignity should it be required. Only the short white coat so indicative of her student status and which I suggested she remove before seeing patients, would have marked her as out of place in an office that otherwise spoke of the ordinary. I’ve always felt that patients would be more accepting of the student’s presence if they were perceived as being part of the process of consultation with a specialist, not an artifice. Not an appendage. Not an add-on.

Maria sat politely against the wall, legs crossed and a smile tattooed on her lips as she listened to the first of my patients describe how she had finally decided she needed another checkup and a pap smear. For some reason, her family doctor had not felt comfortable in acceding to her request. Maria studied her so intensely it made me nervous.

“What are you using for contraception?” I asked as part of the history.

Janet, who looked  forty or so, but was really 28, just shrugged. She was comfortable with the question; she was comfortable with men who asked them. “I try to get them to use condoms, but…” Maria’s eyes opened wide at this, but she refrained from saying anything. I could see it was an effort for her, though.

As I progressed through the history, it became obvious that Janet was struggling with many issues, but I was impressed that she was trying to solve them bit by bit. Life was not easy for her but she was obviously trying to take control of what little she could. I was just one stage in that process…

After I had examined her, done the pap smear and cultures for infection, and given her the form for the lab to take some blood to rule out other conditions to which her lifestyle had made her unduly susceptible, I sat her down in the office again to discuss her needs.

A broad smile creased her face and her eyes narrowed almost seductively. “Is this where you try to convince me to stop the drugs, and follow the straight and narrow, doc?” There was a fatalism in her tone; she’d heard it all before –many times. Too many times. “…‘Cause you know it’s not gonna happen. I’m just trying to keep myself alive until I decide to change. If I decide. Nobody understands…” Her expression didn’t waiver, but I could tell she was on the brink of tears as she reached for the faded coat she’d draped over the chair. “And there’s nothing you can do until I decide, you know.”

And she was right –all I could do was support her until she was ready. We lived on separate sides of a river that was so wide in most places that it couldn’t be bridged. I felt like reaching across the desk and touching her hand to show her I understood, but I stopped myself. However well-intentioned my gesture, it might be misinterpreted –it was a prologue for most of the men she had encountered… So I just smiled in a lame attempt at encouraging her. “If you ever need to talk, Janet…” I said as she stood up before we could discuss anything further. I don’t even know why I said that -it seemed so utterly inadequate to her needs. I told myself I was only a gynaecologist and that she would require far more than I could ever hope to offer. But I still felt humbled and my specialist arrogance melted away as she left the room.

But just as she was about to leave, she turned and smiled briefly at me. Not seductively –not even out of politeness- but there was gratitude in that smile. Maybe she was just happy that I hadn’t tried to change her like her GP, or that I was willing to wait for her -treat her like an adult capable of making her own decisions. I fancied I could see some hope in her eyes before they hardened to face the world outside.

I’d intended to engage Maria in the conversation with Janet but it all happened so quickly I didn’t get a chance.

Maria stared at me as Janet disappeared through the door. She seemed angry. “So what are you going to do now?” It was not said with kindness. It was not said out of curiosity; she had embedded an accusation in it. A condemnation. The tone was polite, but the insinuation was contempt. I was reminded of that speech by Macbeth: ‘Curses, not loud but deep, mouth-honour, breath which the poor heart would fain deny and dare not…

“Janet has to want to change,” I said. It was a weak reply, but I already felt depressed.

“And until then..?” She said it sweetly enough, but I could hear the anger in her voice.

I sighed and looked at her. “What would you do, Maria?”

I sensed she wanted to throw up her hands and pace around the room, but I could see she was trying to control herself. “Well, talk to her social worker, for one thing…”

“And tell her what, exactly? That Janet took a small first step to help herself? That she seems to be developing a little bit of insight? That I, for one, see the glimmerings of hope that she will change?”

Maria’s eyebrows shot up. “Change?” –she almost spit the word at me. “How can you say that? We’ve been facilitating her, not trying to help her!”

