Wednesday, September 25, 2019
Conversation as a resource in Kigali
Lara Vogel, MD
Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH,
Conversations surrounding code status and informed consent are a huge practicality of my job, and one I think I will always feel less prepared for than I should be. In the ER, I frequently give bad news, explain complex medical conditions, try to parse the high uncertainty of early diagnosis and ask for consent for treatment in only a few minutes. In another language, across a cultural barrier, with interpreters, there is of course additional layers of complexity. But even in my native language, these conversations are riddled with small misunderstandings and subtle nuance that make them difficult to leave feeling certain that we all share the same understanding of the patient’s condition and values and what I hope to treat and how.
In Kigali, I was a teacher—I could not speak to many of the patients without interpretation (Kinyarwanda was the strongly dominant language for this patient population), and I appropriately did not independently manage their care without residents and attendings involved in my decision making. However, even with interpreters I trusted and with time to talk to patients as my administrative duties were lessened, my chance for truly informed consent seemed slight given the vast distance of culture, language, and medical training between me and my patients. As a result, I often left these conversations to the residents directly caring for patients, intervening only when I thought medical care was not being discussed at all. However, I was not prepared for the additional layer of consent conversations that had to be done by the physicians prior to the patients and their families. In a relatively resource-poor setting, there was often no conversation to be had with patients and their families. When we ran out of ventilators, when radiologists would not read a study, when the lab ran out of a certain test’s supplies, when patients could not afford central line or other equipment, we did everything else we could. I personally had not prepared for the brief but important preliminary discussion that had to be had among physicians regarding the resources available at any given time- resources were a fluid and changing thing but when they were gone, there was not always an alternative to discuss with a patient.