Journal
Entries Week 7/7 – 7/10
Monday: Monday
marked my first day at the Intensive Outpatient Clinic (IOC) of Denver Health,
and it proved to be an eventful one. I arrived shortly after the clinic had
opened as was soon introduced to Dr. Cynthia Crews, a busy woman who only came
in to the IOC three days a week. After finishing with her first patient of the
day, she sat down with me and took some time to get to know me and tell me
about herself. She described herself in a unique way: she was part-doctor,
part-social worker. Of course, she did not mean by education or instruction,
but rather by practice. Soon, I saw this to be true. The patients who came into
the clinic were seen for one hour on their first visit and a half-hour on any
subsequent ones. Nonetheless, most of the doctors in the clinic took an hour or
more to see nearly every patient, sacrificing their lunch breaks and staying
late if needed. This was a place where the holistic patient was considered, for
life habits and mental states were as important to physical health as anything
else. Dr. Crews demonstrated this with her first patient. This woman had been a
longtime patient of the doctor, and there was a familiarity about their
interactions which was evident, even to me. Nonetheless, as Dr. Crews began to
question the woman about her medications, their eyes locked, and a struggle
seemed to ensue. The woman claimed to have been diligent, but the doctor’s
steady gaze was sternly mistrusting. Under the firm gaze, the woman seemed to
lose some of her ability to lie, and steadily admitted things she had intended
to hide. After the appointment, I spoke with Dr. Crews, noting the nonverbal
communication that took place. She agreed, sometimes there needed to be a
struggle which took neither words nor actions, but only a message conveyed in a
look.
The
next patient for the day was a man who had never been seen before in the
Intensive Outpatient Clinic. Dr. Crews spent some time getting to know him and
his various conditions, extending from his heart to his feet. Dr. Crews
suspected, also, that there may be some interesting diagnoses to be made within
his head, though by someone more psychologically-minded. He was homeless, like
many of the patients the clinic saw, and was open to some information provided
by the social worker, Katie, whom I followed into his room. She spoke with him
about shelters and day clinics. However, he sought somewhere where he could
stay for the day without being forced to vacate and look for a job. This sort
of provision was few and far between, and generally only afforded to the very
ill. Regardless, Katie and Dr. Crews extended the help they could to the man. In
addition to providing resources, they offered a sort of therapeutic problem
solving. In reference to our own psychological studies, it seemed as if the
women employed both emotion- and problem-focused reasoning, as needed. Seeing
these strategies in action was far more beneficial than experiencing them in a
textbook. The man was sent on his way, after nearly two hours in the clinic.
After a few more
patients, Dr. Crews left in the early afternoon and a new doctor took over the
clinic, Dr. Joshua Blum. This man seemed to have little more than a second to
spare, and for good reason. Rushing between an HIV clinic in the mornings and
the IOC in the afternoons, while also putting in some time at a state prison
facility, Dr. Blum was busy. Nonetheless, he took me in with him to see a slew
of patients over the span of the afternoon. I saw in him the same pat-social
worker affectations which Dr. Crews had shown. One of his first patients was a
middle-aged woman with a slightly reserved attitude. After talking a bit about
her health and weight, Dr. Blum asked her to speak about her life at home with
her husband. Soon, tears erupted as she spoke of the man who didn’t seem to
desire her any more. Her aging and health issues had caused small changes in
her body, such as losing body hair, and her husband no longer wanted to engage
her sexually or sleep in the same bed as her. He had made comments which had
not seemed very meaningful to him, but were all but destroying her. Dr. Blum
responded empathetically to all of his patient’s stories, and calmly advised
her to speak to her husband about how he was making her feel. Her depression,
no doubt, would benefit from better treatment from him. The patient gained her
composure and nodded, thanking the doctor for his words. I felt drawn, myself,
to console her, but decided to leave that to Dr. Blum. As she left, she seemed
to at least have a plan for how to fix the things that were most disrupting her
life. Some patients got more psychotherapy than physiology, it seemed. With one
man, Dr. Blum even took the time to explain some of the handout “5 Wishes,”
which details what someone wants to be done with them if their judgment is
compromised, or if they pass away. It was important for this patient to
understand the implications that came with health conditions, and not just the
conditions themselves. It was not just health care that the doctor had
provided, but general care. It was almost a behavioral medicine which the
doctors practiced, introducing the inherent psychology behind conditions into
their practices as methods to diagnose and treat patients’ cases.