I took a deep breath and relaxed my face. Maria was not as mature as I had thought. “We’ve been listening to her, Maria.” I smiled to diffuse her eyes. “How often do you think somebody has actually listened to her before? Not tried to change her, warn her, or use her?” I softened my expression even more. “The initial step in any change is actually hearing what the other person has to say. Hearing what she thinks and why. Listening; not judging. Not continually interfering, continually trying to impose our idea of the world on her.”

Maria’s whole demeanour tensed with the injustice of it all. “But we didn’t even get a chance to listen! She walked out of here before…”

“Before I had a chance to advise her? Tell her what she should do?” I shook my head slowly.

“But…”

“But sometimes we have to be patient, Maria. Advise when asked; help when needed.” I shrugged to indicate how hard that was. “She may never change –never want to change. We need to try to understand that… Understand her.”

I don’t think Maria understood; I don’t think she felt her own opinion was acknowledged either. I could tell that in her eyes, I had failed as a doctor. Failed as a person. I had committed with her the same sin that I had committed with Janet: not acting on what I had heard.

Maybe she’s right; maybe one’s own principles should be subsumed in those generally held by a society. And yet… And yet I can’t help thinking of Shakespeare again -this time, Polonius in Hamlet: This above all: to thine own self be true, and it must follow, as the night the day, thou canst not then be false to any man… –or woman, in this case

If age has taught me anything, it is that we live in our own worlds for a reason… I think we must sit with the door open. And if Janet wanders back..? Well, I will be here.

Aboriginal Women Deserve a Public Inquiry.

We Canadians have always been proud of ourselves; we are a democratic society ruled by the will of the people. We vote and the majority governs, represents our interests, and crafts the laws accordingly -or does it? We have a say in what happens in our several levels of government –a voice in what is done to us… Unless we are a minority. Then we must depend upon the goodwill of those in power to understand and protect our interests. We must trust that, in their blinkered majority, they will not abuse us. Neglect us. Forget us.

But suppose they do. Suppose they surround themselves with their own advisors and see the world through their own lenses, their own authority, their own priorities? Suppose they don’t even understand that anyone could see things differently..? History, after all, is written by the victors, and culture by the dominant.

A case in point is the growing concern in Canada over a series of  missing and murdered aboriginal women –over 1000 in the past 30 years: http://www.nwac.ca/files/download/NWAC_3D_Toolkit_e_0.pdf

There have been various attempts to address the problems of  our First Nations –from a 1996 Royal Commission on Aboriginal People (http://www.aadnc-aandc.gc.ca/eng/1307458586498/1307458751962 ) which did not address the issue of the missing women, to a Royal Canadian Mounted Police (RCMP) Task Force in 2011 (http://www.rcmp-grc.gc.ca/pubs/mmaw-faapd-eng.pdf ) which apparently did…

But the problem remains and the perception that it is not really being addressed is building. In fairness, though, solutions are not only complex, but also expensive and so excuses are rife and rationalizations abundant. Missing women –murdered women- are crimes, not sociological phenomena, says the Prime Minister. Then why are aboriginal women –only one of several minorities in Canada- over-represented in the list, says the other side? An inquiry will tell us nothing new so we should put the money  into solving the problem instead, says the government. http://www.huffingtonpost.ca/chelsea-vowel/missing-and-murdered-women_b_5729738.html?utm_hp_ref=email_share  The cheque’s in the mail in other words; we’re looking into it -you might get it tomorrow… Maybe.

And on and on it goes –I am reminded of Macbeth’s Tomorrow, and tomorrow, and tomorrow, creeps in this petty pace from day to day, to the last syllable of recorded time…  Authority versus Minority. Civitas versus Communitas

But hold on; I think both sides are missing something: a conversation closes when one side or the other is adamant that only their view is the correct one.  Dialogue is an exchange of ideas on a particular issue whose aim should be to reach a consensus, an amicable settlement agreeable to both sides. Dialogue is communal, discursive at times, but inclusive. It does not stem from authority, nor resort to it especially when all have not been heard.

