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How Can I Help?
A doctor learns that social ills keep patients sick.
By Joanna D'Afflitti, MD, MPH
From the beginning I dreaded going to clinic. This was an uncomfortable feeling for me. I had spent the last 10 years struggling through physics, biochemistry, and endless multiple-choice exams in order to do what I do: practice primary care medicine in an urban health center. “What I love about medicine are the stories,” I wrote in my personal statement for residency programs. “I want to work with people whose lives are complicated.” Yet here I was, two years into a general internal medicine residency, wishing for a torrential downpour every clinic day so that none of my patients would show up.
Most of us who go into medicine do so because we want to make people’s lives better. We are not naïve about this; we appreciate that forces more powerful than we are at work shaping health outcomes. In spite of this, we hold on to the belief that we can make people’s lives better, at least in some small way.
In clinic, however, this often feels impossible. Patients’ health problems are so tightly woven into the fabric of their complicated lives that we cannot
adequately address them without addressing the underlying social turmoil. I have one patient who comes to see me every two or three months for chronic, lower back pain due to several herniated discs. He has seen an orthopedic surgeon, who recommends surgery. But the patient, who is homeless, lives in his car, and the surgeon, quite reasonably, is unwilling to perform the operation without a stable, safe place for the patient to recover once he leaves the hospital. Nor does the patient have health insurance; he cannot even go to a nursing home for rehabilitation. No home, no surgery; no surgery, no improvement in back pain; no improvement, no ability to work and earn money; and no money, no home or health insurance. The cycle is dizzying.
I see another patient regularly for pain in her right wrist. An extensive work-up has revealed no medical cause of her symptoms, yet the pain is disabling. Each encounter is the same: I ask how she is doing, and she puts her head in her hands and says, “I’m running away, I’m just going to run away.”
I ask, “From what?” and she replies, “From the pain.” She has tried physical therapy and all of the medications I have in my armamentarium. I have sent her to specialists who send her back to me with notes stating that her pain is not neurologic, or rheumatologic, or orthopedic, or vascular. I do not know how to treat her pain. What I do know is that at 37 she has four children and two grandchildren; they have all been evicted from their apartment and are living with a friend; and the father of her children has been incarcerated for the past nine years.
One story is more complex than the next, and I leave clinic at the end of the day with a pounding headache that has no medical cause. What can I do for these patients? I can listen, try to comfort, but they need homes, jobs, childcare, education, access to mental health services, and, most of all, stability. Without these, my success in managing their pain, high blood pressure, and diabetes is limited. The problem is that there is no one to address the underlying issues. I refer my patients to the clinic social worker; I know that she, too, will listen and try to help. But she is no more equipped to single-handedly fix the social ills of our country than I am. I dread going to clinic because it is a constant reminder of how we, as a society, have failed to take care of our citizens and how I, as a primary care doctor, now feel responsible for shouldering the burden.
Joanna D'Afflitti is in her third year of Brown's internal medicine residency training program.
Alpert Medical School