Balint Journal 2012; 13(03): 82-86
DOI: 10.1055/s-0031-1284031
Preisträgerarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Doña Paulina

Doña Paulina
P. Cooch*
1   University of Vermont College of Medicine
› Institutsangaben
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
20. September 2012 (online)

Preview

Having started medical school less than 5 months ago, it feels premature for me to speak of a truly personal student-patient interaction. Yet from the moment I saw this essay prompt, I knew that I needed to write about Doña Paulina. More than anything, I am writing to catalogue my experiences for my own reflection and future recollection.

The story I will recount occurred prior to my entrance into medical school, during the 10 months I spent volunteering at a clinic in Guatemala. For 5 of those months, I worked as an aide of sorts for an elderly Mayan woman suffering from a considerable ulcer. My friendship with this octogenarian hermit, with whom I share almost no language or cultural background, is the oddest relationship I have experienced with another human being so far in my life. Yet, perhaps just for the reason, it has been among the most meaningful.

Who is Doña Paulina, and how did we come to meet? In most ways, it was by chance. I had first come to Guatemala working as a whitewater rafting guide. During my travels, I encountered Santa Cruz la Laguna, an indigenous Mayan community in the highlands. The 6 000 inhabitants of the municipality were scattered across a half-dozen villages along the shore of a volcanic lake. There, I encountered a small clinic run by 2 married physicians, a American and Guatemalan. They had worked, unpaid, for the past 6 years to provide free primary healthcare to the Mayans in the community. I was growing deeply attached to Guatemala and felt a unique connection with the clinic. After shadowing the staff for several days, I made arrangements to stay as a full-time volunteer for the next 7 months.

As an Emergency Medical Technician by training, I my individual focus was designing a project to train local volunteers as first responders for obstetric emergencies. However, most of my efforts went into the clinic’s daily activities, to the extent my limited medical experience allowed. The clinic’s success was built around mobile outreach clinics, usually 2 per week. For each clinic, we’d pack up medications and equipment and travel to several nearby villages, seeing from 30 to 90 patients throughout the day.

It was during one such outreach clinic that we first heard of Doña Paulina. We were in Tzununá, a community of several 1 000 Mayans that we usually visited on Thursdays. It was mid-September, about 5 months into my stay at the clinic. That afternoon, a visitor at the outreach clinic asked if we could come care for an ancianita (little old lady) in dire health. A neighbor had stopped by her home to inquire about harvesting jocotes, a small pitted fruit popular with the locals. He had found her bedridden and delirious, her hut overpowered with a gangrenous miasma.

After seeing our last patient, one of the physicians and our nurse practitioner Guadalupe set off hiking to investigate. They encountered a heartbreaking situation.

Although we’d never heard of her before, Doña Paulina was perhaps the oldest living person in Tzununá. In Spanish, “Doña” is a title conferring respect, a step above “Señora”. She believed she’d been alive for 85 years – placing her decades past the average Mayan life expectancy. Having long outlived her husband and children, she was left with absolutely no one to care for her.

However, this remarkable spirit now seemed close to fading away. A nearly circumferential ulcer had eaten away most of her left calf. It had eroded down to the fascia and swollen her foot like an inflated rubber glove. Now Dona Paulina hovered on the verge of sepsis. She was scalding to the touch, reduced to a sack of flesh and bones weighing less than 30 kilograms.

We never determined the origin of the ulcer. She wasn’t diabetic, nor did her other leg have varicosities. Although I tried on many occasions, I was never able to confirm a story from her. We imagined a small cut, bite or burn had festered over months of infection, while she remained unable to seek (or unaware of) options for outside care.

A similar infection in the U.S. would warrant hospitalization, IV antibiotics, and whirlpool wound-care treatment. In Tzununá, all of those were out of the question. Over her 85 years, Doña Paulina had likely never left the outskirts of her village. The department hospital in Sololá, several hours away, is cramped and understaffed. Among Mayans, it is still considered an option of last resort. We considered the shock of pulling her from her home and placing her in an utterly alien institution, with no guarantee of receiving superior care. It seemed we’d be doing more harm than we could hope to cure.

