Don’t Judge a Book by its Cover

Betty is a pleasant 45 year old homeless woman who came into our shelter clinic for persistent nausea and vomiting with associated weight loss.  The nausea and vomiting started approximately 2 weeks ago, occurred 5-6 times per day exacerbated by eating, but has remained non-bilious and non-bloody.  As a result, she has had reduced food and liquid intake and has had a 20lb weight loss.  She has not had fever, chills, abdominal pain or changes in her bowel habits.  She was admitted to a local academic medical center for 2 days where she was rehydrated then discharged with a diagnosis of viral gastroenteritis.  Since then, she has returned to her regular shelter but with continued nausea/vomiting and has only been able to drink clear liquids. 

Betty has a past medical history of alcohol-induced liver disease, a diagnosis she has long been aware of.  She started drinking at the age of 10, but has been sober for the past 8 years.  When she was discharged from her hospitalization for nausea and vomiting, she was given a packet of information that included a diagnosis of “cirrhosis.”  Betty was infuriated to see this in her paperwork because she was unaware of this diagnosis and none of her healthcare providers during the admission had explained to her the extent of her liver disease despite an upper GI endoscopy and multiple CT scans.  She asked me if her liver disease was the reason why one of her physicians had told her to “come back to the hospital if [her] belly got bigger.” The doctor was referring to increased ascites, which is fluid accumulation in the abdomen with end-stage liver disease.

            It was apparent that as a patient, Betty felt disrespected by the academic medical system, which resulted in her transferring medical care to a community health center.  To me, she seemed like a competent woman – she knew her medical history, remembered her physician’s name and location, and had insight into her condition.  However, factors prevented the proper communication of information between Betty and her healthcare providers.  Despite Betty’s 8 years of sobriety, did her doctors perceive her differently because of her past history of substance abuse? Did her caretakers find her less capable of understanding her disease because of the social complexities of being homeless?  Or was Betty herself unable to advocate for her care by asking for clarifications and details of her diagnosis? Either way, is there ever a reason why a patient receptive to information is not fully informed of their medical condition?

Betty’s story is an all too common example of the communication gap that occurs between the homeless women we care for and the traditional healthcare system.  Sometimes physicians get so caught up with the demands and busywork of caring for patients that they may forget to share enough information with those same individuals despite doing what is in their best interests.  Having come from a year of clinical medicine at a Harvard institution, hearing stories from women like Betty has given me a new perspective on the doctor-patient relationship - it is an awakening for me to always respect my patients’ right to knowledge no matter what their background.