Eight weeks later and I’m done playing Family Medicine doctor and I’m preparing to pretend to be a surgeon, starting next week. As I’ve previously written about, the patient population in the county clinic has been, at times, challenging to work with – and indeed many days were filled with people so dysfunctional that trying to practice any medicine other than crisis mitigation was laughable. Now, a few days have gone by and the sharp image of those hostile people has blurred a little bit and I find myself reflecting on the less dramatic segment of patient population. These are people who, for whatever reason are without health insurance and income (as to get this insurance, you basically cannot have an income of any kind.) Perhaps they found themselves suddenly without a job or had an acute sickness or trauma rendering them unable to work. It could really be anyone though – I found myself connecting with people I have very little in common with constantly, and really, this is a huge part of the job description. Some people are a few degrees more displaced from living in the woods than others, but none of us are completely immune to losing everything -- including our health, at any time.
It is no secret that young men and on into middle age are a group of people that generally avoid the doctor’s office – until something fails, of course. Sometimes it is diabetes, sometimes its angina, gout or any other of the classics and it takes the men by surprise. They soon find themselves having to visit the doctor on a regular basis for management of a serious chronic disease.
There are a couple of patients in particular that I saw numerous times in the clinic who I know I was able to make comfortable and get them to open up just enough so that we could have some meaningful dialog. One in particular, who made an impression on me, was nearing 50 years old and he had been a “gang-banger” for many years, had been in and out of jail and prison multiple times. As the years advanced he started to work in construction and lead a decent life – “for his children” – he said. He had never had any health problems other than a few uncomplicated GSWs and simple knifings until last year when his leg turned gangrenous in the span of 3 days. After three missed diagnoses at three different emergency departments, he found that his leg needed to be amputated at the knee. He went from playing pick-up in the park to losing a leg in 10 short days. The transition from taking his health for granted to trying to comprehend that his days have been severely reduced unless he takes drastic proactive action to prevent further progression of his uncontrolled diabetes and propensity to DVTs (the duo that precipitated the necrosis in the first place) is one that he has been trying hard to make. And to be sure, there have many pitfalls along the way for many reasons.
This particular individual has so little in common with most of the doctors that he has encountered that he has said that he grew to dread every visit. He went as far to admit that often times he doesn’t even know what doctors are saying, as many of the medical words mean nothing to him (I would also argue that this is common, even for well educated people) but for him, stopping the doctor and asking for an explanation is not only humiliating but furthers the relationship dynamic wherein the patient feels powerless and helpless. Trying to imagine a culture where even the perception of weakness is attacked aggressively helps to understand that a patient like this needs a manner of communication drastically different. Now, I was never a gang-banger, never went to jail and never smoked crack but I do feel like I can identify with this guy on a level that not many clinicians can. The years spent as a skateboarder brought a very wide variety of characters in and out of my life –- working in restaurant kitchens and the service industry in general is a lesson in how to party hard and still manage to scrape yourself out of bed for the next day’s shift. The years I spent in construction demonstrated the awesomeness of a fellow contractor breaking parole (not that construction workers have to be criminals, but there is no doubt that its a field surpassed in criminality only by politics,) which meant I had extra work that week.
A character from the wire -- Dennis "Cutty" Wise is a character that I sort of (perhaps in a naive sort of way) found myself viewing some of these patients through. In short, for those not familiar, Cutty is a reformed gang-member and is trying to make positive changes in his life, but of course, the past doesn't always stay in the past. I tried not to fall into a role where I was making assumptions of one's past, but usually I didn't have to once I had the patients in a place where they were willing to talk. All this to say that I was thankful I was in the position to help these patients get access to care by breaking down some subtle yet insidious barriers.