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This year, the last celebrations before the bicentenial and centenial celebrations. The first revolution, for independence from Spain began in 1810. The second, for independence from a very modern dictator named Porfirio Díaz, began in 1910. September 15, around midnight, Mexicans celebrate and echo El Grito, the shout (or maybe today we should say shout-out) for independence marking Miguel Hidalgo's call to revolution which literally occred around midnight, September 15-16, 1910 in the small town of Dolores in the state of Guanajato. Wikipedia has a good summary here. The revolution with all its twists and turns lasted until 1820, for the most part, though there were resistant Spaniards until around 1824 holding on to the fort at historic San Juan de Ulua in the port of Veracruz.
Here are some photos from this year's celebrations.
Our young neighbor, Blanca, goes to school in San Marcos, about a mile from our Colonia. She is part of a singing group in her school which was going to perform last night. Below some pictures from the evening. Unfortunately, delays in setting up the stage lasted so long we left before Blanca's group sang.
In very arty format (due to lighting), kids having fun in the Salon Social (community center) while waiting....
Blanca on the left and two friends:
A view across the street from the Salon Social into a house where a party was getting underway.
A view down hill from the salon social to Ursulo Galvan which is actually past the lower collection of lights. There were fireworks in Ursulo. Some of the dots are fireworks, others are light rain.
After a too-dry winter, spring and early summer, after, in fact, the most serious drought recorded in Mexico in sixty years, comes the deluge. In the past week, we have had record rainfalls: hard, long, driving rainfalls that have wrought destruction on houses, roads, crops, hillside; rains that have quickened the pace of of soil rushing and tumbling down treeless slopes.
In our neighborhood, only the newly completed strip of street from the main road to the first street that crosses it, remains undamaged. We have watched the main road that goes past our colonia peel away over the past week and we now run past numerous baches, piles of gravel, small mudslides and streams washing over what's left of the pavement. The road between Las Puentas/San Marcos and Coatepec, the road we always take, is a disaster. It made the report of terrible roads today in El Diario de Xalapa which gave up trying to list all the problems in Xalapa saying, "an infinite number of streets exists which have become impassable because of this season of rains."
The Las Puentes/San Marcos -- Coatepec road -- our main road into Coatepec-- has its very own article in El Diario, in fact. In it Ceilia Gayosso, the reporter, notes that "just two weeks ago, the road was in pretty good shape, but now it is in such deplorable condition that drivers have to proceed very slowly and single file which results in long lines." As she says, this road is very important, since it is the main road for getting to many municipalities including Xico, Teocelo, Cosautlán, Ixhuacán de los Reyes and a lot more, as well as our own colonia. Authorities in the area say that it is vital for the survival of the region that roads in this area be well-maintained, not only for basic transport, but also because to slide off them in this area of barrancas (canyons) is fatal.
The paper also reports that the Coatepec-Las Trancas highway is in danger of collapsing. This is the road that runs from Coatepec to highway 140, the main Veracruz-Mexico City route.
City officials in Coatepec have written to the governor urgently seeking help. Among other things, they said, "....At present, this important artery which links municipalities like Ixhuacán, Cosautlán, Ayahualculco, Teocelo and Xico, through which thousands of cars and at least three buslines travel daily and which sees an enormous weekend flow of tourist vehicles is like a minefield. There exist stretches ... where there is no longer any asphalt and ... where the highway is totally destroyed, being nothing more than one bache (pothole) after another."
They conclude,
"Mr. Governor, we trst that this petition to will be heard and attended to since we who have signed it only are a means to transmit the concern and anger of thousands of citizens of more than five mncipalities affected by having to drive daily on tis dangerous road.
As happens when roads wash out, youngsters come out with shovels and bags of sand. They throw a few shovelfulls in the holes and then stick out their hands for payment, as you can see in this picture below, taken from EnlaceVeracruz 212, a local news blog.
Blanca, my young neighbor is supposed to be one of the "court of honor" in tomorrow's Independence Day parade in San Marcos. She came in third in the voting for Miss Independence Day. We were going to go to Xalapa to look for a red dress for her (the other two girls wer green and white respectively -- Mexico's colors). She hadn't been able to find a red dress in Coatepec. I fear we will end up improvising something which I hope works, because we won't have the hours it will take now to go back and forth to Xalapa.
