The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.
– Sir William Osler
“You’re not gonna be happy with me, doc,” Richard said as he walked into the exam room at the Pine Street Inn homeless shelter clinic. I inquired why. “Well, I did good for a week,” he said, eyes looking down, “but then I started drinking again.” His face was full of remorse.
Labor Day marked my three-year anniversary as a primary care physician serving Boston’s homeless men and women. It was my first job out of residency — and the learning curve was steep. In addition to geographic changes, North Carolina to Massachusetts, and the accompanying change in accents, I also had to learn three different electronic medical record systems. And a 3-year dissertation on addiction …
Alcohol was Richard’s drug of choice — as it is for nearly one-third of the homeless population — and had been for the last 40 years. As if chronic alcoholism wasn’t enough to deal with, Richard also had hypertension, diabetes, COPD, pulmonary amyloid and depression. He was also a proud Marine Corps veteran. For the past decade, he called the streets of Boston home.
My visit with Richard consisted mostly of support and a positive attitude, which I found went a long way. I encouraged him to attend AA, to see his substance abuse counselor, to attend group therapy and to see his psychiatrist. I also decided to prescribe naltrexone, an opioid receptor antagonist which has been shown to curb alcohol cravings.
As I accompanied Richard out of the exam room, the shelter’s experienced nurse manager, Karen, hurriedly approached me. “A guy in the triage area is drowsy, disoriented. One of our regulars. Looks like benzos.” As I evaluated this somnolent gentleman, another shelter guest started knocking on the clinic entrance window, asking to see the doctor. “The doc needs to fill out my disability forms,” he shouted, “My back’s hurtin’, and I can’t work!”
Alcohol intoxication, benzodiazepine overdose, disability insurance paperwork, as well as food stamps, transportation and special-accommodation letters for housing were routinely dealt with in my job as doctor to the homeless. Yet these issues — vital to living — were minimally addressed, if at all, during residency. And certainly not in med school, at least not formally (I worked in a grassroots clinic in post-Katrina New Orleans, caring for locals who lost everything; but I’m doubt that this exposure to the underserved is not in the official med school curriculum).
Among the many valuable lessons I’ve learned, the greatest learning point was about the meaning of health. Health, as I discovered through this special, vulnerable population, isn’t really about the medicines I prescribe or the specialty referrals I place. If a patient is worried about his next meal, or where she’s going to sleep, or whether to report her abusive father, or if he has enough “oxy’s” to trade for heroin (“it takes away my pain, doc”), then “med compliance” with metformin or metoprolol just isn’t a priority. Under these nerve-racking circumstances, who can blame them?
Having minimal exposure to homeless patients in residency and certainly no formal lectures on homeless health care, I came into this position with many preconceived notions. Within a few weeks, these misconceptions quickly dissipated. My patients come from across the nation, across the globe: from New Mexico to New Hampshire; from New Delhi to Nigeria. They are lawyers, writers, athletes and PhD scientists. Many are artistically inclined. One patient, originally from Illinois, is a prolific painter. In between management of his Paget’s disease and hypertension, we talked about our mutual love of portrait drawing and piano. A few months after his stroke, he saw me at a homeless shelter clinic nearby Boston’s theatre district. He pulled out a large envelope from his briefcase; it was one of his paintings. “I know how much you love art, so I want you to have this.” My eyes swelled up with tears.
In spite of the perceived differences (poverty, homelessness, mental illness, unemployment), the truth is that there is very little separating “them” from “us.” In fact, there is no “them” and “us.” I remind the many students and residents who shadow me and my fellow “homeless docs” about the importance of always providing nonjudgmental and compassionate care. I remind them of the precariousness of life, of how quickly things can change. Once a person loses his job, it’s a rapid downward spiral after that. He can’t pay the bills or the rent, becomes frustrated and depressed, self-medicates with alcohol, opioids and/or benzos, and poof! — life as he used to know it has disintegrated. No one asks for this. Yet anyone is vulnerable to it.
Another critical lesson that this job has taught me is to treat substance abuse seriously. Addiction should be treated like any medical condition such as heart failure or osteoarthritis. And it was crucial to apply this rule now. A 2013 study from our program showed that the number one cause of death in the Boston homeless population was prescription drug overdose, surpassing heart disease and cancer. Opioid-related death, in fact, is a national problem. According to the CDC, death from drug overdose has been steadily on the rise and is now the leading cause of injury death in the U.S. In 2011, 74% of the 22,810 deaths related to prescription drug overdose involved opioid painkillers, and 30% involved benzodiazepines. Examples of such unnecessary deaths in popular culture are abundant: Errol Flynn, Sigmund Freud, Janis Joplin, Whitney Houston, Philip Seymour Hoffman, Hank Williams, and so many, many more.
Medical school and residency taught me something that homeless health care illustrates poignantly on a daily basis: it is a privilege to be a doctor. Sure, I complain about the ever-unpredictable New England weather, the always-packed subways and the malfunctioning elevator in my building. But spending the entire listening to patients sleep in the snow and rain, whose daily commute is via foot and who would dream to live in a building with an elevator, I am humbly reminded of just how lucky I am. Working as a house staff in a busy inpatient setting taught me the importance of teamwork, which is 100% accurate in clinical practice. I could not provide the care that I do if it were not for the compassionate and dedicated work by nurses, nurse practitioners, case managers, social workers, drivers, administrative staff and AmeriCorps volunteers.
Two and half years after our first meeting, Richard is now housed, sober for 180 days and avoids all triggers. He is compliant with his medications and appointments, and is applying for jobs. But he realizes what he’s been through and how easily he could fall back into an abyss of despair. As he modestly reminds me, “one day at a time.”
Lipi Roy is an internal medicine physician who blogs at Spices for Life.