Growing into my white coat: improving the patient-provider relationship through diverse patient interviews.

The "Patient Diversity" assignment is an integral component for all medical and other health care professional students rotating through the Surgery clerkship at the Yale School of Medicine. Students are instructed to interview a surgical patient who is of a varied social or cultural background to identify how psychosocial factors impact patient coping strategies. In the process, students often appreciate how health care providers' own social and cultural backgrounds similarly shape their sentiments and reactions in patient care. In this interview with a 26-year-old surgical patient, one student strives to come to terms with her personal insecurities in patient interactions and seeks to overcome them through open conversation and honest introspection. By working to acknowledge and understand patient diversity, health care providers can enhance understanding of their patients' conditions and form more trustful and empathic relationships with both their patients and colleagues.

Introduction

There are moments where I am uncomfortably aware of my white coat. There are moments where its whiteness is blinding, where the stark contrast between my bleached coat and a patient’s pastel hospital gown is almost embarrassing. This, I cringed to realize, was one of those moments.

“May I sit down?” I ask, cognizant of the fact that rarely does a patient actually deny the request from one of the many white coats he or she sees in a given day. “Sure,” Mr. A replies, shifting slightly in bed and nodding at me … or is it at my coat? After 3 years of medical school, I still find it difficult to tell.

Adjacent to the hospital room’s window, napping in her throne of vigilance, his mother stirs, opening her eyes to another visitor in the stream of staff that flow in and out of the room each hour. I attempt my best I-am-still-a-medical-student-and-somewhat-uncertain-of-myself smile, to which both patient and mother smile back, cautious affirmations for me to continue.

Taking a breath, I begin to explain. I explain that as medical students, we are asked to explore the story of a patient we find interesting and relay that story to our classmates as an exercise in patient diversity. I explain that I heard about Mr. A’s story on team rounds and was intrigued by the path that led him to his illness. During my winded clarification, however, there are some things I leave out — not to deceive Mr. A and his mother in any way and not in an attempt to shelter myself, but because I am at a loss for the right words. I find myself slightly tongue-tied navigating the explanation as to why Mr. A and I are “diverse,” worried he will perceive my questions as judgmental or patronizing.

Things Left Unsaid

Because the truth is, his story — one of a young male in his 20s who dropped out of high school and began selling drugs—is very different than mine. In the past 12 years that Mr. A has spent distanced from a formal education setting, I have devoted an equal amount calling the classroom my second home. I may have griped about homework, applications, and student loans during those 12 years, but never has there been the thought — the option, really — of leaving school.

Mr. A was first introduced to the health care system this past year tragically with the label “gunshot wound victim” — shot twice by an unknown assailant following an argument. At the time, Mr. A states his primary source of income was selling illicit drugs, specifically crack cocaine. He relied on this income to support his family, but his true passion was music. He spent most nights working on producing and editing tracks and was deeply involved with managing a friend’s music career.

Facing the Present

Sitting with Mr. A in a dimly lit hospital room 7 months after the shooting, containers of salve and gauze serving as décor, it is difficult to imagine the soft-spoken man before me acting beyond the boundaries of the law. He speaks of selling drugs and dropping out of school in a distant monotone, as if reading aloud from the newspaper about some stranger neither of us knows. He tells me how he was raised in a large, loving Puerto Rican family, and how his mother is still his biggest advocate. He speaks of falling in with the wrong crowd in middle school and recalls the moment when he woke up in the hospital following the shooting to learn there had been two penetrating bullet wounds. One bullet crossed through his left mandible, leaving him with a permanent titanium plate in his jaw and incapable of speaking for an unforetold amount of time. The other bullet entered his left buttocks and rocketed through his colon, perforating the bowel. Mr. A underwent a partial colon resection with surgical diversion of the remaining colon to an opening in his abdomen where waste was now collected in an external “ostomy bag.” In the process of tearing his colon, the second bullet also pierced his urethra, explaining the bladder-draining tube Mr. A awoke to find emerging from above his pelvis.

Mr. A was monitored intensely in the hospital for over 2 months, ultimately discharged to home with recovery of his speech and a revitalized outlook on life. At a follow-up visit, however, Mr. A was noted to have urethral narrowing, a condition that can lead to obstruction of urine flow from the bladder and kidney damage. To avoid complications, Mr. A underwent a surgical reconstruction of his urethra, referred to as a “urethroplasty.” If successful, the urethral reconstruction would allow removal of his suprapubic tube.

When I met Mr. A, he was on post-operative day 3 following the urethroplasty, with all signs pointing to a full recovery. The final step (hopefully in the not-too-distant future) is to reverse the ostomy bag and reconnect the proximal and distal portions of Mr. A’s bowel, finally returning him to independent bladder and bowel function.

Moving Forward

In our conversations, Mr. A described his decision to leave school as one made for “all the wrong reasons,” and one he feels contributed to his clinical condition. Reflecting on our interactions, I was awed by the level of serenity with which Mr. A regarded his injuries and residual impairments. As someone so accustomed to perpetual activity, the concept of performing my daily routine attached to various receptacles for bodily secretions was frankly terrifying. However, this was a young adult who, when asked how his medical issues affected his life, courageously smiled and stated, “I don’t feel too bad for myself; I’m just happy to be alive. I am fortunate. There are people in worse situations. I can’t do things I used to do, but now … I am trying to do something positive.”

