COMMENTARY

These Patients 'Ennoble' Us as Physicians

Richard M. Plotzker, MD

Disclosures

February 20, 2020

Among the most poignant symposia I have attended at an annual Endocrine Society meeting was one on managing diabetes in unfavorable circumstances. Speakers presented what they experienced during an American natural disaster, a famine in Africa, and a war in Syria. These physicians and their patients coped with reality as best they could, often securing insulin with creative ingenuity.

Matching diet and medicine, which is so vital to optimal care, cannot happen when neither is secure. In some areas, war or famine threaten life far sooner than will the end-organ sequelae of diabetes. This changes the focus of the medical staff to getting the patient safely to the next week, not the next decade, as is common in US medical practices.

In the United States, food is abundant (perhaps too abundant). Medicines may cost a lot, but in a pinch, we physicians can find a few insulin pens in our refrigerators and some DPP-4 tablets or SGLT2 inhibitors in our sample closets to avert a crisis. Our emergency departments and critical care units run 24/7 to rescue patients when diabetes control fails. For all the very real concerns about city crime, personal safety does not typically preempt thoughtful medical care; we expect that those with diabetes will survive long enough to incur its feared organ damage unless we prevent it.

Caring for the Homeless Patient

Despite the availability of care in the country, disparities in outcome on the basis of ethnicity, geography, or financial situation challenge physicians. No one demands more think time and creative use of resources than the homeless patient with diabetes.

Such patients were commonly admitted to the inner-city hospital where I worked but were much less commonly available for the follow-up that is so vital to the care of someone with a chronic progressive disorder.

This may be one time when it is best to expand the use of the hospital beyond what is only essential.

Even taking the patient history differs from that of usual consultations. Medication histories have to be expanded from what was prescribed to what has been available, what the source was, and for how long. Because many homeless people stay with friends or relatives, they may take what medication is in that home. For those in shelters, some may have had their medications from their last hospitalization stolen by another resident, or will admit to having swiped a few pills from another person.

For users of insulin or sulfonylureas, matching food intake to peak effects of medicines does not always happen. Shelters and soup kitchens often schedule one meal a day, which can vary from a hot dog or two to a more sumptuous selection of leftovers donated by a bar mitzvah caterer. Much of the predictability we depend on for diabetes management requires more consistency than many homeless patients can attain.

System Challenges

Alas, our house staff no longer seems to provide a thorough, hands-on examination. While you can see advanced osteomyelitis on an x-ray, you cannot see the ulcer that caused it without taking the patient's socks off. Necrobiosis lipoidica diabeticorum does not image well on the CT that is so often part of the admissions orders. And there is an ophthalmoscope kept in one of the charting rooms, but it is rarely retrieved.

Even lab testing poses a challenge. In the hospital, it is possible and usually desirable to take advantage of the opportunity to update all American Diabetes Association recommended testing and still have the patient on site to address the results. That becomes less likely during office visits, whether they are with the endocrinologist or with a city or VA clinic—or, as in my home community, a mobile medical outreach van that seeks out the homeless. In-office A1c testing with results available before the patient leaves has a big advantage over sending blood work to a commercial lab covered by Medicaid, and then having to track the patient down.

Because the hospital stay may provide the best opportunity to address these medical needs, this may be one time when it is best to expand the use of the hospital beyond what is only essential. Most of these patients need a team. The best quarterback may be the hospitalist, endocrinologist, or the discharge planner, but the opportunity for assessment and planning for the intermediate term is brief.

Like the basketball player who takes an intentional foul for a good cause, getting dinged on our precious quality metrics can sometimes reflect the best medical care for a person who needs it most.

The interdisciplinary group may include a surgeon, podiatrist, dermatologist, neurologist, dentist, or pharmacist, as well as a dietitian to review ways to adapt to tenuous food availability, maybe a psychiatrist, and sometimes provisions for substance abuse management.

Often, the most important team member is an experienced discharge planner who has familiarity with securing housing, obtaining Medicaid, finding an emergency contact with a telephone, and knowing who can be absorbed by the VA or a city clinic—and who has the ability to convey to the receiving providers the loose ends, such as eye exams or gynecologic care, how long the homelessness is likely to last, and transportation resources for follow-up care.

Reclaiming Our Ingenuity

Taking care of a homeless patient on the medical brink often intrudes on other expected professional tasks and does not provide the financial compensation to offset the effort. But few obligations in our contemporary world ennoble us as much as the Hippocratic Oath. In an era when we click circles on a screen to fill in a medical progress template, these people take us off our protocols toward our reasoning skills. We ask for information beyond what we would for other patients with diabetes. Circumstances force us to look beyond our readily available consultants.

On more than one occasion, physicians responsible for the care of these individuals need to call in favors from colleagues, and thus remind us of the importance of keeping our usual working relationships in top order. Pharmaceutical reps who intrude on our space at unwelcome times have their moments of glory when they supply a patient who cannot pay for their valuable product. Those inheriting these patients, often with medical complexity on short notice, appreciate the quality of a pertinent summary of care. And like the basketball player who takes an intentional foul for a good cause, getting dinged once in a while on our precious quality metrics can sometimes reflect the best medical care for a person who needs it most.

As so much of medicine has transformed from caring for unique individuals to processing populations with medical similarities, the homeless may be the last vestige of individualized, selective care for many of us. We reclaim a certain amount of the ingenuity that was nurtured when we were medical students but then often stomped to oblivion when we became house staff.

Even if you hold political views hostile to Medicaid expansion, when it becomes available to a homeless person who would benefit, for that moment you accept its availability graciously. We do our best to enhance the lives of these most challenging diabetic patients. As our reward, we can be for a short time the type of doctor we had hoped to become.

Richard M. Plotzker, MD, is a retired endocrinologist with 40 years of experience treating patients in both the private practice and hospital settings. He has been a Medscape contributor since 2012.

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