Chapter 17 - The Eight Questions (Cont.)

When the author took Selvidge’s information to Neil Ernst, he said that if he’d thought that Lia was septic, he would have done a lumbar puncture. Bill didn’t assign blame to Neil for not catching the sepsis. He believed her fate was sealed, because everyone at MCMC focused entire on the seizures and Lia was her seizures. In fact, she continued to be her seizures because of the memory of those terrifying nights in the ER. They always spoke of Lia in the past tense, and to the author, it wasn’t just absentmindedness. It was an admission of defeat. Lia was dead to her physicians, because medicine had once made extravagant claims on her behalf and had had to renounce them.

The author asked Neil if he had ever wished he had never met Lia.. He vehemently denied such a thing and told her that Lia had taught him that when there is a very dense cultural barrier, you do the best you can, and if something happens despite that, you have to be satisfied with little successes instead of total successes. You have to give up total control. Unfortunately, Foua didn’t feel the same way. She said she just felt confused and wondered how the doctors could say that Lia would be in the same condition the rest of her life and not know how to change it. She worried about who would take care of Lia when she and Nao Kao passed away. She didn’t want her daughter in an institution whoch she called a house for the dead. She believed that if that happened, Lia would want to die and would only suffer instead. She insisted that if this had happened in Laos, they could have cured her, but it happened in the US. Americans had done this to her, and their medicine now could not fix it. The author knew the truth: if the Lees had stayed in Laos, Lia would never have lived beyond her infancy, so, ironically, American medicine had both preserved her life and compromised it.

What was not clear to the author was who, if anyone, should be held accountable. She made a list of what if situations. When she presented them to Dan Murphy, he said he believed the gulf between the Lees and their doctors was unbridgeable, and that nothing could have been done to change the outcome. However, the author questioned whether it really was unbridgeable. She wondered whether the residents in the ER could have managed to elicit the Lees’ trust at the outset – or at least managed not to crush it – by finding out what they believed, feared and hoped. After all, trying to understand Lia and her family by reading her medical chart was like deconstructing a love sonnet by reducing it to a series of syllogisms. But to the all the medical staff who had cared for her, there was no guide except the chart.

The author then remembered that almost every discussion of cross-cultural medicine that she had ever read quoted a series of eight questions designed to elicit a “patient’s explanatory model.” It was developed by Arthur Kleinman, a psychiatrist and medical anthropologist who chairs the department of social medicine at Harvard Medical School. She began to think that they might actually be a work of genius. She told Dr. Kleinman that she had answered the eight questions the way she thought the Lees would have before any medicine had been administered. She thought he might have believed her answers were way too bizarre, but to each one, he answered affirmatively. From his perspective, a physician could encounter no more captivating a patient than Lia, no finer set of parents than the Lees. She then told him what had really happened and asked him for any retroactive suggestions for her pediatricians. He said he had three: get rid of the term compliance; second, instead of looking at a model of coercion, look at a model of mediation; and three, understand that as powerful as the culture of the Hmong patient and her family is on this case, the culture of biomedicine has its own set of interests, emotions, and biases, so how can you expect to deal successfully with someone else’s culture?

Notes

This chapter serves as a retrospective of Lia’s case and how so much could have done to make sure the outcome was different. That’s the tragedy when thinking of the potential of that little girl. So much could have been different.