Its Easier To Say Yes

Haruna Choijilsuren

“Doctor, is what I am feeling from the medication?” the patient asks. 

“Yes,” the provider responds. 

Then our patient, Jane, nods hesitantly and continues to stare at the fluorescent lights. You can see her anxiety beading her forehead, her grip tightening on me. Her husband has not entered the operating room yet.

Moments later, the provider addresses the rest of the room and says, “Well, the right answer is no, but it’s easier to say yes.”

This was yet another moment of frustration and disappointment I felt during the day as part of Jane’s care team. Regardless of specialty, training level, gender, or ethnicity, several providers overlooked Jane’s concerns and dismissed her as having limited health literacy. Her desire to have only female providers was seen as restrictive and “difficult to work with.” Her reluctance to move towards a cesarean delivery was seen as “unable to understand” her circumstances. Providers talked about her—outside of her room, at the nurses’ station, in the resident workroom, and in the hallways. 

As an institution, we talk about cultural humility and understanding. We encourage curiosity about one another and about our patients. Yet we do not adequately put this into our practice. 

Jane’s desire to have female providers was rooted in trauma. Childhood trauma of genital mutilation, trauma of intimate partner violence, and many other things that we do not fully know and do not need to know to respect her wishes. No one is, nor should be, required to defend their wishes for trauma-informed care. Despite her past experiences, she also understood that having only female providers would not be entirely possible, but something that we could strive for. She only wished for us to understand her, to empathize with her, and to be considerate. 

Yet I worry that we failed her. 

Despite being informed about her wishes and about her history, male providers barged in routinely. We often had little time, if there was any, to help cover her up. Towering over Jane, a woman exhausted from labor, they stood with their arms crossed and spoke at her. They were understandably concerned about her labor progression and wanted to discuss moving towards a cesarean delivery. They repeatedly explained what necessitated a cesarean delivery and the details of the procedure. Each time Jane refused to sign the consent for the operation, the providers would get frustrated and talk about how she did not understand the implications this would have on her well-being and the well-being of her unborn child. Within the confines of other providers, they would regard her like a child, unable to understand her own circumstances. 

If we had only listened to her more closely hours earlier, we would have been able to answer the one question that she needed answered most,

“You said I couldn’t get surgery for my genital mutilation because my chronic condition made recovery dangerous for me. Why is this surgery okay, but the one I begged for wasn’t? What’s different now?” 

If we had not spoken over her or interrupted her earlier, this could have gone differently. This was not Jane’s first pregnancy nor her first delivery. She was a mother already, and had years of experience managing her condition while going through childbirth. She understood far better than anyone else what the stakes were for her. However, she was receiving conflicting information from both her obstetrics team and gynecology team. The two teams were not on the same page. Her delay in care was not merely from her hesitancy but rather from ineffective team communication. 

To further complicate the situation, Jane communicated with us through interpreters. 

It would be easy to blame the interpreters and claim that this delay resulted from having bad interpreter services. Yet, this problem did not exist for every provider. Some providers communicated effectively with Jane, relayed her concerns, and answered her questions dutifully. They did not consider her case to be “complicated by language barriers.” They did not see her preferred language as a hindrance or annoyance. Nor did they do her a disservice by lying through the interpreter so they would not have to give a detailed explanation or have to answer any additional questions. They gave her interpreter time to relay what they had said. They asked Jane to repeat her understanding so that we could ensure our information had been relayed correctly, and whenever necessary, they asked Jane to repeat her questions so that she was heard. 

As a learner and as a human, I was deeply disappointed about what I had seen that day. It was not the norm, but it was not a rare case either. Furthermore, I was disappointed that it was not appropriately addressed by other members of the care team, even as shifts changed. The story of Jane being difficult, stubborn, and having low health literacy was perpetuated across several patient hand-offs. There are providers fluent in cultural humility and understanding and treat patients equitably. However, many more are not. I hope that throughout my own training, the field improves.

Yes, using an interpreter takes more time. Yes, the interpreters vary in quality. Yes, it feels less personal to go through another person. However, our patients deserve to be heard and listened to, regardless of what language they speak or do not speak. And they deserve to be told the truth and not lied to for convenience. 

Haruna Choijilsuren is a third year MD/PhD student at UMass Chan Medical School and a graduate of the Medicine, Science, and the Humanities program at the Johns Hopkins University. Her interests span narratives in medicine and the human experience.