Archive for West Virginia

“The meaning emerges from the interaction.” ~ Dr. Dan Doyle

Throughout the past two weeks we have been discovering the meaning within these words that were shared with us one night over dinner with a physician from the New River Health System. “Within the clinical encounter,” Dr. Doyle said,” the meaning emerges from the interaction.” We have been taught a certain approach to patient interaction. When a patient presents to a clinic visit, we poke and prod with questions, seeking specific information. But, even with the intended good will behind our approach, something is still not working. What would happen if we handed over the control? If we stepped out of the driver’s seat and let the patient steer the conversation. What if we let go of our expectations, the drive for answers, and simply listened? William Osler, father of modern medicine, is quoted as saying, “Listen to your patients. Listen and they will tell you what is wrong with them. Listen long enough, and they will even tell you what will make them well.” Maybe what we need is a return to his philosophy; a return to oral history.

During the last few days of our stay in the West Virginian mountains, we put our final touches on the project we had been given to do. I say “our” final touches, because the work we have done is merely the foundation of an approach or tool that the Cabin Creek Health Systems (CCHS) may use to increase the effectiveness of their communication with patients. In the hopes of increasing our understanding of the Oral History approach, we split into pairs and went on home visits throughout the communities surrounding Cabin Creek. Patrick Krueger and I visited three different homes, and came away with three very different experiences. As a group we created this list of “lessons” learned and tips to conducting an effective oral history interview:

  • The goal of the interaction is to establish the relationship and foundation
  • The emphasis should always be listening
  • Learn to be comfortable with silence
  • Digressions do not exist; affirm the  participants’ stories
  • Utilize neutral facial expressions/avoid nodding/verbalizations
  • Avoid the urge to use “teachable moments”; mentally note the statement for later follow-up or motivational interviewing
  • Keep follow-up questions or statements succinct and open
  • Be present; focus on the client
  • Respect time limitations

I would like to emphasize three of these points, one through a story, and two for their poignancy. At the first home Patrick and I visited, we spent 30 minutes listening to this woman share her struggles with diabetes and weight loss. She haltingly shared her story. But, as soon as we thanked her for her time and turned off the recorder, our true education began. In talking about her home and her hobbies, she casually mentioned her frequent use of the tanning bed in her back room. Unable to control my surprise, my mouth fell open. That, of course, raised her defenses, and we ended up doing a little risk-factor education. This was a departure from the true nature of our visit, which was to hear her story, not judge it. Utilizing neutral facial expressions is paramount. When someone is sharing their story, judgmental expressions, such as raised eyebrows, and a jaw dropped in disbelief, can effectively close the book of their lives they had so graciously opened for you to read.

We presented our findings to CCHS as a tool for their Health Coaches to use in forging a strong relationship with their clients. The aim is for the Oral History approach to be utilized on the first visit, in order to lay the foundation for more effective motivational interviewing on subsequent visits. In receiving someone’s oral history, you are being given a window into their lives. It is a beautiful way to come to truly know someone. What a better way to start a therapeutic relationship. But, in order to foster this type of openness, the interviewer needs to avoid the urge to capitalize on any and all “teachable moments.” As nurses, we have been taught to never let a opportunity for education slip by. However, in this setting especially, imparting knowledge or advice through education, however well intended, creates a power differential. So, it is imperative to hold back on those urges. Make mental notes only. And simply continue to listen, opening yourself to truly hearing their story.

Lastly – probably the hardest part of this approach – is silence. Silence is a powerful force. And under its power we saw individuals blossom. By our silence we them gave the gift of time to construct and relive their stories, and we conveyed our genuine interest in their lives. I know I have yet to reach the point where I am comfortable with silence. But, I have seen the beauty that comes out of letting that silence stretch a few moments longer than normal. Fears are confessed, joys are shared, truth emerges.

For two weeks, our team of 7 persevered through long days; hours and hours of commuting on curing country roads between the clinics, the communities, and our beautiful forest cabin. We also spent countless hours researching, conversing, and compiling our plan to present to CCHS. (If you would like to view the fruits of our labor, please visit www.oralhistorytrainingmodule.com ). We also cooked delicious meals every nights, wandered through the forested hills surrounding New River, and even spent an afternoon rafting down its turbulent waters. All in all, I believe that we came away from West Virginia changed. This experience has reshaped the way we will approach communication with our clients; to focus less on searching for the right questions to ask, and more on the relationship built, and the words that are spoken. For it is true – the meaning we are searching for emerges from the interaction we foster with being open.

            

 

The Golden Rule of Primary Care

Throughout the last two weeks, a majority of our mornings have been spent shadowing providers in the various clinics within the Cabin Creek and New River Health Systems. Bettina Hall, one of our group members, described this experience best; “It has been a remarkable experience. Because access to care is limited, providers have to utilize their creative and skilled efforts to offer the best and most appropriate medical care for their clients, many of whom are economically disadvantaged. I think one of the main things that has really stood out to me is the commitment and sincerity providers put into the well-being of all their patients, and its clearly evident that the patients equally value their time, and the support that they receive from the whole medical team.”

Being that we will be starting our master’s program in the fall, and a lot of us are aiming to be primary care providers, these mornings offered an exciting sneek peak into our careers. I was blessed with the opportunity to observe PAs, NPs, and MDs in action – serving their clients with the utmost compassion, perseverance, and creativity. The health care challenges that the Cabin Creek Community faces are complex; rooted in a social history of oppression and isolation. Through what amounted to hours of conversations with providers and medical assistants, nurses and aministrative staff, we discovered that the major health issues in the area were hypertension, diabetes, obesity, and depression. The vast majority of clients I saw were under an opiate contract due to the prescriptions they had for managing their chronic pain. I had conversation upon conversation with providers about how best to manage pain, and how to work with a population in which the percentage of narcotic abuse is tragically high. Both health systems are fighting this battle with perseverance. They are turning to the evidence within the literatire to offer their clients the best care possible, and to help their entire communities break free from the chains of addiction.