In
the US, it seems as if the dominant perception of medicine is that the best is
provided by high-technology equipment and pharmaceuticals exclusively. Fears of
reforming health care by limiting access to these technological marvels, at
least some of them, center around whether or not people will be deprived of the
treatment they need to get better. I don't quite know where to draw the
line at what high-tech treatment is, but most of us don't need it most of the
time.
In
fact it is often the lowest of the low-tech treatment that helps us to avoid
much of that fancy stuff and that can prevent serious problems or keep them in
check: a healthy diet, exercise, washing hands, being aware of changes in our
bodies, following doctor's orders, taking prescribed medicines as prescribed,
not smoking, not drinking excessively, etc. Compliance with these less
invasive and less fancy interventions has a lot to do with the importance of
re-establishing significant relationships between doctor and patient.
We
have become accustomed, in many cases I think, to depend on machines and tests
-- technology-- to replace treatment by huma beings rather than enhance it. If
you go to the doctor with a symptom you don't understand and the doctor says,
"Let's wait and see for a week..." if we don't see the same doctor
very often, and if we see him for five minutes when we do, and if he looks at
the records more than at us, it is easy to understand why we might want a test
to confirm what he tells us.
But
medicine -- treatment of problems with our bodies and minds -- is not just
technology and chemicals. As my dad, a cardiologist, used to say, medicine is
as much an art as a science. By that, he meant, I think, a number of
things. He meant, yes, that sometimes doctors had and have to use their
intuition, piece together bits of stuff from their experience because they
didn't and don't have the scientific knowledge (it wasn't and isn't always
available) to come up with an answer any other way. But more than that,
he meant that there was an art to matching patients with treatments, knowing
how to talk to them about their problems, knowing how to teach, how to care so
that the patient felt your advice was for her, not just a generic
patient. It also meant knowing that sometimes it's not the medicine at all, or
not only the medicine, that makes a patient better. This gets called the
placebo effect, a generic term referring to whatever is NOT medicine, not scientically
tested, that contributes to improvement, for instance improvement,
literally, in those few cases where terrible diseases remit without
medical explanation, or improvement where improvement in outlook, perhaps a
growth of hope or faith, leads to physical improvement in other areas as when a
patient starts to exercise or follow a diet or improvement whe a patient take
medicines his grandmother used or when he prays to a certain saint leads to the
strength to overcome a disease.
Indeed
all the glittery modern technology isn't foolproof, and it is a LOT more
expensive especially when overused or incorrectly used. The Harvard
physician and surgeon and writer Atul Gawunde wrote an article in the New Yorker showing that the use of tests and technology in
Brownsville, Texas far outstripped that used in El Paso, Texas, and yet the
outcomes were not better, and in some cases were worse. As Gawunde noted in his commencement speech at
the University of Chicago,
Nothing in medicine is
without risks, it turns out. Complications can arise from hospital stays,
drugs, procedures, and tests, and when they are of marginal value, the harm can
outweigh the benefit. To make matters worse, high-cost communities appear to do
the low-cost, low-profit stuff—like providing preventive-care measures, hospice
for the dying, and ready access to a primary-care doctor—less consistently
for their patients. The patients get more stuff, but not necessarily more of
what they need. [Italics are mine]
As Gawande says, low-cost measures may actually
provide more of what a patient needs than high-cost measures. An increase in
primary care physicians trained to deal with the whole person (and to some
extent, his family), and to do it in terms of that person's world: physicians
who get to know their patients by touching them, listening to them, knowing the
support systems they have, their culture: by caring about them, may save costs
AND lives. I suspect such physicians could contribute substantially to a
healthier citizenry at lower cost -- and to healthier citizens at all levels of
society. (I think all physicians benefit from these skills, not just
primary care providers, but that well-equipped primary care physicians could
become the pilots of the ships of their patients' care).
A
year or so ago I created the index for a lovely book called The Art of Healing
Latinos, edited by David E.
Hayes-Bautista and the late Roberto Chiprut. It is comprised of accounts
written by physicians and other health care advocates, not all Latinos, as a
means of explaining to Anglo physicians how they might work effectively with
Latino patients. But in fact it has lessons for practitioners, and patients,
too, throughout the cultures in the US on how doctors can establish healing
relationships with their patients and how patients can help them. I offer below
some quotes from the introduction to give you an idea of what they are talking
about.