Autonomy -the right to make an informed choice- is a difficult issue in politics, of course. And because in this context choice usually involves large groups of people, there has to be an accommodation, an appreciation of how any decision might affect the well-being of the rest of the population. It has to be fair, in other words. But more than that, it has to be seen to be fair. And for that to occur, the issue cannot always be resolved by simply resorting to a vote. The majority and its own world-view bias will always win. Some things require discussion. Consensus. Open, accessible and representative input from all affected parties.

A Public Inquiry, by its very nature, invites public participation -a dialogue between those in power and those who aren’t- and a chance for all who are interested to have a say, voice their own opinions. It is healing to be heard –especially for a minority. To discuss things openly and publically often exposes underlying issues that need addressing: poverty, access to services, educational gaps, cultural safety, discrimination… A problem that has been swept under a carpet of denial or ignorance cannot be solved until it is uncovered for all –not just the minority affected- to see and appreciate.

I have discussed relational autonomy in a previous essay. It involves considering information in the cultural context, societal values, and the community needs of the groups involved. It is the expectation of cultural safety that will allow the people to express those needs without fear of ridicule or disdain. And it is what a representative democracy should encourage. Nothing less will do.

It seems to me that we all need to sit around a table somewhere and talk with –not at– each other. Remember Summer Camp when we were kids? As soon as the lights were turned off and the adults had left, we regaled outselves for hours with stories and discussions about what really mattered. Everybody had something to say, and everybody listened. We felt heard; we felt known. And slowly, by the end of the week, no matter our differences and annoying ideosyncrasies, we felt bonded in a community. Although we still remained individuals with different pasts and different futures, and although there were still disagreements we were, at least, no longer strangers. And, if the need arose, we could talk again – and actually listen. Friends can do that.

 

 

A Patient Named Cindy

I enjoyed Cindy (not her real name); how could I not? Short, plump, with uncertain hair of indescribable colour that was tossed on her head like a salad begging for dressing, she captured my interest the first time I saw her in the waiting room.

She was pretending to look at a magazine, all the while sneaking amused glances at the more staid and nervous patients waiting for their turns on the obstetrical pedestal. Her heavily made-up eyes whispered fashion but her dress screamed Walmart. I could see others in the room look away in embarrassment –confusion, more likely- but Cindy just smiled: a queen supremely aware of the distance between her and her court. Regally bemused at their furtive glances, she would sometimes confront the faces hiding behind their own pretended reading, inadequately camouflaged with turning pages, or pointing out a picture to a curious child.

Something about her made them uneasy. Maybe it was the hem of her sequined dress that she wore distressingly close to the edge of her more brightly coloured panties. Or the tattoos on her legs that stretched ever upwards even beyond the hem. But I suspect it was that she knew they were looking and didn’t care. Relished the attention, actually…

And yet the attention her clothes seemed to invite was as unimportant to her as the screen in a movie theater: you needed to stare at it, but it wasn’t really the center of your attention. It was the vehicle necessary for you to appreciate the show. And Cindy knew she was the show.

It was hard to be formal with her –she was so… out there. She did not invite –she would not permit– the usual power pyramid so rampant in a medical office: she was Cindy, and I was the doctor –with a small ‘d’. She needed advice, and I was its purveyor. Period. If she needed shoes, or a dress, she would have gone somewhere else. I was merely the seller of medical suggestions; she could pick and choose from the assortment offered.

When she sat in the chair by my desk that first time –provocatively again, over-revealingly again- she stared at me for a moment, probably wondering if I would react. But I only smiled, kept my eyes riveted on her eyes, and asked her why she had been referred.

A hint of a smile touched her face briefly and then immediately exploded into a delightful and disarming laugh. “Guys never know where to look when I sit like this,” she said, adjusting her posture to a more socially acceptable form and sliding her hem back down over her knees. “You can judge a man by where he puts his eyes, don’t you think?”

“And..?”

