ENTRY 1:
This month in clinic I had an interesting experience with a new patient. The patient had not seen a doctor in many years and wanted a full check-up. I noticed that he had not written anything down about his family medical history on the form that new patients fill out. I asked him a few questions about his family history, including asking if anyone in his family had high blood pressure or diabetes. He responded no to my questions. However, later during the interview, he mentioned that several of his family members had “the sugar” and that he was worried that he might too. It turns out that he was not familiar with the term “diabetes” because his family members had always called it “the sugar”.
I realized with this encounter that I often take health literacy for granted. No one in my family is a physician, but they do know a fair amount about the more common health terms and ideas. Sometimes I forget that not everyone was raised in a family or in a school where health terms were explained and used commonly. I take for granted that not everyone knows terms like diabetes that seem so ordinary to me and to much of the general population.
I need to be more aware of health literacy barriers and work towards reducing the impact of that barrier. I think it is important to meet patients where they are. In other words, it is important to find out what they know and how they understand a health issue. By meeting them where they are, a physician can better guide the patient, while also having an opportunity to educate the patient about their health condition in terms that they can understand. This is not limited to health terms, like diabetes, but also to health ideas. For example, one patient did not understand why his blood pressure would still be up, even though he took the medicine we prescribed him. In his mind, taking the pill we prescribed every day like we told him would lower his blood pressure and he would be done with that health problem. I had to explain to him that sometimes patients need a higher dose or even two medicines in order to lower their blood pressure enough. I think he understood this after I explained it a couple times, but that concept had never crossed his mind before. Health literacy can be a barrier to improving health, especially in rural and less educated populations, but it is also a barrier that can be overcome with a little extra time and patience.
ENTRY 2:
Today in clinic I had an experience that really caught me off guard. I was talking to a woman in her late fifties. She was laid off of her secretarial job a couple years ago and lost her health insurance when she lost the job. She has applied to hundreds of jobs, but even with thirty years of experience, she has not been able to find a full-time job in this economy. She can no longer afford her rent and had to move in with her daughter and son-in-law.
We began to talk about health maintenance issues. I asked her when she last had a mammogram. She said it had been a few years. I tried to explain to her that it would be a good idea for her to get one soon since it had been a few years since her last one. What she said next shocked me. She said that even if she could find the money or get one for free at the health department, she would not want to get one because if they found something, she would not have the money to pay for further tests or treatment, so she would “just rather not know.”
I do not know exactly why this shocked me so much. It may be because I have been fortunate enough to always have health insurance and sufficient resources to not have to think about things like this. In addition, in school we have been repeatedly lectured on the benefits of screening, when there is sufficient evidence to support the screening method. I have thought about people turning down screening because of the risk of pain or other harm, but I have never thought about refusing screening for the reason this woman gave. Clearly I have been naïve and have not tried hard enough to see things from the perspective of our patients, which is something that I need to work on.
The patient explained further that she did not want to be a burden on others, especially on taxpayers who end up paying for Medicaid and other assistance programs. She told us that she had made a point to save what she could while she was working, which is allowing her to get by now, except for not being able to pay for rent or health insurance. I truly admire her independence and her desire to not be a burden to taxpayers. It seems noble to me. On the other hand, if someone needs help, I do not think that they should feel ashamed to ask. In her case, if she did have breast cancer, the treatment now would likely be less expensive overall than the treatment if the cancer was found later at a more advanced stage. To me, this makes it logical to have the screening, especially if it can be done for free or at a reduced rate at the health department. However, this experience taught me to not be so narrow-minded and to make sure that I try to put myself in my patients’ “shoes”. This way, I can better understand their perspective, instead of expecting them to think like me. I still think that she should get the mammogram, but I also understand that things are not always as black-and-white as my analytical mind would like them to be.
ENTRY 3:
Mr. H is a patient at the clinic who I have seen at least five times. He has been at the clinic every month that I have gone to clinic, both during first year and now during second year. He is morbidly obese and has diabetes, hypertension, and chronic back pain. Last semester, after raising multiple anti-hypertensives to their maximum doses, we finally got Mr. H’s blood pressure under 130/80, the recommended goal for diabetics. Unfortunately, we did not have as much luck controlling his diabetes. Last semester, his HbA1C was 11.4 while on multiple medicines, yet he continued to refuse insulin after lengthy discussions each month.
