These past few months I've spent time in clinic at the Men's Jail for my Fall term rotations. It felt as if I was living a weekly TV show. If you can imagine jail cells, guards, locked units, thumb prints to open doors, and inmates in orange, red, or padded in chains and cuffs. Some un-kept, aggressive and anxious. Some you would never have known were drug abusers, burglars, or murders. That was my reality and at the core of each individual was a human being that needed care.
The medical practice in jail had many restrictions. Many times the patients would request narcotics, pain medications, sleeping aids, or anti-anxiety medications. All of which had strict constraints and were virtually never prescribed. Working under restriction, I had to be creative. During my time at the Men's Jail clinic, I developed a format that broke down barriers, instilled self-control and empowered the inmates to make the right decisions.
1. The Art of Code Switching
After working in the ever changing health care field for more than a decade, I can rely on one thing being consistent, that all patients come from different walks of life. Asian, African-American, White, Latino, Jewish. Religious. Atheist. Young. Old. Urban. Suburban. Well, you get the point.
Being able to code switch gave me a huge advantage. Code switching means speaking to meet a person's level of understanding. It shows cultural context and mindfulness for people's backgrounds. This opens the door to a space for individuals to step into and feel comfortable enough to trust, listen, and learn. It allows me to speak openly, honestly and be effectively heard.
At times I'd address a young man with "Hey what sup man? I'm Andy Nguyen, Nurse Practitioner student. Have a seat." I'd give the patient a dab (a friendly gesture that meets my fist to the patient's fist) and point them to chair. If I came across an older Caucasian male, I might keep it simple and formal.
When I'd have a limited English-Spanish speaking patient, I'd still use as much as my non-existent Spanish vocabulary as possible. My terrible attempt would make the patient feel better, it'd break the ice, make them laugh and surprisingly build commonality. Then on with the interpreter we'd proceed to get to the real order of business (insert laugh). Cause, let's be real.
The simple act of "trying to relate" makes the patients feel as if they are valued. It shows that I humble myself down. That I'm working with and for them. But it is a fine balance.
I always made sure to introduce myself with "I'm Andy Nguyen, Nurse Practitioner student" Providing my full name with credentials enables the feeling of being treated by a professional. It allows the patient to understand they have a guide who will help them find the solutions to their problems. Cause really, when you are seeking professional consultation, you want to be treated by a professional who acts his part. Not another joe-shmoe.
The trick to code switching is being genuine. It is not necessary to meet patients exactly where they are at but partial way makes a significant different. You can draw from your past experiences and interactions with people then bring it out in your own voice. It may not be easy for every person to constantly code switch. Sometimes it's exhausting, but with practice it has can be learned. It's proven to be a powerful tool for me.
2. Listen with intent and read-back
A huge barrier that blocks a person from listening to others is the perception that they aren't being fully heard themselves.
Ghandi said, "An eye for and eye makes the world go blind." or something like that...
True, however, if the concept of trade for trade is applied with building rather than breaking down, such as, "An ear for and ear will lead to some cheers!" (Insert cornball laugh).
The clinic appointment is made for problems to be solved and a space for the patient to voice their concerns. As I care for my patients, I always listen with the intent of figuring out "What are they trying convey to me." A patient's body language, tone, and patterns speaks just as loud as the words they are saying.
I recently had a patient tell me he didn't know what was wrong with him. Looking at him though, his rapid speech pattern, heavy breathing, and slumped shoulders conveyed to me something deeper. He told me his hypertension and diabetes were bad and that his mother had been helping him manage his conditions. However, in jail, we found that his blood pressure and blood sugar were within normal limits without any intervention.
When I told him he was doing so well that monitoring his blood pressure and sugars on a rigid schedule was no longer necessary, his aggression rose. He started yelling at me, "IF SOMETHING HAPPENS TO ME IT'S ON YOU!! I HAVE SO MUCH ON MY MIND I CAN'T THINK OF THESE THINGS. IT'S ON YOU!"
Now, here's a 31-year-old man still dependent on his mother. I could have judged him with anger or I could have looked at him with the understanding. I understood that he was conveying to me fear and the lack of control over his life.
I held my hands up in surrender mode and spoke in a stern tone, "Hey! I'm on your side. You can blame and point the finger on me all you want. But this is for you. This is not for me and I'm not taking anything anyway from you. You know, I sense, you are somewhat afraid. Is that what you're feeling?" He backed off, and nodded his head "yes."
After I've allowed my patients to voice their corners, I follow-up with the read-back. I learned the best way to help demonstrate to the patient that you've heard them is to repeat what you understand. I repeat the main important points of their concerns, then add my thought process on how to treat their concerns. It helps the patients feel they are included in the process. When a patient is able to vent out their concerns and feels heard, they are able to clear space for the information you provide them. The education pieces offered tends to touch the patients in a more effective and deeper manner.
3. Offer positive re-enforcement and encouragement on the process for improvement
This may seem like common knowledge, and it is. What I want to touch on in this section is what it means to the clinic appointment.
When a patient divulges their concerns, they release that negative energy built up from dealing with their health issues. Offering positive re-enforcement and encouragement changes the dynamic of the clinic visit into a lighter environment.
