Category Archives: medicine

Holding the Space for Expectations Challenged

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Ray Great Wall 2016

Those of you who follow this blog know that I meet regularly with a group of insightful and engaging medical students. I have written about them here and here. At our meeting last month, one of them described his recent rotation in China, and I invited him to share his experience here. I’m so grateful for this continued connection to physicians in training—it keeps me grounded. It reminds me that no matter how old and wise I may consider myself, I always have much to learn from others.

Enjoy, everybody:

 

Expectations. In the United States, we have come to have certain expectations for how things should be. A meal at burger joint should include a burger, with a side of fries and a Coke. When we check into a hotel, there should at least be a TV and a coffee maker with complimentary coffee. These have become essential (American) assumptions, and because we are the “best in the world,” our way is the best way.

Similarly, when you go see a doctor, there are certain expectations, both good and bad. You expect that it may take a few days to get an appointment. You expect a reminder prior to your appointment. You expect to wait a certain amount of time to see the doctor and to fill out a ton of paperwork. You expect the staff to be courteous. You expect to see a nurse first, and to wait again in an exam room until your doctor arrives. You expect the doctor will listen to all of your health problems closely, and offer helpful suggestions regarding imaging and medications you can take. You expect those prescriptions to be sent to your pharmacy, and that you can to pick them up after your appointment. You expect to get better.

What if your reality ended up very different from these expectations?

Last month, I went abroad to see what the healthcare system is like in China, at an academic teaching hospital in the nation’s capital of Beijing. After spending a year deeply entrenched in the clinical wards of the United States as a third-year medical student, learning from the best of the best doctors, I thought I knew what it meant to provide good medical care. I expected that I could teach them better ways of delivering care based on what I learned in America. I soon found out that I was the one who had a lot to learn.

To provide some perspective on just how different the healthcare system is in China, imagine this scenario, based on an amalgamation of different patient experiences that I witnessed:

You are sick and want to see a doctor. You wake up the next day at 5 in the morning so that you have enough time to take the subway to get to the hospital by 6. When you arrive, there are already 30 people in line ahead of you, and the specialist you want to see only gives out appointments for 25 people for his morning clinic today. You don’t end up getting an appointment.

You go into the doctor’s office when he arrives at 8, bursting in the door with 10 other people who are sick but were unable to get appointments. You fight for the doctor’s attention during his first patient’s appointment, and, luckily, you get an add-on appointment, for after his 25 other morning appointments. You sit in the waiting room until 12:30PM, when you are finally called in.

You see the doctor. He only has 5 minutes to spend with you. As he is doing your physical exam, his next patient enters the room before being called, and watches everything. The doctor says you need imaging, which you need to pay for and schedule yourself. You then need to pick up hard copies of the images and bring them to your next appointment, so that he can make a diagnosis. You also need some medical equipment, and he suggests shopping for it online. He says you may need to be hospitalized, but it may take 2 weeks to get a hospital bed spot, so you should sign up for the waiting list now. You get the imaging and medical equipment, the doctor makes a diagnosis, and you get better.

Your total cost for everything was less than $50.

Your gut reaction to this story may be, “this is madness!” You may feel that your expectations of healthcare delivery, based on your experiences in the United States, are very different from the care provided in China–not only different, but almost certainly better. At least, that was my gut reaction. I was appalled on my first day of clinic; my mind raced with questions: How do patients put up with this disregard for their time and rights to privacy and respect? How are doctors able to treat patients adequately without hearing the patients’ stories? Can patients have a good understanding of their medical condition in this system of care? It made me feel grateful for what we have in our current healthcare system back home, with better customer service, shorter wait times in the doctor’s office, and more privacy during the appointment.

However, take a second to reflect: is our healthcare system universally better? In this compiled scenario in China, you got seen by a specialist on the same day you got sick, which happens on a regular basis for patients familiar with how the hospital system works (even those unfamiliar with the system can still be seen within one or two days). Your overall costs were low and did not involve convoluted paperwork from third and fourth parties. And, most importantly, you were still able to get better. These are all things that hospitals in the United States hope to improve on. By the end of my first week in China, I realized that my gut reaction on the first day was irrational, stemming from discomfort with things I was not accustomed to. As I distanced myself from my premature judgment on what I was seeing, I found that the differences were not bad, just different. China has the challenge of providing healthcare to the largest patient population in the world, and with that, factors like cost containment and short visit times are prioritized. In the United States, we have also had to prioritize certain factors, specifically patient satisfaction, due to our cultural values and our legal system. In both countries, though, positive patient health outcomes are the highest priority.

Dr. Cheng asked me what three things I learned primarily from doing a clinical rotation abroad. First, different does not equal bad. While China and the United States do not have the same priorities for or access to healthcare, both have well-functioning healthcare systems. Second, withhold judgment from your expectations. Your gut reaction may not always be correct and may limit you from fully understanding things unfamiliar to you. Third, be grateful for what you have. Though our own healthcare system has its problems, we should be grateful for everything that works well, and we should not take it for granted.

#AtoZChallenge: Xerophyte People

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Webster’s Ninth New Collegiate Dictionary

Xerophyte: a plant structurally adapted for life and growth with a limited water supply esp. by means of mechanisms that limit transpiration or that provide for the storage of water.

