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Improving the health of the population in Romania by increasing TB control

Project financed by the Norwegian Grants 2009 - 2014, within the RO 19 - Public Health Initiative.

The establishment of a trust relationship between the physician and the patient is extremely important, say the specialists in the TB hospitals and dispensaries, and another important aspect is the effective communication between the two,” psychologists who work with the patients diagnosed with tuberculosis emphasize. Every Thursday, at the “Marius Nasta” Institute of Pulmonology in Bucharest, psychologist Andreea Dumitrescu meets with the patients hospitalised in the ward where those with multidrug-resistant tuberculosis (MDR-TB) are treated.

“Blind man’s buff in pairs” – game and mirror

On Thursdays, before lunch, several pairs of footsteps can be heard getting out of the hospital rooms and gathering in the hallway on the first floor of the hospital wing, where the meeting usually takes place. When the patients do not have any specific questions or certain topics to propose for discussion, Andreea Dumitrescu comes up with exercises that may be useful for them. One of the exercises Andreea often proposes for these meetings is “Blind man’s buff in pairs,” the purpose of which is to increase trust in others. In Andreea’s approach, the exercise seeks to increase patients’ trust in the physician who treats them.

This time, ten patients are present at the meeting. A middle-aged man, a talkative young man, a shy girl, a jovial gentleman, an elegant-looking lady, some of them just walking around, other sitting thoughtfully on the chairs. Andreea’s voice brings them together. “First, we have some fun, then we talk.” The chairs are placed randomly along the corridor and the patients form pairs of two.

Some are hesitant, others can’t find a partner. Jokes are thrown around, to hide the unease, while Andreea reveals what they have to do: one of the two team members will be blindfolded, spun round a few times, then guided by his or her teammate through the “maze” of chairs to the other end. The basic rule: the blindfolded person must only be guided verbally. “You are not allowed to take them by the hand, pull them by the sleeve or push them from behind, nothing. The blindfolded person must be helped get out of the maze only by verbal indications. Right, left, one step forward and so on.” “I want to be blindfolded,” says Constantin, the talkative young man, throwing himself into the game. Very tall and slightly hunch-backed, with a punk cut that gives him a somewhat dangerous look, he soon goes from jokes to irritation, he speaks a lot and has trouble concentrating. He is not very popular. “Who wants to work with Constantin?” Andreea asks. After a couple of moments during which the others look away, Constantin designates Marin: “You.”

The path to healing

  

Andreea ties the scarf around Constantin’s eyes, she spins him round and explains again to Marin what he has to do. Everybody quiets down and Marin’s voice becomes clear. “One step forward. Stop! Right… left… more to the left… that’s it, that’s good. Now go straight ahead…” Constantin walks slower than ever, he keeps asking questions, he is anxious and irritated. He only relies on what he hears, and Marin’s indications are too rare. He spends too much time thinking. “Right, slowly, that’s it…, a little to the left…” And Constantin permanently prompts him: “Like this?”, “What now?”, “Say something!”, “Do I keep going?”. He takes bigger and bigger steps only to get it over with sooner. Two minutes have passed and he’s only halfway through the maze when he touches a chair with his foot. He turns into a little tornado and starts throwing the chairs around, he pulls out the scarf from around his eyes and grumbles at Marin: “I’ve already touched two chairs!” He has not made it through the maze. Now it’s his turn to guide Marin. Blindfolded, Marin barely nears a chair when Constantin drives him on: “Come on, come on, straight, straight, that’s it, come on!” He pulls him by the sleeve, “Come on, man!”, Andreea corrects him and he returns to the verbal guidance rule. “To this side, come on!”, he shows Marin, forgetting that Marin is blindfolded. “Over here, come on!” Everybody is laughing and Marin finishes in less than a minute, but he was guided with the hands too, not just verbally. The exercise ends with a patient being guided by Andreea herself, because the rest of the patients refuse to play. This is either because they have just taken their treatment and feel dizzy from the drugs, or because they are embarrassed and afraid not to make wrong moves through the maze of chairs. Florin was spun round and now is ready to listen. “Take one step forward. Stop. Take one step to the left. One step forward. Half a step to the right. Two steps forward.” After a minute and a half, Florin has made it through to the other side of the maze without having touched a chair. Guidance is essential, but observing the instructions is as well, and Florin did exactly as was told.

“Now, let’s talk. What did you think about all this?”, Andreea asks. The chairs are rearranged in a circle. “Children’s play,” someone says. Florin says something essential: “You let yourself be guided by someone you trust, about whom you know precisely that they would not guide you wrong.” Constantin gets the idea and immediately apologizes: “I got angry because… with all that right, left, right, left, I thought that he was not guiding me properly.” I was feeling disoriented because my team partner did not know how to guide me. He was saying ‘over here, over there’ but I could not orient myself after what he was saying,” another patient says.