With limited resources and hundreds of other patients, many young and very curable, our physicians were reluctant to go to drastic measures on her behalf. Daily home visits to bring her infection and dehydration under control seemed to be the most we could offer. After that, someone might make intermittent trips to change her dressings and bring food and potable water. None of the staff who’d visited her believed she would live for many more weeks.

Although I had very little medical training, I had been treating a gentleman with a similarly sized (although far more superficial) venous stasis ulcer for several months. As the most expendable member of the clinic staff, and eager to undertake any medical assignment, I was chosen to be her caregiver and “wound technician”.

Despite my enthusiasm and recent experiences, my first few trips still shook me to my core. Doña Paulina’s home lay at the end of a muddy, garbage-strewn pathway deep in the forest above the village. She lived in a wattle and daub hut that measured perhaps 3 meters per side, with well under 2 meter of headroom. There was no electricity, water or plumbing.

I knocked and entered. Sunspots pulsated on my retina as my vision adjusted to the dark. The only illumination came from slivers of sunlight between the bamboo stays. I made a note to bring a headlamp in the future. But any visual sensory deprivation was countered by the overwhelming olfactory stimuli. I had never smelled anything similar before (although knowing that at some point most healthcare providers have, I will refrain from description). In the corner, I could detect a dark shape wrapped in a pile of blankets.

The inside of her dwelling seemed like the set from a movie. Other than some pots and utensils, plastic buckets and the corrugated tin roof, there were almost no industrially-fabricated objects – in a country inundated with cheap plastics. The bedding and baskets were hand woven, the walls bound with twine and the stool and bed frame appeared simple carpentry. The floor was earth and ceiling was glazed with creosote from indoor cookfires. Bundles of herbs hung from the ceiling, and a rosary between 2 candle stubs clearly served as a shrine.

I knelt at the side of a makeshift pallet containing a child-sized woman. Her white hair was pulled into a braid in back; the loose wisps in front had been stained yellow from smoke. She seemed to speak absolutely no Spanish. I introduced myself and explained my new role, but her murmured response was indistinguishable. Although I was accompanied by an interpreter, I could tell our communication has hampered by a gulf much more profound than language. Her eyes, deeply sunken in parchment flesh, flickered with pain and sorrow that was beyond my comprehension. I hesitated a moment, uncertain how to proceed. Then I donned rubber gloves and lifted her bandaged leg off the edge of the bed over to a drape I’d spread on the floor.

Changing her dressings eventually became a familiar routine, but that was not the case on the first day. I’d start by unpeeling the invariably-saturated layers of cling-gauze. Next I’d tease away the stuck non-stick pads, revealing the wound itself. The first time, I was reminded of a panorama from the American southwest. Canyons and mesas, fissures and reefs scored her flesh in angry reds, green patinas, and yellow seeps. I’d work through half-a-liter of saline irrigating the deep fissures with a syringe. I’d then apply a coat of silver sulfadiazine antibiotic ointment. I’d finish by pressing 5 or 6 large non-stick pads over the surface, and securing them with roller-gauze. Initially, the whole process would take me almost an hour.

After finishing the dressings, the 2 of us would be exhausted. I had been hunched over, eyes stinging with sweat, meticulously trying to avoid cross-contaminating my cache of wound care materials. She had held herself upright during the entire changing, eyes rolled, murmuring padre and dios. I would then ask her permission to administer an i. m. dose of ceftriaxone into her gluteal region. There was barely a string of muscle over her skeletal hip to give the injection.

This final indignity completed, I would mix a thick brew of powdered milk and give her a multivitamin and some acetaminophen. Before swallowing each pill, she crossed herself. She would then slowly drain the mug, swing her bandaged leg into the bed and lower down to the pillow. When I stood to leave, she would ask me when we’d be back. “2 days”, I’d repeat, and motion with my hands. She would nod, murmur her thanks, and appear to drift off to sleep.

