Patients with Special Circumstances
by Jenny Torpey
Ms. AM cannot remember her birth date. She is pretty sure it is July 31st but she has trouble with the year. Maybe 1950, maybe 1939; she remembers the age of her eldest child is around 49 years, which makes 1950 unlikely. She has 19 children, 12 girls and 7 boys, who live all over the East Coast and all have too many of their own children to take care of her, so she says. She drifts between the streets and the various shelters of Boston and New Hampshire, and once every three to four months she stops in to Rosie's Place, a shelter for poor and homeless women, to see Nurse Mary and Dr. Deb in the Wellness Center.
Today she brings 14 pieces of dirty, crumpled paper with her; these were the papers she was given when she was discharged from the Boston Medical Center Emergency Department (ED) last month. She hands them to us to decipher because she doesn't read or write.
It all started a few weeks ago when she was beaten up and didn't clean a cut on her finger. The cut became infected, and she was seen at the ED, where the cut was incised and drained. Before she left, she was given basic instructions on which antibiotic to pick up from the pharmacy and how to care for her finger, and told to return for follow-up in the hand clinic a few days later.
These directions must have seemed straightforward to the doctors in the ED; they'd provided written instructions and even scheduled the follow-up appointment. But, unfortunately, it still wasn't enough. Ms. AM came to us because she'd missed her appointments — she didn't have bus fare to get to the hospital and didn't have the $5 co-pay it would take to see the doctor. Moreover, she couldn't even fill the prescription she'd been given in the ED for Augmentin because she didn't have enough money. And, several days after discharge when the hospital found out it was MRSA and wanted to let her know that she needed something stronger than Augmentin, they couldn't get in touch with her; she didn't have a phone, and her permanent mailing address was a homeless shelter that she only visited occasionally to pick up her mail. They sent her a letter saying a prescription had been called into a local pharmacy, but it was no good by the time she got the message.
After going through the papers, we found out that her primary care doctor was an intern at BIDMC. Her ED visit had been at BMC. I called both hospitals to get the needed antibiotic, but they both passed off the responsibility to each other; BMC couldn't give the prescription because she had missed her appointments, and BIDMC didn't want to give the prescription because they hadn't prescribed it initially. Even assuming the best of intentions, there was clearly a systems failure preventing Ms. AM from getting the care she needed and deserved.
Although the physicians caring for Ms. AM followed the "standard of care" by conducting appropriate tests, attempting to notify the patient of test results, performing adequate treatment protocol, and providing detailed after-care instructions and scheduled follow up, Ms. AM was not a "standard" patient. How did they expect a woman who couldn't read or write, who didn't have a phone or enough money to ride the bus, to stand up for herself and take care of herself in such a convoluted system that even a medical student couldn't tackle after an hour on the phone?
After exhausting all other options, including digging through the off-label bottles and miscellaneous remains available at the Wellness Center, we called Dr. Deb, the physician overseeing the Wellness Center. She was finally able to write a prescription for Ms. AM. It certainly was not the best option, since we would ideally get a prescription from one of Ms. AM's regular health care providers, but this was the last resort. We were also able to get Ms. AM in touch with the Advocates at Rosie's Place, who gave Ms. AM enough money for the prescription co-payment. In the end, because of Rosie's Place, Ms. AM found the resources she needed and was able to fill and use the simple antibiotic to help heal her infection and save her finger.
Ms. AM's case exemplifies the fragmented and haphazard care that homeless patients often endure. This experience provided valuable information for me as I look ahead to my future as a healthcare provider. In the hurried medical system we have today, where the most disadvantaged have trouble finding continuous providers and providers have less than 20 minutes to see a patient, it reminds me that we as health practitioners need to take a few seconds to think about the recommendations we make and the importance of considering the whole package, especially for those already on the edge of society. These are the people who need the most help — and often end up getting the least.
Jenny Torpey is a fourth-year medical student at Harvard Medical School.