Journal Entries Week 7/7 – 7/10

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.