Early on, I noticed 2 5-gallon, dirt-encrusted buckets stacked in the corner. I discovered they were full of dried corn with a Rotary logo printed on the side. I recognized that the buckets were the components of a water filter from some past, forgotten humanitarian mission. Buried beneath the kernels I found the critical element, the ceramic filter prongs. They looked completely unused. Up to that point, we had treated her with antiparasitics and had brought her liters of purified water. Now, with a good cleaning, Doña Paulina had a 5-gallon reservoir of potable water that we could top off every visit. I was buoyed by this minor achievement.

Over the next 2 months, I made trips every other day to Doña Paulina’s home. To get to Tzununá was a 15-min motorboat ride or a one-h hike along the shore. Our routine progressed. I enjoyed the long walks, and became speedier and more proficient with the dressings. She made requests for sundry items, like candles or matches.

The initial antibiotics and cleanings had had a dramatic effect. The exudate had grown clearer, the smell had gone, and her discomfort was clearly less. The margins were pinkish-white and slowly growing. When I showed up, I was just as likely to see her up and tending a smoldering cookfire as in bed. It was remarkable how seeing Doña Paulina upright changed my perception of her home’s size. She stood well under a meter-and-a-half tall, making her home’s dimensions seem comparatively spacious. With her inquisitive eyes, wrinkled skin, bare feet and walking staff, she often reminded me of Yoda from Star Wars.

Just as gratifyingly, our patchwork system of communication had improved significantly. Of course, every few weeks I’d come with a local clinic staff member to clear up any recent miscommunications. Nonetheless, we had been finding remarkable overlap between the handful of Spanish words she periodically revealed and the Kaq’chikel I was practicing. We had a formal greeting every time I arrived and could make small talk about the weather. I could ask her about her pain, explain medication schedules, and ask what she needed. When she broke into an animated chatter, to be sure, I found the words as indistinguishable as ever. Yet the tones were unmistakable: bantering, reproach, curiosity.

It was clear this mission might end up much more than palliative care. Unfortunately, my 7 months were nearly over. I had spent my savings and was having limited success fundraising. I needed to regroup with a paying job for a few months, and had the option of returning to Montana to work another winter as a ski patroller. I spent my final few weeks transitioning her care to the clinic staff.

I spent the next 5 months fundraising, working, and making plans for my return in the spring. I devised a plan to drive my old pickup truck from Montana to Guatemala to convert to an ambulance. There, I would donate it to 3 villages served by the clinic, whose inhabitants had no access to emergency care. I left in early May from Montana, the truck loaded with donated medical gear. Over the next 3 weeks I drove almost 7 000 kilometers across the US and Mexico. The trip was full of adventures including minor engine problems, contentious border crossings, and numerous taxes and fines. In the end the ’94 Toyota completed the journey, breaking 300 000 kilometers along the way.

At the clinic I heard good news about many of the old patients, including Doña Paulina. During my absence, a fourth-year medical student and his wife had volunteered at the clinic. Rather than powdered milk and eggs, he and his wife had brought her homecooked meals. Under his care, Doña Paulina’s ulcer had made incredible progress. Our stays had been separated by a few weeks on either end, so we were never able to meet personally.

The first day I returned, I was greeted by the sight of Doña Paulina standing outside of her house, shooing around a gaggle of chicks with a broom. She was even more talkative, if possible, from the last time I’d ever seen her. She could name off her favorite dishes in Spanish, such as beef stew, chicken and fish, and was not shy about doing so.

The ulcer had healed from the size of 5 or 6 hand-prints to a narrow band on the inside of her leg. The rest had smoothed to mottled pink scar tissue. The improvement was astounding. Yet for all the steps forward, there had been a few backward. In the 3 weeks since the volunteer’s departure, no one on the clinic staff had visited her. Her sore, although much smaller, was encrusted with a thick coating of ash, as well as magenta-colored flakes I’d never seen before. She proudly showed me her leg, but whether to appreciate the diminished ulcer or the homemade poultice I was unsure. What did grab my attention was the oozing pus around the margins. I was taken aback yet again when a deep, hacking cough interrupted her stream of speech.

