On Thursdays, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health and, occasionally, contributors from other departments. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx.
Laura Sullivan Eurich, MD, a third-year resident at Hahnemann Family Health Center, shares her reflection from a home visit. Essays about home visits remind us of how much we can learn simply from meeting our patients where they live. —Hugh Silk, MD
I am glad that Keith (a third-year medical student) is with me. I’ve toured this area with the Worcester Police Department and was familiar with the location of the former People In Peril shelter. But as we pull up, I can’t ignore the number of children and young women swarming on the front stoop of the triple-decker. It’s a hot afternoon in August and all are relishing the last summer days, except for V.
As we descend into the basement to find her apartment, I also can’t ignore the scraps of food littering the stairwell, and the strong smell of ammonia. A disheveled child answers the door wearing her pajamas. We find V in her room, the size of a small office, with a TV that consumes half the space. She is lying on her favored right side on a twin bed and smiles up at us, beads of sweat on her forehead. There is a small circulating fan at the foot of the bed and a tiny basement window opens to the pavement outside. No wall hangings or pictures. The room is cluttered with storage that is clearly not hers: children’s toys and clothes, stuffed animals, pet supplies. She’s wearing a T-shirt without pants or undergarments, just a sheet to cover her. She says it’s easier for her personal care assistants.
I try to imagine existing in her bed, in her room, as I hear the bustle outside my sole window. People walking in and out of my only space as they please. Yelling into the window from outside. Unable to shut my door or window for privacy. Hoping my PCA will be in hearing range when I have to void. Dependent on others for all I was once able to do: walk, drive, shower, brush my teeth, itch my foot.
During her last hospitalization, I was impressed by how many family members were involved in her care as PCAs. I perceived a close-knit family unit, dedicated to helping out V after she suffered a nonsensical accident. On visiting her home, it became clear to me why V did not share the appreciation: lack of appropriate boundaries and a lessened ability to enforce rules and consequences because her caretakers were not employees. They are her niece and son and daughter-in-law. All living under the same roof. Their geographic proximity was an advantage and a drawback. They are always here. V expresses frustration at lack of privacy, independence, modesty.
My care for V will differ in trying to arrange more comprehensive care in a home setting. I hope to work with care advisors to help meet more of her needs, including mental health counseling and health care maintenance, as these are often overshadowed by her frequent acute hospitalizations, and to ensure that her care providers are held to appropriate standards.
A success from our visit was meeting her in a non-acute setting. I had first met her amidst a transfer to the Critical Care Unit with septic shock. I was thankful to see her on a “good day.” It was valuable to meet her on a good day to discuss what we could do to make these days even better and ensure more of them.