From a Week in Practice
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Am Fam Physician. 2004 Oct 1;70(7):1262-1263.
The triage nurse, MF, asked hesitantly if JOH wanted to see the patient who had taken “four buses” to reach the mobile clinic. Her problem was really more social than medical. She had bipolar disorder and was taking two potent medications for this problem, but she would soon run out. However, her most pressing problem this morning was not having the resources to purchase a narcotic prescribed by another physician who was treating her for chronic neck and low back pain. She had been evicted from her apartment, was in the process of divorce, had no employment, and had lost her insurance benefits. The situation seemed bleak, and she had been to several other clinics without receiving help. As a general rule, narcotics are neither supplied nor prescribed from the mobile clinic. The patient’s vital signs and back and neck examination did not reveal any severe impingement findings, making JOH believe the pain was more disabling for her psyche than for her body. This particular patient presentation was not typical of those seeking narcotics, but was dealt with by calling the office of the prescribing physician, who was willing to prescribe a cheaper narcotic with a generic equivalent that would prevent withdrawal symptoms. JOH was thankful for the resourceful nurse, MF, whose efforts paid off. The patient was grateful for the help and left the mobile clinic in a much better frame of mind.
When patients bring in a plastic baggie containing “specimens” they have culled from some body part, JOH’s suspicions are immediately aroused. In many instances, the specimen turns out to be something other than what the patient thinks it is. Flakes of eczematoid epidermis are touted as parasites, toilet tissue waddings are alleged as worms, and dandruff is described as if it were a living creature. So, it was with some skepticism that JOH examined the contents of the baggie that Willie brought to the mobile clinic today. A frequent visitor to the clinic for uncontrolled blood sugar levels and scabies, Willie, who had recently moved back into the shelter from temporary housing, proudly held up the object of his concern, which had crawled out from underneath one of his gloves. It certainly had the appearance of a living creature, but was too big to be a body louse. It appeared to be a black ant. Stroking his beard slowly and nodding his head, JOH praised Willie on his perceptive acumen, examined his deeply scratched arms and torso with multiple punctate lesions, and gave him permethrin to kill the actual invaders, which had wreaked havoc on his unwashed, unkempt body.
Life is not always fair. When a person is homeless and mentally ill, however, it is intolerable. Ali was fluent in five languages—Arabic, English, Spanish, French, and German. He had been taught all of them growing up in Kuwait. But, he was living in a homeless shelter and was unable to find a job. He came to the mobile clinic for treatment of bronchitis and a “burning pain” in his chest when he coughed. His examination revealed no pneumonia, and JOH believed the problem to be viral. Symptomatic treatment was accepted with gratitude. Ali was not angry or self-pitying; he seemed resigned to continuing his search for gainful employment. His attitude was admirable. The medications that kept his mental illness under control had side effects of their own—they could not remove the stigma of mental illness or make an employer hire Ali. Our country professes that everyone is equal, but the reality is that some are more equal than others.
Nothing says “thank you” like a hug. The present day liability climate seems to have decreased the incidence of this wonderful occurrence, but when it comes from the heart, it is indeed special. JOH received one of those special hugs from a patient he saw today. She had been seen originally on the mobile clinic when her diastolic blood pressure was higher than 120 mm Hg. Antihypertensive medication was quickly initiated, and the patient was referred for follow-up care at Mount Carmel’s recently opened neighborhood health center for the underserved. Her blood pressure today was much improved, and she wanted to express her gratitude for being given a medical home. JOH had to admit that the feeling was mutual.
It was evident from his deliberate, strained gait walking from the shelter to the mobile coach that Marvin had a medical problem. The history was an abrupt onset of “stiffness” in his legs after sitting, which began one year earlier and was progressing. The examination revealed no visible fasciculations in the legs, but four beats of clonus in the feet, bilateral hyperreflexia, and muscle rigidity. It all pointed to an upper motor neuron lesion, but JOH knew that the mobile clinic was not the venue to pursue the proper work-up. Unfortunately, access to specialty referral for patients unable to pay is not easy in the present health care environment. Funding cuts to neighborhood health centers and restrictions on resident work hours at teaching hospital clinics limit the resources available to indigent patients. But, the Outreach nurses and case managers were resourceful. The Columbus Medical Association was doing its part by staffing a Monday night clinic with generalists and subspecialists, and this was where he would follow up. It was not an ideal situation, but then again, it is not an ideal world.
There is a point at which a physician must draw a line and accept the fact that a patient’s own self-destructive behavior has severed the physician-patient relationship. The first patient of the day was close to crossing that line. She had been under the care of another physician, whose tolerance had to be of epic proportions. JOH saw her for the first time today, but her complaint of sleep difficulty had been addressed on numerous occasions. In fact, she had tried every soporific, every anxiolytic, every tricyclic, and every selective serotonin reuptake inhibitor known to humankind. At the mention of each drug name, her response was “didn’t work.” But what really pushed JOH’s buttons was the fact that she smoked three packs of cigarettes a day and did not want to quit. Now, inhaling 1,000-plus chemicals daily for 40 years is known to be detrimental to one’s health. What the patient was essentially saying was, “I defy you to find a chemical that is going to give me a perfect night’s sleep.” JOH admitted to being stumped and ended the encounter explaining that if the patient was not willing to at least cut back on her addiction, he was at a loss in solving her sleep disorder. It was not the best way to begin the morning.
After years spent in private family practice and academia, John O’Handley, M.D., is medical director of the Mount Carmel Outreach Program in Columbus, Ohio. The program provides free medical care to uninsured and homeless patients throughout the city on a mobile coach clinic. Dr. O’Handley continues to see private patients two mornings a week.
Address correspondence to John O’Handley, M.D., 4040 East Broad Street, Columbus, OH 43213 (e-mail: email@example.com).
In order to preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario.
Copyright © 2004 by the American Academy of Family Physicians.
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