One of the last
patients of the day came in bragging about her previous night’s meal. At 1:30
in the morning, she had eaten barbeque ribs, chicken, potato salad, cornbread,
and a tall glass of lemonade. She talked about it joyfully, all but licking her
lips. Dr. Blum, of course, was less joyful. She tried to explain to her that
her insulin shots were not enough to keep her diabetes at bay if she ate so
poorly on a consistent basis. She seemed to understand, and yet also seemed to
dismiss his advice. For her, this was
simply what she ate. Smoking was simply what she did, as well. And, to her,
these things were unchangeable. Medications, she could manage. In fact, she
requested a set of vitamins to help her nail and hair health. But anything outside
of her comfort zone was quickly dismissed. Dr. Blum finished with the woman,
shaking his head. There are just some people you can’t help, he told me. After
another patient or two, Dr. Blum’s day way over, and I thanked him and looked
forward to the next day.
Tuesday: The
second day of the week, my shadowing focused exclusively on Dr. Vishnu
Kulasekaran, a sociable and high-energy doctor. He saw a whole set of patients
throughout the day. Many suffered from health conditions and severe depression.
Others added previous addiction to the list. Dr. Vishnu allowed me to ask
questions of the patient, and help him build confidence by chatting with new
patients. He asked patients to call him Dr. K and had a way about him which was
both charming and trustworthy. If I had anything to learn from him, it was how
to interact with a patient. He took just as much time to listen to patients’
feelings, thoughts, and personal lives as he did to make a diagnosis. No doubt,
his diagnoses benefitted from the time he spent learning anything and
everything about patients. As patients passed out of the IOC, they did so with
a smile and a resounding feeling that things were better than they had been 30
minutes or an hour before.
The
final two patients of the day were some of the most interesting. The first was
a woman who brought her daughter along. Though, perhaps, the more proper way to
phrase this would be to say that the daughter brought the mother with her. The
mother was scarcely able to formulate a sentence on her own, between the
overall weakness in her slim frame and the shortness of her breath. She was
dying. This was the sad but simple truth. What was needed now was to talk about
hospice and power of attorney. The most surprising part of the situation was
the way that the mother and daughter took the news. They were strong or
resigned, wise or apathetic, for they took the news with nods and listened
intently to Dr. K’s instruction about what hospices were nearby and what the “5
Wishes” were. The old woman cared only that her children and grandchildren were
provided for by the little that she left them. As the pair left, slowly, Dr. K
shared his happiness that the encounter had gone as well as it did with me. “I
wasn’t sure if we should have that conversation today,” he said, “But you have
to sort of read the room.”
Then we saw the last
patient of the day, a very overweight woman, with an oxygen tube extending from
her nose. I was briefed beforehand: this was the most depressed woman that Dr.
K had ever known. She was chronically suicidal, and had a past filled with pain
and sadness. She and the doctor had a calm conversation; she seemed very open
with him. She had been taking her medications and had a few concerns with her
health and her mood. Then, the conversation turned to her depression. The
response she gave to the doctor’s questioning on this was incredible. She said,
“You know, Dr. K, I still don’t want to be here. You know that. But this who
team—system—its made me think, maybe, I’ll just give it a shot.” Dr. K nodded,
but I couldn’t hide a warm smile. This woman, who had failed at suicide
attempts time and time again and still lived with chronic health and mental
health issues, was thinking about staying alive. If there was a better way to
end the day, I couldn’t think of it. The psychology behind the interaction was
obvious, yet also too beautiful to fully encapsulate. I left for the day, happy
to return the day after the next, on Thursday.
