Why It Matters
Dr. Nia Zalamea, faculty on a new IHI Open School course, talks about how she stays inspired while working with patients facing serious challenges to good health.
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The Joy of Serving the Underserved: Q&A with Dr. Nia Zalamea

By Stephanie Garry Garfunkel | Wednesday, October 5, 2016
Nia Zalamea Church Health Center

Dr. Nia Zalamea has some advice for providers who are struggling with burnout.  

“I think it’s important to allow ourselves to experience the joys in addition to the challenges of our work,” she says. “We forget because we just expect those good outcomes all the time, and we are only really affected emotionally when we have negative ones.”

Zalamea worked as a surgeon at the Church Health Center until this year, when she took a position teaching residents at Methodist Le Bonheur Healthcare and the University of Tennessee. Zalamea, who is faculty on a new Open School course on person-centered care, is passionate about working with patients living in poverty and who are affected by racism. In this interview, she shared her suggestions on how to better serve underserved patients, while also avoiding burnout.

Why did you decide to go into health care?

In 1999, I went with my father, who is a nurse anesthetist, on a medical mission trip to the Philippines. I had just finished at University of Virginia, and I wasn’t sure what I was going to do for my career.

When I was overseas, my job was to hold the floor lamp for the operating room — for an entire week. I had a lot of time to think and reflect about what I was doing, aside from exercising my triceps. And so I decided that I was going to go into health care for the purpose of mission work. I felt that if my parents, who had immigrated to the US from the Philippines in the 1970s as nurses, could go back and give this much value and multiply the blessings they had, then it was my responsibility to do the same.

How do you avoid burnout when you’re serving underserved patients?

Burnout to me is really defined as kind of losing sense of hope in the work that we do.

I think it’s important to allow ourselves to experience the joys in addition to the challenges of our work. Sometimes we forget to experience the joy. We forget to remind ourselves of all the good stories, the cures and the good outcomes — for example, getting a job after [having a] colectomy or going to school and graduating after having a hernia surgery. We forget because we just expect those good outcomes all the time, and we are only really affected emotionally when we have negative ones.

I think the opposite needs to happen, to be intentional about experiencing the joy. I record my outcomes in a database,  which is very informative for me to remember both the joys and challenges.

You shared a story in our new course, PFC 101: Introduction to Patient-Centered Care, about a patient we called “Jerome,” who had to have a full leg amputation after he wasn’t able to attend the surgery you worked so hard to schedule for him. How did you handle this negative outcome emotionally? Did you feel guilty?

I felt maybe more than guilt. I felt that I didn’t work hard enough, that I could’ve done more. I kept thinking that maybe I could have done something differently that day in the office.

At the end of the day, I had to remember that I am not Jerome. Jerome is an adult. He’s 35 years old, and he’s been making his decisions the majority of his life since he was about 17 or 18. He’s been navigating his own situation all that time. I think Jerome was in this place where he had complete lack of control over what was happening with his leg, or felt that he had lack of control. I know that his economic situation was motivating him to choose work over health, and that’s again something just I could not understand.

I think part of the guilt is alleviated by doing our best for every person who comes through our door every single day. If at the end of the day it doesn’t work, we tried. If we do that with every individual, every day, and really try to check ourselves for not judging, then I think that we are delivering on the promise of why we do what we do — which is essentially doing no harm.

You’ve pointed out that medicine sometimes makes judgments about the people it serves, with terminology such as “non-compliance” or “difficult patients.” Why is it so important that providers avoid judging their patients’ choices and behaviors?

I think the reason why it’s so important not to judge is twofold. The first is that it leads to some dangerous behaviors. It’s dangerous to assume that we understand where a person comes from and why they make the decisions they make. Similar to navigating a map, it can lead us in directions that leave us completely lost as a clinician. For example, you think your patient is making an economic decision, but it’s actually a faith-based decision. Or you think it’s a family-based decision, but it’s actually a professional decision they’re making. So the first danger in judging is that we make assumptions. We’re limiting how much information comes in to help us make the best clinical decisions with our patients.

The second is that there’s really no compassion in judging, and we tend to build walls around our hearts and our minds. We have several decades, if not centuries, of judging behind us. We see where it’s led us in terms of race, religion, and gender. It’s led us into some very dark things that we continue to deal with, especially in the US. And I think those judgements based on very categorical relationships are limiting, not just as individuals but as a society. The injustices around socioeconomics, gender, and race are further reinforced whenever a clinician judges a patient.

What do you think providers can do to avoid judging patients?

I think the first thing is to recognize that we’re having that reaction inside, to understand it for what it is and not be afraid of it. It’s a summation of many years of experience, teaching, and media, all of which affect how I make assumptions about a patient like Jerome based on what I see, hear, and smell.

In the very next moment, I remember that I actually don’t know Jerome, for example. I know nothing about him. It’s similar to how we’re trained in medicine to think about diagnostics. Assumptions are very dangerous. So I try to recognize that Jerome is a stranger to me, and I am a stranger to Jerome, as well, and we actually know nothing about each other. That’s what helps us not judge each other.

What can providers do to be more empathetic in their patient encounters?

I think there are a couple of things. In the clinical environment, we can take better histories, and spend more time understanding our patients’ life experiences and life situations.

Outside of the health care setting, we can be with individuals in those life situations. I’m a strong proponent of going to the neighborhoods and being there. If you have a specific group within your practice that is particularly challenged, go and be with them — at community events, in their churches, at their community centers. Have a clinic there. Try to understand what it’s like to walk in their shoes.

Learn more in the course PFC 101: Introduction to Patient-Centered Care.

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