On
the contributor Jerome Block, Roberto Chiprut says:
"As
one of the most culturally competent no-Latino physicians in this country,
Block understood the roles that religion, family, healers, and most important
of all, faith have in the healing process. His perspectives on weaving
religion and spirituality into teatment, on the emotional commitment that
Latino patients expect of their caregivers, and on the sensitive introdction of
pain medications and advanced technologies into treatment were qcquired through
trial and error over his years ofpractice. By seeing Latinos at the
moment of death [Block was an
oncologist],Block learned much about
ho his patients lived their lives. Block showed us that a practitioner
can achieve high levels of cultural competence through sensitivity, respect,
and patience."
Chiprut
says of Dr. America Bracho:
"Nobody
uses cultural symbols to achieve patiet compliance like Dr. America
Bracho." Bracho has a program for teaching patient compliance in the
treatment of chronic diabetes which has had "remarkable success."
Bracho's commitment is as important as her patients'. "She is
not afraid to sing alog with patiets in her weekly two-hour educational
sessions or to teach them how to read numbers so they can read their glucose
meter, or to spend a Sunday cooking and selling tamales to raise money for more
otreach efforts....She stresses...the power that comes from understanding--of
cultre, of illness, of self.
Chiprut
continues:
"Offenses
that occur between a physician and a patient frequently are the result of poor
communication. But this may be a matter not so much of lanuage as it is
of cultural-psychological knowledge. In spite of what is commonly taught
about modern medical diagnostic and therapeutic methods, ultimately what
patients want is a doctor who is available, who treats them with compassion,
and who tries to open a path through the thicket of modern medical care. That
is precisely what Dr. Camilo Jorge has done for his patients for over fifty
years of medical practice....One quality that stands ot...is his understanding
of Latino patients. This is nor more than the difficult task of
perceiving what the patient truly wants from a doctor. [He obtains
compliance by never offending.] What this meas in practice is that Jore listens
carefully and respectfully, treats even the humblest of his patients without
arrogance, and acknowledges the patient's fears and apprehensions, no matter
how rooted in superstition. Thus, like other Latinno physicians, he
frequently shares with a healer or curandero in the treatment of folk ailments.
Discussing
Dr. Margarita Keusayan, he says,
"Dr.
Margarita Keusayan agrees with Dr. Jorge that all caregivers should include
prudence and respect in their daily practice. Physicians with a abrupt
manner who only spend a short time with each patient, frequently find
themselves faced with the 'unhappy patient.' Keusayan went so far as to
say 'I become part of my patient; I feel the patient's anguish and share in his
suffering."
In
The Art of Healing Latinos, we see vividly how healing is much more than
pharmacology and machinery. But we need doctors who understand this: who
can build trust with their patients so that the human connection has strength.
I think people are afraid of not having access to the latest technology for a number of reasons (fear of death often being mentioned) including the lack of reliable human connections. In the US, it seems as if the dominant perception of medicine is that the best is provided by high-technology equipment and pharmaceuticals exclusively. Fears of reforming health care by limiting access to these technological marvels, at least some of them, center around whether or not people will be deprived of the treatment they need to get better. I don't quite know where to draw the line at what high-tech treatment is, but most of us don't need it most of the time.
In
fact it is often the lowest of the low-tech treatment that helps us to avoid
much of that fancy stuff and that can prevent serious problems or keep them in
check: a healthy diet, exercise, washing hands, being aware of changes in our
bodies, following doctor's orders, taking prescribed medicines as prescribed,
not smoking, not drinking excessively, etc. Compliance with these less
invasive and less fancy interventions has a lot to do with the importance of
re-establishing significant relationships between doctor and patient.
We
have become accustomed, in many cases I think, to depend on machines and tests
-- technology-- to replace treatment by huma beings rather than enhance it. If
you go to the doctor with a symptom you don't understand and the doctor says,
"Let's wait and see for a week..." if we don't see the same doctor
very often, and if we see him for five minutes when we do, and if he looks at
the records more than at us, it is easy to understand why we might want a test
to confirm what he tells us.
