Bandaid And Therapy
Bandaid and therapy
Toronto family doctor Debbie Honickman chronicles a day in the life
of a healthcare system that’s in need of a fresh diagnosis.
8.30am On my way to work I cycle past a crowd of protesters outside the College of Physicians and Surgeons. They’re carrying placards supporting a doctor who practises environmental medicine. He’s been accused of using ‘unproven’ methods by the College’s Discipline Committee.
Some of the placards speak about pollution, claiming the doctor helps to treat its effects. I muse over an irony. People can be motivated to take action in defence of someone who can protect them from the effects of industrialism. But have any of them driven their cars to the protest? And would they be willing to carry their placards outside polluting workplaces? Perhaps I’m being overly cynical but I wonder if it’s mainly self-interest that’s politicizing these protesters, while the root causes of environmental diseases go unchallenged. I go on an internal tirade over issues of prevention and advocacy, and arrive at work determined to incorporate protection of the environment into my everyday practice.
9.30am It’s an odd coincidence: my first patient may have an environmentally induced problem. He complains that his asthma has gotten worse in the last few weeks. I have to sort out whether this is because it’s allergy season; because the CO2 emissions are worse lately; or because he’s sick from his work. P has come recently from South America and is working in Canada illegally. He’s being paid far below union wages in a factory with disgusting air quality.
I realize that if I report his employer he’ll lose his job – whether or not the factory is shut down. I can’t file a worker’s compensation claim for him as he doesn’t have landed-immigrant status yet. I could tell him that this city is making him sick and advise him to move to the country – where the unemployment rate is even higher and he will face more blatant racism. We could discuss the fact that the Earth and his work environment need to be healed.
Instead, I explain his so-called options and the possible causes for the aggravation of his breathing. Then I write a prescription for inhaled steroids (warning him that these may cause thrush which would then have to be treated with further medication) and I feel like shit. He decides he’ll marry a Canadian with a place in the country and wonders if I am available. Some might say I’m being harassed by my patient. I decide to laugh. He has enough worries. And after all, who has the real power in the relationship?
My next patient is a 20-year-old woman from the Caribbean who is also here illegally. Her boyfriend is sponsoring her. S has had two clinical abortions. Recently I treated her for a sexually transmitted disease with metronidazole, which is known to cause foetal abnormalities in rats. At the time I advised her not to take the medication until she got her period, because while the infection wouldn’t be harmful to a foetus, the drug potentially was. She took the medication. She got pregnant. She decided to have another abortion because of the risks and because her partner was abusing her physically.
Today she tells me that he found out. He beat her up and told her he would have her deported if she didn’t go through with the pregnancy. She tells me she’ll keep the baby. She and our outreach nurse call MotherRisk, a programme affiliated with our city’s paediatric hospital. MotherRisk’s view is different from mine. They inform her that the foetus is not at risk from the medication. I fret for several minutes, still having my doubts and fears. I call MotherRisk again to confirm that she really isn’t endangered. This is the easy part of the problem. Her ‘boyfriend’ is abusing her physically and sexually in exchange for not reporting her to immigration. I feel very helpless and unsure how I can be of help. Sponsor her, share my income, raise her child, get rid of her boyfriend?!
Before my 11.00am appointment I return two phone calls. If I were in private practice I would probably be feeling anxious, as I wouldn’t be receiving payment for time on the phone. The first caller is an Ojibway woman who had been my patient when I was working for a First Nations-run community health centre. She is asking for a referral to a renowned Canadian aboriginal healing centre that deals specifically with substance overuse and incest-survival issues. She is upset that her current doctor won’t fill out the forms for her referral until he knows her better. She requires to be cleared medically before the treatment centre can accept her application.
She is frustrated by her total dependence on the medical profession to enable her to get what, from her perspective, she knows she needs. I suggest that I call her doctor for her and explain why the forms need to be filled out. I’m struck by the fact that she needs another person with ‘power’ to deal with a person who made her feel powerless.
The next call I answer results in my being behind with my appointments for the rest of the morning. It’s from a man I know from Street Patrol (an evening service that provides food, clothing and comfort for people living on the street). He’s calling to tell me that David has died. David was an Anishnawbe man (half of my patients are Anishnawbe) whom I’d known for four years, an ironworker who had lost his job after a fairly serious accident. Though he recovered physically, he never worked again.
When I met him he was living in parks, in alleyways, and was well on his way to cirrhosis of the liver. When David wasn’t drinking he was a gentle, sad, thoughtful man. When he was drinking he expressed his rage verbally and could be pretty mean. But I was never afraid of him, even though he did once threaten my colleague with a knife in my office. When I find out he has died behind our local liquor store I feel as if I am somehow responsible. Most of the times he came to our health centre he was so intoxicated it was difficult to assess him. We didn’t have the facilities to detoxify him and he would always storm out before we could get him to hospital or a detox. Most of what I could do for him was bandaid.
I feel so horrible this morning, thinking about how I failed to address with him the problems that kept him drinking – racism, homelessness and sexual abuse by his father (who had been sexually abused by his father, who had been sexually abused by the priest in the residential school he was forced to go to). I feel pretty helpless, have a good cry and share my grief with colleagues who also knew David. Then I go to see my next patient. I don’t think I have time to think properly about his death and I know this is a reflection of how it has always been for him. Not enough time and not enough resources.
A memorial will take place next week at the drop-in centre where he had been barred several times for rude and dangerous behaviour.
