Stefan, a resident, peeked into the checkout room, displaying a pleased grin: “Come, Dr. Fisher, you need to see this!” What was he beaming about? It was a typically busy afternoon in our community clinic. I followed him into his patient’s room.
Ms. Bolden was kempt, making intermittent eye contact, and her blood pressure was controlled. Tova, who was, as always, accompanying Ms. Bolden, enthusiastically shared that Ms. Bolden had seen her daughter and grandson over the past weekend, and it had been a “good visit.” Ms. Bolden was becoming more comfortable in her new apartment. Tova asked about resources and activities for Ms. Bolden, so she could get more engaged with others. We concluded our visit by offering our sincere congratulations to Ms. Bolden for her success, a refill of her metoprolol, and the date for her follow-up visit. I asked Stefan how he felt about the encounter, and he exclaimed, “Happy, very happy!”
It was strange. I had a mix of emotions—I was happy for Ms. Bolden’s health but also disappointed in myself and our system. Six months ago, she had been living across the street from our county hospital in a nearby park. She had been homeless for more than 15 years, during which time she visited the emergency room for various problems, ranging from bizarre behavior to severely infected leg wounds that were maggot infested. It was in this park where Tova, while out on her daily jogs, met and eventually befriended Ms. Bolden.
Tova brought her food and supplies and gradually acquired her trust. Ms. Bolden allowed Tova to facilitate her medical and psychiatric care, change her dressings, obtain an ID for her, and enroll her in social services. Through this relationship, Tova gained Ms. Bolden’s confidence and helped foster the reconciliation between Ms. Bolden and her children, whom she had not seen in many years. For the past two years, Tova had been bringing Ms. Bolden to our clinic where she had been receiving medical care. Most recently, Ms. Bolden was granted housing and was learning to live inside, in an apartment, instead of simply surviving on the streets.
Medications quieted the paranoid voices, controlled her blood pressure, and healed her leg wounds; yet, medical care was only a small part of Ms. Bolden’s return to wellness. Reflecting on “our success” makes me cringe when I think of the missed opportunities when she visited our emergency room over and over again. However, her story also reinforces the power of relationships—Tova, a complete stranger, transformed Ms. Bolden’s life by establishing a positive rapport. When I get reprimanded for a long cycle time due to a lengthy conversation with my patient, I think of Ms. Bolden and how the lack of relationships contributed to her extended poor health.
As a preceptor, I am aware that the residents do not want me initiating long discussions about “nonmedical” (social) issues when I go into a patient’s room. On the other hand, one resident was astonished when we learned that our patient, who had a negative costly evaluation for weight loss, had actually been losing weight because of inadequate food. This patient ran out of her food stamps during week three of each month. When we referred her to social services, we made a difference. When, after an extended initial interview, a new geriatric patient with multiple comorbidities, who had been avoiding care for many years, returned the following week and told us, “Thanks, Docs. I told you I’d be back,” the resident smiled. These connections are priceless. As I saw with Ms. Bolden, medical care is only a small part of patient care.
Joslyn W. Fisher, MD, MPH
Dr. Fisher is associate professor of medicine and medical ethics, Section of General Medicine, Baylor College of Medicine, Houston, Texas; e-mail: firstname.lastname@example.org.