Learning to heal, one patient at a time

Treating migrant workers, and forced to improvise in primitive conditions, this second-year resident learned that delivering care is more about trust than expediency.

By Rebecca Bame, MD

It was early on a Saturday morning when I rendezvoused with Susan Howard, a faculty member of my family practice residency program, in a suburban Handy Way parking lot. We set off on Route 40 to the tiny town of Pierson, home to large numbers of Mexican migrant farm workers.

The 40-minute ride was like traveling to a third-world country. The Mexican section of Pierson is dirt poor, with a steep high school dropout rate, limited local transportation and day care, lots of drug and alcohol abuse, and dilapidated housing.

Howard and I had gone there a few times before to meet with social service groups that wanted to provide health care to this migrant population. There was one doctor in town, but most of the migrants couldn't afford his fees, and the nearest health department and hospital were 25 miles away. My residency program had received a federal grant to increase multicultural awareness within the FP curriculum, which is how we found out about underserved Pierson.

Howard and I weren't Pierson's first volunteer doctors. A nun turned FP had been coming there twice a month for about a decade, usually with a small cadre of dedicated bilingual volunteers from her Orlando office. Dr. Mayo—she modestly asked that her real name not be used—is from Cuba, and the migrants had come to trust her.

They clearly did not trust the health department, even before it left town two years earlier. The migrants complained that the department's staff had been unfriendly and held office hours when they were working in the fields. Howard and I knew we'd have to tread carefully to gain their trust. We hoped to learn from Mayo's example.

Nervously, we pulled up to the abandoned health department building. A dozen people were already haphazardly lined up on the steps. Mayo pulled up next to us in a Ford Ranger. She was tall and slim, her dark hair was flecked with gray, and her skin was a marvelous olive color. She smiled pleasantly, shook our hands, then asked us to help carry big packs of medicine and supplies.

The building had obviously deteriorated since the health department pulled up stakes. Probably because of the heavy rains, huge mildew spots covered the walls. And the exam room floors had gaping holes, either from termites or the constantly leaking roof. We can't work here, I thought—our cross-cultural experience is over. But Mayo took one look around and briskly announced, "Well, I guess we'll see patients outside today."

We assumed she was joking until she said, "Come on. The front step will be our exam room, and we'll use the front office to give out samples and update charts."

And that's how we saw the 30 patients who showed up that day. Many had musculoskeletal problems, like the jackhammer operator with achy hands. Or the woman farm worker with the rotator cuff problem. Those were easy to treat, because they didn't require lab tests or MRIs—just nonsteroidal anti-inflammatory medication.

Communication was rough. Mayo encouraged me to use my rudimentary Spanish. With that and hand gestures and help from her staff, I managed to get by.

Sometimes our foggy communication resulted in peals of laughter in that depressing setting. Perhaps the most startling involved a woman whose face was pinched with pain as she cupped her hand tightly over her right ear. I suspected Meniere's disease or vertigo. Instead, upon inserting the speculum of the otoscope, I was shocked to find the biggest cockroach I had ever seen. Before its untimely death, it had created havoc in this woman's ear.

I proudly said, "La cucaracha!" The woman looked at me confused. I repeated myself, and then began singing the song lyric, "La cucaracha, la cucaracha . . ." The patient and the translator laughed so hard tears ran down their faces.

But now, how to get the bug out of her ear? At the hospital I would have had the right forceps, but out here I was at a loss. Mayo, as always, remained unfazed. She rigged up an irrigation system with a plastic venous catheter, a syringe, an emesis basin, and some warm water. The bug came out easily. It was so large that the patient asked us to put it in a bag so she could show her husband. She left happily, humming the cucaracha song.

Not all patients were smiling when they left our makeshift clinic, though. A middle-aged woman, dressed neatly in a print skirt and blouse, her socks and shoes dusty from a long walk, complained of failing vision in her left eye. She was unable to move the eye all the way to the left, and she saw double when she looked straight ahead. A diabetic for over a decade, she didn't always take her medications because she couldn't afford them. Her sugars, she said, had been running slightly higher than usual—in the 200s.

Two weeks earlier, Mayo had persuaded an ophthalmologist friend to examine the patient gratis. He found no retinal artery or vein occlusions, but thought a lateral sixth nerve palsy or tumor was possible. The patient needed an MRI, but in addition to not understanding what an MRI was, she had no insurance. She had come in today to see if we could help her.

Like many migrant workers, her family of eight lived in a trailer off a nameless dirt road. Even her little children worked picking ferns at the farm. Used to being badly treated, these migrants trusted no one, so it took a leap of faith or an act of desperation for them to seek our care.

While the patient waited, I called a network of specialists established by the health department as well as various social service agencies to, first, find a doctor willing to do the MRI and, second, figure out a way to pay for it. I received no commitment, which caused the patient to cry softly in despair.

Although I felt helpless that we couldn't do a stat MRI and diagnose the problem, I kept trying to reassure her through a translator that we wouldn't abandon her. Mayo fashioned an eye patch from part of a Styrofoam cup, we adjusted her diabetes medications, gave her plenty of samples, and assigned a nurse to follow up. I didn't see any family members waiting for her, so I assume she walked home alone.

"How have you been able to do this for so long?" I asked Mayo, exasperated. "Aren't you tired of no resources and having to beg others to help these people?"

Mayo smiled patiently. "These people appreciate any help you can give them," she said. "But don't expect miracles. It may take a long time to see results. I've waited 10 years for some diabetics to lower their hemoglobin A1c from 15 to 9. Take pride in the incremental steps you make; that's enough for now."

We did help several patients that day, one at a time, on the steps of a condemned building. The woman who thought she was going blind eventually got the MRI; the cause of her vision problems turned out to be a sixth nerve palsy. She's now doing much better.

When Howard and I got in the truck to drive home, she just looked at me and said, "Wow!" No other word could describe the powerful experience we'd just had. Patients in Pierson really needed us, unlike many of the worried well we saw in the clinic back home. I had come totally unprepared to deliver care in such a medically primitive environment. What I learned was to try my best and not be too judgmental about how a process should work. It's more important to try something than to wait until a perfect plan is ready.

After working with Mayo for several months on alternate Saturdays in Pierson, Howard and I started seeing the migrants on the Saturdays Mayo wasn't there. And in June, we moved from the steps of the old health department building into a tiny trailer. It's better than an outdoor clinic, but still offers less than ideal working conditions, not to mention no privacy for patients and no running water. But our patients appreciate our efforts, and now that volunteering at Pierson is a requirement for all the FP residents in my program, many young doctors are being exposed to cross-cultural medicine.

When my residency ends, I would love to become a full-time doctor in Pierson, but currently there's no funding for a medical office or a salary. For now, I have to be content that we're able to help about three-fourths of the migrants who come to us. And, by slowly building up a network of others willing to help, we don't have to send many patients away without hope.

As Mayo advised, we abandon our ideals of crisp efficiency and focus on healing one patient at a time—however long it takes.

The author is a family practice resident in Ormond Beach, FL.

 

Rebecca Bame. Learning to heal, one patient at a time. Medical Economics 2001;8:121.