“And I suppose I can trust you,” she said with an expression that seemed older and wiser than her twenty-three years.

“Well,” I said, carefully avoiding the mine-fields she had already sprinkled around the conversation, “what can I do for you?” I thought it was the most direct way to elicit a usable response.

A smile so large it nearly split her face in two suddenly materialized. “You know, doc, your question almost makes me dizzy… It’s usually my question. The one I  have to start with as well.” I have to admit that I shifted uncomfortably in my seat. She noticed it, of course. Cindy would. She straightened politely in her chair and dropped her smile to a category B and shrugged. “Sorry. Everybody says I’m a bit direct. I think it goes with the job.”

“Which is?” I asked when I recovered a bit of my usual equanimity.

The smile turned wicked. Naughty. “I’m a hooker.” She thought about the word for the briefest of moments and then added: “Well, actually I usually use the word ‘escort’ but I figured you’d see through that right away. Most men don’t –or at least pretend they don’t. Guys are like that –they like to pretend that you’re not doing it just for the money.” She stared at me for a moment, as if waiting for me to respond. Then she shrugged dramatically. Theatrically.

I casually picked up my pen as if I were going to write it all down and, as with everything I did, she noticed. It was almost as if she felt she could control me with her words. She did, I suppose…

“You want me to stop wasting your time and tell you why I’m here,” she said with a loud sigh and leaned forward across my desk. Normally I feel a need to protect the space on my desk –over the years it has become an extension of my authority, my personal space- but she did it so naturally, it caught me off guard. Anyway, before I could react she said “I want to have a child,” and sat back, retreating into neutral territory.

I must have looked puzzled –You couldn’t hide anything from Cindy, because she answered my expression before I had even framed a question. “Even strumpets want babies, doc.” Then she smiled at my apparent amusement with her vocabulary. “We also read sometimes…”

“Anyway, I came more just to size you up today…” She tittered at her unintended trade-talk pun. She was silent for a moment –something I came to realize was an uncommon jewel with Cindy – and then her eyes twinkled and her whole body smiled. “I think you’ll do, doc. I think I like you.” Praise indeed.

I never succeeded in helping Cindy with her infertility issues, but all the same, she became a regular distraction in the waiting room. She modified her clothes and hair styles, of course, but I had the impression they were all for the same effect. She found ‘regular’ people banal, uninteresting, and so she teased them. Goaded them, really. She seemed to relish harsh looks, and her body language spoke novels about the seating arrangements she usually provoked. She was the only relaxed one in the room, and she knew it. Loved it. Craved it, maybe.

One day, when I peeked around the corner to see if a particularly obnoxious patient had arrived, I noticed Cindy sitting in the corner seat with a heavy looking briefcase. She had placed it between her lewdly open legs, almost daring anyone to try for it. And she had an oddly satisfied look on her face.

When her turn finally came to be invited into the office, she started talking –as usual- before I could open the chart. Not that I needed a chart for her. After preliminary investigations had suggested that the reason for her failure to conceive was that her Fallopian tubes were no longer open –blocked, perhaps, by one of the many episodes of infection she had encountered in her life on the street- I had tried to refer her to an infertility clinic. She hadn’t liked their attitude after one visit, so she kept coming back to see me.

“Got something for you, doc,” she said, positively beaming. “I wrote a novel,” she said, anticipating my question. “I thought you might like to read it before it’s published,” she continued. My eyebrows must have twitched, because she immediately continued. “Yeah, one of my…friends is a publisher; we did a trade.” I didn’t ask.

But I did read it when I got home that night. It was short –fifteen chapters and more of a novella- but amazingly well-written. It didn’t surprise me – Cindy was obviously bright and a shrewd observer of mankind (I use the word advisedly). What did surprise me, however, was the subject matter: the medical system in general and me –disguised, of course- in particular.

It was a story of the life she knew best: she and her friends in the business –the violence of the street, the drugs, the john-encounters, but more poignantly the unsuccessful attempts of the women to be taken seriously. To be treated as needful humans, not occasionally-moving receptacles. Her words were street-harsh, but no less effective. Certainly no less persuasive. It was a book written from the heart, not from the mind, and this made it all the more compelling to me.

