Linda Smith: Meeting started yet?
Joan McBride: When, in three months Dr. Brown has been here, has a Friday staff meeting ever started on time?
Linda Smith: Good point. Oh. That'll be him. Morning, Dr. B. Ready for the meeting?
Dr. Brown: Umm, meeting. Right. Yeah. I -- I -- I'll be right there.
Dr. Johnson: Are you all right, Mike?
Dr. Brown: Aaron, have you ever had a case that made you doubt your professional abilities? Everything about why you became a doctor?
Dr. Johnson: No, sir.
Dr. Brown: Try two in one week.
Dr. Rivera: What's wrong, Mike? Tell us.
Dr. Brown: Back when I had my suburban practice on the East Coast, there wasn't what you'd call a substantial minority population to deal with. I don't know how to say this without sounding bad, but I think both these problems stem from the fact that both my patients this week were minorities.
Linda Smith: Maybe you should explain these cases to us, Mike, and we can help.
Dr. Brown: You're all familiar with Arturo Gonzales, one of Carmen's patients. Well, as you know, while Carmen was out of town, I was seeing the boy and his mother. He OD'd on the prescription I renewed for him, Apparently because his mother couldn't understand the instructions and had him take a bunch of pills at the same time.
Rose Baker: What about the other case?
Dr. Brown: It's Geraldine Williams. She thinks she can cure her diabetes with traditional American Indian practices. She's already lost a leg, but she kept her appointment to see me. She wants my help. She wants me to do something. But what? It's really the same problem in both cases. With Arturo and his mother, I couldn't speak Spanish. And with Mrs. Williams, we were both speaking in English but it was like a different language.
Dr. Johnson: When we were in medical school, we learned the way to BATHE.
Dr. Brown: Bathe? Are you saying this is happening because I don't bathe?
Dr. Johnson: No. That's not a -- what I meant is --
Linda Smith: It's always important to define terms in a conversation. BATHE is an acronym for a model of communicating with patients. Aaron, you should explain.
Dr. Johnson: Sure thing. The idea is that patients bring their own understanding to health care. Often their understanding is based in cultural beliefs and practices. One of the challenges is to figure out the patient's cultural understanding of their illness so that you can treat it effectively while still being respectful of their beliefs. BATHE stands for background, affect, trouble, handling, and empathy. The model pretty much focuses on understanding how the patient sees the illness, then negotiating treatment that works for both parties.
Dr. Brown: Look. Mrs. Williams' diabetes complications are very serious. Life-threatening, even. I can't take the time to figure out here favorite herb tea. She could die in the meantime. In addition to everything, now I have to become an expert on yoga as well?
Dr. Rivera: Mike, yoga is India Indian, not American Indian. And look at it this way. If you had taken the time to talk to Arturo and Mrs. Gonzales, it could have prevented the overdose. It was not taking the time that almost caused the death. You said so yourself that talking to Mrs. Williams was like speaking in a different language. Do you want it to have the same effect on her as when you couldn't communicate with Mrs. Gonzales?
Dr. Brown: So how would it work?
Linda Smith: It's a matter of thinking differently about your patient's role in his or her own care. You're the expert in the disease, but your patient's the expert in the illness. You ask yourself why Mrs. Williams was seeking treatment from both you and from her traditional approach. Why not create a plan that offers her both? I know that we can't be expert in every cultural approach to health care, but that's why we talk to our patients. We need to ask them about their beliefs.
Dr. Rivera: What did Mrs. Williams tell you about her beliefs?
Dr. Brown: Well, she told me that she felt better and at peace in the desert because she was with her family, eating traditional food, gathering herbs, and praying. She thinks she'll die in the hospital because she believes that's what killed her husband and took her leg.
Dr. Rivera: Well, now we know why she would rather be in the desert.
Joan Baker: And Mrs. Williams did make a follow-up appointment for next week.
Dr. Brown: Aaron, do you think you can show me how this BATHE thing works?
Dr. Johnson: Yeah, I'd be happy to. Linda, would you role-play it with me?
Linda Smith: Sure, I think we kind of need to move the table away.
Group: Oh. You're right. This chair.
Dr. Johnson: The first thing you start with is background. Good morning, Mrs. Williams. First of all, let's get that chair situated so we can see each other. So tell me about your trip to Arizona.
