Case Studies

I found the case study about Phyllis Gripman helpful in terms of
illustrating a specific example of how various factors can contribute to
one individual's health disparities, and how as an African American
woman she often received derogatory complaints-- and that took a toll on
her health & well-being. As the reading suggests Health disparities are
the sequelae of social injustice and African Americans have a long
history of being discriminated against in this country. The cumulative
effects of Race/Ethnicity and SES (the strongest predictors of health
disparity) are definitely key factors in the poor health outcomes listed
in Table 1.1 in which African Americans are over represented. As Polina
pointed out for "some health outcomes" the disparities between African
Americans and whites become negligible when the comparisons are
controlled for SES. However, "there is still a residual effect
associated with race/ethnicity." Perhaps this residual effect is
secondary to the discomfort we feel as a society when we are discussing
race. No one wants to talk about racism, and no one wants to be called
a racist, and I believe this results in dissonance between providers and
patients of different cultures, interfering with building an effective
rapport. I am curious to see what changes will come with the Obama
administration. I am hoping it will open up discussions of
racial/ethnic, and SES disparities, and hopefully lead to new strategies
to reduce such disparities.

B. I agree with my classmates that the extended family network of the
Latino community serves as a protective factor which enhances Latino
birth outcomes and infant health, in many cases in spite of low SES.
Some Latinos may also benefit from the 1st generation effect, some may
benefit from the genes passed onto them by their "healthy immigrant"
parents whose characteristics enabled them to emigrate to the US, and
make a living here. In addition to tight family networks which promote
family support of pregnant mothers, there is also a lot of emotional
support, and value placed on pregnant women. There are also a lot of
agencies which are devoted to promoting prenatal care, and obstetrics
tailored to the Latino community, not to mention faith based
organizations which may support Latino families in the community.


1. One case in particular stands out for me: 25 yo undocumented female patient, 3rd trimester pregnancy, unstable living situation with her father who has implied on numerous occasions throughout this pregnancy that if she were to get pregnant and have the baby he would kill her. The PT gave her father all the money she made at her job, so she had no resources of her own. The PT was afraid to tell her father she was pregnant and was trying to hide it from him by wearing a heavy winter coat. Her father had given her a cell phone that he used to call her with to track her whereabouts. The PT did not view him as abusive, she told us he just had a strong personality. She said that the FOB also had a strong personality. She explained that the FOB's jealousy was the reason why she wouldn't take Flagyl to treat her Trichomonas infection, or give her partner the prescription to get his own dose. The PT was ambivalent about her pregnancy and her life. Her ambivalence was unsettling to me, and it was something that I never developed a comfort level with. My concern for her and her baby was tangible when I entered the building in the morning. It became clear over the course of prenatal care visits that her ambivalence was protective: submission was the only behavior that did not go punished by her father. She told us that her brother lived in the same house and was similarly afraid of and completely controlled by their father. We offered to meet with the patient’s father to help her tell him she was going to have the baby, but she declined. We asked her if she was interested in putting the baby up for adoption, but she said that wasn’t what she had in mind. She wanted to move in with the father of the baby, and to do that she had to keep him happy so she couldn’t tell him about the Trich infection, and wasn’t interested in having him come in so that we could discuss it with him either. We asked her what would be so bad about returning to her country of origin- where she would be able to be with her other children. She said that she would only be another mouth to feed and she wouldn’t be able to help support the family.
Ultimatley, being there for her was the most therapeutic thing I did. Trying to understand her and not feel defeated by her ambivalence was one of the most challenging things I've had to do. It wasn't about me, or a bad therapeutic alliance it was about a woman who had managed to survive very difficult circumstances through ambivalence. We did our best to discuss the various options available to her: including calling the police to help her move out of her father’s house with her own belongings. Eventually she had the baby, and our part in her narrative ended.


4. I feel that the key to building an effective therapeutic alliance is to finding something you respect about your patient. Finding something you respect about them forces you recognize that they are not helpless and it facilitates collaboration. As an NP I need to convey respect for the PT’s experience of their illness and how the PT has made sense of that experience. Taking a thorough history in the patient’s own words may be our most powerful in with them. Treating the PT as an expert, finding out what made them come in and addressing it, are all key to building rapport. We need them to know we respect what they’re going through. We need them to trust us enough to tell us what they are most afraid may be going on. No one wants to be sick--- and a lot of patients don’t bring up what they are most concerned about until the end of their visit when they finally are comfortable enough to tell us about what symptom/disease process they are most concerned about--- the one they hope is really nothing.