Question

What are three aspects of the case that consider new information or that offered deeper context.

What are two aspects of the case that can apply in practice healthcare field now or in the future.

What is one aspect of the case that found confusing, created question for further consideration, or which would to learning more.

This case focuses on the interaction of a physician and three families. As you read, pay attention to how Dr. Williams’ interactions with each family differ and how these different interactions could affect the health outcomes of each child. Dr. Brent Williams is having a terrible day. Medical school prepared him for the hectic pace and difficult, needy patients. And most of them don’t even have health insurance! Does nobody work anymore? Medicaid reimbursement is hardly worth the clinic’s time. It won’t be long before his blond hair will be streaked with gray. After a day in Sleep Clinic, he feels as if he has been around the world in 80 hours. Maybe he should rethink this job. But he likes practicing in Minneapolis, near his family and his buddies from residency. It's hard to believe its been a year since they completed their program. To Dr. Williams’ relief, his first afternoon patient is Johnny Reese. Today, as he enters the room, Becki Reese has four year old Johnny on her lap and is reading to him while Johnny pulls on his mother’s blond pony tail. Dr. Williams chats with Becki for a few minutes about horses, a shared interest. He then regretfully confirms that according to the sleep study Johnny’s obstructive sleep apnea (OSA) has not improved, despite having had his tonsils and adenoids out. In fact, he adds that the second sleep study was worse than the first and Johnny will need to use CPAP. Becki nods sadly, “I was afraid of that”. She listens carefully as he explains that Rita, the nurse will order the CPAP machine and mask from Pedi-delight Homecare and it will be delivered in the next few days. “It is very important that Johnny wear the mask every night”. After a few more comments, he leaves the room. Later, he is discussing the homecare equipment with Rita. Rita says that Becki mentioned she has been really stressed recently as she has three children under the age of five and bedtime is often chaotic. Rita wonders whether Becki will realistically be able to get Johnny to use CPAP on a consistent basis. “I wouldn’t worry about that, they are a nice family,” Dr. Williams replies. “It should not be a problem.” “Still,” Rita says, “I’d feel better if we saw them in a one month follow-up just to make sure.” “Well, okay,” says Dr. Williams, “they have good insurance, we can do that.”

     

As Dr. Williams enters the second room, he groans under his breath.   Another African American family. This probably means Medicaid and low adherence. No matter how long he spends with these families, they usually don’t do what he says anyway. He glances down at the chart to get the parents’ names, Fahari and Mendi Waleed. It is a new eight month old patient and her name is Breshay. “Where do they get these names?!” he wonders. He wonders why Mr. Waleed is not at work. “They are probably on welfare. I wonder how many other kids they have.” Dr. Williams figures that he might as well plunge in and asks what brought them to clinic today. He is surprised when Mr. Waleed speaks with an accent. “He’s probably from Haiti,” Dr. Williams thinks. Mr. Waleed goes on to explain that his daughter seems to stop breathing at night. She seems very quiet during sleep and doesn’t seem to be breathing very hard. He has noticed that her lips look dark at times. His wife believes someone has cast the evil eye on Breshay. “The church members wanted us to come to the clinic, but it is expensive and we thought we could fix on our own.” Mr. Waleed explained that the family consulted an oracle who conducted a ceremony in which a white chicken was sacrificed. Dr. Williams thinks to himself, “Good Heavens, those Caribbean countries are really superstitious.” He takes an inadvertent step backward. He wonders what kind of church they are involved with. After examining Breshay, Dr. Williams wants to rule out the possibility that she has central hypoventilation syndrome. “I would like her to have a sleep study” he says. Mr. Waleed looks confused and asks if this will cost money. “Don’t you have Medicaid?” Dr. Williams asks. Mr. Waleed explains that they came from the Sudan six months ago and do not have their green cards yet. Dr. Williams tries to remember where the Sudan is located. He decides not to refer Breshay for a sleep study, but tells the family if she becomes symptomatic, they can go to the emergency room. Telling Rita about it later, he says, “With no insurance, there is really nothing that we can do. They didn’t really want healthcare anyway.”

