I received a message from the front desk. “I have Dawn Davis here saying she has an appointment with you at 11:00. She is not on the schedule, but she has a card with the appointment time.”
I responded, “I will see her now.”
Dawn was a quiet Black woman in her late 60s, small in stature, with chronic suicidal ideation, who permanently stared at the ground during our visits. At her last primary care physician (PCP) appointment the Mobile Crisis Outreach Team (MCOT) determined she did not meet criteria for hospitalization. I fully expected to focus on establishing a trusting relationship while talking about suicidal ideation in our appointment.
Dawn lumbered into the room and lowered herself into the chair. Her muscles were tight, mouth squeezed shut, head cast down, and PHQ-9 in hand. I thought, it makes sense she is upset after MCOT and the schedule mistake.
“It is good to see you again, Dawn. Thank you for coming in. I am sorry about the schedule mistake. I’ll take that questionnaire from you and we can get started.” I anxiously zeroed in on question 9 about suicidal ideation. It was blank.
“I noticed you left question number 9 blank. Are you having thoughts of being better off dead or hurting yourself?”
She gritted her teeth and slowly answered, “I don’t like questions.”
At that moment questions were all I had. Is she at risk? Does she have access to means? Do we need to hospitalize? How am I going to find any of this out without asking? So, I asked another question, “Are you worried that you might be hospitalized if you answer?”
Silence.
I recapped our discussion from the last visit. “If you are having thoughts of killing yourself that does not mean you would have to be hospitalized. We can figure out the best option for you to stay safe.”
It was my turn to be tense. I took a deep breath, and I said to myself, ok Brittany, I know you have a lot of questions, but if you ask them there is good chance you won’t get answers. You will create resistance and ruin rapport. I needed to focus on relationship building before I returned to assessing safety and updating her crisis response plan established in prior visits. The motivational interviewing (MI) mantra, “Roll with Resistance” appeared in my mind. I recapped the MI technique of OARS (Open-ended Questions, Affirmations, Reflective Listening, and Summaries). Before I spoke again, I reminded myself: don’t use the open-ended questions!
“I can understand it might be scary to answer that question, especially after your last appointment and your experience with hospitalization in your 20s.”
After a long silence she answered, “I am afraid of saying the wrong thing.”
I reflected, “You’re afraid of saying the wrong thing that might get you into trouble.”
She said, “My family always tells me to not say anything. Don’t trust anyone, especially doctors.”
I remembered her comments in our first visit about not taking the medication her PCP prescribed for her uncontrolled diabetes because someone online said it was slowly killing her. So, I affirmed another trusted relationship.
“You trust your family and what they tell you.”
Sinking further into her seat she murmured, “Sometimes, but with everything going on in the world, I stay quiet with them as well.”
As a Black woman, even though I am White passing, I connected with what I predicted was her amplified fear related to saying the wrong thing in the current political climate. I voiced my assumption.
She almost shouted, “Yes! Nowadays you say the wrong thing and some one will pull out a gun and shoot you. I get called all sorts of things. ‘Monkey.’ You can’t trust anyone”.
I internally flinched when hearing the hate speech. I thanked her for trusting me with our conversation. She shifted in her seat and looked at me from the side of her eye. I realized I inferred trust too soon.
She hesitated and said “And the hospitalization in my 20s was awful. I don’t ever want to do that again.”
“It was not helpful and sounds like you had a horrible experience,” I reflected.
She added, “Yes! And I am nowhere near as depressed as I was when I was thinking about driving my car into a lake.”
“Your depression is bad, but not as bad as when you had plans to kill yourself,” I said.
She nodded her head and replied, “Right.”
I began to relax. I affirmed, “You can tell the difference, and you do not think you need hospitalization right now.”
She lifted her head. We locked eyes and she said, “No, I don’t need to be hospitalized.”
At the end of our 25 minutes appointment after updating her crisis response plan, I hoped she would return. Dawn and I saw each other multiple times. Sometimes for a behavioral health appointment. Other times with her PCP.
I held an important awareness that my “White passing” privilege impacts how society may treat her and I differently. I could not be sure if she identified me as Black without making it explicit. So, I did. In later visits we discussed her mistrust in the medical system which echoed generations of fear related to “being guinea pigs” and hesitancy to add specialties to her care due to uncertainty of future discrimination by unknown providers. She is a fighter. She fought through domestic violence in her previous marriage. She fights for her safety against racism. She fights to stay engaged in a health care system where health disparities and discrimination exist for Black people.
She reminded me in this fast-paced environment to slow down, listen, and create a safe place where answers can be given, not extracted. For communities harmed by the medical system the patient-provider relationship is key to healing. Without trust and recognition of the context that both patient and provider bring into the visit severe consequences for patient’s body, mind, and spirit can occur. I recognize that in our medical system, we have a lot more work to do to create a trusting relationship with her and patients like her. Fortunately, primary care supports the longitudinal relationship in which that hard work can be done. We just need to stay patient, aware, and compassionate.
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