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Learning To See In Primary Care

By Diana Tucci

“There – there’s a space between those two layers that you have to fold that edge into, do you see that?” I said to the older woman sitting next to me. I had never met anyone worse at following directions. It was a Lunar New Year celebration and she wanted to learn how to make origami paper cranes. It had been a long and tiring day, and I was in a bad mood for most of that time. My friends had left without me and I was waiting for someone, anyone, to drive me home so I wouldn’t have to walk back in the cold of a Pittsburgh winter. She sat there, bent over her work, apparently ignoring the things I was showing her. I was really starting to get frustrated.

“No, I can’t see anything,” she replied. It wasn’t until then that I realized she was blind.

How often do we blame our failures on someone else? And even worse, how many of us are ignorant
of this fact? So much of medicine depends on how well a doctor can teach his or her patient – whether
this involves explaining how to take medications, how to properly care for a wound, or the importance
of adopting a healthy lifestyle. The quality of our instructions dictates the caliber of our results. And
yet, when our patients fall short of our teachings, we blame them. We call them “non-compliant”, “non-
adherent”, or any other slew of medical and non-medical terms that all mean the same thing – they
failed to follow our instructions.

Perhaps, though, we could shift our mindsets and apply a different lens. In the journey to treatment,
there can be errors and breakdowns at any step along the way, including the steps involving physicians.
Patient education requires physician investment in understanding where the individual is coming from.
Techniques such as Motivational Interviewing attempt to bridge this gap, but many medical schools
give only a cursory introduction to this and other vital topics, leaving students with the vague notion
that we could be doing something better but completely clueless as to how. We instead spend our time
agonizing over the details of rare diagnoses that most of us will never see in our careers, and ignore
strategies that will help us improve health in every office visit, every day. Our training is geared towards
figuring out what is wrong, but not to seeing how our patients’ daily struggles and triumphs hold them
back or allow them to overcome the pathology we have detected.

Some lucky providers will gain this experience during residency training, at a time when they are already
beginning to practice. I would argue that this is not soon enough. After all, if you don’t know that
someone is blind, it is very difficult to show her how to make origami.

After Linda told me that she was blind, I understood that I could not point to the folded paper she was
holding, or tell her to “fold this like that.” The task presented challenges, but together we soldiered on.
After I understood that she could feel the difference between the shiny and dull sides of the paper, I
could issue effective, descriptive instructions based on her level. Before I understood Linda’s abilities
and her perspective, I too was blind.

And so it is with our patients. We must let them teach us in order for us to teach them. When they fail,
we must consider the possibility that we have failed them, and we must ask how we can do better. So
much of primary care is about relating to people, but it is easy to lose sight of that in the day-to-day
grind. Yet all our work is for nothing if we cannot convey its meaning to our patients. Their futures, and
ours, depend on it.

Diana Tucci is a third year medical student at the University of Pittsburgh, and is planning on a career in Family Medicine.  She is a National Health Service Corps scholar and has been featured on CNN Money for her interest in primary care. This essay was the winning entry in Primary Care Progress' first National Primary Care Week essay contest.

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Posted by Alex Folkl on Feb 14, 2012 11:27 AM America/New_York
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