UBC Objectives: Family Medicine, UBC Objectives: Surgical + Procedural Skills, & UBC Objectives: Professional

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Analyze the communities or environments in which patients live and work with regards to their impact on patient health
• Prepare for a procedure by preparation of physical environment (ex: equipment, personal protection, aseptic technique) and by cognitive preparation (ex: mentally rehearse anatomic landmarks, technical steps and potential complications and their management)
• During performance of a procedure, keep the patient informed and ensure patient comfort and safety always
• Display commitment to societal and community well being

Like all days working with the Portland Hotel Society (PHS), I started my day with focused medical learning objectives (I read over all of my extensive notes on how to prepare for and perform the perfect Pap) and came away feeling a mixture of overwhelm, curiosity, and passion to continue to provide care to marginalised people. While running a Pap clinic today (I say that because there was no attending physician present, just me), I learned of one particular woman's history involving significant physical abuse and associated emotional trauma that occurred within the environment surrounding the PHS clinic. I think PHS is amazing in how it brings access to primary care to the people of the Downtown Eastside (DTES), but I hadn't thought about how patients who no longer live and work in the DTES may re-live trauma every time they return to the DTES for ongoing primary care. Needless to say, I was very intentional about obtaining informed consent before the Pap test, with extra sensitivity to explaining why we perform Pap tests, the details of the procedure, and associated risks (physically, potentially a bit of vaginal spotting and pelvic cramping). I also gave her the opportunity to ask any questions, and let her know that if ever during the procedure she was feeling uncomfortable, we could always stop. During the procedure, I kept her informed by explaining what I was doing as I was doing it, and continued to check in to ensure she was comfortable (as comfortable as a Pap test can be, anyhow). The first principle in medicine is First Do No Harm, and in patients with a history of trauma, taking precautions to prevent re-traumatization is an important aspect of providing patient-centered care. After the Pap smear was all done, we discussed the possible transfer of her primary care to another low-barrier clinic situated outside of the DTES, but this was mostly kept as a conversation for another day given the multitude of other things that took precedence at this visit. 

Recently (aka from 8 am yesterday to almost 4 in the morning - we had a deadline to meet), my resident colleague and I were working on a literature review on the risk factors, protective factors, barriers and facilitators to treatment, and recommendations to promote better care of refugee women with peripartum depression. I was over it when I went to bed in the wee hours last night, but it was at the same time such a good learning experience, and today I was prompted to look to the literature to see what has been published regarding trauma that women have experienced living in the DTES. I found this informative article entitled, "'Like a lots happened with my whole childhood': violence, trauma, and addiction in pregnant and postpartum women from Vancouver’s Downtown Eastside" by Torchalla et al. (2015) as published in the open access Harm Reduction Journal. If you are at all interested in the peripartum experience of marginalised women, I recommend reading it. It also drives home pretty well perfectly the reality of this learning objective and why it matters for primary healthcare providers to understand and critically analyze the environments within which all patients work and live. The social determinants are more powerful than the prescriptions I pen.