Confusion Immersion

In the past two weeks since I arrived in the Dominican Republic, I have spent more time confused than in the last five years of my life.

Sometimes I don’t understand what people are saying, the conversation flashing past me in accelerated Dominican Spanish. Sometimes I don’t understand what people are doing: I follow people when I’m supposed to stay where I am just as often as I stay where I am when I am supposed to follow. But, worst of all, nearly all the time, I don’t understand what people are thinking.

This is not all together an unfamiliar sensation. I experienced this kind of confusion when I lived in South Africa, when I visited Santiago earlier this year and often when I interact with patients from various cultures and with variable levels of health literacy in New York City. But in recent years, as I have become more comfortable as a doctor and, really, as an adult, these times when I have felt completely out of my element have become increasingly scarce.

A worthwhile return to the basics

Though I don’t have this sensation as much as I used to, in the last few days, I have come to the conclusion that surrendering to my limited ability to understand the motivations of those around me is liberating.

Here is a example from last week: I attended a teaching conference for Geriatrics residents at the hospital where my rotation in based. A resident was presenting on an article from a medical journal. She began with the title of the article, an unbelievably long phrase which I could barely finish reading before she was onto the next slide. Soon after, however, she was interrupted by Dr. Medrano, the head of the residency program who sits in on most of the conferences. I didn’t catch every word that he said, but he seemed annoyed and then she seemed embarrassed and apologetic. As her presentation went on, he continued to interrupt her with questions and comments. At the end, he made a summary statement about the poor quality of something; this seemed to refer to the article, but also might have referred to the translation of the article or to the presentation.

Throughout the thirty minutes of the presentation, my mind was flitting all over the place trying to interpret what was going on in front of me. Was the resident unprepared? Was Dr. Medrano being malicious? Was this the usual teaching style for medical presentations in the DR? Or, was it something completely different, like the article was bad?

Despite my confusion, I noticed I was extremely engaged in trying to interpret what was going on. I used all sorts of observation techniques that I don’t often call upon explicitly when I’m in a comfortable situation: I paid close attention to facial expressions, body language, the reactions of the others in the room to the back and forth between Dr. Medrano and the resident. I’m sure these kinds of observations factor into my understanding of all situations, foreign and otherwise, but the way in which I was using them consciously made me realize how often I don’t listen to these observations closely enough.

If I had witnessed this situation at Columbia, I might have observed only for a minute or two before deciding that the resident was inexperienced or unprepared, or that the attending was a particularly engaged teacher or just cruel. Because I don’t trust my judgments here in Santiago, I kept my mind open to observe the situation for much longer.

In the end, was I able to reach a conclusion on what was going on? No. But I did succeed in lengthening the list of possible factors contributing to the interaction: the journal played a role, the translation, the structure of the presentation, the resident, the audience, the attending and on and on. As I participate in these teaching conferences during my time here, I can take this list with me and both refine it and, inevitably, expand it, as I continue to try to make sense of everything new and unfamiliar I am observing.

Taking this message home with me

There is an obvious parallel between my attempts to understanding the motivations of individuals in this foreign setting and my similarly challenging attempts to understand my patients in New York City who come from vastly different backgrounds. In my outpatient clinic, when I urge my patients to follow my instructions (to take their medication regularly, to check their blood sugar, to follow a particular diet), I know I often jump to conclusions when things don’t seem to be going well:

This patient is never going to understand how important it is to take their blood pressure medication.

This patient’s life at home is hopelessly complicated and preventing them from following a healthy diet.

This patient clearly does not believe a word I’m saying.

These interactions are layered with complexities that I cannot even begin to characterize—language, education, culture, life at home. Yet, I jump at the chance to label the reason behind my failure to communicate even when I know there’s a good chance there is much I don’t understand about the lives of my patients. My experiences this past week have made me think that I need to surrender more to my inability to quickly and easily understand my patients.

When I know things are not getting across, I need to acknowledge it and tell myself it’s possible I do not possess the tools to understand exactly why. If my time here is any indication, I should then be able to continue to brainstorm the reason behind the obstacle. Rather than shutting down the process before I get anywhere, I can put it on hold until my next opportunity to interact with the patient and keep thinking broadly. Ideally, this approach will enable me to catch the opportunities that do pop up for improved understanding of my patients. If nothing else, I will stop fighting the confusion and stay engaged in the conversation.