But
medicine -- treatment of problems with our bodies and minds -- is not just
technology and chemicals. As my dad, a cardiologist, used to say, medicine is
as much an art as a science. By that, he meant, I think, a number of
things. He meant, yes, that sometimes doctors had and have to use their
intuition, piece together bits of stuff from their experience because they
didn't and don't have the scientific knowledge (it wasn't and isn't always
available) to come up with an answer any other way. But more than that,
he meant that there was an art to matching patients with treatments, knowing
how to talk to them about their problems, knowing how to teach, how to care so
that the patient felt your advice was for her, not just a generic
patient. It also meant knowing that sometimes it's not the medicine at all, or
not only the medicine, that makes a patient better. This gets called the
placebo effect, a generic term referring to whatever is NOT medicine, not scientically
tested, that contributes to improvement, for instance improvement,
literally, in those few cases where terrible diseases remit without
medical explanation, or improvement where improvement in outlook, perhaps a
growth of hope or faith, leads to physical improvement in other areas as when a
patient starts to exercise or follow a diet or improvement whe a patient take
medicines his grandmother used or when he prays to a certain saint leads to the
strength to overcome a disease.
Indeed
all the glittery modern technology isn't foolproof, and it is a LOT more
expensive especially when overused or incorrectly used. The Harvard
physician and surgeon and writer Atul Gawunde wrote an article in the New Yorker showing that the use of tests and technology in
Brownsville, Texas far outstripped that used in El Paso, Texas, and yet the
outcomes were not better, and in some cases were worse. As Gawunde noted in his commencement speech at
the University of Chicago,
Nothing in medicine is
without risks, it turns out. Complications can arise from hospital stays,
drugs, procedures, and tests, and when they are of marginal value, the harm can
outweigh the benefit. To make matters worse, high-cost communities appear to do
the low-cost, low-profit stuff—like providing preventive-care measures, hospice
for the dying, and ready access to a primary-care doctor—less consistently
for their patients. The patients get more stuff, but not necessarily more of
what they need. [Italics are mine]
As Gawande says, low-cost measures may actually
provide more of what a patient needs than high-cost measures. An increase in
primary care physicians trained to deal with the whole person (and to some
extent, his family), and to do it in terms of that person's world: physicians
who get to know their patients by touching them, listening to them, knowing the
support systems they have, their culture: by caring about them, may save costs
AND lives. I suspect such physicians could contribute substantially to a
healthier citizenry at lower cost -- and to healthier citizens at all levels of
society. (I think all physicians benefit from these skills, not just
primary care providers, but that well-equipped primary care physicians could
become the pilots of the ships of their patients' care).
A
year or so ago I created the index for a lovely book called The Art of Healing
Latinos, edited by David E.
Hayes-Bautista and the late Roberto Chiprut. It is comprised of accounts
written by physicians and other health care advocates, not all Latinos, as a
means of explaining to Anglo physicians how they might work effectively with
Latino patients. But in fact it has lessons for practitioners, and patients,
too, throughout the cultures in the US on how doctors can establish healing
relationships with their patients and how patients can help them. I offer below
some quotes from the introduction to give you an idea of what they are talking
about.
On
the contributor Jerome Block, Roberto Chiprut says:
"As
one of the most culturally competent no-Latino physicians in this country,
Block understood the roles that religion, family, healers, and most important
of all, faith have in the healing process. His perspectives on weaving
religion and spirituality into teatment, on the emotional commitment that
Latino patients expect of their caregivers, and on the sensitive introdction of
pain medications and advanced technologies into treatment were qcquired through
trial and error over his years ofpractice. By seeing Latinos at the
moment of death [Block was an
oncologist],Block learned much about
ho his patients lived their lives. Block showed us that a practitioner
can achieve high levels of cultural competence through sensitivity, respect,
and patience."
Chiprut
says of Dr. America Bracho:
"Nobody
uses cultural symbols to achieve patiet compliance like Dr. America
Bracho." Bracho has a program for teaching patient compliance in the
treatment of chronic diabetes which has had "remarkable success."
Bracho's commitment is as important as her patients'. "She is
not afraid to sing alog with patiets in her weekly two-hour educational
sessions or to teach them how to read numbers so they can read their glucose
meter, or to spend a Sunday cooking and selling tamales to raise money for more
otreach efforts....She stresses...the power that comes from understanding--of
cultre, of illness, of self.
