In truth, I’m scared because the stakes are high: people will die young
I'm trying to be a pro-equity practitioner, but it turns out I’m not doing so well.
It’s just really, really hard to create more equitable health outcomes. I mean well; I’ve always hated injustice.
In my room, I’m armed with HealthPathways and motivational interviewing skills, but it’s a big ask to get someone who feels perfectly well to take four pills for diabetes, so they will still feel well in 10 years.
I’m asking them to be a believer, and to believe so strongly that they will swallow those pills every morning and every night, even if the pills make them feel worse.
I’m a doctor, so I am a believer: “Take those medications and you will be saved.” So, for me, there is great distress when patients don’t convert, and I can see the bad medical outcomes ahead.
Today I’m worrying about a young woman with type 2 diabetes. She has had a glycated haemoglobin over 100, for five years. She is 26 years old.
I did well when I saw her eight months ago. She even had a first shot of Trulicity and was excited about how easy this was going to be. Could she tell her sister about this new wonder drug that you only inject once a week?
But we have never seen her again, she never picked up the prescription, she doesn’t answer our calls. I have sent texts full of encouragement and lightness and yes, doses of aroha, but still she has not come in the door.
I’m wondering if the door is the problem.
When I go through that door, I’m entering my place in the world. I’ve probably just parked my late-model hybrid Yaris and am carrying my packed lunch of home-made goddess bowl (because I’m concerned about my cholesterol, even though I’m guessing my life expectancy will be decades longer than that of the patients I see, and the ones I am not seeing).
I know that any cross-cultural communication is going to be tricky, and I even understand that medicine in itself is a cultural construct. Our health outcomes and health literacy are actually medical outcomes and medical literacy as defined by our world view. Another view of health may be very different, perhaps incomprehensible to me.
I’m trying to understand why she can’t come through the door into my room, because I’m pretty friendly, but I know that isn’t enough.
I’m wondering if maybe the door means time and cost, and opens up the shame of the scales, maybe an unpaid bill and the blood test not being good enough. And the doctor looking disappointed while trying to be nice, because the doctor knows a pro-equity practitioner is measured on how well they get the blood sugars and blood pressures down, and the life expectancy up. In truth, I’m scared because the stakes are high: people will die young.
So I worry about her and the women in their 30s with blood pressure 180 systolic not just once, but also two and three years ago, and the man in his 30s already on dialysis who probably won’t get a transplant because his second name is DNA. This is such a common second name here that I’m wondering if it means Door Needs Attention (rather than Did Not Attend).
And I am wondering if someone from her world needs to help her through.
That door between the world of her life and my room full of medicines is really a threshold, a liminal space. I remember someone telling me about the concept of the va, the meeting of two worlds, the sacred relational space.1
“Pay attention to the va,” says my wise friend Ben Gray. “Without relationship, you can do nothing.”
Lucy O’Hagan is a medical educator and specialist GP working in the Wellington region