The story was one of suspicion of life outside her world. How it disappointed and disparaged the protagonist and her friends; how they mistrusted outsiders by necessity –survival was knit by acquiescence and tribe. Even in illness and need, they felt themselves alone, bereft of help from a mistrustful and unkind society whose judgments were cruel and who forced impoverished expectations of treatment on them.

Then the woman decides her need for a child is so great, and her attempts to become pregnant so unsuccessful, she needs some outside help. So she visits various clinics where the doctors don’t take her seriously. Her friends just shrug and shake their heads. Of course there’s no help out there for people like her –people like them.

But she persists and manages to get a referral to a specialist –a male specialist is all she could get, but she decides to visit him anyway. The waiting room she finds herself in is middle class and she thinks the women sitting there are so intense she is amused. Not a good sign, she figures, but she has gone this far so she is determined to persist.

When the doctor finally leads her into his office she is struck by one thing: a tall carved wooden statue of a thin native woman holding a baby. It is sitting on his desk and there is a plant beside it through which it peeks with curious eyes. And it is smiling. The carving seems to talk to her about refuge. Safety. And it comforts her. This is the man who can help her, she decides. He’d put the carving on his desk beside a beautiful plant for a reason.

And the story ends with her feeling hopeful. No, he can’t help her, although he tries. But that is the point for her: he tries. And that’s what really matters. Not the result, not the abnormal tests, not even the fact that she probably can’t have a baby. Somebody heard her cry of desperation; somebody listened. And maybe that’s what she really wanted all these years: someone who cared.

I have to admit I cried. My god, is taking notice of someone that important? Is what some of us are searching for merely to be heard? Noticed? To be distinguishable from the background?

You know she never returned to the office after that. Maybe she was too embarrassed, or maybe she had no further need, but I really hope her novel was published. And I hope the man who had promised her a voice, became one and not just another moveable shadow in her life.

Lost… in an ER?

There is an incident which resurfaced in the news recently that has both embarrassed and outraged me: the inquest into a death. Five years ago, a double amputee in a wheelchair died in an Emergency Room after being overlooked -and neglected- for 34 hours! ( http://www.huffingtonpost.ca/2013/08/06/brian-sinclair-inquest-waiting-room-death_n_3711355.html?utm_hp_ref=email_share ) No, this is not a woman’s issue -although it might as easily have been a woman- it is an everybody issue; it could happen to anybody… Or could it? Would it?

Imagine showing up in a hospital emergency room needing help and then being forgotten. Forgotten -or ignored? Avoided? Scorned..? I’m trying to find a word that describes it best. Maybe discounted… You see, the person was aboriginal and apparently had been there before: he struggled with substance abuse -as if that were an excuse to discount any pressing need to address his presence in the ER. As if he could be dropped to the bottom of the list before his needs had been properly ascertained… No, not dropped to the bottom of some arbitrary list – dropped from the list: a man crying wolf! Sometimes I am embarrassed to be identified with the Health Care system, or to call myself a doctor.

The lawyer for the Regional Health Authority -I suppose as a way of deflecting accusations of the obvious (the patient was aboriginal, homeless, prone to substance abuse, and probably known as such to the staff in the Emergency Department)- was quoted as saying “These events could have happened to anyone.” Oh really? Does he honestly think that if he had showed up in Emerg in a wheelchair -especially as a double amputee- he would have been overlooked? Expecting more, he would have demanded more. He might have had to wait -a hospital ER is a busy place and triage of patients according to the urgency of their conditions is both necessary and appropriate. But 34 hours? Only someone used to being ignored would not put up a fuss -even if they were dying…

Oh, and there are the video surveillance tapes of a man, alone, in a wheelchair, not causing a disturbance, patiently waiting his turn! Here’s a sample (with commentary) from the CBC news site: http://www.cbc.ca/news/canada/manitoba/story/2013/08/26/mb-er-video-sinclair-inquest-winnipeg.html Or, how about this one: http://www.cbc.ca/news/canada/manitoba/story/2013/08/28/mb-brian-sinclair-inquest-security-guard-winnipeg.html  Apparently the Emergency Department was not even terribly busy that night. My god how can this happen? How can someone disappear in plain sight?

