Sixteen: The minimum number of patients on my schedule each day. Thirty: The number of minutes I have to earn the confidence of a total stranger over the phone. Make that 20 minutes if you consider the time I spend documenting each case and action items. Divide that number in half for a two-way dialogue.
This means I have a maximum of ten minutes to make a person who has never met or seen me become so comfortable she will share with me intimacies she might never tell her mother, best friend, her doctor or her lover. In less time than it takes to brew a cup of coffee, I must earn a stranger’s trust so she will confess her most intimate fears, her insecurities and her problems.
And not only am I racing against the clock, I am also competing to gain her confidence in a world where telemarketers and professional telescammers also vie for her invaluable trust. Cell phones, televisions and other home occupants threaten to decrease the significance of my patient encounter with untimely distractions. Unforeseen cultural nuances create additional barriers threatening to amplify the preexisting disconnect — even when I’m speaking to a patient who speaks English or Spanish, languages I have spoken for most of my life.
The stakes are high, the pressure intensified by the fact that each encounter falls under the intense scrutiny of my managers, who use the federal government’s predefined metrics as the moral yardsticks by which they quantify the value of my calls.
While government and corporate parameters generally require that I focus on solving health problems related to prescription medications, following this convention is risky and does my patients — and the healthcare system — an extreme disservice. Focusing on the bare minimum requirements means I might inadvertently overlook an herbal sedative taken by a patient who is about to undergo surgery. What if the herb makes it more difficult to reverse the effects of anesthesia and “wake the patient up” after surgery? Or perhaps the same patient uses Gingko biloba to support memory, without realizing it might enhance the effects of his prescription blood thinner before he goes under the knife?
But my hurdles do not end here. Many patients do not consider over-the-counter medications or herbal products to be medications even though they may use them for medicinal effects. Whether the patient speaks English, Spanish or a language that requires me to use an interpreter, the challenge remains the same.
“¿Ahora que he revisado todos sus medicamentos recetados, hay otros medicamentos que usted se toma, señora? Now that I’ve reviewed all your prescription medications, are there any other medications you’re taking, ma’am?” I ask Maria*, a 67-year-old woman from the Dominican Republic who lives in the Bronx. “Pueden ser vitaminas, medicamentos sin recetas, or hierbas. These may be vitamins, over-the-counter medications or herbal products that don’t require a prescription,” I explain.
“Ya te dije toda mi medicina. I’ve already told you all the medication I’m taking,” Maria responds, a slightly defiant inflection in her voice. “No tomo nada más. I’m not taking anything else.”
I sense her growing irritation, but conceding to her initial reluctance might come with some major consequences. At least 38%, more than one in every three adults living in the United States, uses some form of herbal or “natural” therapy, according to the World Health Organization. That number almost doubles or triples among some international populations. As many as 90% of African residents and 70% of people living in India rely on traditional medicines, many of which invoke the healing powers of plants. My patient population includes international, multiracial and multiethnic immigrants, increasing my sensitivity to this potential issue.
According to a 2004 survey conducted by the American Society of Health-System Pharmacists, 72% of participants stated they did not report their use of complementary and alternative therapies to their healthcare providers. A 2002 study found that not only did 40% of Latina women opt not to tell their healthcare providers about their supplements and alternative medications, but that more than 60% of healthcare providers did not ask patients about their use of complementary and alternative medicine. Similarly, only about 30% of patients with chronic diseases such as heart disease and diabetes tell their doctors about their alternative treatments. Many healthcare providers report feeling uncomfortable discussing alternative treatments with their patients, which makes initiating these conversations even more difficult.
My dilemma is a precarious one. Should I remain silent, I will risk a potential herbal-drug interaction. If I push too hard, an already frustrated Maria might hang up on me. While I certainly don’t want to irritate her further, I am determined to break down the barrier while treading very carefully.
My decision to go above and beyond corporate expectations is a gamble well worth the risk. Earning Maria’s confidence will grant me access into her world, allowing me to gather important information that could transform her health, and ultimately her life. If I’m successful, not only will she confess invaluable information about her medication use and challenges, but she’ll also divulge intimate clues about her culture, her language, her perception of the health information she has received to date and her understanding of how her medications work.
