Bonnie Larson is Family Physician at Calgary Urban Project Society (CUPS) Health Centre
Recently I called the emergency department from my outreach clinic in an urban shelter. Near the end of the day, the nurse mentioned that one of the clients staying there, a young aboriginal woman I will call Ms. Rain, was supposed to follow up on an abnormal lab result from a few days earlier. As I looked the patient up on the ancient clinic laptop, I thought about the promise I had made to my daughter that morning to try to be home by suppertime. I willed the computer to load the results a little faster so I could get home to my family.
Finally, several abnormal results, including an elevated D-Dimer, appeared. I read the brief note available to me from the emergency room on our system; it indicated that the patient had been seen for a chief complaint of “chest pain” and discharged “home” after several hours in the emergency department. There were results for a chest x-ray and ECG, and both appeared normal.
I asked Ms. Rain to come in to the tiny clinic room. She was distracted, grieving a close family member who had died only the day before. She reported her left-sided chest pain, worse with position and deep inspiration, had remained unchanged. She thought it was stress, and had been relieved when the emergency physician reassured her. She said that he was 90 percent sure that there was nothing serious wrong. Her gaze across the table to me was clear and quizzical.
Discharged thus from the emergency department but without a home to go to, Ms. Rain had made her way to the shelter where she planned to regroup and rest. She had family to see and comfort, grieving to do, and a funeral to plan. I saw her in my clinic 48 hours after her conversation with the emergency physician.
I have the privilege of caring for a diverse patient population, including many with indigenous heritage. I had not met this particular patient before, and took my time with her, knowing that moving too fast could ruin any chances for a trusting collaboration. Lack of time can be a barrier to care. Cultural knowledge, patience, and a non-judgmental approach can help. Patient factors, such as poverty, and lack of transportation and social supports, can also be barriers in delivering care to a complex patient.
Ms. Rain, despite her grief and very difficult situation, was agreeable to whatever care I suggested. She disclosed several risk factors for a pulmonary embolism, including having had a prior venous thromboembolism. I struggled with the decision of the emergency room physician to send her “home” to the street - a young woman with chest pain, at high risk for VTE - without having ruled out a potentially life-threatening pulmonary embolism. The only response to my inner voice screaming, “Why???” was, “because she’s Aboriginal, that’s why”.
I called the emergency department. I spoke with several colleagues as a courtesy. I make a habit of these phone calls not to make their day easier, but rather to take the opportunity to say something humanizing about the patient I am referring to them. In my experience, this increases the chances that my patient will be well cared for in the hospital. The most equitable outcomes for my highly complex patients have occurred only when my colleagues trust my competence in my area of clinical expertise: inner city medicine and indigenous health. I should be able to include in my reason for referral such known determinants of health as homelessness and poverty; in such cases our system and staff should respond with a scaled up response, rather than resignation.
I spent 45 minutes arranging for Ms. Rain to return to the hospital for her CT PE, which she should have had 3 days prior. I experienced the hospital-based health care workers I spoke with as being reluctant to rise to the challenges of Ms. Rain’s care, questioning my clinical judgment and telling me “not to make any promises to the patient”. Some inferred that she must have refused the CT scan or left the emergency room against medical advice on her previous visit, neither of which occurred.
Research has shown that Aboriginal patients get life-saving interventions, e.g. for myocardial infarction and kidney disease, less often than their non-Aboriginal counterparts. Given my experience of that day, trying to get the right care for my patient, I find these disparities to be sadly unsurprising.
Our health care system and everyone in it is under pressure. I really wanted to get home to my family that day. It was very, very difficult not to rush. I admire the resilience of my colleagues in acute care, and I doubt I could weather the kind of pressures they endure shift after shift. We all have a role to play, but often I think we hide behind the system chaos and refuse to acknowledge our prejudices, and then treat our front-line colleagues as though they were adversaries rather than allies. If we do that we fail our patients. The Truth and Reconciliation Commission has made a recommendation for training new health care providers.
We call upon medical and nursing schools in Canada to require all students to take a course dealing with Aboriginal health issues, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices. This will require skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism. (Recommendation #24, Truth and Reconciliation Commission of Canada)
But what of those who are currently delivering care? What has changed since Brian Sinclair? We may have been forced to look closely at what happened that day, but we may have been peering through rose-tinted glasses. Given what I experienced with trying to refer Ms. Rain, and on too many other days, I fear it is only a matter of time before what happened to Brian Sinclair will happen again. Let’s work hard to examine our prejudices and ensure that barriers to care for patients like Ms. Rain, do not come down to lack of compassion that impairs our ability to work effectively in a team.
Dr. Larson obtained consent from her patient for publication of this story. Names and identifying details have been changed to protect the patient's identity.