I walked into the exam room. A disheveled, middle-aged woman named Dakota* was sitting on the bed holding a line drawing. She showed me the sketch and said, “This is my heart. I have more than 20 stents.” I thought, “Oh, my goodness! How am I going to manage her heart?” We began talking, and I discovered she was homeless. I learned all about her: Where she had lived. Why she had moved. The medical condition she referred to as an “over healing disorder,” which she had dealt with her entire life.
Throughout the time I was her physician, Dakota suffered five more heart attacks. She often came to our appointments with paperwork indicating that she had gone to the emergency room and left against medical advice. After looking over the documents and speaking with her, I discovered a communication gap: Since Dakota had been living with a heart condition for her entire life, she felt that she knew which medications worked well and which ones did not. However, Dakota believed physicians were failing to listen to her, because she only had a high school education and was living on the streets. They were talking at her and following protocol, which explained why she repeatedly left the hospital out of exasperation.
During one of our appointments, Dakota reported chest pain, so I encouraged her to check into the hospital. She reluctantly went, but refused treatment once again. Instead of letting Dakota go—letting her repeat the cycle of miscommunication and frustration—I decided to visit her in the hospital. As I entered the room, she turned to her friend and said, “That’s my doctor. I’m scared.” The two of us spoke for awhile. I listened to Dakota’s needs, concerns, and fears. I explained the reasons for her different medications and procedures. We connected. Dakota became amenable to treatment, but reported another frustration: “They keep telling me to watch my diet and exercise. I’m homeless. I eat shelter food. I don’t have options. Exercise? I live on the streets.” Dakota made a good point: How could she choose the healthier food option when she had only one choice?
Dakota inspired me to paint The Whole, on the cover of this issue. One half of the image represents the detached, black-and-white thinking that we as doctors can have when interacting with our patients. We need to step back from our clinical mind-set and look at a patient’s individual parts, like a colorful puzzle, to understand her whole image: the lion. When I followed this practice, I realized that Dakota had a unique medical condition that she lived with for her entire life. She had valuable knowledge and needed to be listened to and learned from. By taking her social circumstances into consideration, I understood that physicians didn’t need to encourage Dakota to exercise. She was getting exercise, though in a nontraditional way: She had to carry her belongings for at least 5 to 10 miles per day to meet her basic needs, as opposed to running on a treadmill. When interacting with our patients, we should consider their whole being as opposed to solely focusing on the presenting problem.