11.30am Last patient of the morning. Someone who almost certainly has one of the hundred-or-so viruses that cause the common cold. I usually start by examining the person to make sure they don’t have something unusual – for instance, are they about to asphyxiate from epiglottitis? could it be the ‘flesh-eating bacteria’? were they exposed to mouse droppings and are they about to die of Hanta virus? I may take a throat swab if they are (or I am) particularly anxious. Then I explain what they can do next time they have a cold, what environmental factors might be ever so slightly lowering their resistance, and then I do my drug-company spiel. About the TV adverts that are designed to make them think that I’ll be able to provide them with medicine to cure them. About the profits that drug companies make from this advertising. About the uselessness of most of these cold remedies. About the simple measures that they can take to feel better. Like not smoking. This is a good time to quit, I explain to this woman. (According to the Canadian Consensus Guidelines for Clinical Medicine, one of the few things doctors do well is to counsel people on how to quit smoking.)
All of my patients are booked for a full half hour, so if someone comes in with a cold that takes only a few minutes to assess it’s an opportunity to find out if I can support them in other ways. It’s time for education, time for humour therapy (get those endorphins going) and time for... doing all the paperwork I’m behind on. They never taught me in medical school that I would be doing so much paperwork. It makes me think of deforestation. The welfare department should have a hemp plantation.
1.30pm Missed lunch.
1.45pm House call. Sophia, a 75-year-old Portuguese woman married to the same abusive man for 40 years. Alcoholic son still living at home. Daughter married to intravenous-drug-using man. Sophia is grieving the loss of her sister, who died during open-heart surgery. Sophia has unstable angina and is refusing surgery from which she might benefit. Could her refusal be part of a prolonged grief reaction to her sister’s death and to her miserable marriage? Maybe her depression could be resolved with drugs. Maybe therapy would be more helpful. Maybe then she’ll want open-heart surgery. And maybe then she’ll die on the operating table, just like her sister. Obviously I have no easy answers. And unfortunately we haven’t really gotten to this stage of analysis together, partly because her English is not proficient enough and she refuses to see a Portuguese-speaking therapist. Her community might find out.
I resolve to spend more time with her, bringing a translator to address these issues in a meaningful way. I remember that this is not a new resolution for me.
Fortunately I work in a community health centre where I meet with other staff, nurses, doctors and therapists as well as community outreach workers and health-promotion workers. I can take my problem about Sophia to the group.
3.00pm Paul. Goes by the nickname of Skinny. Former heavy solvent user. Work with him has focused on harm reduction. He is now finally housed and is only sporadically using. Good use of supports in the community. Needs major dental work. Most of it not covered by his health plan. Gum disease. He can’t eat without major pain. Wants canned nutrition but the Ontario Drug Benefits programme has cut that off the list of benefits. Now I have to fill out a special form stating why he needs liquid nutrition, for how long and how many cans a day. These cuts will only get worse with our newly elected Conservative Government.
3.30pm Lou. Former IV drug user. Positive for hepatitis C antibodies. Liver tests slightly abnormal. We now have the technology to screen for it. But we also have an expensive new drug to treat it. Funny how the ability to screen for it and the discovery of this new drug happened to coincide. I mention this to Lou as I make the referral to the liver specialist.
4.30pm My last patient of the day has become more of a friend than a patient. I’m sure the College of Physicians and Surgeons would counsel me wisely against this. I have known him for five years and he has just been diagnosed as having a malignant tumour. His prognosis for one-year survival is five per cent. He is 40.
He has a very positive attitude about death. Sometimes I feel that I get much more out of his visits than he does. The Ministry of Health should pay him for doctor education. I call our encounters ‘supportive therapy’ on the diagnostic sheet. I’m not sure who is getting more support.
We go across the street for coffee – part of the therapy. He smokes. I don’t advise him to quit. Our hardest problem in the last six months was in trying to arrange his radiation for early in the day so he didn’t have to go too long without a cigarette. He is a Cree man from Northern Manitoba and he misses the bush. Can part of my treatment be to take him out there for the day or would that be considered inappropriate? Too bad, I decide – I have Friday off, I ask him if he wants to go. We will take someone from the health centre, to ensure this is not considered sexual harassment by a physician.
5.45pm End of the day. Stayed late to do a bit of paperwork, but not much because I generally try to do it between patients. Some people might think that if I’m not seeing ‘patients’ then I’m not working. I resent this. It means that all the advocacy work I do is, according to them, not work. And yet advocacy often feels like the only effective thing I can do. Use my so-called power to effect change.
Of the women I saw today, 80 per cent had been sexually abused. Is there something about me that attracts sexually abused women? I think not. I believe the statistics are wrong and far more women are incest survivors than most studies reveal.
Of all the people I saw today, 20 per cent were inadequately housed or homeless. I wrote one letter advocating better housing, filled out four welfare forms, wrote one ‘sorry, he missed parole today but he was not well’ letter (a lie – he had no money to get to his appointment), filled out seven prescriptions and only felt ambivalent about two of them. I grieved over one dead person and one dying person and I encouraged one to quit smoking. One person let me try out my novice acupuncture skills on him and I actually managed to relieve some of his shoulder pain. That’s pretty gratifying since most of the day I wonder why I’m being paid as well as I am because it feels as if I never do anything to make people better. Are my listening skills really worth that much?
10.30pm I’ve eaten supper and am now trying to write an article for the NI. Trying to discuss several ideas with my partner. I’m becoming incoherent... Word-finding difficulties... Have to stop...
Debbie Honickman works at the Niagara Health Centre in Toronto and is a member of the Medical Reform Group.
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