Mastering the Art of Prioritization

             Donna is a 45 year old woman with a past medical history of HIV infection, IV drug use, and anal cancer who was escorted to the clinic by a shelter staff member after complaining of a fall.  The staff member states that Donna reported right knee pain and “torn ligaments,” and was asking for “some percs” (Percocet: acetaminophen+oxycodone) to ease the pain.  When I initially question Donna about her fall, she tells me with pressured speech that she slipped while walking indoors, but denies landing on her knee.  However, a few minutes later, when asked the same question, she says she fell out of her chair in the dining room and did hit her knee.

            Donna has a history of IV drug use (heroin) from which she claims 6 months of sobriety and for which she is on 70mg of methadone daily.  Likely from her IV drug use, she has HIV infection, for which takes daily triple antiretroviral therapy and has steady follow-up with her HIV specialist at a local academic medical center.  She also reports a history of anal cancer, for which she is currently undergoing radiation therapy.  Notably, Donna denies any history of musculoskeletal problems or surgeries.  She undergoing the housing process with the help of shelter advocates, and currently lives with her boyfriend, who she adamantly insists “does not do drugs, and is going to be lawyer.” 

            On exam, Donna is initially alert and irritable with psychomotor agitation.  However, while sitting in the exam room, she becomes progressively more somnolent with slurred speech to the point of dozing in and out of sleep.  Examination of her bilateral lower extremities reveals multiple linear scars over her anterior lower extremities and knees that Donna admits are from “shooting up.”  Her right knee is slightly more erythematous and enlarged compared to the left, with a small effusion over the anterior/proximal aspect of the knee but without bruising or deformity.  Passive and active range of motion in the right knee is otherwise normal, and Donna is able to bear weight without significant pain or presence of antalgic gait.  The most likely diagnosis was a ligamentous sprain.

            Donna is a woman with an acute medical complaint in the context of a complex medical background including IV drug abuse.  In fact, her symptoms suggest continued drug use despite claims of sobriety.  From her, I learned the importance of prioritization.  Oftentimes with intoxicated patients, medical, social, and psychological issues cannot be adequately addressed on the spot.  While it may be appropriate to assess Donna’s desire to achieve sobriety and her barriers to success, such matters should be addressed when a patient is sober and lucid.  Luckily, Donna is well-connected to her HIV specialist, as she knew both her doctor’s name and location.  Therefore, in this specific situation, we decided to address Donna’s acute medical issue by resting and icing her right knee and providing non-steroidal anti-inflammatory medication.  However, knowing that she frequents the shelter, I made a mental note to check-in with Donna the next time I see her.  I’ll keep my fingers crossed that next time she will be more able and willing to talk about some of the important medical issues in her life…

A Nudge in the Right Direction

            Mary is a lovely 56-year old Haitian woman who comes to the shelter clinic for a blood pressure check.  I have not seen her since December, but she is well known to me and Dr. Means, as she frequents the clinic, sometimes just to say hi and other times for her weekly supply of calcium+vitamin D.  Today, her blood pressure is 125/80, which is quite low for her.  She beams and says, “Doctor, I remember you told me stress can give high blood pressure.”  Apparently, it is her New Year’s resolution to try to reduce her stress level, and she points to her blood pressure level today as evidence. 

As she tells me about her several crochet projects, she brings up new complaints of “leg swelling” and “chest cramping” since the last time I saw her.  I elicit more information.  She describes the chest discomfort as a dull/cramping and localized to her right chest but without radiation or additional symptoms of chest pain, dizziness, light-headedness, sweating, or nausea.  It occurs approximately once every 2-3 weeks and is unrelated to physical activity or meals.  Most episodes, including the one last night, came on while at rest, and are relieved by drinking warm water.

            On exam, Mary is a well-nourished, slightly-obese woman.  Her lungs are clear and her heart has a regular rate and rhythm and is without murmurs. Palpation of her chest does not elicit pain, which might indicate a musculoskeletal cause of her chest cramping. Her abdomen is soft and non-tender. On examination of her extremities, she has slight 1+ edema (swelling) of her lower extremities bilaterally, but no skin changes or other abnormalities. Normally, leg swelling can be a sign of heart disease and reduced capability of the heart to pump blood forward, but especially in a woman such as Mary who spends most of her day on her feet, edema can be a much less specific sign of heart failure.

            Reassured that Mary’s complaints do not represent an imminent medical issue, I focus on some medical education and cardiovascular prevention.  While Mary’s blood pressure was within the normal range today, she regularly has blood pressures in the high 130s/90s, which places her in the pre-hypertension range. In fact, she has several risk factors for hypertension and heart disease including her weight, age, and post-menopausal status.  Furthermore, she is not aware of whether she has high cholesterol, but I have high suspicion that she does given the candy bars she stores in her handbag. 

Knowing Mary, I have faith that she truly wants to improve her health.  However, barriers such as culture and medical insight prevent her from doing so in the most effective way.  For example, when asked her how her diet is, Mary responded with “Oh, I eat very well!” indicating that she has a good appetite.  This was a nice moment to introduce portion control and emphasize the importance of fruits and vegetables as well as reduced salt and cholesterol intake.  Her pride in reducing her stress as the cause of high blood pressure demonstrates another slightly misguided understanding of blood pressure. While praising her efforts to reduce her stress and lower her blood pressure, I directed our conversation back towards increasing exercise and reducing alcohol intake. 

            My interactions with Mary have illustrated to me the intricacies of medical prevention with women like her.  Many truly want to improve their health, and are able to with some education and a nudge in the right direction…

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. 

The Experiences of a Harvard Medical Student

My name is Monica Fung, and I am a fourth-year Harvard Medical student who is taking the 2011-2012 academic year to obtain a Masters of Public Health. Serving marginalized populations has been rooted in my interest in medicine long before starting medical school. Some of my most rewarding clinical experiences I have had include treating the homeless and LGBT populations of San Francisco in the setting of an acute sexually transmitted disease clinic as well as working with the HIV-afflicted population of rural India.

During my third year of medical school that ended in the summer of 2011, I experienced some amazing learning in my primary clerkships at the Brigham and Women’s Hospital.  At the same time, I noticed that there was a wide range of patients that presented to the hospital – some who navigated the maze of the medical world smoothly while others were unable to advocate for themselves and benefit from mainstream medicine due to complex social and psychiatric situations.

I met Dr. Roseanna Means at a Boston shelter during my Ambulatory Medicine Clerkship on a day that she was being filmed by CNN for her years of medical service to Boston’s community of homeless and marginally-housed women.  From my interaction with her and conversations with several of the guests, I realized that Dr. Means served this population so effectively by addressing the medical needs of homeless women at a level individualized to the patient, factoring in their emotional, social, mental and physical functioning – their ability to access transportation, their medical knowledge, their psychiatric co-morbidities.

Having been deeply influenced by Dr. Means, I have dedicated a portion of my year to working with these women.  As a member of the Women of Means team, my goal is to provide the best medical care for these women, with the hope of benefiting their entire wellbeing and integrating them into mainstream medical practice.  I attend clinic every week and have gotten to know several women.  I invite you to join me in my medical learning of providing the best medical care in a setting of juxtaposed sometimes limited resources but always deepest care and understanding for the women we serve.

Launch of Women of Means Blog

11/28/11

Women of Means is delighted to share stories as well as information about our work with homeless women and families in and around Boston.  For more information, please visit our website at http://www.womenofmeans.org/.