Instructional Strategies: Case Studies

Case Study 1

Case Study 1

A geriatrician is working at a Veterans Affairs clinic. He sees a new patient, an elderly Native Hawaiian whose blood sugar is 400 mg/dL, and blood pressure is 220/150 mmHg. The patient has some difficulty walking because of arthritis in both knees.

The blood sugar and blood pressure are so high that the geriatrician wishes the patient to start treatment immediately and to return to the clinic every day until he is certain that the conditions are under control. The patient listens carefully, but seems hesitant.

He rarely leaves his home. He has never had health problems before except for knee pain and currently feels fine. He came to the clinic today only at the insistence of his granddaughter. He is unsure about a return visit.

Questions for Discussion What might the geriatrician do?
Answer: The geriatrician should consider asking the patient if it is all right to bring the granddaughter into the office.

The physician asks the patient if the granddaughter can join them in the exam room. The patient readily agrees. The granddaughter is willing to bring her grandfather back and to supervise the medication administration. However, she works most days and this is her only day off this week. In addition, he is home alone until the grandchildren come home from school.

Questions for Discussion What might the geriatrician do?
Answer: The geriatrician may want inquire as to the availability of any other family members or suggest a family meeting to address how to best manage these potentially life threatening problems.

The physician discovers that all of the family members work or go to school so he suggests a family meeting. The granddaughter agrees to try to arrange one for next week. In the meantime, she will try to take a vacation day tomorrow to bring him in. The geriatrician sees the patient in the office the next day. The patient seems more relaxed. He asks the physician many personal questions about his family, where he lives, where he grew up and things that he cares about, and yet seems disinterested in the physician’s academic/medical credentials.

To the physician, this feels like an invasion of privacy, but he goes along with it because he is so worried about the patient’s condition. The patient is excited to find out that his aunt is a next door neighbor. He visibly relaxes, agrees to take the prescribed medications and is willing to be enrolled in the Veterans Affairs’ Home Care Program.

Questions for Discussion What happened in this encounter?
Answer: To many elderly Native Hawaiians, trust must be established before deciding whether or not to accept your proposed treatment plan. Traditionally, treatment provided by a native healer involved spending time to get to know the person, not only the disease. Treatment was accomplished within the context of knowing the whole person, and was often highly effective. This allowed the patient and the practitioner time to establish trust and show respect. This process is often impractical in a western medicine clinic. In this case, a good alternative is the introduction of a home care team which can be effective as long as team members feel comfortable sharing some personal information about themselves and are willing to spend the time needed to educate and explain the treatment plan. Health care providers may also find that involving family members and setting aside some extra time to focus on the patient’s concerns will be time well spent.