Chiprut
continues:
"Offenses
that occur between a physician and a patient frequently are the result of poor
communication. But this may be a matter not so much of lanuage as it is
of cultural-psychological knowledge. In spite of what is commonly taught
about modern medical diagnostic and therapeutic methods, ultimately what
patients want is a doctor who is available, who treats them with compassion,
and who tries to open a path through the thicket of modern medical care. That
is precisely what Dr. Camilo Jorge has done for his patients for over fifty
years of medical practice....One quality that stands ot...is his understanding
of Latino patients. This is nor more than the difficult task of
perceiving what the patient truly wants from a doctor. [He obtains
compliance by never offending.] What this meas in practice is that Jore listens
carefully and respectfully, treats even the humblest of his patients without
arrogance, and acknowledges the patient's fears and apprehensions, no matter
how rooted in superstition. Thus, like other Latinno physicians, he
frequently shares with a healer or curandero in the treatment of folk ailments.
Discussing
Dr. Margarita Keusayan, he says,
"Dr.
Margarita Keusayan agrees with Dr. Jorge that all caregivers should include
prudence and respect in their daily practice. Physicians with a abrupt
manner who only spend a short time with each patient, frequently find
themselves faced with the 'unhappy patient.' Keusayan went so far as to
say 'I become part of my patient; I feel the patient's anguish and share in his
suffering."
In
The Art of Healing Latinos, we see vividly how healing is much more than
pharmacology and machinery. But we need doctors who understand this: who
can build trust with their patients so that the human connection has strength.
I
think people are afraid of not having access to the latest technology for a
number of reasons (fear of death often being mentioned) including the lack of
reliable human connections. How many of us really have been able to
choose a physician and spend enough time with her to think she really knows who
we are? Lowering the costs of providing treatment by reining in costs of
unnecessary tests and treatments makes huge sense, not simply in terms of the
money saved, but in terms of eliminating harm and improving outsomes. But
only if we invest (much less money) in the development of physicians who can
look more into the world of their patients and learn to incorporate it in their
treatment.
How many of us really have been able to
choose a physician and spend enough time with her to think she really knows who
we are? Lowering the costs of providing treatment by reining in costs of
unnecessary tests and treatments makes huge sense, not simply in terms of the
money saved, but in terms of eliminating harm and improving outsomes. But
only if we invest in the development of physicians who can
look more into the world of their patients and learn to incorporate it in their
treatment.
In
the US, it seems as if the dominant perception of medicine is that the best is
provided by high-technology equipment and pharmaceuticals exclusively. Fears of
reforming health care by limiting access to these technological marvels, at
least some of them, center around whether or not people will be deprived of the
treatment they need to get better. I don't quite know where to draw the
line at what high-tech treatment is, but most of us don't need it most of the
time.
In
fact it is often the lowest of the low-tech treatment that helps us to avoid
much of that fancy stuff and that can prevent serious problems or keep them in
check: a healthy diet, exercise, washing hands, being aware of changes in our
bodies, following doctor's orders, taking prescribed medicines as prescribed,
not smoking, not drinking excessively, etc. Compliance with these less
invasive and less fancy interventions has a lot to do with the importance of
re-establishing significant relationships between doctor and patient.
We
have become accustomed, in many cases I think, to depend on machines and tests
-- technology-- to replace treatment by huma beings rather than enhance it. If
you go to the doctor with a symptom you don't understand and the doctor says,
"Let's wait and see for a week..." if we don't see the same doctor
very often, and if we see him for five minutes when we do, and if he looks at
the records more than at us, it is easy to understand why we might want a test
to confirm what he tells us.
But
medicine -- treatment of problems with our bodies and minds -- is not just
technology and chemicals. As my dad, a cardiologist, used to say, medicine is
as much an art as a science. By that, he meant, I think, a number of
things. He meant, yes, that sometimes doctors had and have to use their
intuition, piece together bits of stuff from their experience because they
didn't and don't have the scientific knowledge (it wasn't and isn't always
available) to come up with an answer any other way. But more than that,
he meant that there was an art to matching patients with treatments, knowing
how to talk to them about their problems, knowing how to teach, how to care so
that the patient felt your advice was for her, not just a generic
patient. It also meant knowing that sometimes it's not the medicine at all, or
not only the medicine, that makes a patient better. This gets called the
placebo effect, a generic term referring to whatever is NOT medicine, not scientically
tested, that contributes to improvement, for instance improvement,
literally, in those few cases where terrible diseases remit without
medical explanation, or improvement where improvement in outlook, perhaps a
growth of hope or faith, leads to physical improvement in other areas as when a
patient starts to exercise or follow a diet or improvement whe a patient take
medicines his grandmother used or when he prays to a certain saint leads to the
strength to overcome a disease.
