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Piece I wrote during Residency: Social justice in healthcare

Dr. Rosa KW Lee

Copyright 2021

During my early stage of residency, I thought that a good resident (and physician) is an efficient one, who can address the presenting medical concern effectively (“fix” the problem) in the least amount of time, as to maximize the number of patients seen and thus, the number of concerns “cured” or at least, addressed. This utilitarian approach led me to “do my job,” and while most patients were happy with the fast, efficient pace, I often wondered if I am really making an impact.

Approaching the end of residency, however, my style has completely changed. Rather than ten “quick fixes,” I see greater value in changing the trajectory of a single, complex patient, whose problem – while complex – would lead to greater impact in their life if revealed and addressed. This change came from a shift in mindset, in realizing that things are not always as simple as they appear, and one cannot know what one does not know unless one approaches any situation with an open mind, sans judgement.

I was shocked by how my patients responded to this shift in my mindset. More and more percentage of patients began to offer sensitive and personal information, and gave me a glimpse into the context of their medical concern. It was as if they could tell that I am now ready to truly listen – simply listening without judging – and seeing things for what they really are.

For instance, I saw a woman in her 40s for a postpartum visit. She had been seen four times before at the same clinic for well baby checks and to check weight of the baby due to initial difficulty breastfeeding. During this particular visit, however, I sincerely thought in her perspective and empathized about how difficult it must be to be a new mom, and have issues breastfeeding and worry about the baby’s weight, with feeling of guilt that somehow it’s her fault for breastfeeding issues. I offered her genuine words of comfort and asked how she was coping. She then offered me a crucial information that she never revealed to anyone else before (including the four prior postpartum visits): she was a victim of domestic violence. Normally a strong character not accustomed to showing her emotions, she burst out in tears. We were able to assess safety of this patient and the baby, make a safety plan, provide her with resources and made alternative arrangements for close follow up.

Apart from this case, since change in my attitude, I am astonished by how often patients bring up issues they never mentioned to any other medical professionals before, and how often patients tear up and truly open up to me, even when they are presenting with what seems to be a simple concern. Just yesterday in a single urgent care shift, I had: (1) a patient, same age as me (late 20s) with Mallory Weiss tear from polysubstance-use associated vomiting telling me why he uses substance despite his privileged background; (2) a women in 40s with recurrent BV crying about how no one took her issue seriously, and it turned out underlying her emotional response was her infertility that was complicated by familial/ cultural expectations; (3) a patient telling me he does not take his antihypertensives because no one took the time to explain why he needs it, and that he felt he was not being heard and that no one cared. The kind of information patients offered me when I simply paused, looked at them and resisted urge the think about next steps/ differentials and emptied my mind to listen, show me how ignorant I was previously to make assumptions about patients. It also made me realize that rather than labelling patients with recurrent visits as “frequent flyers,” stopping to think in their perspective can easily reveal how their needs were not met, and when that is recognized and addressed, there is a clear change in patients’ response and attitude.

In context of social justice, I truly believe social justice in medicine starts with non-judgement and trying to see from the patient’s perspective, not “if I – given my values, past experiences and beliefs, and personality – were in their position,” but how “the patient – with their values, past experiences, beliefs, personality and context – would feel in their current situation.” There is one quote that resonated with me in Pocahontas, and it goes: “if you walk the footsteps of a strangers, you’ll learn things you never knew you never knew.” I came from a privileged background, I have never experienced abuse and I will always have my blindspots. There is no way I can directly, or even indirectly experience all different walks of life. However, I feel that patients intuitively know when a physician truly cares and is ready to listen. Fighting the natural urge to judge and stereotype patients, by approaching each patient with a blank slate, ready to listen and caring for them not as a “medical problem” but a human being suffering from an ailment, patients grant us the privilege to experience what it is like to walk in their footstep. In that way, I can make up for my ignorance by having my patients become my teacher, while I become their health advocate.

In retrospect, I think about how many patients, whose medical concern appeared simple at prima facie, actually had a much deeper, complex context but did not bring this up because they felt that they would not be heard, or that I am not in a position to help them. How many opportunities I would have missed to truly “change” a life. On the other hand, I am eternally grateful for all my patients who opened up once I changed my attitude, for by sharing their life stories with me, they gave me the privilege of walking footsteps of life paths that have been so different from mine, adding one more layer each time to my understanding of – and thus appreciation of – social justice. Through this privilege I matured not only as a doctor, but as a human with wisdom to know how little I know, and how foolish it is to make any assumptions about a patient and their decisions.

I realize how arrogant it was for me to judge a patient’s decision as irrational, or to think I know what is best for the patient. I may know the standard of care and statics on NNT or prognosis based on various treatments, but the patient in front of me is not a statistics game. S/he is a human being with complex compilation of personality, history, experiences and trauma, complexes, culture, societal role, familial role and more, and often, the numbers reveal nothing about these contexts. That is where the art of medicine enters, and no answer is same for any two patients.

In the future, I plan to integrate this mentality by reminding myself each morning that my MD does not grant me the right to heal a patient: each patient makes that decision for themselves when they interact with me. I will remember that this privilege is gained when patients feel the doctor in front of them is someone they can tell their story to without being judged, and if they are truly cared for. I hope to become a health advocate for each of my patients if they bless me with this privilege by integrating psychosocial layer to medical concerns. Most of all, rather than prioritizing efficiency, I plan to have an impact-centric practice, with emphasis on quality and depth over quantity.

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