AC cactus 2016

Photo courtesy of Cyndie Abbott, Green Valley, Arizona, 2016

 

Water is essential for growth and survival—of plants and animals alike. So how is it that some plants can not only survive, but thrive and even reproduce, with so little water?  On top of that, they also provide beauty, habitation, and even sustenance for others.  Their short-lived flowers splash color onto monochromatic landscapes.  Regional animals are adapted to live nestled among some xerophytes’ barbs.  Survival programs tell us to seek these plants as a source of essential hydration when stranded in the dessert.

Humans share many of these tough flora’s adaptive qualities. We evolved as omnivores, able to eat most things that grow in nature.  Our big forebrains allowed us to cultivate plants to eat.  We learned to capture, then herd, animals for our own use.  We have come so far as to alter and control our environments, in order to live in places where nature may never have intended.

But the more interesting parallel between xerophyte plants and Xerophyte People is resilience.  If we consider metaphorical water for human life, many things come to mind: joy, security, connection, purpose, meaning, love.  Think of all the people who live with little or none of these things.  Think of those who once had these things, and then had them forcibly taken away, often indefinitely—by war, abuse, illness, death.  In medicine, we witness this kind of suffering regularly.  Our hearts break alongside those of our patients and their families.  But it’s not always forever.  In primary care, where I have the privilege of knowing patients over long periods, I have also celebrated remarkable reversals.  New relationships, revelations, births, treatment innovations—you never know what will happen to turn the tide.

So what keeps us hanging on? Like plants, maybe we figure out ways to prevent further loss—limit transpiration.  Thick skin and prickly spines keep us protected.  Only the very persistent or the specially equipped can penetrate our defenses.  But more important, we have adapted to store what we need.  Even if we cannot readily identify or articulate it, something keeps us going.  Maybe it’s hope, remembrance, or some core value or aspiration we have yet to realize—some inner pilot light that never goes out.  Some might call it the human spirit.  Whatever it is, I stand in reverence of its mystery, its utterly saving presence.

To all the Xerophyte People in our world, I say as Glennon Doyle Melton does:  Carry On, Warriors.

IMG_1680.JPG

Tent Rocks National Monument, New Mexico, June 2015

#AtoZChallenge: Withhold Judgment

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My brain is so tired. All month I have racked it trying to figure out what to write next, how to render it most authentically, and finally get it out looking close enough to how I intended.  On top of that, I have also engaged in multiple exchanges on Facebook around gender identity, public restroom use, vaccine rationale, and presidential politics.  It really has been shang nao jin, as we say in Chinese—literally wounding the mind.  I realize these are all activities that I choose, and none of them have significant bearing on the world at large.  And, I would do it all again.  My mental exhaustion is the hurt-so-good kind, like the muscle soreness after a particularly strenuous workout, when I know I have pushed myself to my limit and maybe extended it a little.  The writing and conversations are ways that I engage with my world and practice what I preach—open-mindedness, curiosity, and cultivating connection.

After all of this exploration, conversation, debate, research, and observation, once again I conclude that one of the most important practices for inner peace is to Withhold Judgment. Not all judgment, and not indefinitely, but much and for a while.  Here are some illustrations from the past week:

I shared this post on my Facebook page on Saturday.  I agree with the author’s sentiments, basically that discrimination is wrong and we should open our minds and bathrooms to all people.  I also thought her writing was cogent and forceful.  One of my friends pointed out her name calling, as she labeled supporters of the North Carolina HB2 legislation, and people who boycott Target as a result, as hateful.  He then asserted that the left “can’t argue a point without calling people who disagree with them hateful,” or at least they choose not to. At once I see both sides generalizing in ways that preclude any possibility of meaningful mutual understanding.

After this I became more sensitive to name calling in articles I read. Even ones with relevant data and useful information can be tainted, as I found here, in which the writer calls bigots the same people that the previous author called hateful.  Why must we stereotype and label like this?  Is it just to get published, for attention?  Can we not convey our message just as effectively without all this vitriol?

Finally I read and shared this article, in which the author does not call anyone names directly, but writes a brilliant and searing piece of satire that also inflames and incites.  I suppose that is the point of satire, after all?  It was the comments on this last article that really drove home to me the perilous state of assumptions and judgment that drive many of our interactions these days.  If you support this law, you’re hateful.  If you oppose it, you’re irresponsible.  Perform one act that is, superficially, inconsistent with your professed beliefs, you are forever a hypocrite.  Commit one lapse in judgment and you are instantly unworthy of respect, now or in the future.  Snap judgments can degenerate our encounters to a series of sound bites of rhetoric and aggression.  They seriously inhibit, if not completely destroy, our connections, and they consign us to echo chambers of isolation.

The doctor who rushes me through my 15 minute appointment for a sinus infection, after making me wait 30 minutes already, is uncaring and just wants to make more money. Actually, she just spent the last 45 minutes telling her patient of 10 years that he has metastatic cancer and answering his questions, and she is anxious to get to her son’s school play tonight, his first lead role.

The woman who yells at the receptionist and makes a scene with the nurse is just another angry, entitled patient. Actually, her son was killed by a drunk driver last year, she lost her job and her home, and her mother is dying.

Fellow blogger and talented artist Jodi posted this beautiful piece today, including these words:

Skip the religion and politics,

head straight to the compassion.

everything else is a distraction.

— talib kweli

It really spoke to me, because compassion lives at the core of human connection. If we can remember compassion for one another more often, no matter our circumstances and state of mind otherwise, we can probably also remember to Withhold Judgment and listen for the rest of the other person’s story.  Listening more, yelling less, moving slower to the keyboard, showing up in person, asking more questions for understanding—these are the practices of Withholding Judgment.  Please, let us make the effort; it may save us all.