Bao, Chi, and Duong Phan are sitting quietly in the examining room when Dr. Williams rushes in. “Oh geez”, he thinks to himself, “I have to get to Seminar by 5:30 PM and I’m already running an hour behind. I’d better make this quick.” He turns to Chi Phan and says hurriedly, “So, Mom, we have the results of the sleep study. As we thought, it is OSA. His AHI was 120 increased in REM to 250. He had long periods of hypoxemia and hypercarbia. He is at risk for pulmonary hypertension with these results. I doubt that an adenotonsillectomy will adequately treat his problem. The most rapid and effective treatment at this time is CPAP with a Cflex of 3. He may need to tolerate a nasal interface, but if he develops a significant leak we will change him to a Quattro full face mask.)   Chi looks at Bao, who says tentatively, “face? A mask?” “Oh shoot”, Dr. Williams thinks, “here we go again, this is going to take forever.” He figures the mother must be a little slow – she isn’t saying anything. Or maybe she doesn’t care about her son. Dr. Williams responds loudly, “It - will – help - your - child – keep - breathing”.   Frustrated, he decides to proceed with some more questions before trying to explain anymore. When he asks about any medication that six year old Doung is taking, Bao replies that he is not on anything right now. Bao says that their pediatrician had prescribed Ritalin but his wife tried it before giving it to Duong. It made her feel funny, so she decided not to give it to him. Dr. Williams resumes trying to explain OSA and CPAP to the Phan family. He explains it as clearly as he can, but cannot understand why they are not saying anything. “It must be that they do not want to do this,” he thinks. Agitated, he puts his hands in his pockets and starts pacing. Finally he sits down again and says in exasperation, “Well, if you don’t use CPAP, you’ll have to get a trach”. As he says this, he points to neck and demonstrates a hole. He asks, “Do you understand?” Bao and Chi nod politely. “OK, so we’ll order the CPAP and you can do that,” Dr. Williams finishes. He tells the family that the nurse Rita will arrange to have to equipment delivered. As he leaves, Dr. Williams, one hand still in his pocket, hands the checkout sheet to the family. He finds Rita and says, “I want you to call the social worker and see about a referral to child protective services. This Mom is clearly not involved and her tasting the medication is truly bizarre. On their way out of the clinic, Bao tells Chi that he will consult with his mother and father over Duong’s medical problems and will talk to the Buddhist Temple performing a ceremony before considering any medical procedures. “I think we should ask our friends for the name of another doctor, I do not want to come back to this rude place.”

Following clinic, Rita walks to the parking lot with the receptionist, Mary. “I’m really worried about Brent’s approach. There’s so much that he doesn’t know about different cultures let alone dealing with children. He makes such assumptions.   By assuming that the Waleeds are African American, he overlooked the stresses they may have had in emigrating from the Sudan. When he found out they didn’t have insurance, he just blew off the issue of a sleep study. He could have asked the sleep lab to at least do a daytime nap study monitoring sats and CO2. Some times the sleep lab will do that for free, but he didn’t even check. And he never asks for an interpreter. He uses such technical medical terms and doesn’t worry at all about the families’ health literacy.

When we had that cancellation at 4:30, I looked on the internet to learn more about Vietnamese culture. You won’t believe what I learned! Brent really blew it. In Vietnamese families, like the Phan’s, it is impolite to seem loud or in a rush. Also, in their culture, one always addresses the man, not the woman, and its not at all unusual for mother’s to test their children’s medicines. In some parts of Asia, there is inadequate regulation of medicines, or none at all, so mothers do this precisely because they want to protect their children. Worst of all, in Vietnamese culture it is considered downright rude to put your hands in your pockets or hand a form to someone with just one hand. I wish he would look on the internet, or ask families, or use a culture broker.”

Rita sighs, “I’m just so worried that many of the families we see are not getting good care and won’t do well, through no fault of their own. Mary agrees, “As an African-American woman, I think I’d have problems with him. There are so many ways his approach would just get us off on the wrong foot.” Rita decides to talk to Dr. Williams the next day. When she calls to see if there would be a time they could talk, she is pleased to hear him at least say, “Boy, you know, I really thought a lot about my day today on the way home. This can’t be the best way to do things.”

Answer 1

What are three aspects of the case that consider new information or that offered deeper context.

1.Many people don’t even have health insurance.

2In Vietnamese families, not at all unusual for mother’s to test their children’s medicines

3. M of the families are not getting good care and won’t do well, through no fault of their own

What are two aspects of the case that can apply in practice healthcare field now or in the future.

1.Teach health care professional about the different culture and they are taking care of people.

2.We can provide some emergency care to non insurance patienyt. Which will help to save few lives.

What is one aspect of the case that found confusing, created question for further consideration, or which would to learning more.

Understanding different culture and how they are acting to a disease or how they are behave to strange is very important in management of a case and understanding the patient. Studying the different geographical culture will help to improve the quality of health care.