Could it be that we see what we expect? Or maybe we don’t see anything? Triage is the assignation of priorities according to need, but might it also be a selection based on other characteristics at times: appearance, behaviour, demeanour… race? And in the case of this unfortunate man, I find it hard to believe that his past did not influence the assessment as well. We -all of us- drag our histories with us like shadows; heavy clouds that obscure the reality of who we are and what we need. Past and present look all too much alike if we are being judged through a glass darkly. We all see the world with heavily laden eyes. And it is only apparent when it is us who are being evaluated -or should I say interpreted.

But is there any wonder why minorities -be they cultural, social, or economic- have come to mistrust the pretense of equality proffered by those in power? An offer with conditions so tightly attached to appearance and normative expectations that many have chosen not even to seek help, fearful they will be treated differently. Disparagingly. Begrudgingly. Or not at all…

How different are we?

As I get older, it occurs to me with increasing urgency that I do not necessarily inhabit the space that others do. Often I do not have the same beliefs or share the same customs; I value different things, organize my thoughts a different way; I see the world through eyes that have feasted and grown old on different sights. My experiences are necessarily unique, trapped as I am by genetics and circumstance. I should not claim to speak for anything or anybody but myself.

And yet I do. We all do. We speak from everything that has affected us, all that we have endured -or learned. We extrapolate from what has made us unique and try to make it encompass what we encounter, thinking that our own expectations and opinions are not only justified, but likely to be valuable and helpful to others. We long to meet ourselves in a crowd…

But this worries me as a doctor, charged as I am with helping others who cannot be the same as me nor want to. Why would they? What I offer them, what Medicine offers them, is a view-point, a world-view that may be at odds with their own. They come because they want help, and their need usually allows -requires- them to transcend their feelings for a while -help requires sacrifice. But even this necessity, however imperative, often stumbles at two nodes, two doors that are sometimes locked -or at least difficult to open.

The first is an impediment to seeking help in the first place, no matter how serious the problem. If the patient thinks my views are too distinct from hers, too disparate, she may not even seek help. In some contexts this concept is described as cultural safety. Simply put, will the person feel safe in disclosing her needs? Will her difference or her views be recognized and respected, or will they be marginalized and considered irrelevant, unimportant, or even silly? If she comes from a tradition that respects alternative therapies, say, -alternative to us, of course- or perhaps that prioritizes spirituality but expects this to be denigrated in her encounter with the doctor, is she even likely to make an appointment? If her friends tell her of racial, cultural, or socio-economic profiling at a particular hospital, or that the type or even quality of care seems to depend on what stereotype she fits, might this affect her decision to seek help, or at least delay it until she is desperate? I think so.

Or the if doctor is solidly imprisoned in his own views and so convinced of their truth and validity that he cannot or will not listen to your discomfort and try to see your problems as you do, will he be able to help even if you agree to see him? For many people, the concern, the fear, that their own opinions will be mocked, or not taken seriously is an impediment to treatment. Health, wellness, is in many respects subjective. How we feel about ourselves, how others feel about us is part of the equation that defines health. Disease apart, we are how we feel; we are the sum total of a multiplicity of parts that we somehow integrate into a functioning body, a sensing organism. Our opinion matters, if only to hold things together, grant them their eccentricities, tolerate their distinctive habits to which we have long grown accustomed. Who better to know me, than me?

A doctor ignores this at his -and your- peril. It is a difficult world for some to enter; some of us merely talk through a sort of window from the safety -the authority- of our office: encounters at a distance, diagnoses from the opposite side of the desk. Others pretend to understand but only outwardly -thoughts easily readable through body language by anyone nearby. There are a few doctors truly gifted with agape but most of us, try as we might, are creatures of our past.

