Focus
Student Scene
March 4, 2002
 Ellen Rothman Photo by Graham Ramsay |
Somehow, Providing Care Across Cultures
As the two stooped women walked arm-in-arm through the door to our emergency department, I couldn't tell which one was to be my next patient. They were both traditional elders, called shima, or grandmother, according to a Navajo sense of respect. Their gathered skirts, faded to a dusty red by age and environment, worn blouses adorned with elaborate turquoise jewelry, and flowered scarves covering thinned gray hair pulled into a practical knot at the nape of the neck harked back to the early 1900s. Neither spoke English.One of the nurses helped the slightly more frail of the two onto a hospital gurney. The shima looked up at me with milky black eyes. "She's feeling somehow," the nurse, who spoke Navajo, offered by way of explanation.
Defining Illness
The first time I heard that phrase only six months ago when I moved to the Navajo Reservation, I had no idea what to make of it. "'She's feeling somehow?' What does that mean?" The nurse had merely shrugged her shoulders and offered to translate, leaving it up to me to discern what "somehow" could possibly mean. Since then, I've heard this phrase over and over, and I've learned that it could harbinger anything from a simple cold to a life-threatening heart attack.Back in my HMS days, my patient-doctor course drilled into me how to translate a constellation of symptoms into a medical diagnosis. First, I elicited a "chief complaint," the reason the patient had decided to seek out medical attention, followed by a thorough "history of present illness," during which detailed questions would elaborate the symptoms and progression of illness to suggest a list of possible causes. A detailed examination would reveal the final diagnosis. During my three years of pediatric residency at Children's Hospital in Boston, this highly stylized approach became second nature.
Here out on the reservation, medical care is scarce enough that although trained as a pediatrician, I must see all patients, from the elderly to the pregnant to the children I know best. My colleagues trained in adult medicine and I help each other out with difficult cases. Nonetheless, I am not at ease with 90-year-old shimas, especially those who are feeling "somehow."
Her 75-year-old daughter explained to me through the interpreter that her mother had been feeling weak for the last week, and the arthritis in her right leg was paining her. The last time she had come to the clinic, her mother had received IV fluid that she thought made her much better, and she possibly could need that treatment again. "Does your mother feel sick? Is she having trouble breathing?" I asked to get a sense of the illness. "Is she getting better or worse?"
"I don't know," her daughter said. "She's just somehow."
They were frustrated by the questions, so I instead began an intensive investigation including blood and urine tests. I gave her the IV fluid that her daughter requested. After more than two hours in the emergency department, everything was negative, revealing no explanation for why her mother was feeling somehow. Just as I was ready to discharge them, the daughter pulled out a bottle of codeine, a mild narcotic used for pain control. "She's been taking a lot of these this last week. I think this is making her weak, and I want to stop giving them," she said. After extensive, and in retrospect, probably unnecessary testing, our problem was solved.
The Navajo Model
The Navajo approach to illness is fundamentally different from my own Western tradition. Many of our patients, both traditional elders and the younger generations, continue to pursue both Navajo and Western medicine concurrently. The medicine men observe a patient, and without any questioning, discern the problem and prescribe a particular ceremony to restore spiritual harmony and health. I was instructed not to ask too many questions and to continue my interview while examining a patient to preserve their trust in our system. In their world view, the feet, closest to the Earth, are most sacred. All ceremonies begin with the feet and move upward toward the head. In my construct, I approach the body exactly in the opposite direction and even tell patients that I am going to do a thorough "top-to-toe" examination.The Navajo have a broader concept of illness than the Western tradition. They may attribute their problems to a skin walker, an embodiment of an evil spirit that has caused them harm, or to a snake that crossed their path many summers ago. A fall as a child that seems irrelevant to me can carry great significance to an elder with abdominal pain. Very few elders formulate an illness as a discrete episode in an otherwise healthy life. There are always connections to past pains and conflicted spirits.
I recently evaluated a 60-year-old woman with abdominal pain that was probably caused by gallstones. It was after hours, so we were unable to do the diagnostic ultrasound until the following morning. The woman became enraged. "What kind of doctor are you anyway, that you can't do the test? That you can't tell me whether or not I have gallstones? I bet you didn't even graduate from medical school."
Her husband chimed in. "You mean to tell me you can't give me no pills or nothing to take away the gallstones? This is b---s---," he said as they stormed out of the emergency department. My Western medicine had failed to meet their Navajo expectations.
"Don't worry," the nurse said to me after they left. "I know them, and they're always like that."
--Ellen Rothman, HMS '98