For example, I'll use the 31-year-old inmate mentioned in the section above. After redirecting the conversation and acknowledging his feelings of fear and lack of control, I followed up with encouragement. "Man, Your blood pressure and blood sugar are incredible and have been for some time." This opened him up to tell me about his journey. He had lost 30 pounds within the last year, quit smoking cigarettes, quit drinking alcohol, started exercising and eating better. Again, I used these bits of positive information to re-enforce and encourage him. They also became strong selling points to the plan of care.
I always strongly recommend for my patients to focus on their process for improvement rather than get fixated on the numbers. Don't get me wrong. Blood pressures, blood sugars and weight are great benchmarks for success and correlate with one's health. However, for the patient, having a stronger focus on the not eating fatty or processed foods, low salt diets with high nutrients, ensuring adequate exercise, minimizing alcohol intake and never picking up another cigarette will lead to lower blood pressures, lower blood sugars, the reduction of weight and ultimately a healthier and happier person. The numbers just help for tracking progress. The process is what will lead to the goals.
4. Hold space and Re-frame
Everyone is at different points in their own process. As important as it is to help guide and provide a patient direction, it is just as important to hold space for them until they take that step forward on their own.
This concept is one of the most difficult practices to consistently offer. After providing information, holding space enables the time and the room for the patient to accept and carry out the changes they must make in order to progress in their own process for improvement.
There is no exact formula. Everyone is different and requires different spaces. However, I always like re-frame the mindset of my patients by using the "cork in the dam" analogy.
I tell my patient that we can give them medications but it's only going to be a cork in the dam, that if they truly want to fix their problems and fix the dam, they need to get to the root cause. For the most part, medications can buy them some time, much like the cork can, but eventually the dam will still break. They need dig deep from within the dam and change habits. That's what's going to fix them.
It was with that 31-year-old inmate, who's story I've been telling, that I had this realization. It was at the very end of our clinic visit that he asked about anti-anxiety medications and sleeping aides. Now, with the restrictions we have in the jail, there was virtually no way I could prescribe any medications that would help. So working under constraints, I had to be creative and think "What does he have already that would help?" I looked back at own struggles and what has helped me through out the years. It was meditation that had provided me with the mental toughness, fearlessness, and calmness that I needed to persevere.
So I preceded to share my experiences with fear and quieting the mind in order to persevere. I started to explain the process of mediation breathing and had him perform the exercise with me during the appointment. The dialogue went something like this.
- "I know it sounds a little weird, but mediation is the thing that has helped me the most."
- "What I do, is I first breath in and count the number 1. Try it." (We took a breath in and we counted 1 together).
- "Then I breath out and I count the number 1 again. Do it with me." (We took a breath in, counted 1, then exhaled and counted 1 again).
- I explained. "For each breath, I listen to the whole sound for each in and out from start to finish."
- "Then the next one I'll count the number 2 for both the breath in and breath out. Do it with me now." (We took a breath in, counted 2, then we exhaled and counted 2 again.)
- "Then the next one I'll count the number 3 for both the breath in and breath out. Do it with me now" (We took a breath in, counted 3, then we exhaled and counted 3 again.)
- "And I do this counting my breaths all the way until 10."
- "The idea behind these breaths are that the inhaling is to be thankful for the simple act of breathing. And the exhaling is the release of all fears, stress or negativity that you might be feeling."
- "It's harder than it sounds, but in time, the more you do them easier it will be. You'll able to clear your thoughts and focus simply on breathing. It's like a marathon, you won't be able to just run it tomorrow, but with practice you'll get. Just keep on practicing it regardless."
- "Do the mediation breathing exercises at least once a night. If you can do it when you wake up too and during the day if you have time."
Immediately, you could feel the tension in the room lower. The energy changed. The patient looked more calm. Even I, myself, felt more calm. By demonstrating effectiveness of the breathing technique during the clinic visit, I sold my case for meditation.
I saw the same patient a few weeks later sitting in the jail corridor awaiting his psychiatrist appointment. He looked different from when I first met him. No longer was there an inmate with a rapid speech pattern, heavy breathing, and slumped shoulders. Instead, there was a 31-year-old man who looked at peace. I spoke with him.
- Me: "How you doing, man?"
- Inmate: "A lot better."
- Me: "Yeah? You look like you're feeling a lot better."
- Inmate: "Yeah man, I feel more calm, less worried. I don't feel so scared anymore."
- Me: "What changed?"
- Inmate: "It was actually your breathing that you taught me. Man, I've been doing that every night. I'm able to count to 20 now and I can clear my thoughts. I don't have so much on my mind anymore and I'm not worried about the things I can't control."
- Me: "Yo! That's dope, man! That makes me feel really good to hear."
When I sat back and thought about this case, I realized what I did for that 31-year-old inmate. I helped him restore the control back into his life that he felt he had lost. How I did this?
- I code switched to move pass his barriers by speaking at a level he could understand.
- I listened with intent to figure out what message he was truly conveying and I made sure he felt like he was being heard. Although he had come in for a routine check up on his hypertension and diabetes, he was really letting me know that he felt fearful and a lack of control.
- With positive re-enforcement and encouragement, I changed the energy of the environment and his own perceptions of his situation.
- I re-framed the context of control though meditation breathing. It empowered him with the tools he was born with. Through out this process, I held space for him and allowed him to take a step forward on his own.
As I spent more time at the men's jail clinic, I tried this format out. My goal was to provide these guys with the tools to build upon while locked up so when they were released back into the world, they would have been taught the tools for self-restraint and control. I found that it made my clinic appointments very efficient and effective. It became my methodology for patient interviewing.