A piece of my mind. Je vais le faire.


Je Vais le Faire EVER SINCE MY NEIGHBOR PUT A CURSE ON ME.” ALthough the man was 64 years old, the skin hanging on his face, the muscles melting off his bones, and the heaped-up pterygium on both eyes made it seem like his body had been through many more. He was sitting on the middle rock-step of the three-step stoop outside his small oneroom hut. His house was at the end of the row, in a corner of the village far from where people would gather for markets, for celebrations, for arguments. The child who had led me there from the village center gave me a small, handmade three-legged stool to sit on, which put me just below eye level with the man. The child stayed to listen, having earned the right. Of the three of us, I was the only one sweating and the only one wearing shoes. The man had lymphedema of his legs, likely due to past infection with lymphatic filariasis, which is endemic in his native country of Togo. I was on a five-week project spanning the entire country, where our team from the Centers for Disease Control and Prevention was performing an evaluation of the national lymphedema morbidity program in which this patient, along with hundreds of others, was enrolled. His condition was chronic and severe, the highest stage on the World Health Organization’s clinical grading scale. “How long ago was that?” I asked, trying to get a better sense. The man delivered sentences slowly, making it unclear if he was tired, frustrated, or unable to find the words in French. “I stepped on a nail while farming in the village where I grew up. I moved away from there 15 years ago so it was before that. A long time before that. My legs have been swollen a long time.” I continued on through my CDC interpreter, hoping that the child could translate any village dialect from French if necessary. He went on to explain that as part of the treatment for his puncture injury, his neighbor—a traditional healer in the village—had prepared a tincture of herbs and grass for him to rub on the wound. Only later during the rainy season, when his leg ballooned to twice its normal size, and after he and the healer had an argument about an unrelated issue, did he realize that he had been cursed. He had markedly edematous legs up to his knees, his skin taut at the ankles in places where there weren’t deep folds, old and new ulcerations throughout his calves, and buttons on the dorsum of his feet. He disregarded a swarm of flies around his raw skin. It was fairly obvious that he wasn’t following the treatment outlined by the program of leg exercises, elevation, and washing. For completeness, though, I asked him. Without apology or shame, the man said that he hadn’t been, because he found the treatment difficult, and because he didn’t see how the prescribed treatment would help to fix his cursed legs. Two months later, I was back in the United States as a fourth-year medical student on my emergency medicine rotation. With culture shock finally fading, I stood before a patient who’d presented with a “fall-down” headache and a blood pressure of 220/140 mm Hg. After stabilizing his severe hypertension, we eventually talked about his medications and diet. While he didn’t bring up any evil charms, the salient discussion points were the same as the old man I had spoken with in Togo. In both cases, patient education was the critical means in convincing these men to adhere to their treatment plans. For us, this is the gateway tool—the one that is required before patients will allow us to use all the other gadgets we enlist to fix disease. Hammers, nails, levels, and drills are great, but you still need a key to unlock the gate to the construction site. The first step is figuring out what your learner needs to know, the “facts” of teaching. Almost universally, classroom teachers will tell you that mastering the what is the easy part. The same is true for medicine—as a medical student, I heard a thousand variations of the line “By the time you are done with residency, you will have no problem diagnosing and treating disease. The hard part is all the other stuff.” The “other stuff” is the most important part of being a good teacher. It’s also the most difficult and most subtle. This advanced role of an educator is the how and the why: figure out how to make the student understand why the information is important. Two contrasting examples of different learners: My 84year-old immigrant grandmother takes her 14 medications, pill by pill, every morning, because she culturally views physicians in a very specific way. For her, teaching is all of “This is important for your health, Ann.” On the other hand, one of my medical school preceptors gave each member of our small group several plastic storage bags full of candies— some had M&Ms, some Skittles—and went around the room with our individualized treatment plans. “Barb, you have diabetes and high cholesterol. Here’s your glyburide and here’s your simvastatin. Take one of these every morning and one of these before bed.” We had to stick to our “prescriptions” for a full month. It was tough. Most of us would’ve been labeled “noncompliant” at the end of 30 days.

DOI: 10.1001/jama.2011.1411

Cite this paper

@article{Ziperstein2011APO, title={A piece of my mind. Je vais le faire.}, author={Joshua Charles Ziperstein}, journal={JAMA}, year={2011}, volume={306 13}, pages={1418-9} }