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Monday Aug 14, 2017

I Had to 'Unlearn' Medicine to Treat Vulnerable Patients

Two years ago, I started the PurpLE (Purpose: Listen & Engage) Clinic(www.facebook.com) at the Institute for Family Health, a federally qualified health center in New York, N.Y. We offer a health home for people who have been victims of human trafficking and other trauma, and I meet patients of all genders, ages, documentation statuses and backgrounds who are encountering a range of medical issues.   

Sometimes people ask what it's like to provide care to this population. I tell them I've had to "unlearn" how I practice medicine. And then I show them my drawings to explain why. This June, I attended my first Comics and Medicine Conference,(www.graphicmedicine.org) where I had a chance to reflect on unlearning medicine at the PurpLE Clinic by sharing my stick-figure comics. Here are a few examples:

Food

When I prescribed medications such as ibuprofen, reminding people to "avoid taking these on an empty stomach" was reflexive -- until last year. A PurpLE Clinic patient seeking asylum after being tortured while living in his native country had an appointment to address ongoing pain related to his injuries. As I was prescribing him an anti-inflammatory medication, I didn't think twice about saying, "Make sure you take this with food," until I noticed his blank stare.

Ten minutes earlier, he had told me he had no income and relied on a friend who worked in a restaurant to bring leftovers to eat; sometimes there were none. I realized that what I was actually telling him with my prescription instructions was that I had been hearing but not listening. I needed to unlearn the idea that common medical advice has universal applicability, and instead learn that some prescriptions need their own treatment -- such as assisting with food access -- to help a patient.  

My assumptions regarding food have been tested in other ways, too. One patient called to let me know she was running late because she had a chance to get food and hadn't eaten in three days. This was not an uncommon reason for patients to be delayed, so I said I completely understood, envisioning a very specific scenario.

When she arrived that evening, I asked what she had eaten, and she responded, "Nothing," because she had only "collected $3.83 worth." This patient was paying for food by collecting cans and bottles to recycle, and she had come up short.

Hunger is frequently addressed during PurpLE Clinic appointments because they are typically on weekends, when there is limited access to assistance such as food pantries.

"When was the last time you ate?" is something physicians ask when we order labs that require fasting. I've unlearned the purpose of this question. Having implemented a way to provide point-of-care access to food, I now ask "When was the last time you ate?" to ensure no one leaves the clinic hungry.

Transportation

As I mentioned, patients at our clinic often come in later than scheduled for many reasons. Life is unpredictable. Some undocumented patients rely on informal networks for jobs and may find out the night before that a hair-braiding, construction or housekeeping job has become available. Some patients, however, always make it on time and never miss an appointment.

Other patients said they had to decide between eating a meal or paying subway fare -- making appointment days particularly difficult. In New York City, where issues such as turnstile-hopping were resulting in arrest,(gothamist.com) it was troubling that attending appointments could be a link in the cycle of poverty and incarceration. To address this, I needed to unlearn that on-time appointments were a measure of success in health care delivery, and our team implemented a system that made subway cards available to patients.

Housing

I've also learned that sometimes the subway is not just transportation -- it may also be housing.

Initially, I found solace in headlines from population health research that declared ZIP codes have more influence on health than genetic codes because this signaled an important shift in the health care system's understanding of the role of social determinants of health.

But then I started to wonder whether PurpLE Clinic patients were accounted for in these findings. Patients in domestic violence shelters live in confidential locations and have only post office boxes. Their ZIP code may be unrelated to where they live. Patients staying with friends or couch-surfing to escape an abuser have different ZIP codes every day. And patients living on the subway don't have just one ZIP code. They have at least 10 in one day. In our clinic, I have unlearned that a ZIP code tells me where someone lives. It only tells me where they receive their mail.

PurpLE Clinic has made me realize that highlighting the narratives of those whose vulnerable circumstances may be hidden at a population level is an essential form of advocacy. Recommendations rooted in lessons learned from direct patient care offer complementary insight to lessons learned from population health research. Both are necessary to ensure that key stakeholders, including policymakers and health system entrepreneurs, consider the breadth of people's circumstances when they create policy, allocate funding or design their next health care app.  

These are some examples of unlearning the practice of medicine that I have found essential to being a family doctor. I know these lessons may be intuitive to some and largely inapplicable to others. But to students and residents embarking on their careers, I say this: I hope that you will routinely check your own reflexes to make sure that the advice you are taught to give is applicable to the patients you are expected to help. And I hope you have the freedom to question whether innovations in research and policy account for your patients' circumstances -- and the opportunity to design solutions that do.

Anita Ravi, M.D., M.P.H., M.S.H.P., is the founder and clinical director of the PurpLE Clinic at the Institute for Family Health in New York City. She is not an artist, but enjoys using stick figures to promote health and gender equity. You can follow her on Twitter @anitafamilydoc(twitter.com).  

Posted at 04:32PM Aug 14, 2017 by Anita Ravi, M.D., M.P.H., M.S.H.P.

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