That morning’s wound cleaning was painstaking for me and excruciating for her. I picked and irrigated at the crust of dirt over the wound, trying not to damage the tissue below. Doña Paulina clucked and gesticulated in agitation. After an almost an hour the wound was superficially cleaned of dirt, but clearly macerated.

As I packed up to leave, I realized that I’d forgotten the packet of eggs, beans, tortillas and chicken I’d made for her back at home. When it became clear I had brought nothing to eat, she howled the word for “food” in Spanish: “Comida!” Although demanding, the cry was also plaintive and anguished. I cursed myself and tried soothe my distress my giving her a few dollars. Her progress, and our relationship, no longer seemed on such solid footing.

Back at the clinic, I tried to clear my head. I had just over 2 months back in Santa Cruz before I began medical school in the states. I promised myself that I’d do whatever it took to heal the ulcer before I left. 80% of progress had already been made – it was just up to me to finish the job. Once the ulcer had completely healed, I hoped there’d be less worries of new infections, assuring regular visits, or dissuading her home remedies.

Yet my good intentions weren’t sufficient to achieve results. The rainy season was just beginning. It would prove among of the worse the Guatemala had faced in years. Once the rain began, it continued incessantly. The dampness baked in a suffocating haze at midday and sank into an icy chill at night. As rainwater coursed down the hillside around Doña Paulina’s house, her earthen floor churned into a muddy mess. Aweek after I arrived, tropical storm Agatha saturated Guatemala for nearly a week. Flooding and landslides paralyzed the nation, killing hundreds. The villages to either side of Doña Paulina were repeatedly evacuated, at times by the military.

Around Lake Atitlán, latrines washed out, crops rotted, springs become fouled, and families relocated to crowded shelters. The clinic staff worked overtime to counter the rising burden of disease. We doubled the number of weekly outreach clinics from 2 to 4, keeping our doors open until well after dark.

Despite the chaos, I remained steadfast in my visits. I’d wake up at dawn to jog the 2-h round trip to her place before we opened the clinic in the morning. The path was now beset with gutted ravines and steep landslides that added new treachery to the journey.

A regimen of antibiotics cleared up the pus and reddening, but did little to help the cough. Meanwhile, Doña Paulina became more and more resistant to receiving care. I didn’t take long to realize she seemed to tolerate our bandages for no longer than 48 h. If my visits passed that threshold, she would remove the gauze bandages and smear the ulcer with ashes. According to her, the wound appeared dryer, and thereby healthier, when it rubbed with ash.

I tried to assure that 48 h never elapsed between visits, but the threshold dropped to 36. I dabbled in pleading, reason, and bribery. I printed out color photos of her ulcer taken 7 months earlier to emphasize the progress we’d made. I tried to make the food I brought contingent on her bandages being in place. If I found the wound smeared with ashes, I would furrow my brow, wag my finger and place the food back in my backpack. But each time, after explaining the need for patience and consistency, I would relent. She must have known all along that I was only bluffing. I did, however, frequently withhold the petty sums of spending cash I often had often passed her before. But rather than softening her resolve, it only seemed to chill our relations.

I was becoming embroiled in an exploration of that ugliest of words, compliance. Although Doña Paulina still reluctantly allowed me to clean the wound, she would flat-out refuse care from the rest of the clinic staff. She made her displeasure clear every time I treated her, and removed the bandages after I left. Despite the remarkable improvements we’d managed in under a year, she had completely discredited our attempts her mind.

I visiting friend of mine noticed that the perfectionist care she took in daubing the wound with cinders might be indicative of a fierce independence and self-reliance. Perhaps, he suggested, if we taught her to apply her own bandages and silvadene, she might take ownership of the process herself. I was immediately optimistic, and she appeared willing to try. Yet our shared handiwork would be removed just as certainly by my next visit.

