In this Rotation Reflection, Internal Medicine Resident Maria Hanna shares experiences and lessons she learned during a rotation with Indian Health Service on the Navajo Nation in Shiprock, New Mexico.

By Maria Hanna, MD, Stanford Internal Medicine Resident

Near the end of my rotation in Shiprock, I had an interaction with a patient in a clinic that has really stayed with me. The patient was having difficulty managing complex care needs after a recent hospital discharge, as he dealt with cancer and resulting limitations to his mobility. During our conversation, I learned that he was unhoused. He and his child, a young adult who lived with him and cared for him, had nowhere to stay that night. After a long conversation, gathering his story and cataloguing his care needs, I recommended that the patient be admitted to the hospital for placement in a rehabilitation facility. I also recommended housing resources for both of them. While at first the patient seemed relieved and agreeable to this plan, we soon learned that he and his child were terrified of being separated and losing contact with one another. The patient’s child also expressed frustration and disillusionment with healthcare, citing all the ways the system had previously failed their father, including the wait time for the clinic visit that day. Ultimately, despite our pleading, they decided to leave without accepting any care or resources that day.

I was devastated by this interaction. There was so much pain in that room, bolstered by a mutual tenderness between parent and child, neither of whom knew the best way to help the other. And along with that, there was a deep mistrust of the systems that had failed them, which left us powerless to help them in any way.

I bring up this patient not to dwell on one challenging encounter amidst many positive ones, but rather to highlight a common theme among many interactions with the Navajo population – the impact and downstream effects of historical trauma. Housing insecurity and substance use disorders were a constant struggle, as was hesitancy to engage in healthcare, and addressing these as best as we could was an integral part of doctoring for this patient population.

While sometimes we failed to have solutions, other times I was encouraged by the dedication to and passion for combating these challenges among many of the doctors and nurses that I worked with. This has led to a strong infrastructure, including a street medicine program, robust substance use navigation, and a home visits program for everything from public health to palliative care. I was impressed and heartened by the strategies and solutions that had been developed to provide a wide range of medical care to patients despite a variety of barriers.

In some cases, it meant doctors and nurses driving over two hours through the reservation, over dirt roads that could become impassable in inclement weather, to hand-deliver a patient’s medications. Other times, it meant setting up a pap smear in a side room of a charity that was lending its space, in order to provide primary care to unhoused folks. Still other times, it meant recognizing the limitations of our hospital’s capabilities and transferring patients out for a higher level of care.

On the whole, working with the Indian Health Service was a testament to the success of creative solutions to address the unique needs of their patients.

Some of the most positive experiences that I had with patients, perhaps ironically, were around death and dying. Because discussions of death were largely taboo in Navajo culture, and dying in the home was strongly avoided, it was common practice for people to bring their family members to the hospital to die. There were special, larger rooms to accommodate this, and to allow families to be with their loved ones in their final hours. Oftentimes, entire extended families would come, surrounding their loved one with 10-12 familiar faces. They brought items from their home that would instill joy and meaning, hung up photographs, brewed traditional tea, held ceremonies and, sometimes, parties to celebrate their loved one. There were parallels to the hospice experience that I am familiar with, but it was so universal among our patients, and it brought me joy to see that no one was dying alone. Beyond that, it was powerful to witness the healing it brought to family and loved ones, and nearly all seemed at peace when the end came.

There was healing in it for me too; it served as a reminder that doctors are not here to solve all problems but rather to guide people through the challenges of their lives, minimizing suffering as much as possible, and towards peace at the inevitable end.

About Rotation Reflections

In the Rotation Reflections series, we highlight perspectives and learnings from residents and fellows participating in Global Health rotations. Global or “local is global” rotations are one form of bidirectional learning we support in order to promote global health learning by providing the opportunity to work and learn in different healthcare settings. Rotations focus on clinical experiences, service, and teaching. Other bidirectional learning opportunities include programs such as the Stanford African Scholars in Global Health Program, in which scholars from African countries spend time at Stanford.