Taking Little Steps

An older Asian man with sparse gray hair, perhaps a little taller than five feet and weighing no more than 120 pounds, is slumped in a chair in a nondescript HealthEast exam room, waiting for Dr. Shana Sniffen to visit him.

As she enters the room, he sits up and turns to look at her, but then, Sniffen smiles at him, and he quickly turns away, averting his eyes in a show of humility mixed with gratitude. Here, he seems to be thinking, is someone who can help, someone who will listen and perhaps understand.

Beside him on the clinic table are many bottles of medications — at least 15 — and it is clear that there is a great deal to talk about. His eyes are slightly glazed. He is eager to recount the latest chapter of his continuing story, a long nightmare that began years ago in Burma and rolls on like a tidal wave.

A physician’s discourse with a patient — the tone and tenor of the conversation — often lays bare not only the essential elements of intimacy and trust but also the character of the practitioner. In Western medicine, the physician holds the power and, because life and death often hang in the balance, profound questions about the use and abuse of such power are constantly being debated.

In this particular office visit and others like it, an interpreter heightens the sense of cultural confusion even as he clarifies the message. The HealthEast Clinic — Roselawn in Maplewood has a reputation for attracting and listening deeply to refugees from the Karen, Hmong, Vietnamese and Laotian communities, as well as African and Latino communities.

Sniffen, who dedicates much of her medical career to providing healthcare services to displaced people, is the physician of choice for many because she understands the needs of refugees with multiple diseases or disorders.

The following brief excerpt reveals Sniffen’s casual but thorough and humane way of conversing with a Karen refugee patient. She uses a “trauma-informed” approach with her patients, being careful not to trigger bad memories or negative reactions. The conversation here is actually a three-way colloquy in which the interpreter hears the patient’s words, infers meaning and sometimes finishes the sentence on behalf of the patient. In the excerpt below, those times are indicated by the heading “Interpreter.”

What cannot be captured in a transcript is the soothing sound of Sniffen’s voice, her measured indirectness or the sense of openness to new information that she projects. During this encounter, note the way in which Sniffen ends many of her statements with a question, which allows the patient to correct the record.

Sniffen: How has your mood been? When I saw you last time, which was a while ago, we increased your medicine. Then the nurse called, and we increased it again. Did you notice a difference?

Patient: A little bit.

Sniffen: How are you sleeping?

Patient: Good.

Sniffen: Are you having bad dreams?

Patient: Sometimes, still.

Sniffen: I don’t think you’re on the nightmare medicine any more.

Interpreter: He’s still taking it.

Sniffen: Based on your pill bottles, it looks like you’re still taking the one for sleeping but not the one that’s for nightmare, maybe?

Patient: Yes.

Sniffen: When you were here before, you were going to the Wilder program and seeing a case manager. Are you still doing that?

Interpreter: The last two weeks, nobody came to pick him up, so he hasn’t seen anyone for a few weeks.

Sniffen: You were going to the social healing group, the bigger one?

Interpreter: Just him.

Sniffen: (surprised) Just by yourself?

Patient: Yes.

Sniffen: Last time you were here, you told me that you didn’t like to tell them when your mood wasn’t very good?

Patient: I’m starting to tell them.

Sniffen: You are starting to tell them? Do you think it’s helping?

Interpreter: They are trying to convince him to go outside frequently, and he forgets to do that.

Sniffen: (to interpreter) Has he tried that?

Interpreter: No. He doesn’t like to.

Sniffen: (nodding) How is your neck and back pain?

Patient: Still there, like a few days ago, when it was getting colder.

Sniffen: You saw the neurosurgeon, the doctor that was looking at your neck and back. They did that x-ray of your shoulder and your neck. And they did the MRI? Did you ever go back to see them?

Interpreter: He never saw them again. No one told him he needed to go back to see them.

Sniffen: What I suspect is that they tried to call you, but without an interpreter, and they didn’t get a hold of you.

Interpreter: He says he has the same phone number.

Sniffen: Those doctors, when they order all those extra tests, they want to see you again so they can talk to you about what they can do to help you. Would you want me to make an appointment with them so you can go back to see them?

Patient: Yes.

Sniffen: It looks like you also wanted to see an ear, nose and throat doctor. Is that because of the ringing in your ears?

Patient: Yes.

Sniffen: But it doesn’t look like that appointment happened either.

Patient: OK.

Sniffen: When I saw you in June, we also talked to you a lot about sleeping and snoring and not breathing?

Interpreter: His sons get frustrated because he makes too much noise.

Sniffen: Do your sons say that in the middle of the night when you snore, that you stop breathing?

Interpreter: His sons say he has a lot of dreams and punching.

Sniffen: Punching? (pause) Do your sons say that when you are kicking, you are hitting anybody?

Interpreter: Just his son.

Sniffen: Do you hit your son in your sleep?

Patient: Yes.

Sniffen: Your son probably doesn’t like you kicking him. When you were here last, we talked about doing a sleep study or medicine to deal with the bad dreams. Are you interested in doing either of those?

Interpreter: He wants to start with the sleep test.

Sniffen: You scheduled it over the summer, but something happened. I think it was transportation?

Patient: No, I did not have transportation.

Sniffen: We can try again and make another appointment for this week. And then, we’ll make an appointment for the back surgeon. Also, on the 19th, you have an appointment with the cardiologist. Have you been having any chest pain?

Patient: Yes.

Sniffen: Are you taking the nitro(glycerin)? (patient mumbles) I’ll take that as a “No.” (she chuckles). When you see the heart doctor, will you tell him when you have the chest pain? ‘Cause, remember they had to put that stent in to open up that little area and protect your heart? Sometimes, when there is a problem with that it can make your chest hurt again. So, it’s important that you let your doctor know about that.  When was the last time you had that chest pain?

Patient: Two days ago. It’s just once in a while.

Sniffen: How long does it last?

Patient: About five minutes.

Sniffen: OK, and it goes away by itself?

Patient: Yes.

Sniffen: So. How about we make an appointment for the sleeping and back doctor. And you can come back and see me after you see the heart doctor…Your nurse comes every week to check on you?

Patient: Every other week.

Sniffen: If you need to get ahold of me, you can tell her because she calls me sometimes.

Interpreter: He has no transportation, so he just wants to make sure he has transportation.

Sniffen: We will try our best to get you a ride because without it, you can’t get here. You can put your medicine away, and I’ll have the nurse come in and give you your flu shot, and then she’ll take you down so you can schedule your appointment. Anything else today?   

Patient: No.

Comments by Dr. Sniffen:

“This man has some nerve compression in his neck and lower back. And, he has a cardiac stent. He has already done the spinal injection, so they referred him to the neurosurgeon to see if there was anything they could repair.

“He went (to the spinal surgeon) in August and they ordered an MRI of the neck and back and shoulder and a couple of other things and the surgeon never saw him back again. So, I don’t know what the surgeon’s plan is, but I need to know.

“He also has severe PTSD issues. Believe it or not, this is the most animated I’ve seen him in a long time. He has come in slumped over the chair in the past. Even though he says he is not doing as well, the fact that he was engaging at all is a good sign. Maybe the increased dosage on his medication has helped.

“Little steps.”