FGHL Kate Callaghan“I don’t need this test,” the pharmacist-trained, El Salvadorian gentleman told my preceptor and me, quickly dismissing our suggestion that his persistent malaise, fatigue, and chills could be secondary to an underlying thyroid condition. “I have no problems with my thyroid,” he followed, in an effort to reinforce his point. When we proposed a CBC to check for anemia, he similarly protested, pulling down his right eye-lid to remind us that he had no Conjunctival Pallor.

Despite the frustration of not knowing how to help Mr. A in the midst of his unwillingness to do these and a variety of other tests that we offered, I was somewhat charmed by his insistence. It was clear that he had no intention of simply passively agreeing to whatever treatment plan we proposed. He was not expecting some sort of pronouncement or monologue from us; he wanted a conversation.

He saw himself, with his years of experience in the medical field in El Salvador, not to mention his 69 years of living in his own skin, as an integral voice in a broader dialogue. And I appreciated that. It was, in a way, refreshing to encounter a patient who firmly believed that he was to be an actor in, not merely a passive recipient of, his care.

So for the next five to ten minutes, we continued the conversation with a series of questions: “What do you think is going on? What tests would you be willing to do? Why those and not these others?”

As he spoke it became all too clear that money was a significant barrier to him receiving the care we, as a medical team, felt he needed. Further, it wasn’t just that he was concerned about not being able to pay. He was also concerned about how the administrative personnel of the clinic would perceive him were he to go ahead with the tests without having the money to even-up with the clinic that day.

We discussed these concerns, and ultimately, after much back and forth, we were able to convince him that if he would get a few of the tests today, we would talk with the rest of our team in the clinic and ensure that he could pay at another time. While he declined a number of the labs we had hoped to draw, he agreed to a chest x-ray and to give us a urine specimen. “Thank you,” I replied.

He proceeded to go down the hall to have his radiograph, and when he returned, I had the privilege of talking through what we had (or in his case had not) found. I then reconvened with my preceptor, and she wrote a prescription for an antibiotic to treat Mr. A’s urinary symptoms.

As she handed it to me, she said: “I want him to see cardiology in a few weeks. Do you think he’d be willing to do that?”

I replied: “I think the fight is over for today. Trust is a powerful thing.” And I believe that really is true. Somewhere in the midst of the back-and-forth and the battle, somewhere something in Mr. A shifted. I don’t think it was anything we said, really. I just think at some point, in our showing up for him, in our willingness to hear him out, he decided to trust us. That, trusting rather than resisting, became his active role in our dialogue.

I left the encounter mindful of two key ideas that I hope to take away from my time with Mr. A: 1) To build trust takes time. Of course, often this trust is built over years of seeing a patient, but this interaction with Mr. A was a reminder to me that the time given to a patient in a single visit can also, in a different but similarly powerful way, build trust. 2) Trust, whether active or passive on the part of the patient, is what gives me the privilege to try to care for another. What makes me worthy of that trust?

Kate Callaghan is a Frist Global Health Leader working at the Siloam Family Health Center with refugee, immigrant, and other underserved individuals.