In medical school, we learn that our job is to help our patients. This point seems so obvious that we take it for granted; we tell ourselves that this is the purpose served by the endless hours in the library and late nights on the wards. In the abstract, it seems like a simple concept. But what if the patients don’t want to help themselves? Enter Mr. P.
I was spending a month on the medicine wards at the beginning of my fourth year of medical school, and Mr. P was among my patients during his two-week stay at Boston Medical Center, the safety-net hospital for the metro area. We’re used to treating patients who face many obstacles to healthcare—after all, nearly three-quarters of our patients “come from underserved populations, including low-income families, elders, people with disabilities and immigrants,” according to the hospital’s web site (pdf).
Still, this man—my patient—humbled us by illustrating the clinical and social complexities that frame our patients’ everyday lives. I was initially alarmed by this malodorous, dirty and fiercely bellowing 60-something-year-old man with seemingly unending issues; if it wasn’t his shooting leg pains giving him grief, it was his back pain or a headache.
Yet as time went on, before rounds each morning, and when I had a few moments each afternoon, I grew to understand Mr. P as I learned in bits and pieces about the hell that was his life. He was homeless and spent his waking hours riding the T back and forth; the daily vibrations from the train had caused tender abrasions in the spots that touched the subway seats. Once the subway closed, he slept fitfully outside on a bench or in a park, constantly vigilant about the real risk of getting beat up or robbed, and at the mercy of Boston’s frigid rains, humid heat and slushy snow. He was among the many people who eschew spending nights at area shelters for the independence of the streets.
Although he was in his early 60s, he had the wrinkles, stooped posture, and sticklike limbs of a debilitated man 20 years older. He was also strikingly pale, a result of low blood counts due to a combination of kidney disease and a cringeworthy diet consisting of hot dogs and cupcakes purchased from the train station.
Still, my attending—a kind physician who had great patience with Mr. P’s temper and who had much experience caring for the homeless—said he looked pretty good, all things considered. After all, making it to 60 years old was itself an achievement; the average lifespan of a homeless individual is less than 50 (pdf).
Mr. P had other ongoing health problems, including kidney problems and intermittent shooting leg pains attributed to years with poorly controlled diabetes, which prompted his dramatic declarations of pain. He’d been admitted for high blood sugar a few days after his medication regimen—consisting of a staggering 35 prescriptions—was stolen on the street. When first admitted to the hospital, he was unable to communicate, mumbling or yelling unintelligibly when queried as to why he had come to the emergency room or how he was feeling. Mr. P’s demeanor, along with his malodor, was enough to make many of us working on the floor somewhat wary.
He slept constantly for a few days, then awoke a seemingly changed man—calmer, kinder and more patient. And although he still grimaced occasionally from his leg pain, he spoke calmly and in full sentences. As the days passed, Mr. P and I developed a routine. I would visit him each morning, and he’d act grumpy at first—irritated at being bothered—but would soon warm up. Somehow he’d acquired a red vintage “I <3 BU Med School” shirt with an EKG symbol going through the heart.
“I’ll see you later, sir,” I said to him one morning after rounds. “Not if I see you first,” he countered, a hint of a toothless smile on his face.
While in the hospital, Mr. P asked that we fill out a few forms stating his need for first-floor housing, since he couldn’t climb stairs, and we made sure he had the paperwork he needed. Given his complicated medication list, it was especially crucial he have a place to stay.
Our team also, of course, worked to get Mr. P as close to healthy as possible. Blood tests revealed he had vitamin deficiencies rarely seen in people living in this country, a result of his terrible diet and a disease that left him unable to absorb a key component of many foods, causing malnutrition and chronic diarrhea. Initially unable to stand from his hospital bed, Mr. P gained strength on a special vitamin-enriched diet, and he was soon cruising up and down the hallway with his walker.
His new ability to walk was encouraging, but it made treating him much more difficult, since despite our requests, he spent much of his time outside smoking and perusing the cafeteria for the bacon that was forbidden given his kidney issues. This salty diet and his heart problems made him retain so much fluid that oral medications failed to combat the extra water. Although this is usually easily remedied by giving intravenous diuretics, he refused to remain on the floor for the treatment he required. When we told him he’d have to stay in his hospital room to be hooked up to the diuretic drip, he became agitated, swinging his walker at members of the team and tearing out his IVs. He demanded to sign out AMA—against medical advice—and we had no choice but to let him.
I wondered what would become of Mr. P, who had improved remarkably while in the hospital but whose stubbornness and aggression had precluded us from fully treating him. He’d fought to live longer than expected given his homelessness, but with his kidney and heart disease—combined with a hard life and difficulty taking his medications—his remaining years likely could be counted on one hand.
I’d like to say Mr. P found a secure place to live—to store his medications, to sleep, to live his last few years—but the truth is, I don’t know. I have not seen him since he left the hospital. And since so many of our patients have been homeless at some point during their lives, I’ve come to see how tenuous a housing thread the homeless sometimes walk. Caring for him in the hospital put a face on many issues in healthcare, including where to draw the line between the responsibilities of the physician and of the patient for his or her well-being.
I still look for Mr. P’s face whenever I take the Blue Line, hoping he doesn’t still spend his days riding back and forth. I’m not even sure what I’d do if I saw him. But then again, maybe he’d see me first.
The patient’s name and some identifying information have been changed.