Indeed
all the glittery modern technology isn't foolproof, and it is a LOT more
expensive especially when overused or incorrectly used. The Harvard
physician and surgeon and writer Atul Gawunde wrote an article in the New Yorker showing that the use of tests and technology in
Brownsville, Texas far outstripped that used in El Paso, Texas, and yet the
outcomes were not better, and in some cases were worse. As Gawunde noted in his commencement speech at
the University of Chicago,
Nothing in medicine is
without risks, it turns out. Complications can arise from hospital stays,
drugs, procedures, and tests, and when they are of marginal value, the harm can
outweigh the benefit. To make matters worse, high-cost communities appear to do
the low-cost, low-profit stuff—like providing preventive-care measures, hospice
for the dying, and ready access to a primary-care doctor—less consistently
for their patients. The patients get more stuff, but not necessarily more of
what they need. [Italics are mine]
As Gawande says, low-cost measures may actually
provide more of what a patient needs than high-cost measures. An increase in
primary care physicians trained to deal with the whole person (and to some
extent, his family), and to do it in terms of that person's world: physicians
who get to know their patients by touching them, listening to them, knowing the
support systems they have, their culture: by caring about them, may save costs
AND lives. I suspect such physicians could contribute substantially to a
healthier citizenry at lower cost -- and to healthier citizens at all levels of
society. (I think all physicians benefit from these skills, not just
primary care providers, but that well-equipped primary care physicians could
become the pilots of the ships of their patients' care).
A
year or so ago I created the index for a lovely book called The Art of Healing
Latinos, edited by David E.
Hayes-Bautista and the late Roberto Chiprut. It is comprised of accounts
written by physicians and other health care advocates, not all Latinos, as a
means of explaining to Anglo physicians how they might work effectively with
Latino patients. But in fact it has lessons for practitioners, and patients,
too, throughout the cultures in the US on how doctors can establish healing
relationships with their patients and how patients can help them. I offer below
some quotes from the introduction to give you an idea of what they are talking
about.
On
the contributor Jerome Block, Roberto Chiprut says:
"As
one of the most culturally competent no-Latino physicians in this country,
Block understood the roles that religion, family, healers, and most important
of all, faith have in the healing process. His perspectives on weaving
religion and spirituality into teatment, on the emotional commitment that
Latino patients expect of their caregivers, and on the sensitive introdction of
pain medications and advanced technologies into treatment were qcquired through
trial and error over his years ofpractice. By seeing Latinos at the
moment of death [Block was an
oncologist],Block learned much about
ho his patients lived their lives. Block showed us that a practitioner
can achieve high levels of cultural competence through sensitivity, respect,
and patience."
Chiprut
says of Dr. America Bracho:
"Nobody
uses cultural symbols to achieve patiet compliance like Dr. America
Bracho." Bracho has a program for teaching patient compliance in the
treatment of chronic diabetes which has had "remarkable success."
Bracho's commitment is as important as her patients'. "She is
not afraid to sing alog with patiets in her weekly two-hour educational
sessions or to teach them how to read numbers so they can read their glucose
meter, or to spend a Sunday cooking and selling tamales to raise money for more
otreach efforts....She stresses...the power that comes from understanding--of
cultre, of illness, of self.
Chiprut
continues:
"Offenses
that occur between a physician and a patient frequently are the result of poor
communication. But this may be a matter not so much of lanuage as it is
of cultural-psychological knowledge. In spite of what is commonly taught
about modern medical diagnostic and therapeutic methods, ultimately what
patients want is a doctor who is available, who treats them with compassion,
and who tries to open a path through the thicket of modern medical care. That
is precisely what Dr. Camilo Jorge has done for his patients for over fifty
years of medical practice....One quality that stands ot...is his understanding
of Latino patients. This is nor more than the difficult task of
perceiving what the patient truly wants from a doctor. [He obtains
compliance by never offending.] What this meas in practice is that Jore listens
carefully and respectfully, treats even the humblest of his patients without
arrogance, and acknowledges the patient's fears and apprehensions, no matter
how rooted in superstition. Thus, like other Latinno physicians, he
frequently shares with a healer or curandero in the treatment of folk ailments.
