Different doctors have different consulting styles. Coming from a background of general practice, my style is very patient centred, rather than doctor or disease centred. I try to gather as much information about my patient as I can. Do they look unwell? Are they poor? Anxious? What’s going on at home or in the family? And I pick up on their body language, how they express themselves, what they think might be the problem, what are they afraid of? We call this the bio-psycho-social approach to diagnosis.
But this isn’t England. And my patients are either Burmese or one of a dozen types of Karen. I have to rely on nurses and medics to translate for me, after they have already taken the history. If I ask a question which the nurse should have asked, sometimes they don’t reply, they keep quiet and hope I will move on. Or they will give what they think should be the answer, an informed guess.
Ward rounds tended to be a discussion between the medics, nurses and the doctor. The patients looked on passively, trusting that we will do the right thing, make the correct decisions. They know their place. As soon as I took responsibility for the clinic, I changed this. I started asking the patient questions. The nurses and medics found this new approach challenging. They had taken the history, they knew what was going on, I should be asking them, NOT the patient.
I know enough about using translators to keep my questions really simple. One phrase, one idea, no qualifying clauses. When did the pain start? Is it getting better? Where hurts the most? What never ceases to amaze me is that such little questions often result in a long discussion, back and forth for several subsidiary questions, and then an answer is revealed which might have moved on from the original question. But I sort of get an idea of what the answer was.
It is considered rude for Karen people to make eye contact with someone they consider to be their superior. To overcome this, I sometimes have to play the role of crazy foreigner, someone so funny and strange that they are off the scale when it comes to normal social interactions. Dr Cindy says that I make the patients feel uncomfortable, because I stare at them. In reality, I’m scrutinising them, hoping to pick up clues as to what on earth is going on. My “Patch Adams” approach helps to break this down, with a bit of humour, physical touching, a genuine look of concern on my face and my insistence on bringing them into the consultation discussion. Are you happy with what we are doing for your child? Is there anything you are concerned about? Do you feel your baby is making progress? Are you under pressure to go back to your village to look after your other four children/your husband who is ill/your fields?
One woman complained of recurrent urinary tract infections. The nurse approach is to confirm the diagnosis and treat. The medic wonders if there’s an underlying cause such as urinary stones. I ask her to tell me more about her life. We learn that her husband works away for a month at a time. He came back last week and she developed symptoms within 24 hours of his return, with pain and passing urine frequently. This happened six weeks ago as well. But her urine culture was negative, then and now. I’m sure you have already come to the same conclusion I did – honeymoon cystitis, but with the possibility of an STI. This just wasn’t on the nurses’ radar. They look at me strangely when I ask them to be curious about their patients, to imagine what is happening in their patients’ lives.
Since I qualified as a doctor in 1977, I’ve been a stickler for doing a proper examination. This was drummed into me as a student and it has stuck. So I undress the patient when I’m examining the chest, I reveal the abdomen, I don’t listen or palpate through clothes. This is not in keeping with local culture. A senior doctor told me that Thai GPs rarely touch their patients, for example.
Last week, a medic told me that he could not find any abnormality when examining a female patient who was complaining of cramping abdominal pain. I watched him examine the patient again, fully clothed. I explained that it would be better to see the patient’s belly, listen to the bowel sounds, feel for masses and tenderness. I went through the whole procedure with him and found a loaded sigmoid colon – she was constipated. He hadn’t felt this through her clothes. So, expecting the answer “No,” I asked him, “Was this examination culturally insensitive? Did I embarrass the patient?” And he said, “Yes!”
So I asked the patient, and she said, “Yes,” too. “But by doing the examination properly, we now know what is wrong with you and we can fix it,” I replied. “You’re the doctor, you should know what’s wrong with me anyway,” she answered. Clearly, I’ve got to address these attitudes in a culturally sensitive way. I’ve got a lot to learn.