Wednesday, October 12, 2016

The Palestinian Medical Referral Process: A Study of Process in Process

Erica L Nelson
Resident in Emergency Medicine at Massachusetts General Hospital and Brigham and Women’s Hospital

October 9th, 2016

Sandwiched in between Rosh Hashanah and Yom Kippur, volleying between Jerusalem, Hebron, Ramallah, Nablus, nine different hospitals, multiple check points, cups of mint tea and strong coffee, Arabic, English, Hebrew, check-point, vibrant market, dingy office, immaculate NICU and disquieting ED, I find myself in a (needless to say), politically tricky situation. In a context wherein the origin of a mashed chickpea dip is contentious, I somehow have the audacity to attempt to examine the Palestinian/Israeli medical referral process. Even writing a blog post about it, trying to to craft each word to be perceived as politically neutral, is giving me tremendous anxiety.

Perhaps a year ago, when this project to study and potentially improve the Palestinian medical referral process started to take on solid form, I knew how wrought it would be. A feasibility assessment in January uncovered numerous interpretations of the non-standardized, untracked process that brought a Palestinian patient to East Jerusalem or Israel. A several month-long struggle with Western-trained empiricists trying to lend statistical validity to a study that inevitably could be nothing more than convenience sampling stalled international IRB processes. Imperative, quantitative data lay in distant hands, on paper, in spreadsheets, awaiting data-sharing negotiations before the woeful process of cleansing and justification even began. And politics colored every word and movement, document, grant application, border crossing and hospital visit. Nothing about this is easy.

And that, nestled beside simple human compassion and lofty Hippocratic imperatives, is why it is so compelling. The delivery of healthcare or, in this case, the delivery of patients to healthcare, is complex, context-bound, political and socio-economic. Systems that efficiently and effectively deliver healthcare, whether it be a Public Health Department or an Emergency Department, a ‘medical mission’ or a longitudinal development initiative must continuously examine the environment that surrounds their patients and their institutions. Any initiative, study, treatment plan or discharge that ignores context, will at very least lack generalizability and at worst, fail.

This reality, as an intellectual concept, is easy to understand. But the cognitive and logistical burdens it creates, the resources and time required to complete a comprehensive needs assessment and contextual analysis (of a system in crisis or a patient in crisis) often feels insurmountable. More than the tangible Likert-survey distribution and database creation, the logistical regressions and geoanalytics, this experience has been about tenacity, continuous re-calibration and humility. Whether it be in a Ministry of Health meeting or in Acute Bay 1 at Massachusetts General Hospital, these are the attributes that I must take a moment (to breathe) and summon.

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