BY: JUDY CASSIDY
An Interview with Lori Arviso Alvord, MD
Lori Arviso Alvord is a practicing surgeon and associate dean for student and minority affairs, Dartmouth Medical School, Hanover, NH. She spoke with Health Progress about her experiences as a Dartmouth University undergraduate, a Stanford University medical student, a surgeon, and an academic administrator. Dr. Alvord is the author of the book The Scalpel and the Silver Bear: The First Navajo Woman Surgeon Combines Western Medicine and Traditional Healing, which will be published in June by Bantam.
Lori Arviso Alvord grew up in Crown Point, a small New Mexico town on the eastern border of the Navajo reservation. The town was about 98 percent Navajo and most people spoke Navajo and had Navajo traditional values. "It was like a Third World setting in the United States," she says. Alvord, the daughter of a Navajo father and white mother, followed a winding path from her remote village to where she is today — a path surprising even to her.
As she grew up, the only physicians she encountered were white doctors fulfilling an obligation by serving in the Indian Health Service. "Most of them left after two or three years, so there was never a chance of developing a long-term relationship."
But she was deeply impressed by the IHS pharmacists, who worked with fascinating pills. "With their knowledge of medications, I thought they were brilliant," she says. So she entered Dartmouth with the goal of becoming a pharmacist.
But events took her in another direction. Although her high school test scores had been high and she was accepted to college at the age of 16, Alvord was not happy with her performance in premed courses the first semester. Away from home for the first time, at college she encountered glaring differences between Navajo and Western culture and behavior. For example, she was reserved, having been trained not to call attention to herself by speaking out in class, raising her voice, or making prolonged eye contact. Discouraged by her grades, she left the sciences and majored in psychology.
Fortuitously, in her senior year she took a course in neuroanatomy as part of her psychology studies and discovered she had a deep interest in the anatomy of the brain. After she graduated, this interest led her to work in an Albuquerque neurobiologist's laboratory as a research assistant.
The neurobiologist suggested that Alvord go to medical school. Even with his encouragement, she says, "I don't know what possessed me to go." But she was accepted to Stanford Medical School. This time she did well in her science classes, but again cultural differences sometimes made her uncomfortable. She found cadaver dissection difficult at first. Navajos are reluctant to touch a dead body (a practice probably based on medicine men's observations that disease could be transmitted from handling a dead person).
During medical school Alvord met a Native American surgeon. "I had never considered surgery till I worked with him; it was amazing how beautiful his practice was, how comfortable he made patients feel," she explains. Because of his influence, Alvord decided to pursue a six-year surgical residency at Stanford, after which she returned to New Mexico to work with Navajo and Zuni people in Gallup.
Respect for Diversity
"The work was extremely interesting because I found ways of integrating Navajo traditional beliefs with Western medicine," she says. "Bringing them together involves respecting the beliefs of patients. If you don't develop a relationship of trust with patients, you won't be able to heal them fully," Alvord insists. "You may be able to do a procedure, but results won't be optimal." The ideal way to practice, she says, is "to offer good medical care and allow patients to practice their beliefs at the same time."
"I really give myself to my patients when I'm with them, even if only for a few minutes," Alvord says. "It matters what relationship the patient has with the doctor. Medicine men know this; old-time doctors knew it." She finds that the patients who recover most quickly after surgery are those who have a strong belief in their doctor. "They trust that they'll be treated well and that they will do well."
To create an atmosphere of trust, physicians need to know their patients and demonstrate respect for differences, Alvord says. Another reason for understanding differences is that patients' disease processes and responses to treatments vary by race, sex, and age. The results of medical research on men, for example, are not always borne out when applied to women, she notes. Alvord is quick to point out that respecting diversity enhances care for all patients, regardless of their ethnic background, religious tradition, sex, or age.
Broad View of Health
According to Alvord, America needs to take a broader view of health, like the Navajos'. Medicine men, she says, see illness as a sign that something in one's life is out of harmony or balance. "This makes sense. We now know that, for example, too much stress can cause migraines, ulcers, and other physical problems. Native people don't separate out liver or heart problems from other problems in patients' lives. They see that spiritual, physical, and relationship problems all affect each other," she explains.
When physicians examine an ill person, they should consider marital problems, family relationships, and all other parts of the patient's life, she insists. "We have to live a healthy life in every facet. But we want a quick fix, to just take a pill and be well, and it's not working. America's penchant for overwork, avoiding exercise, and living at a fast pace, as well as the disintegration of community and family life, is leading to a host of physical and mental problems."
Influencing Medical Practice
This broad view of health has led Alvord to Dartmouth, a place where she can be an advocate for patients. Like her route to becoming a surgeon, the path to her current position was unplanned. Happily practicing medicine in New Mexico, she was not looking for new job when the chairperson of the university's Board of Overseers suggested she apply for the associate dean position. But, she says, "I believe in being alert and watchful to what is happening in my life, so I thought I should explore the possibility."
When interviews resulted in a job offer, she accepted because she felt that this change was meant to happen in her life. Having worked with the medical school's Native American Visiting Committee, which evaluates programs for Native Americans, she was already committed to the success of Dartmouth's programs for native peoples. She also saw an opportunity to shape how physicians thought about medicine, as well as to "break the glass ceiling" for Native Americans in academia.
Changing the Health System
In her current and future work, Alvord hopes to influence changes in the American healthcare system that encourage the establishment of long-lasting relationships between doctors and patients. Managed care policies that disrupt patient-physician relations interfere with an essential component of healing — that is, doctors and their patients working together to achieve maximum healing, she says.
Another change that Alvord believes would aid healing is for hospitals to become warm, welcoming environments. "Why are hospitals so impersonal? Why do they have cold linoleum floors?" she asks. "We need softer colors and lights and people who want to care for people — staff who take time to smile and show they care. If you go to a health club, you're treated better than in most hospitals."
Pediatric and maternal/neonatal units have made some inroads, but most rooms for adults are "gray," bland and boring. "When we're sick, we're all children. We want to be taken care of and reassured. We do better when we are surrounded by beautiful things."
Alvord also hopes to influence public policies that affect the Indian Health Service as the federal government encourages tribes, who may not have expertise in healthcare, to take over IHS programs. "I understand that the government wants to get out of the business of healthcare, but I want to be sure that people will not be hurt."
Alvord is optimistic that the increasing emphasis on building cultural competence in healthcare organizations will be effective. The Association of American Medical Colleges has set a goal to increase cultural competence in medical school curricula. Dartmouth is analyzing when during the school's four-year curriculum students are taught subjects relating to cultural differences (e.g., palliative care, women's health) and what areas need to be expanded.
If diversity programs result in a greater societal respect for cultural differences, the benefits will be inestimable. "Navajos consider natural things and animals to be sacred. It's not always obvious why they are important, but when we don't respect the environment — by polluting our water and earth — people get sick. When we disrupt ecosystems, we will eventually disrupt our own world," Alvord cautions. Incorporating a new, broad model of health, which is common in Navajo and other cultures, into the narrow Western approach can lead to a healthier world.
—Judy Cassidy