Mr. A described how his mindset changed after waking up in the hospital. “I needed to stop speeding and living on the edge and slow down a little bit,” he stated. Beaming, he discussed the organization he now works for — an after school program that teaches high school students the basics of music and music production. “It’s for kids like me,” he told me, then paused, “well, not exactly like me, because we want to get them off the streets early on.”

Perspectives

Mr. A’s story is one that will stay with me throughout my training and beyond. It is a reminder that too often diversity is viewed as a barrier to the patient-provider relationship. As care providers, it is essential to not only acknowledge diversity, but also to embrace it. Diversity is not a barrier, but rather an open door, through which we can better appreciate the context in which our patients present and build stronger, more transparent patient-provider relationships.

I am incredibly fortunate to be pursuing my dreams, and I am eternally grateful for the opportunities provided to me along the way. However, I wonder if my life would look different today if those opportunities had been farther from my reach, buried under adversity. Who is to say that my white coat, an age-old symbol of integrity and endurance, does not instead belong on the shoulders of Mr. A? Mr. A — a young man who in 1 week of conversation illustrated for me the true nature of empathy and wisdom.

At the end of our visits, I would thank Mr. A as I reloaded my phone, papers, pens, and stethoscope back into the abyss that is my white coat pockets. On my final departure, I asked him what he wanted me to relay to my colleagues — his lesson for us. His response?

“I’m not really a bad person, ya know? I still have not quite figured out how I got to where I did. But through everything I have been through, even being able to talk again … I’m glad … Out of all the negative I’ve done, I am trying to not feel bad for myself. I just have to do something positive and guide others in a positive direction. Because it’s not what happens that determines your future, it’s what you do with it … Do not wish for less challenge, wish for more wisdom.”

Wisdom, Mr. A reminds us, is not merely another item we carry amid the myriad instruments in our white coats, tangled somewhere between a reflex hammer and yesterday’s sign-out report. Wisdom, he reminds us, is something that comes with time, with experience, and with viewing each patient through an individualized, holistic lens.

Conclusions and Outlook

At the start of each clerkship, students are provided a list of objectives and requirements pertaining to the rotation. Eager to meet our teams and get immersed in direct patient care, there is a general tendency for these lists to travel straight from our hands to our pockets, with a mental note to return to them later. Admittedly, when initially given the Patient Diversity assignment, I tacked it on to my generic to-do list for the Surgery rotation, not truly weighing its significance until my time with Mr. A. I overestimated my comfort with the topic, positive that regardless of a patient’s journey to the medical system, I would be unfazed. Empathy and warmth would open the door to strong, trustful relationships with my patients, and honest communication would fortify those bonds.

When first meeting Mr. A, however, I was taken aback by how unsure I was of myself. Would he feel comfortable sharing his story with a stranger? Would he allow me a glimpse into the struggles he has faced — faced and now conquered? I entered this assignment with the misconception that I understood the breadth of diversity among patients, when really my experience to that point had merely scratched the surface of what diversity truly means. I had categorized “diversity” under the heading of “demographics,” failing to realize that diversity can manifest in not just background or ethnicity, but in every aspect of a patient-provider relationship.

Take Mr. A, for example. Despite my prediction that our life paths and cultural backgrounds would serve as the foundation of “diversity” between us, they ultimately played a minor role. The most diverse aspect of our relationship was the incredible resilience Mr. A maintained throughout his recovery — not only resilience, but also an acceptance and a soulful wisdom beyond his years. I cannot say how similar my emotional endurance would be if the patient-provider roles were reversed. I cannot say that I would have emerged from adversity with the same spirit, and I am forever touched to have met someone with such strength and perseverance.

The Patient Diversity assignment is a model for medical student education, as well as for more advanced levels of training. There are various diversity-enriching opportunities for health care professional students at Yale, such as HAVEN (a student-run free community clinic) and the Yale Refugee Project (a community service group focused on assisting refugees to New Haven). These outlets are incredibly rewarding, as students work with diverse populations and see the impact of their efforts on the local community. The Patient Diversity assignment adds to these opportunities by encouraging students to reflect on individual patient-provider relationships they have built along the way. In the classroom, the assignment then provides a forum for students to discuss their experiences and the influence on their medical education.

A recent study suggests that cross-cultural interactions among fellow medical students are associated with a higher self-rated ability to care for patients from diverse backgrounds [1], and Mr. A is a reminder that “diversity” comes in many forms. With time, with recognizing the extent of diversity in regards to patient care (as well as colleague interactions), and with a little more Mr. A-like wisdom, my white coat will lose that occasional feeling of awkwardness, that intermittent feeling of playing dress-up in a professional’s closet. Hopefully with further years of rolling up my sleeves and striving to understand my patients within the context of their diversity, my white coat will even get a little worn-in. As Mr. A taught me, there is always a second chance to clean it off and start afresh.