Discussing
Dr. Margarita Keusayan, he says,
"Dr.
Margarita Keusayan agrees with Dr. Jorge that all caregivers should include
prudence and respect in their daily practice. Physicians with a abrupt
manner who only spend a short time with each patient, frequently find
themselves faced with the 'unhappy patient.' Keusayan went so far as to
say 'I become part of my patient; I feel the patient's anguish and share in his
suffering."
In
The Art of Healing Latinos, we see vividly how healing is much more than
pharmacology and machinery. But we need doctors who understand this: who
can build trust with their patients so that the human connection has strength.
I think people are afraid of not having access to the latest technology for a number of reasons (fear of death often being mentioned) including the lack of reliable human connections. In the US, it seems as if the dominant perception of medicine is that the best is provided by high-technology equipment and pharmaceuticals exclusively. Fears of reforming health care by limiting access to these technological marvels, at least some of them, center around whether or not people will be deprived of the treatment they need to get better. I don't quite know where to draw the line at what high-tech treatment is, but most of us don't need it most of the time.
In
fact it is often the lowest of the low-tech treatment that helps us to avoid
much of that fancy stuff and that can prevent serious problems or keep them in
check: a healthy diet, exercise, washing hands, being aware of changes in our
bodies, following doctor's orders, taking prescribed medicines as prescribed,
not smoking, not drinking excessively, etc. Compliance with these less
invasive and less fancy interventions has a lot to do with the importance of
re-establishing significant relationships between doctor and patient.
We
have become accustomed, in many cases I think, to depend on machines and tests
-- technology-- to replace treatment by huma beings rather than enhance it. If
you go to the doctor with a symptom you don't understand and the doctor says,
"Let's wait and see for a week..." if we don't see the same doctor
very often, and if we see him for five minutes when we do, and if he looks at
the records more than at us, it is easy to understand why we might want a test
to confirm what he tells us.
But
medicine -- treatment of problems with our bodies and minds -- is not just
technology and chemicals. As my dad, a cardiologist, used to say, medicine is
as much an art as a science. By that, he meant, I think, a number of
things. He meant, yes, that sometimes doctors had and have to use their
intuition, piece together bits of stuff from their experience because they
didn't and don't have the scientific knowledge (it wasn't and isn't always
available) to come up with an answer any other way. But more than that,
he meant that there was an art to matching patients with treatments, knowing
how to talk to them about their problems, knowing how to teach, how to care so
that the patient felt your advice was for her, not just a generic
patient. It also meant knowing that sometimes it's not the medicine at all, or
not only the medicine, that makes a patient better. This gets called the
placebo effect, a generic term referring to whatever is NOT medicine, not scientically
tested, that contributes to improvement, for instance improvement,
literally, in those few cases where terrible diseases remit without
medical explanation, or improvement where improvement in outlook, perhaps a
growth of hope or faith, leads to physical improvement in other areas as when a
patient starts to exercise or follow a diet or improvement whe a patient take
medicines his grandmother used or when he prays to a certain saint leads to the
strength to overcome a disease.
Indeed
all the glittery modern technology isn't foolproof, and it is a LOT more
expensive especially when overused or incorrectly used. The Harvard
physician and surgeon and writer Atul Gawunde wrote an article in the New Yorker showing that the use of tests and technology in
Brownsville, Texas far outstripped that used in El Paso, Texas, and yet the
outcomes were not better, and in some cases were worse. As Gawunde noted in his commencement speech at
the University of Chicago,
Nothing in medicine is
without risks, it turns out. Complications can arise from hospital stays,
drugs, procedures, and tests, and when they are of marginal value, the harm can
outweigh the benefit. To make matters worse, high-cost communities appear to do
the low-cost, low-profit stuff—like providing preventive-care measures, hospice
for the dying, and ready access to a primary-care doctor—less consistently
for their patients. The patients get more stuff, but not necessarily more of
what they need. [Italics are mine]
As Gawande says, low-cost measures may actually
provide more of what a patient needs than high-cost measures. An increase in
primary care physicians trained to deal with the whole person (and to some
extent, his family), and to do it in terms of that person's world: physicians
who get to know their patients by touching them, listening to them, knowing the
support systems they have, their culture: by caring about them, may save costs
AND lives. I suspect such physicians could contribute substantially to a
healthier citizenry at lower cost -- and to healthier citizens at all levels of
society. (I think all physicians benefit from these skills, not just
primary care providers, but that well-equipped primary care physicians could
become the pilots of the ships of their patients' care).
