Posts Tagged ‘DeSales Free Clinic’

Tonight, I was playing mommy referee mediating yet another squabble between by two daughters. They are 23 months apart and like most siblings love and hate each other with 150% effort.  While I am sure repeating myself over and over must sink into their brains somewhere, sometimes I bore myself with the repetition. After the one millionth melt down in the course of 45 minutes, I finally said “Girls! You are a mirror to each other! What one does, the other will also do! If you want to be treated nicely, be nice!” They kind of looked at me like I had three heads. But then started to smile, then giggle, then run off to play pretending to be each other’s mirror and see what they could make the other do in response.

It reminds me of a patient I saw last week for the first time. I am fairly new to one of our local nursing homes so I am sure the staff there hasn’t been notified for my love of homeless patients. That would be the reason for ‘ the warning ‘. I am sure the staff member meant it to be an act of comradery. Give the new girl a heads up. She went on to tell me that my new patient was homeless (followed by an eyeroll) and had AIDS (“of course”) and had the audacity to spend 20 minutes in the shower while she was waiting to start his treatments (sigh, huff, puff). “Good luck with that one!” she said. I thumbed through the 9 million un-useful pieces of paper that had accompanied the patient from the hospital and came across a psychiatric consult that stated the patient lacked the capacity to make his own decisions.  A rather big deal in the medical world that essentially means the patient lacks insight into consequences and can’t be trusted to make their own treatment decisions. It was also particularly relevant to this man since he had tried to sign out of the nursing home against medical advice earlier that day- something that is not allowed if you can’t make your own decisions. Trust me – that only added to his popularity.

I hung out with this patient for over an hour. We talked family, hobbies (a guitar player since age 12), his HIV mode of transmission (not IV drug use as the chart had stated), his medical history (he knew all of his providers names from his previous residence and their phone numbers), wishes and concerns. I asked him about the psychiatric assessment to which he responded “If you’re and asshole to me, I’m an asshole to you.” He went on to describe the interaction with the doctor and how he knew what to say to make ‘that dude disappear’. “It’s really not that hard to be left alone. People don’t want you and so you don’t want then nether.”

His interactions with me were far different than what had been described or documented in his medical chart. There are many reasons for this to have been and I don’t presume that it is all chalked up to my comfort talking about things that, for many providers, are uncomfortable. But I do think that we can become somewhat childish in our interactions. The patient throws up a barrier, then we throw up a barrier. Then the patient pushes our buttons, then we retreat from the interaction. And before you know it, this relationship is going nowhere. And the patient will soon be “non-compliant with a history of multiple no call/no shows”.

Why? Just look in the mirror.

~CF

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The weather has always baffeled me. In a strange way, weather has a way of forcing you into the next phase of the year, ready or not. Saturday had temps in the 90s with humidity so high that it made my normally very straight hair resemble the before shot of an antifrizz hair product commercial. Heavy rains came Saturday night and just like that, Fall arrived. Football, crisp morning air, windows open.  

Last Fall, Brett and I attended our first Street Medicine Symposium in Boston. The Boston Healthcare for the Homeless Program has been the program that all others compare themselves to. It is a huge, well established program that has the most comprehensive programs, resources and street teams. The tentacles of this program seem to reach into all the parks, shelters, hospitals etc. To say we learned a lot would be a stupid understatement.  I recall having a conversation with Dr. Jim O’Connell, president and founding physician of the Boston program.  We were talking about funding (of course) and I said I was amazed at the multi million dollar budget of his program.  He inquired as to the budget of the DeSales Free Clinic and the scope of services. After I told him our annual operating budget was $15,000 he response was ” jeez, we must be doing something wrong if we need so much money”. We then talked about how we operate on limited funds. This is the attitude in Street Medicine – no matter how big or small your program is, fledgling or benchmark status, we can all learn from each other.

A unique feature of these conferences is participating in street rounds with the hosting institution. We really got to see how the pros get it done. I was rounding with a case manager who was looking for one patient in particular- John. She had not been able to find him for the last two weeks and was worried about him. We checked all the usual places that he hung out. We met his street friends who had much to tell us – except for where John was. And so our search continued.

It was about 6pm and downtown Boston was bustling with people leaving work. The streets and the crosswalks were very crowded, horns blaring, quick feet. At a particularly busy intersection, we began to cross just as we see a large dip form in the sea of humanity. As we approached, we saw that our lost patient- John- was right at our feet.  Wheelchair bound, he had lost his balance and tipped right out of his wheelchair and onto the ground. I was impresssed at the number of busy Bostonians who stopped to help him and make sure traffic would not hit him when the light changed to green. We scooped John back into his chair and moved him to the sidewalk. 

John was a rather imposing figure, both in size and in scowl. When you close your eyes and picture a chronically homeless man on a wheelchair, you are likely picturing John. Standing, he was most likely over 6 feet tall. He was wearing many layers of well worn and tattered clothing. He had on an old navy blue winter hat that was a little lopsided so only one eyebrow was showing. He was missing most of his teeth and had a rosy hue to his deeply wrinkled skin. He was not particularly friendly toward me and answered the case managers questions in a short and gruff tone. Yes he had been drinking. No, he didn’t need anything. No, he wasn’t hurt. Then she asked if he was hungry- and for a second, the fiercly guarded wall came down. He was hungry, and thirsty too.  He hadn’t eaten in several days. 