Linda Smith: Why, Dr. Brown. I tell you. I feel so much better than I did before. I saw my family. I -- I'd missed them so much. We gathered herbs and made tea and cooked all the foods we used to when we were children. I was finally able to relax. And you know what? I'd barely thought about sickness.
Dr. Johnson: Sounds like a wonderful vacation. How was it coming back home?
Linda Smith: Well, my daughter keeps insisting that I see a doctor. She's concerned about all my problems. And I tell her, child, that's just life. Everybody I know seems to have some sickness or another. The problem with people, I think, is that they're focused too much on worrying about their illness and they just forget how to live their life. But, of course, my daughter'll be calling me to see if I went to see the doctor, so here I am.
Dr. Johnson: Well, how are you feeling?
Linda Smith: Peaceful. I really enjoyed being away, and seeing my family was wonderful. And I really liked not worrying about things, at least for a little while.
Dr. Johnson: Are you worried about things now?
Linda Smith: Well, my daughter knows a lot about medical things, and she keeps telling me how dangerous diabetes is. I get nervous just to think about it. I'm not ready to leave this planet yet.
Dr. Johnson: What makes you think you might die?
Linda Smith: Well, I still have problems sometimes.
Dr. Johnson: What kinds of problems?
Linda Smith: Well, I get dizzy from time to time, and -- and my foot hurts constantly. And -- and this stubborn bladder infection just won't seem to go away. Makes a woman feel weak and tired all the time. And my poor old heart just isn't healthy. I know that.
Dr. Johnson: Geraldine, what scares you the most about how you're feeling?
Linda Smith: What keeps me awake at night more than anything is what if I have to go to the hospital.
Dr. Johnson: And what is it about hospitals that troubles you so much?
Linda Smith: Doctor, you know why. My poor Frankie, he wasn't in that hospital two days when he died. And then when they put me in, they took my leg. What if I have to go back? Doctor, my grandchildren are just babies. I can't die yet.
Dr. Johnson: I can see why the thought of going to the hospital frightens you. How are you handling the problems you having now?
Linda Smith: Well, my daughter keeps telling me that by losing weight, I'll -- I'll feel better. So I'm trying to eat less, but sometimes I get so hungry.
Dr. Johnson: I think your daughter's right, Geraldine.
Linda Smith: and I'm -- I'm trying to check my sugar. I'm getting better, but I still forget sometimes.
Dr. Johnson: Anything else you're doing?
Linda Smith: I wanted to stop taking that horrible heart medicine, but my daughter, she keeps nagging me to remember to take it. I was so relaxed when I was in the desert. Eating the way I was and just being peaceful. I wish I could just do that instead of taking the medicine.
Dr. Johnson: Well, Geraldine, I'm glad to hear all this. It seems to me that you're working on the problems that I would want you to work on.
Linda Smith: Uh-huh.
Dr. Johnson: I'm also very glad to hear that your daughter is working closely with you to be sure that your diabetes and heart disease are handled well. Would you like to bring her with you the next you come to visit me? If you would, we could all sit down together and go over our plan of approach. And you'd have a partner to help you do all the things you want to do to feel better.
Linda Smith: I think I'd like that, Doctor. I don't have to go to the hospital, do I?
Dr. Johnson: I need you to make me a promise, Geraldine. If you can continue working on all the things we're talking about, I don't think you have to go to a hospital. But I would like you to see a nutritionist. I think that would help you develop the right eating plan. The nutritionist could help you choose foods that are good for you but that wouldn't leave you feeling hungry if you were to eat less.
Linda Smith: I'd do that. I'm so used to certain foods that I don't even know what other foods I could be eating.
Dr. Johnson: And we definitely want you to continue your heart medication. I know it's unpleasant sometimes, but it's very important. But there's no reason why you can't continue doing all the things that make you feel better, like tea and relaxation and prayer with your family.
Linda Smith: Doctor, you've got yourself a deal.
Dr. Johnson: One more thing. I'd like to do a few tests today just to see about your insulin. We can decide if we need to change your dosage, and we can help you figure out when and how often you should be testing yourself. Maybe we could go over the results on your next visit when you bring your daughter.
Linda Smith: I don't have to go to the hospital for the tests, do I?
Dr. Johnson: Oh, not at all. We can handle all of that right here.
Linda Smith: Doctor, I want to thank you so much for being so patient and understanding with me.
Dr. Johnson: It's my pleasure. I know it's hard, having diabetes and heart disease. But we're going to make sure that you see those grandchildren grow up.