A
year or so ago I created the index for a lovely book called The Art of Healing
Latinos, edited by David E.
Hayes-Bautista and the late Roberto Chiprut. It is comprised of accounts
written by physicians and other health care advocates, not all Latinos, as a
means of explaining to Anglo physicians how they might work effectively with
Latino patients. But in fact it has lessons for practitioners, and patients,
too, throughout the cultures in the US on how doctors can establish healing
relationships with their patients and how patients can help them. I offer below
some quotes from the introduction to give you an idea of what they are talking
about.
On
the contributor Jerome Block, Roberto Chiprut says:
"As
one of the most culturally competent no-Latino physicians in this country,
Block understood the roles that religion, family, healers, and most important
of all, faith have in the healing process. His perspectives on weaving
religion and spirituality into teatment, on the emotional commitment that
Latino patients expect of their caregivers, and on the sensitive introdction of
pain medications and advanced technologies into treatment were qcquired through
trial and error over his years ofpractice. By seeing Latinos at the
moment of death [Block was an
oncologist],Block learned much about
ho his patients lived their lives. Block showed us that a practitioner
can achieve high levels of cultural competence through sensitivity, respect,
and patience."
Chiprut
says of Dr. America Bracho:
"Nobody
uses cultural symbols to achieve patiet compliance like Dr. America
Bracho." Bracho has a program for teaching patient compliance in the
treatment of chronic diabetes which has had "remarkable success."
Bracho's commitment is as important as her patients'. "She is
not afraid to sing alog with patiets in her weekly two-hour educational
sessions or to teach them how to read numbers so they can read their glucose
meter, or to spend a Sunday cooking and selling tamales to raise money for more
otreach efforts....She stresses...the power that comes from understanding--of
cultre, of illness, of self.
Chiprut
continues:
"Offenses
that occur between a physician and a patient frequently are the result of poor
communication. But this may be a matter not so much of lanuage as it is
of cultural-psychological knowledge. In spite of what is commonly taught
about modern medical diagnostic and therapeutic methods, ultimately what
patients want is a doctor who is available, who treats them with compassion,
and who tries to open a path through the thicket of modern medical care. That
is precisely what Dr. Camilo Jorge has done for his patients for over fifty
years of medical practice....One quality that stands ot...is his understanding
of Latino patients. This is nor more than the difficult task of
perceiving what the patient truly wants from a doctor. [He obtains
compliance by never offending.] What this meas in practice is that Jore listens
carefully and respectfully, treats even the humblest of his patients without
arrogance, and acknowledges the patient's fears and apprehensions, no matter
how rooted in superstition. Thus, like other Latinno physicians, he
frequently shares with a healer or curandero in the treatment of folk ailments.
Discussing
Dr. Margarita Keusayan, he says,
"Dr.
Margarita Keusayan agrees with Dr. Jorge that all caregivers should include
prudence and respect in their daily practice. Physicians with a abrupt
manner who only spend a short time with each patient, frequently find
themselves faced with the 'unhappy patient.' Keusayan went so far as to
say 'I become part of my patient; I feel the patient's anguish and share in his
suffering."
In
The Art of Healing Latinos, we see vividly how healing is much more than
pharmacology and machinery. But we need doctors who understand this: who
can build trust with their patients so that the human connection has strength.
I
think people are afraid of not having access to the latest technology for a
number of reasons (fear of death often being mentioned) including the lack of
reliable human connections. How many of us really have been able to
choose a physician and spend enough time with her to think she really knows who
we are? Lowering the costs of providing treatment by reining in costs of
unnecessary tests and treatments makes huge sense, not simply in terms of the
money saved, but in terms of eliminating harm and improving outsomes. But
only if we invest (much less money) in the development of physicians who can
look more into the world of their patients and learn to incorporate it in their
treatment.
How many of us really have been able to
choose a physician and spend enough time with her to think she really knows who
we are? Lowering the costs of providing treatment by reining in costs of
unnecessary tests and treatments makes huge sense, not simply in terms of the
money saved, but in terms of eliminating harm and improving outsomes. But
only if we invest in the development of physicians who can
look more into the world of their patients and learn to incorporate it in their
treatment.
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