Why was she upset? I couldn’t make sense of her complaints or reasoning. Her leg hurt badly. The pain must have been unbearable, even with mild painkillers. She would repeat that the dressings made the pain worse. After she would pluck and tug and the cling gauze, I guessed we might have been applying it too tightly. We switched to taping the non-stick pads on, but that make no difference. She wanted to let the wound air out, a concept with a certain intrinsic appeal. But living in such a septic environment, there seemed no way to let her do that without dirtying the wound.

What else could we be missing? Did her personal treatment have any validity? At the clinic we took great pains to remain culturally sensitive. We conducted most of our consultations with an interpreter, as very few of our patients spoke Spanish. The local villagers we hired and trained were just as adept as navigating cultural as linguistic obstacles. Likewise, our beloved nurse practitioner Guadalupe, who had the highest level of medical training available to a nurse in Guatemala, was a Mayan woman who spoke 3 indigenous dialects. Although we were far from perfect, the clinic had overcome initial mistrust to become trusted, even beloved, by most of the community.

I was asked by others, as I sometimes wondered myself, why I insisted on carrying on. She stated that she didn’t want our assistance. If she had her full decision-making capacity, didn’t that mean we have no business visiting her? I told myself that I had always been able to convince her continue treatment. Shying away from coercion was likely why I had never been able to withhold food. I was loathe to write off the hundreds of hours myself and others had spent on her as a lost cause. I’m sure I felt a sense of duty to the fourth year medical student who had made so much progress. Most of all, I believed I was looking out for her wellbeing. Of course, everything boiled down to my certainty that I knew what was best for her.

Not many others bought into my convoluted ethical justification. In the time I took me to care for Doña Paulina, one of our physicians or nurses might finish 4 consultations. Most of the patients seen at the clinic had acute but easily treatable tropical maladies, such as ascaris, impetigo, or bacterial diarrhea. Prevention and treating acute illness was a much more efficient use of the clinic’s meager resources than the quagmire I had enmeshed myself in. I knew that after I left it was unlikely anyone would carry on with her treatment, especially against such stiff resistance. Of course, this realization only added to the pressure I felt to do what I could.

In the meantime, I had started to notice Doña Paulina scratching at her back and arms. A closer inspection revealed that her skin was covered in scabs and bites, compounded by her frequent scraping. She confirmed that she had been bitten by insects while she slept. Doña Paulina’s mattress was an ancient, thinly-stuffed burlap pallet which had once nearly been her deathbed. Her fast growing brood of chickens roosted there whenever given the chance. Although we’d brought her new blankets over the years, these too were long overdue for a washing.

Although the presentation was ambiguous, I still suspected she had scabies, a dermatological affliction endemic in the developing world. Scabies is notoriously difficult to exterminate. The mites that cause it easily cross with physical contact, lay their eggs in fabric and mattresses, and are resistant to washing.

In the city of Sololá, the department capital, I purchased a plush replacement mattress and cheap American clothes from a thrift store. Early the next morning, before outreach clinic, I visited her with an interpreter. I gave her a dose of ivermectin for the suspected scabies, and asked her change out of her elaborate, hand-sewn traje into the western outfit. A few minutes later she emerged from her front door with a sheepish smile, clad in a baggy black t-shirt and a cotton skirt. To this day, this remains my absolute favorite memory of Doña Paulina. She started to giggle, our interpreter burst out in laughter, and before long the 3 of us were howling in mirth at her outfit.

After we had wiped the tears from our eyes, I set about stuffing her blankets and clothing into bags. We were in for a surprise when I pulled aside her old mattress. A writhing ants’ nest, swarming with eggs, larvae, and pincered workers, lay between her pallet and the floor. My amusement evaporated in guilt. I was horrified at the conditions she had been enduring. I was humbled that I had blindly assumed the insects she’d spoken of were microscopic mites that caused scabies. I’d never taken the time to ask more in-depth questions, or even look through her bedding.