And so what’s the answer? How can a doctor ever hope to help anyone? Surely each of us is an other, a stranger to anyone but ourselves. We all come from disparate backgrounds so what we hear is filtered, what we encounter: a confirmation bias; it makes us fallible and closed. And yet…

And yet if we take the time to listen to the other and listen with respectful curiosity -dignify their thoughts and opinions with our considered silence- we have come a long way. A hard part of illness is just being heard. After all, listening is how we form opinions in the first place; its how we learn; its how we connect; its how we understand… Listening enables relationship. It’s part of how we heal -a larger part than we may think.

Health care is one thing,  access to health care is another. There are many barriers to its acquisition: in some countries it is money, in others,availability of services. But for most non life-threatening health care needs, an underlying problem in all I would suspect, is fear. Not so much fear for safety as a feeling of unease: is what I have serious, will the doctor think I’m wasting his time, will he actually listen to me? So much of who we are -who we think we are- is bound up in our relationships and encounters with others. The medical visit is no different.

Illness, however serious, is still an article of clothing we wear. No matter how much of us it covers, no matter how it weighs us down, it is still we who wear it, we who peek out through the folds. It is important therefore that we meet with acceptance and respect when we finally bare ourselves enough to seek advice.

Cultural safety is one aspect of it. We are less likely to seek help if we feel that our views -cultural or otherwise- will meet with derision or condescension. I’ve always felt that my own specialty -certainly  the obstetrics side of it- is very much like the United Nations. It’s hard to miss the obvious; there’s a common theme that runs through my day; no matter the culture, the background, the social stratum, we all want the same things: our families to be happy, healthy and safe. We want that for ourselves as well. I would think it would be difficult to be prejudiced and a good obstetrician at the same time. I often learn more from my patients than they ever learn from me.

But along with the grateful acceptance of our superficial differences, I think there are other things that make the medical encounter more comfortable, less stressful. The waiting room for example. A picture on the wall, a plant in the corner, or even a carpet on the floor may seem trivial and unnecessary -I suppose they are- but they go a long way to helping the person seeking help feel less like they are about to visit a stethoscope and more that there may be a human in the other room. I realize that the physical constraints of an office impose many limits on the ability to make it look more appealing, but if you lived in that space -and most doctors do for the majority of the week- would you leave it bare and tasteless? Does it really have to look like a holding area, a resting place in a mall? A waiting room says a lot about who the patient is about to see. It can alter expectations.

If ambience is important in a waiting room, it is even more critical in the office. That is where secrets are told, trust is engendered, rapport is established. For new patients especially, what they see is what they judge. They haven’t met you yet, and they are both nervous and fearful. Putting them at their ease is part of establishing a meaningful contact, part of teasing a story out of them, part of actually helping them. It is not the Emergency Department where symptoms speak louder than words, and the diagnosis is often enabled by a wordless glance or an expressionless examination of a person lying on a bed. I’m certainly not suggesting than compassion and rapport are not important under those circumstances because they always are, but merely that the severity of symptoms and the urgency of need is often different in an office.  The approach is usually slower, more gradual -more dependent on mutual understanding and trust. The doctor is more able to explore the issues that surround the need for the visit, as much as the concern itself. He is, in short, more able to talk to the patient, understand her, listen to her -according her the respect and dignity she expects and needs from a health care encounter. It is never easy to confide in a stranger, let alone trust him with personal and often embarrassing problems. But a non-threatening environment may help to ease the transition in an otherwise awkward and frightening meeting.

I realize that considering the venue where health care is administered may seem trivial, but for some it may prove to be the difference between feeling comfortable with seeking help, and deciding to wait until it is truly an emergency. That comfort level takes time. It has to be earned and friends need to be consulted about their experiences. Many important things depend on the word of mouth: reputation, trustworthiness, honesty… and maybe health care utilization.

Health care is…