Thursday: Thursday
was to be my last day at the Intensive Outpatient Clinic of Denver Health. I
arrived in the bullpen to find Dr. Jeremy Long going through paperwork. He informed
me that it would be a slow morning. We talked while he finished filling in
notes from previous days. Then, a patient finally made his way into the office.
The man had many of the usual conditions: smoking had worn down his
cardiovascular and respiratory systems. Yet he wasn’t taking his medications.
Dr. Long found that he hadn’t even been filling the prescriptions which he
claimed he had. The reason? Money. The $0.15 copays on the man’s monthly
supplies of medicine were too much, according to the man. Dr. Long, of course,
doubted that this was true. The patient was another example of the resistance
which many had shown at the Denver Rescue Mission. Sometimes, conformity to
rules and guidelines seems to be too much for individuals. Perhaps it is
obedience itself which is the problem. If people were not told what to do, they
may not be opposed to doing it. I was sympathetic to this attitude, yet also recognized
its part in perpetuating the positions which many indigent people are in.
The next patient was
even more interesting. He was a homeless man who felt that society should
provide him a place to eat, drink, and sleep alone, in peace. Admittedly, the
part of that triad which he preferred was drinking, and he wanted to do it “as
a recluse.” When Dr. Long began talking to him about resources which might
require him to play by someone else’s rules, the man began to yell, “You don’t
know shit about me!” and Dr. Long later stated, “That’s where I lost him.” The
man spoke also with the addiction councilor, but there was little for them to
do. The man did not want the help available. The need for a psych evaluation
was noted, for the man likely had a borderline personality disorder. It seemed
as if the root of his entire situation may have been more concerned with mental
than physical health.
For a few hours, Dr.
Long and Dr. Blum, when he arrived, saw more patients: a mother whose daughter
did much of her translating, a man who spoke merrily in Spanish to Dr. Blum
about his heart condition, and a man who did not seem to want to take his
medications, because he usually forgot to before bed. This latter man was
homeless, as well, and did not even want a free glucometer, for he thought it
would take up too much room in his small satchel. The man repeatedly said that the
solution for his health was housing. If he could get a place to live, he could
take his insulin and care for his heart. Until then, he refused to take any
sort of initiative over his health. Dr. Blum was not able to help him greatly,
but scheduled a future visit, as usual. A few more patients were seen. One man
upped his own Oxycodone dosage, without Dr. Blum’s direction. Another patient
was the perfect example of a distended jugular vein.
The last man of the
day, however, was the most interesting of all. As I entered the room, he
greeted me warmly, for we recognized each other from the food line at the
Denver Rescue Mission. He then approached much of the check-up with Dr. Blum as
would any other. But this man was different, though he did not appear to be. He
had been seen by doctors 540 times within the past year and was, quite
literally, the single greatest user of Medicare within the entire state of
Colorado, by a considerable margin. He was a known abuser of cocaine and the
pain pills he received. The man spoke of being prescribed medications which he
had not picked up yet and stated that he was in a hurry to get to the Denver
Rescue Mission for the night. He left quickly after a brief conversation with
Dr. Blum. Dr. Blum told him that he had to check on how much the hospital had
prescribed him in medications, before he picked them up. Only after the man had
gone and Dr. Blum had called down to the hospital did the truth come out: a new
resident had prescribed far too much of each pain-reliever to a known user—a
thirty day supply. He had already picked up the supply before seeing Dr. Blum,
and was now on his way, with a bag full of narcotics. “I’ve been played,”
stated the doctor. This homeless man was no fool. This experience showed me a
side of the homeless population which the Denver Rescue Mission had not been
able to. This man was a problem for the system, simply using it to fuel his
destructive and wasteful habits. It was men like him which served as anecdotes
for those opposed to helping the unfortunate in society. It was from him that
attribution errors and stereotypes were derived. The day ended on this
unfortunate note, adding to many defeats for the day. Nonetheless, many
victories had been won between bouts of helplessness, and the IOC had done its
job. Dr. Blum asked me to return for another week, a welcome bit of news for
one who had not wholly expected it.
