I don't often get to sit in with Dr Rusty while he sees patients in thyroid clinic - which means I miss out on some interesting stories. Nurses are often too busy screening patients, taking blood for tests, or scheduling follow-up visits to sit and listen to a physician's interaction with a patient.
Luckily, this week I happened to pop in on a situation that illustrates the complexity of being a physician in Cambodia. Two weeks before, we'd seen a middle-aged woman (we'll call her "Syna" for a possible overactive thyroid. We took blood to check her thyroid hormone levels and told her to return this week. When she came back, Dr Rusty asked about her symptoms again. Her blood test had shown the opposite of what he initially suspected - a very under active thyroid. Syna then proceeded to take an envelope out of her purse and show Dr Rusty blood test results, done two weeks before her first visit with us, and a box of thyroid medication that another doctor had given her. She explained that about a month ago, she had seen a Cambodian doctor, who ordered the same blood test we ordered two weeks later, and gave her medication to treat her slightly overactive thyroid - the same medication we'd have given her, had we seen her at that time.
We asked her, a bit bewildered, why she hadn't told us this when we first saw her.
"Oh, I didn't dare - I was afraid!"
"Afraid of what?"
"That you'd be angry - or maybe that you wouldn't understand because you weren't using a translator."
Now, Dr Rusty has worked in Cambodia over 14 years and speaks fluent Khmer (Cambodian language). The entire conversation was in Khmer. But for some reason, at her first visit with him, she "didn't dare" tell him she'd actually seen a different doctor and was taking medication for her thyroid. Dr Rusty explained to her he wasn't angry, but he could have diagnosed her wrong and given her the wrong medication if she hadn't told him everything.
Unfortunately, her fear of the doctor's wrath may have been partially justified. I have heard so many stories of Cambodian physicians becoming angry with patients when they seek a second opinion or even ask questions about medications, because they feel their authority is being threatened. What, you don't blindly trust me enough to take this without question? You can go find another doctor you like better is a common response among doctors who don't have appropriate respect for their patients and are motivated by the money they're making than by the people they are helping. This attitude is not characteristic of every Cambodian physician, but it is common enough that patients feel intimidated by all doctors - and especially doctors whose skin is a different color and speak Khmer with an American accent. This doesn't exactly encourage patients to be honest with their physicians about their anxieties or confusion, and it can also cause patients to withhold information with possibly dangerous consequences.
Happily, Syna came clean about her other doctor. She decided to stick with Dr Rusty, as his clinic was closer to her home, and we were able to give her the right medication - and not the one that would just exacerbate her condition. I wish this was the first time we'd had a patient intentionally leave out important details when talking to us about their health, but it's not. Patients aren't always completely honest with their healthcare providers for a variety of reasons - I'm sure this surprises none of the medical professionals reading this!
This story illustrates why it is so important for those working overseas to understand all the cultural nuances that affect how patients view us and communicate with us. It takes a lot of patience and language study to reach that understanding - as well as a willingness to ask the same question over and over to the same patient and not act surprised when we get different answers!