I swept out the nest and doused the area with rubbing alcohol. It still seemed more worthwhile than ever to carry through with the washing plan. We carried the bags down to the docks to be met by our clinic staff on the way to outreach clinic in San Pablo. I left her clothes with a laundry service to go through multiple rounds of bleach and hot water. Coming back that evening, we rolled out the clean mattress on wooden pallets, made the bed with fresh blankets, and presented her with a packet of washed trajes. I have never slept as well as I did that night, knowing that Doña Paulina was snuggling into clean sheets for the first time in years.

A few weeks later I went to visit Doña Paulina with a translator and our clinic’s attending physician. My concern over her unremitting cough and ulcer had been growing.

With some prodding from our attending and insightful questioning by our interpreter, the truth came pouring out. Doña Paulina gleefully launched into her confession. She admitted to buying plugs of tobacco with the money I’d been given her. I was completely blindsided – I’d never encountered any evidence of her smoking, and the habit is almost unheard of among Mayans. We told her that tobacco was causing her cough. She countered that smoking was the only thing that helped. In fact, she claimed the cough had only worsened because we hadn’t given her enough money to buy tobacco recently.

She continued her denouement by stating that her own treatments were only thing that had ever healed the ulcer. In fact, the past years progress had been thanks to her own special medicine. She produced a small bag of magenta granules, the same flakes I’d seen in the ulcer the first time I’d visited. Our interpreter recognized the substance as a potent agricultural insecticide commonly used by farmers. Suddenly, tears welled in her eyes and she turned and addressed me. “Pedro, why have you abandoned me?” translated our interpreter. It was less than a day after I’d spent an hour carefully washing her swollen feet and massaging them with lotion.

After an unsuccessful attempt to confiscate the flakes, we departed. Our doctor had found the exchange hilarious, but I felt at a complete loss. I had only a few weeks remaining of my time in Guatemala. There was no way the ulcer would be healed by the time I left – it looked worse than it had 2 months before. Establishing a continuity of care for Doña Paulina was my next best hope. Yet that appeared just as unlikely. We had known each other for almost a year, had probably spent 100 h in each other’s company, and yet I was scarcely welcome. How could I transfer care of such a recalcitrant change?

I did what I could. I kept up my visits, although I knew the bandages were likely removed the second I left. When I realized her edematous feet no longer fit into the plastic slippers universally worn by Mayan women, I bought her a pair of “Crocs”-brand clogs. They were identical to my own giant pair, only one-third as long. That earned us some laughter and perhaps restored a little good will. The clinic recruited another volunteer to spend a few months in Santa Cruz and potentially carry on my visits. A European couple who owned a small hotel a 10-min walk from Paulina’s agreed to bring her meal and leftovers from their kitchen after I left.

Once again, I departed with very little sense of closure. That was 5 months ago. The clinic informed me that after I left, Doña Paulina began refusing treatment altogether. She hasn’t been visited since then, and no one can tell me how she is doing.

I will not return to Guatemala for another 5 months. I keep imagining that I will hike in to find her herding chickens outside her home, or stoking her little cookfire. Perhaps, I think, the transition from rainy to dry season will make the same dramatic difference as it did during my first absence. Or maybe, as improbable as it seems, there is a gem of truth in her home remedies. Sometimes she strikes me as so resilient and resourceful I can’t imagine her departing this earth. Other times she seemed so vulnerable and ephemeral I marveled she didn’t wisp away in front of me.

Our worlds were so different it seemed improbable we had ever found common ground at all. I had been 24, while she was old enough to have lost track of how old she actually was. I had traveled from thousands of kilometers away, while she had never been 5 km from the place she’d been born. I’ve spent 2 decades in school; she spent 2 decades waiting out civil war. I saw medicine as infallible, while he had been alive 60 years before I was even born, likely without ever seeing a doctor. While I enjoyed perfect health, she had endured years of agony. She scrabbled for every meal, while I often considered food an afterthought. While I plugged in my laptop and turned on the lights, she lay in the dark from sunset to sunrise.

