We're in the midst of an entitlement epidemic. We even see it in health care. No place is immune, not even the ED.
I got a full dose of privileged attitude working in an affluent part of Richmond. I frequently encountered a VIP mentality that kept people from realizing that every patient was important. I often felt that nothing I did was good enough or that patients believed their connections or power should influence our relationship. Then I changed jobs and began caring for patients in one of Richmond's poorest areas, and I realized that gratitude hides in unexpected places.
The neighborhood surrounding our ED has a lower per capita income, more single-mother households, and a child poverty rate higher than 99.9 percent of the neighborhoods in America. (Neighborhood Scout. http://bit.ly/2Oc37XD.) People in this community are less likely to have jobs and healthy food and more likely to face violence in and outside their homes. They also have lower health literacy about basic health needs.
Sadly, hospitals in this type of community are closing nationwide. Research shows that being poor is highly correlated with poorer health, and we need hospitals and physicians to remain anchored in communities with the greatest needs. Yet, hospitals across the country are moving out of poor neighborhoods into wealthier ones. The number of hospitals still operating in 52 big cities fell to 426 in 2010 from 781 in 1970. Meanwhile, hundreds of medical centers opened in affluent suburbs. (Journal Sentinel. June 14, 2014; http://bit.ly/2yv8d6u.) This push to move resources to higher-income communities is leaving many low-income ones without an effective safety net.
You would think my underprivileged patient population would be adamant that they deserve more, but I've learned that those who have the least somehow have the most gratitude. These are the most grateful patients for whom I have ever cared.
‘Why Are You So Nice?’
I'll never forget the patient in cuffs, beaten to a pulp, and about to be hauled off to jail. He refused medical evaluation, and I tried to persuade him to let me help him. He said he had bigger problems, grabbed one of the industrial-strength disinfectant wipes, and started wiping his wounds with it. I politely asked him to let me get him a better wipe for his skin because that one was for counters. Nothing I did or said was overly sweet; it was just a courteous doctor-patient interaction. Yet, he took a moment in the middle of his horrible night to look me in the eye, and asked, “Why are you being so nice to me?” How badly are people treating you that a doctor offering you an appropriate facial wipe is being so nice? I left the room blinking back tears. Had he ever known real niceness? I have no real understanding of what his world must be like nor how diametrically opposed his past must have been to my privileged upbringing, but I've gotten enough glimpses into the day-to-day life of my patients to know he had endured hardships.
Medics who serve this community told me these people often have three generations in a one-bedroom apartment, often just grandma, mom, and kids because the men die young. Poverty traps many families in these unfortunate circumstances. The child brought in with “just a cold” may not have had a good meal. The sweet little girl who looked longingly at my paper and pen was as excited as my spoiled kids would have been looking at an iPhone. I left them with her while we ran her tests, and her overwhelming gratitude for such a small gesture melted my heart. She drew me a picture that said, “I love you.” It hangs on my fridge to this day. (See image.)
Other doctors were incredulous when I started at my ED: “You really want to work there?” We are all conditioned in residency to think that good cases involve zebra diagnoses or pulling people from the brink of death. But I think good cases are the ones where you get a drawing from a child.
Disbelieving colleagues say, “There's so much psych.” We do have an in-patient psychiatric unit (but not an ICU), but maybe psychiatric resources help, given the overlap between the mentally ill and the impoverished. “You'll see the patients coming in for vaginal discharge at 3 a.m. who should go to their PCPs.” Maybe, but the level of gratitude makes it worth it.
I see plenty of non-emergencies in the wee hours of the morning, but for the first time in my career, I can stop asking myself, “Why are they here for this at 3 a.m.?” because I understand my patients' needs. One gracious and thankful mom came at 2 a.m. for her back pain because she worked two jobs to support her children and didn't want to miss work. I can't think of more meaningful work.
What we do is especially rewarding when we are lucky enough to feel gratitude from our patients. The unique gratitude I get from poor inner-city patients makes me feel like I'm making a difference, even when I'm evaluating vaginal discharge at 3 a.m. Caring for this population combats the compassion fatigue and burnout I was beginning to feel after a decade in emergency medicine. Finding meaningful work in the middle of the projects has been a soul-satisfying blessing, and I'm happier and more content than ever. I've found my niche, and my heart is full.