Those benefits are multifold. Not only will I gain Maria’s trust, but our new relationship will facilitate my ability to connect with other patients who come from the same region of the Dominican Republic. This could further delineate cultural habits and practices among people from other Latin American countries who reside in the United States.
“Entiendo si usted no quisiera discutir otras cosas, señora, pero como usted ya sabe, productos naturales tienen effectos medicinales también. Y estas cosas pueden tener una reacción con los medicamentos que su doctor la recetó. I understand if you’d rather not talk about other things, ma’am, but as you already know, natural products also have medicinal effects. And these things can have a reaction with the medications your doctor prescribed you.”
If I’m exceptionally lucky during these precious 20 minutes, Maria will give me exclusive insight into her personal care regimen that includes her use of prescription and over-the-counter medications, but she will also reveal the precious home remedies and ethnobotanical practices she secretly combines with her doctor’s orders.
“Me tomo la moringa pa’ las vitaminas. I take moringa for its vitamins,” says Maria. “Y cada mañana, me tomo un puñado de la avena cruda porque es bueno para mi colesterol. And every morning, I eat a handful of raw oatmeal because it’s good for my cholesterol.”
Maria’s statement confirms that I have managed to earn her trust. Her confession might seem trite, but it is especially significant for Maria, a patient who also takes medication for high blood pressure, diabetes and arrhythmias. Native to the sub-Himalayan regions of South Asia, Moringa oleifera (Moringaceae) now grows throughout these regions as well as Africa, China and the Caribbean.
In recent years, the plant has gained popularity in the United States as a superfood. Like many superfoods touted for their nutrient-dense properties, moringa is significantly high in many nutrients including vitamins, minerals, antioxidants and other phytonutrients. Additionally, it is so loaded with vital nutrients that many healers use it to help address medical conditions where the body suffers from inflammation and nutrient depletion.
A whole food plant, moringa has been used in poor countries endemic to starvation and malnutrition. Some proponents believe the plant can help solve global problems of food shortage and starvation crises.
Used for thousands of years by indigenous peoples in various parts of the world, the plant also exhibits significant medicinal properties that ethnobotanical healers have relied on to treat conditions such as anemia, diabetes and digestive disorders.
Researchers are studying the plant and some of its constituents for its medicinal properties, including its effects on diabetes. The amount and frequency of moringa Maria takes might affect her blood sugar, heightening the significance of gaining her trust and sparking her invaluable confession.
Maria told me she takes moringa every day, although she didn’t always remember to take diabetes medication. She also noticed that her blood sugar seemed lower some days than others. Expanding our dialogue created an opportunity for me to help her prevent another episode of hypoglycemia. I asked her what she thought about recording her blood sugar in addition to the days when she remembered to take her diabetes medication. This might help her remember to take her medications and observe how her daily routine affected her blood sugar. This gesture placed Maria in a position of power over her health.
I also learned that Maria had trouble getting to the pharmacy to pick up her medications regularly, complicated by her long commute to the pharmacy.
Maria lives in a part of the United States where independent pharmacies tend to flourish and patients often remain loyal to a specific pharmacy even if they move to a different area. I told Maria she could transfer her medications to a pharmacy in her new neighborhood or sign up for mail order. She refused both options, stating that she really liked her current pharmacy and the staff. Her relationship with the staff was worth the trip, she said.
I might have lost the battle of helping Maria take her prescription medications regularly, but I still managed to make an impact on her health. Since Maria took moringa every day, I sold her on the idea of sharing her blood sugar log and moringa use with her doctor to help her figure out whether the dose of her diabetes medication might need an adjustment.
At the end of the day, I know I made a difference in Maria’s life, even though my score sheet from the government evaluation may suggest otherwise. But not every patient encounter will be a slam dunk. I’ve learned to make baby steps and celebrate the smallest successes. The government does not quantify or recognize them, but I can.
Patient victories are sometimes a struggle, especially when patients are reluctant to open up or feel healthcare professionals won’t understand them for whatever reason. But by showing empathy and interest in their situation as well as a respect for cultural habits and practices, we can lay the foundation for a dialogue that transforms our relationships and our patients’ lives. True relationships take time. As healthcare providers, we may not always have all the answers, but we won’t know until we start asking those important questions.
*Patient’s name changed for confidentiality.