Although I felt frustration, it must have been dwarfed by what she felt. The troubles of a provider and a patient occupy entirely different planes of existence. She had a debilitating injury. She couldn’t know where it had come from, whether it would ever go away, or if and when it would kill her. For a year, she had let strangers come into her home. I had told her what to do. I had scolded, bribed, and questioned her. Each time, she’d been subjected to invasive procedures, via pills, injections, or tubes placed into her veins.

When I had first started, I faced almost no expectations. No one thought she would even live. I was merely providing palliative comfort to preserve a dying patient’s dignity. Medically, of course, treating such a sizeable and infected wound was a formidable challenge for someone so inexperienced. I had several physicians tell me they’d never seen anything like it in their careers. We were both fortunate I’d already had the opportunity to expose myself to a similar situation treating a patient’s venous stasis ulcer. Yet, as is the case with so many challenges, in due time it become commonplace. And how does could the unpleasantness of cleaning such an ulcer compare to the unpleasantness of having it?

When I returned for the following summer, the expectations I felt had risen with her considerable improvements. I tried to meet the demands I perceived with determination and perseverance. This was not always the most constructive tact to take. I took complete responsibility for her, despite knowing I’d eventually cease my time with her. My frustrations arose from failing to meet my expectations, from feeling underappreciated, and from watching the neglect of what I considered to be my handiwork.

Despite these gulfs, a connection had indeed existed between us. We’d shared laughter at the incongruity of those cotton clothes, or holding my massive shoes next to her miniscule pair. There had been effort on both our parts to communicate. As I practiced Kaq’chikel, she attempted Spanish, and we had comfortably bantered in this middle ground. When she thanked us for food and gifts, I was sure her gratitude was always sincere. She most likely had tolerated my presence and interventions far beyond her own intuition or comfort.

It is hard to avoid feeling a sense of guilt and failure regarding entire affair. Yet I hope my experiences will allow me to better navigate conflict-fraught aspects of patient care most in the future. Thanks to my experiences with Doña Paulina, I have been able to put considerable thought into working across cultural barriers and trying to build relationships with reluctant patients.

The concept of compliance is a rife with paternalism and inequality. Yet as much as clinicians try to rebrand the phrase, the problem it represents – a breakdown in the patient/physician relationship – are all too common. The potential for such conflicts increases significantly when medicine serves as the tenuous link between parties of remarkably different cultures or backgrounds. It is not necessary to travel abroad in order to experience such divides. While practicing almost anywhere in the US, most clinicians will interact with patients from different cultural or socioeconomic backgrounds. The book The Spirit Catches You and You Fall Down, by Anne Fadiman, chronicles the history of a Hmong girl with epilepsy and the inability of her Californian doctors and Laotian parents to see eye-to-eye. The story is described as one of the most contentious and tragic in the hospital’s history. It is a perfect example of how easily medicine can break down at cultural interfaces, and how destructive the results can be.

It is true that I knew almost nothing of Doña Paulina’s world view. Mayan culture in rich is superstition, mythology, animism, spirituality, and magic. Curses, witchcraft, deities, ancestors, the calendar and heavenly bodies all hold enormous portent. Our nurse practitioner, who has studied and practiced western medicine for decades, still believes that a menstruating woman give it the evil eye to infants, for example. I wish I had spent more time inquiring about her beliefs of the cause and cure for her wound, or explored her worries and concerns.

As the patient-caregiver paradigm so often invites, our contact was founded on dependency and inequality. At times our interactions have brought out my most judgmental, ethnocentric, and patronizing characteristics. Yet she has had a deep transformative effect on me. I’ve felt humility, frustration, elation, and sorrow in her presence. I have enormous respect and affection for her. I am sure, through my retelling, our history will seem to oscillate between comical and tragic elements. Yet for me, the proceedings resonate with a sense of dignity. I hope I was able to extend some comfort into the years of a formidable individual. I wish that I had been able to do more. I am determined not to rewrite our history to my benefit, but to honestly learn and gain from our interactions. Above all, I am grateful to have been able to play a role in her life.

*

* 2. Preisträger: Ascona Prize for Medical Students, International Balint Congress Philadelphia, September 2011