This past month, I did not go to clinic, but later in the day, another student called me to tell me about her experience with Mr. H. She exclaimed, “You’ll never believe this, but Mr. H’s HbA1C has been so high because he hasn’t been taking ANY of his diabetes medicines!! He has been taking his other medicines, but NONE of the diabetes medicines.” I was completely shocked. After hanging up with her, I sat for a few minutes replaying conversations in my head that I have had with Mr. H. Every month I had asked him what medicines he was taking. I knew he was unemployed, so every month I had also asked him if he was able to get his medicines filled. Every month, he had explained to me that he could not afford them, but that he was lucky to have a niece and nephew who alternated paying for his long list of medicines. I had always believed him. He seemed like he was being completely honest with me, and would even admit when he missed a day or two of medicines in a month.
The next day, I saw my friend at school and told her about all the conversations I had had with Mr. H about him taking all of his medicines. Since I was still baffled at what she had discovered, I asked her why he had decided to reveal his secret to her after all this time of promising me that he was getting and taking all of his medicines. I will never forget what she said. She held her arms out and said, “ look at me! I look like him. And he looks like anyone in my family. I just treated him like I would treat my brother. I guess he felt comfortable being honest with me.”
I have been thinking a lot about what she said. Was Mr. H really honest with her because she looks more like him and thus made him more comfortable? Even though I cannot change the color of my skin or my physical features, this experience will always be a reminder to me to try to make my patients feel as comfortable as possible. Perhaps I can do this by finding some kind of common ground. I have noticed that this does help in community week and at Bloomer Hill. For example, after finding out that patients work on a farm or have their own farms, I have told them that I grew up on a small farm as well. I immediately noticed patients relax and noticeably open up more to me. While I do not think it is a good idea to share a large amount of personal information with a patient, sharing something small like this seems to be a good way to establish a better relationship with them and make them more comfortable. I do not know exactly what I could have done to make Mr. H open up honestly to me like he did for my friend, but I am definitely more aware of this issue now and will try to make an extra effort to make patients comfortable opening up to me in the future.
ENTRY 4 – Community Activity:
For my community activity, I decided to visit the Rocky Mount farmer’s market one Saturday. The farmer’s market is outdoors in a poorer area of town, surrounded by many houses in obvious need of repair. This made me expect to see many people, both sellers and customers, who would look very much like the patients that we serve at Bloomer Hill. As I began walking around though, I was shocked to be surrounded by all middle-class Caucasian people. In fact, I only saw one African American person the entire time I was there.
Even though it is still early in the season, there were plenty of locally grown strawberries, sweet potatoes, lettuces, and even one farmer with an early tomato crop. There were even more plants for sell, both decorative flowers and edible herbs. I was really surprised at the amount of baked goods for sale. There were far more breads and cakes for sell than fresh produce. This made me think how easy it would be to go to the farmer’s market for healthy, fresh produce, but come home with not-so-healthy cakes and pies instead. I was also surprised that about one-third of the items at the market were not food at all, but were homemade crafts like painted glasses, cloth purses, and jewelry.
While I was there, I got into a long conversation with an older couple selling hand-painted glass nail-files. They had both retired from their careers and had been selling these files for the last five years for fun. It came up that I was not from around there and they then asked me what brought me there. I explained to them that I was a medical student at Chapel Hill and that I volunteered at a monthly free medical clinic just down the road in Whitakers. The way they responded to this was very strange. The woman said harshly, “Well, there is certainly a need for that around here.” This could have been a kind statement, but instead, the way she said it was very disapproving. It was obvious from the look on both of their faces that they looked down on the kind of people that need our help at the clinic.
On the drive back, I began thinking about my experience at the market. I was disturbed by the lack of lower socioeconomic status people and the reaction of the older couple. There seemed to be many barriers keeping people of lower socioeconomic status from buying fresh produce, even though it was located in their own neighborhood. First of all, I know many of our Bloomer Hill patients rely on food stamps, but food stamps cannot be used at the farmer’s market. Even if they have the money to spend on food, produce can be expensive, both at the farmer’s market and at the grocery store. At the farmer’s market a small tub of strawberries was $6.50 and a bag of fresh lettuce was $5.00. This is more than our patients pay for a month of a generic drug. It is easy to imagine how a person on a tight budget might choose to spend $6.50 on a month’s worth of a needed medicine and two fast-food value menu cheeseburgers, rather than on a single tub of strawberries. Moreover, before the days of $4.00 generics, it is easy to imagine how a patient might go without medicines just like they go without fresh produce.
Another disturbing barrier keeping our patients from healthy eating is the possibility of them not being welcome at the farmer’s market, as was suggested by my conversation with the older couple. While I came home from the market with strawberries, herbs to plant, and a Mother’s Day present for my mom, I also came home feeling unsettled about our patients’ access to healthy and affordable food choices.