Thank you, teacher

Scholtens, Martina

An oversized pink uterus flanked by a matching set of ovaries was projected onto the wall. Eleven Burmese women gazed at it, paper plates of cake balanced on their laps.  As I began to explain the anatomy, one of them abruptly walked up to the screen, spread her arms wide, and clapped a hand over each ovary. “I know this,” she said, quiet and proud. “I know this!” The others murmured and nodded. She had been a health instructor at their refugee camp.

The nurse and I had organized this women’s health group visit for the new Burmese arrivals who had been presenting to our Vancouver clinic over the past few months. None of them were familiar with cervical screening or mammography, and most of their pregnancies were unplanned. Teaching them as a group, we reasoned, would be much more efficient than the individual counseling we were currently doing.

And here they were, eating snacks in our clinic’s meeting room, a collection of women aged eighteen to seventy-eight who’d taken the bus in from Langley together that morning. I felt like a hostess, responsible for the event’s success and concerned that the guests enjoy themselves; I was relieved that they’d shown up at all. These were considerations foreign to a typical clinic day in my office.  

That nervous feeling - that I was on unfamiliar ground, outside the comfortable routine of one patient, one exam room, twenty minutes - was the first suggestion that moving all of us into this new context might result in something unexpected.

Our experience to this point was that the Burmese women were particularly pleasant patients: uncomplaining, compliant, deferential to a fault. Eliciting any kind of medical history was a real challenge. Repeatedly I found myself seated across from a slight smiling woman in a bright woven skirt, with just a hint at a problem, doing the medical version of twenty questions. I worried that I’d miss a diagnosis because the history hung almost completely on me; I wasn’t sure a patient would divulge a symptom like severe right lower quadrant pain unless I enquired about it directly.

But here as a group, with an interpreter, they were transformed. They interrupted our presentations with comments and anecdotes. They asked questions and made jokes. There was a continuous soft running commentary the entire morning, and the atmosphere was congenial, even festive.

The nurse showed a slide with an image of a heap of packaged condoms in a rainbow of colours. There was laughter and discussion in the Karen language, and the interpreter relayed to us: “When someone handed those out at the camp we took a lot, because we thought it was candy!”

The nurse passed around an IUD, and the women examined the tiny T with long trailing strings closely. A discussion among them ensued. They looked concerned. “They’re wondering,” said the interpreter, “whether their husbands might become tangled in the strings. Trapped. Perhaps even injured.” We trimmed the threads for future demonstrations.

As I explained the procedure of mammography, a woman raised her hand and asked slyly, elbowing her neighbour, “What about women with very small breasts - do they still need this test?” Giggling and more nudging ensued, and I realized that some jokes really are universal.

I went on to explain the purposes of cervical screening. A hand went up, waving urgently. I paused. “She says,” explained the interpreter, “that she needs that test. She must have it, right away.” There would be a chance at the end of the morning to have that exam, I informed her. Two more hands shot up. In the end, every woman in the group wanted a pap test that morning.

Once we’d finished the teaching, I distributed evaluation forms. Most of the women weren’t literate even in their first language, so we’d kept it simple: four statements for the interpreter to read out, and a choice of circling a happy or sad face to demonstrate whether the respondent agreed. “We’d like to know how to improve this visit,” I said. “This is anonymous. There’s no need to write your name on the paper.”

“But they want to,” the interpreter relayed back to me. “They insist.”

She read the first statement: “I liked the group visit today.”

“Yes!” the women responded in chorus. The interpreter explained again that the answers needn’t be shared. The women continued to cheerfully voice their affirmative responses to each question. When I reviewed the evaluations later, sure enough, all eleven respondents had given us a perfect score.

Each participant then had an opportunity to meet briefly with me one on one, to answer any questions, and review contraceptive and screening needs. I’d expected that I could meet with each individual in the corner of the room, while the others visited and had more tea. But the other women gathered around my makeshift desk and listened intently to each exchange; the patient in question appeared entirely comfortable with this. I tried in vain to disperse the audience. I found myself whispering, as discreetly as possible, “When was the first day of your last menstrual period?” as the nurse tried to distract the women with more contraceptive demonstrations.

Then followed a whirlwind of pap tests, by three practitioners in three exam rooms, with one interpreter dashing from room to room. By the end of the morning, we’d done six pap tests, discovered a pelvic mass, diagnosed a pregnancy, and written four prescriptions for birth control.

It was a satisfying morning from a clinical standpoint. I felt confident that the visit had solidified prior knowledge and would result in dissemination of new information to the Karen community. I anticipated that the women would feel more confident discussing women’s health issues with health providers in the future, and that there would be increased screening uptake.

More than that, though, the group visit experience was unexpectedly moving. Hearing stories of a jungle tree bark that would prevent pregnancy; watching the women banter with each other; answering their sometimes primitive, sometimes sophisticated questions on pelvic anatomy - it was me who was the guest. For once, I was the odd one out: they had the solidarity in numbers, language, culture. It was a reversal of positions, and I felt the humility and privilege of it.

At the end of the morning, one of the women looped her arm through mine as we walked back to the waiting room. It wasn’t just me, then, that felt that meeting in a group setting had done more for doctor-patient rapport than any private visit had.

“Thank you, teacher,” she said in careful English.

I didn’t let the interpreter correct her. She had it exactly right.

Theme: Community | Communauté
Theme: Health Care Delivery | Prestation des soins de santé
Theme: Patients | Patients
Theme: Relationships | Relations

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.




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