This is just one example of the quality of care that these clinics seek to provide. Cabin Creek Health System (CCHS) is constantly addressing the needs of their community in an innovative, honest, and team-centered manner. I was truly inspired by the unparalleled commitment to service that was exhibited by the CCHS staff. John Rice, PA.C is a prime example of this. An article about the outstanding care he give his patients was printed in the Charleston Gazette. One of their patients credited John Rice and CCHS as helping her win the fight against food, and subsequently gain back control of her health. He is committed to the health and well-being of his patients – seeing them as whole human beings worthy of respect and love. And through that he empowers them to take charge of their health and their lives. Bettina, who shadowed him for these two weeks, shared an example of the thoughtfulness and intentionality with which he approaches the relationship with his patients. He is so in-tune with his patients that he picks up the small things; nothing a patient tells him is irrelevant. A patient told him it would be their birthday the day of their appointment. So, John made him a brownie, decorated on a plate that said “Happy Birthday.” Bettina called him “a quintessential good Samaritan.” It is stories like this that truly inspire and encourage me. Providers who are working and living within their communities – serving a whole community. They are completely immersed, committed, and persevering, offering the continuity of care that is needed to effect true and sustainable change.

Happy Birthday Gift

It was in this environment that we got to spend each morning of the past two weeks – deepening our understanding of the culture and the lives of the people, through the eyes of their providers. Dr. Dan Doyle, a committed and passionate physician who has provided over 30 years of service to both the Cabin Creek and New River clinics, penned a Golden Rule of Primary Care, which is hanging in most of the clinics buildings. I will leave you with his words, and please stay tuned for more of our journey, and how we used what we learned in the clinics, combined with our oral history training, to create a plan for effective patient communication.

Dr. Dan Doyle’s Golden Rule of Primary Care

 

“Through the telling of what they know, people figure out what they think.” ~ Michael Kline

West Virginia Bound

In a Dodge minivan, every nook and cranny packed, our seven member team departed from Atlanta early Sunday morning, bound for the tree-covered mountains of West Virginia. We knew little of what to expect over the next two weeks as we watched the surroundings transform into rolling hills. We knew only of our destination: Cabin Creek Health Systems (CCHS), a network of rural clinics delivering primary care to the under-served mining communities in the counties outside of Charleston, WV. We are all in our last semester of the Emory ABSN program. After a year of metropolitan hospital clinical experience, we were ready to get a taste of rural primary care – with all of its challenges and surprising rewards. We were also bound together by a mutual curiosity about the culture of these West Virginian mountain communities, which heightened our anticipation for what this experience would hold in store for us.

Patrick, Bettina, Colleen, Hardie, Lora, Lauren, & Shawn Marie

After a warm welcome from the CCHS director, Craig Robinson, his wife Judy, and the CCHS education and program coordinator, Amber Crist, we eagerly listened to the project idea they have outlined for us. As a continuation of their unceasing, and innovative journey to improve the quality of their patient care, they organized a two-day orientation and training to introduce us to the richness of the local culture, and to acquaint our team with a methodology of obtaining oral histories. The idea behind this training is to equip us with an effective tool with which to untangle the complex web that characterizes the health of these communities.

Our arrival at the CCHS administrative offices early Monday morning was greeted by the gentle strumming of a pair of guitars as voices rose in the wholesome harmony of Appalachian ballads. That was the opening to our immersion into the local culture, seeing for ourselves the environmental and social impact that strip and deep mining have had on this area.

Mountain Top Removal Site

The true cost of coal

Within a culture that values land as their identity and their heritage, a seemingly incurable pain comes out when family land is taken or destroyed. A majority of this population struggles with what Amber calls the West Virginia Quad – hypertension, hyperlipidemia, obesity, and diabetes. Dr. Westfall, a family practice physician who serves with CCHS, added two more co-morbidities to the group – pain and depression. The harsh and violent reign of coal mining has left its mark upon the hearts of both the mountains and the families who have called them home for generations upon generations. Dr Westfall offered a new perspective when I asked about her most rewarding experience in working with these community individuals. She paused for a few moments, deep in thought. “It is hard to pick one out,” she said. “Being with the people. Seeing their strength and resilience. I may not see the good outcomes, but I do see their strength. And I get to sit with them through it.”

The harmony of Appalachian ballads

Michael and Carrie Kline, a couple who have dedicated their lives to listening to the stories of Appalachian miners and giving the voiceless a voice, lead us through a condensed training in eliciting an oral history. Theirs is a specific methodology that transfers the power of the telling to the teller. It is not driven by questions, but by the power of merely listening. For two days we wrestled through this possible new approach to obtaining a health history; an approach that places the patient truly at the center, enables the listener to see the individual within their own social context, and to hopefully elicit goals, values, and knowledge without the prodding interrogative questions. This afternoon, at the end these two long days, volunteers from the community came to be interviewed. We practiced the skills we had learned, framing the interview as a time to talk about their life and community health. We opened with the statement “Tell me about your people and where you were raised.” At the end, when we were collecting our thoughts, we all realized that we have a lot of work cut out for us over the next two weeks, working through this new technique and discerning how this could possibly be used within the CCHS patient care. Stay tuned as we discover what happens to an individual and a community when they share their story, and what that can mean to their health and well-being.