Trust – the key element

What do they, the patients, think was the purpose of this exercise? Patience, self-control, orientation, some say. A lady who did not participate because the treatment she is under for MDR has affected her hearing and she must lip-read, says it was relaxing. From a corner, a gentleman, white-haired despite his age, only speaks out when asked: trust. A test for the trust in your team partner. The others seem to agree. Yes, this exercise showed them how important is the trust of the blindfolded in the partner who has more information than he or she does. Mr. Nicolescu adds: “How to make the other trust what you say, and, if you are the one who is guided, to know how to do what the other member of the team tells you to do”.

Andreea Dumitrescu encourages them to tell their opinions and then she clears things up: “If I told you that I did this exercise to illustrate the relationship you have with your physician throughout the treatment, what would you think? What if you were to think that, yes, that’s about how the relationship I have with my pulmonologist looks like and this is the route I have to take together with him or her?” Silence. Everybody retraces in their own mind the route through the maze and compares it with their situation as a patient. During the exercise, Constantin did not trust Marin, he got angry and abandoned the path through the maze. As a patient, he did not trust his physician and abandoned his treatment several times, which is why he went from sensitive TB to MDR. Marin instead observes the treatment and the physician’s indications totally, just as he observed the indications for going through the maze. Florin also complies with the treatment. The shy young woman, Marcela, declares that she has blind trust in her physician and that she sees him as her only chance to heal.

“The important thing is to get to the other end”

After they understood the purpose of the exercise very well, the patients must also understand what each of the two partners – patient and physician – must do for the treatment to end well and for the patient to heal. Because, as the psychologists working with the patients explained, each of the two persons involved has his or her share of responsibility.

Therefore, Andreea asks, what did they think was key in getting to the end of the road together? “The fact that you can trust someone, another person,” says Florin. “Overcoming obstacles,” says Mr. Nicolescu. Marcela follows strictly what her physician tells her and she noticed that this was visible in the results of her tests which have continued to improve. “It was worth the effort of staying here, in the hospital, for so long – I’ve completed five months this week…” “Yes,” Mr. Nicolescu agrees. “But you as a patient also must have a little will of your own to complete this treatment, to keep in mind the doctor’s recommendations. I, for example, have taken my treatment now and I feel, I don’t know… a little unwell. But this is the treatment. It’s not the first time I take it. I have taken another treatment scheme before, but I go on, I have to heal!”

Speaking from the patient’s side, they find it easy to analyse the situation. But what if they were in the shoes of the person who guided them, in the physician’s shoes? One moment of thinking and the answer comes shortly: the important thing is how they communicate, whether one is understood by the other. “The patient must trust the physician, and the physician must trust the patient,” Florin explains. “And the patients must trust themselves to complete the treatment. Walking around among the chairs, blindfolded, guided only by someone telling you what to do means having great trust in the person guiding you. They bumped into chairs now and then, so no matter how much trust you have, you will certainly run into some doubts along the way, doubts in yourself, in the one who guides you, there is hardship… And then the important thing is to get to the other end.”

Communication – the key to success

“But what do you think,” Andreea asks, “what would the physician need in order to guide the patient better?” “As far as the physician-patient relationship is concerned, I have seen that there is quite a lot of effort being spent for us. The physician understands us, you understand us and the others do as well, and I have a satisfaction… and I have trust, I really have trust,” says Marin.

“It’s as if you let your life in someone’s hands. That person with special training who can bring you to the shore. But you must trust that person, and that person must know how to collaborate with you. Because if you don’t trust…,” Ms. Petrescu adds.

In fact, the physician-patient relationship is the key element for treatment success. And for the physician-patient relationship to be satisfying, both must communicate effectively. “This guidance is like the path through life. If you make mistakes…,” Mr. Ilie leaves his sentence hanging. “Maybe a patient is a little thick-brained or something and then the physician must explain things two or three times. And, as a patient, to help the communication with the physician, to understand things better, you must know what to ask.” “Of course,” Mr. Nicolescu adds. “And if you want to get out of this well, you must comply with what your doctor tells you. If he or she tells you left and you go right, everything amounts to nothing.”

“So – Andreea Dumitrescu concludes –, the exercise was meant to show, on the one hand, that there is a relationship between you and the physician who takes care of you, and, on the other hand, that this relationship depends on how you communicate. The more you pay attention to what is indicated to you, the more chances you have to understand and, as a result, to comply with those indications. No matter how knowledgeable and skilful your physician is, the outcome of his or her work is also up to you, and up to the relationship you have with him or her. The relationship is one of collaboration, and you, the patient, have the highest interest. The physician has all the best intentions and it is very important to have a good relationship with your physician so that, together, you can complete the treatment and heal. In order for the physician to cure you, you yourself must be receptive, and for you to be receptive, the physician must communicate clearly, so that you to understand what you have to do. Ask questions! You have several months, from the time you are admitted, to ask everything that is unclear and everything you want to know.”

* The names of the patients have been changed, upon their request.