While the case manager went into a Panera Bread, I had a chance to talk to John (or attempt). I started by trying to figure out if he needed anything else since it seemed the peace offering of food had opened the door just a smidge. He told me part of the reason he had a hard time eating despite the available soup kitchens and food vans was that he had a peanut allergy. A severe peanut allergy. Imagine the great lengths moms across America go to in order protect their childreen from inadvertant peanut ingestion. There is even a service through my children’s daycare to find them a playdate with a child whose allergies match your childs ( think match.com but for kids with allergies). Before John, I had never considered what it would be like to have a food allergy on the street. I asked him a few questions about his peanut allergy and then, apparently, crossed the threshold of number of questions allowed.  

I had squatted down to talk to him. Being at the same eyelevel of someone who is wheelchair bound (homeless or not) is extremely important for leveling the playing field. Suddenly, John looked angry. He was nose to nose with me and yelled with a slurred speech, ” Do you reaaaaaaallllllllyyyyy care?” Pause. ” Well, do ya?!” I told him that I really did care. He looked away and muttered, “Well, I don’t know why.” 

There was they key to this whole interaction. Imagine wanting to be helped but feeling inside that you are so worthless that no one in their right mind should want to help you. Therefore, you prophylactically refuse the help because somewhere inside of you, you believe that you are protecting yourself from the inevitable. The dissapointment you will feel when the person decides you aren’t worth it and that they don’t care. Self preservation is a vital survival tool when living on the streets.

We walked with John to a location across town that he liked to hang out ( we had actually been there earlier that day looking for him). He was greeted warmly by his street brothers. A fleeting smile crossed his eyes (but not his lips). As we walked away, I turned back to see John breaking his sandwhich into four pieces – one for him and one for each of his street friends while they passed the bottle of newly purchased lemonade around. A reminder that the parable of the fishes and the loaves is lived every day on the street. 

 

 

The first clinic that Brett and I worked to open was the DeSales Free Clinic (check the Where Are We page for more information) in 2007. To the credit of the DeSales University faculty (long before I was a member), they made attending the Clinic a required part of the curriculum. This is no small feat and did not come without it’s share of controversy. In fact, many medical institutions who offer a homeless clinic experience do not require it but rather just make it available. There are a million reasons stated to take this approach- it is better to have people who really want to be there, the students are already so busy, it is really more of a club-type activity and the list goes on. However, academic research has shown that in the medical school and residency model, the greatest impact on the attitudes of students and fledgling practitioners about this population is seen in programs that require participation in the experience.

Early on in the life of the DeSales Free Clinic, I was going about my business of coaching students and seeing patients. One student in particular looked very uncomfortable. At first I thought it was just nerves. The clinic requires a team of first and second year PA students to see a patient as a team. This expectation is both exciting and obnoxiously intimidating for the students. This usually causes GI distress for 48 hours before the Clinic night in anticipation and 48 hours after the Clinic night as they ponder if they know anything at all. I assumed that student was panicking about repeatedly putting their stethoscope in their ears backwards.

I was wrong.

After the student continued to sweat uncontrollably for over an hour and looked as if they were on the verge of passing out, I pulled them aside and asked them if they were ok. Reluctantly, they told me they were terrified of being at the clinic with ‘these’ patients and had no idea how to relate to “them”.  They wanted to be helpful and they wanted to connect but in the students eyes, there was no common ground. They didn’t look the same, they didn’t act the same, they seemed to share no common experiences. Even their dentition was different. As the night had progressed, this young student had generalized this experience to mean they could never relate to any patient. Ever. The whole night was on the verge of catastrophe.

In my experience working with the homeless (and talking the ear off about homelessness of anyone who doesn’t have the good sense to stop me) I think this is a common feeling that becomes a barrier for getting involved at any level.  I have asked myself the question before too.

I grew up mostly in Kansas and Indiana. I am more familiar with tornados, farm land and suburbia than the inner city. I listen mostly to country music.  I don’t have a history of addiction or incarceration or abandonment. I say ya’ll and when I am tired, tend to sound more like a hillbilly than a college professor. I have parents that are still married after 41 years and always had plenty of love. It is not to say that there were never hardships and difficult times but a big difference is those struggles were conquered with the support of a loving environment. So, simply put, how do I relate? Where is the ‘street cred’?

Respect. Dignity. Humility. Authenticity.

It is really very simple.  When we treat people with respect and dignity, they appreciate it. They may not show it right away but they see it, they hear it and they feel it.  Often, in medicine we are told that the homeless are a ‘difficult population’ who never follow up and never follow through (usually accompanied by an eye roll or heavy sigh). This has not been our experience. In fact, one way our patients show us that they have felt the respect and have been treated with dignity is that they either come back to the Clinic or invite us back to their encampment- their home.

There are certain things in life that are exceedingly difficult to fake. Humility and authenticity are two of them. Most of my patients have experienced things that are unspeakable. I don’t know how they have walked on this Earth for all these years bearing these burdens of emotional (and often physical) trauma. And certainly, sometimes they are suffering the consequences of their own actions. But often, no one listens to them. They don’t listen to how they ended up sleeping on a friends couch. They don’t listen to how they ended up sleeping in their car, the woods or in a shelter. They don’t ask why they never took any of the medications they were discharged home on. They simply determine- by way of a sideways glance- that a persons homelessness is the rightful consequence of a mistake and simply cannot be helped.

Dr. Jim Withers (seriously, if you don’t know how he is- Google him) always says that we have to suspend our reality and step into our patients reality in order to truly understand how to help them.  Suspending reality takes some courage. Once you see the world through different glasses, it can be hard to ever see it any other way. Like the former lifeguard in me that cannot go to a swimming pool without constantly scanning the water for someone in trouble. However, if you are willing to take a journey into someone else’s life, you will be enlightened and only the can you really know how to help.

-C

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