Friday, January 27, 2006

The Calculus of Caring

For reasons of liability, my colleagues and I are encouraged to refrain from transporting patients in our own cars, and we are told in no uncertain terms that the risk is ours if we choose to do so. At various times, I have attempted to eschew taking patients to appointments in my car, but every time I do it "just this once", I'm reminded of how often it seems like the easiest and most convenient thing to do. The poor and disabled often have great difficulties with transportation. Through Medicaid, van service to medical appointments can be arranged, but it takes a prescription from the primary doctor which has to be renewed every year. The patient then has to call to arrange rides which often prove to be unreliable, especially when Medicaid contracts the rides out to private vendors and taxi companies. Still other patients are unable to use the phone to schedule appointments due to hearing impairment, language barriers, or cognitive deficits, while others simply cannot negotiate the series of voicemail message hoops which must be jumped through to speak with a real operator. Couple that with frequent wait times of up to 30 or 60 minutes to schedule a ride, mental illness, and physical disability---frustration and exasperation reign.

Taking all of this into account, I choose wisely when I take a patient in my car, and I try to use that close proximity and captive audience for therapeutic purposes. Being in a car can foster conversational intimacy. The car is like a cocoon in which the driver and passenger ride---private, temperature-controlled, comfortable, quiet. Sometimes deep conversations can be engendered simply by the simultaneous closeness and relative lack of eye contact that drivers and passengers must somehow finesse in order to converse. Keeping my eyes on the road with occasional glimpses towards the passenger seat, my patient is able to be in their own world but speak to me freely, and this can often bring about aspects of conversation which might be less comfortable while sitting together in an exam room at the clinic or even in the patient's living room. I appreciate this difference and make use of it in various ways.

My work allows me the ability to see patients in their homes, experiencing their personal daily environment, interacting with their family and children, looking in their refrigerators and cupboards to assess their nutritional practices (with permission, of course), while also assessing their home for physical impediments which might compromise their safety or otherwise thwart their independent self-care at home. I also attempt to ascertain if there are firearms in the home, smoke alarms, working locks on the doors, safe electrical wiring and outlet use, and relative cleanliness. This information---generally unavailable to any doctor---is also under-appreciated by most doctors and not taken into account during those brief patient visits, although the providers with whom I work are more tuned in than most to the psychosocial aspects of our patients' lives.

Today I visited a patient who is basically squatting in her oldest daughter's apartment for want of a better situation. She sleeps in a medium-sized bedroom with her two school-age children, sharing an inflatable queen-size bed. To my surprise, a one-year-old pit-bull was curled in her lap as she sat on the bed, and I was greeted by this new family member's demonstrative and unbridled affections. She obviously sensed her owner's positive reaction to my entrance, and immediately embraced me as one of the pack. I sat on the dirty carpet and communed with this canine soul, who looked into my eyes as only a dog can.

This woman is dear to me, and we have had many heart to heart talks over the years--some in the car, some at the clinic, many in her myriad apartments. Due to our friendly intimacy and familiarity, I imagined that rolling on the floor with her new puppy was in no way professionally inappropriate. It was, in fact, therapeutic for us all.

These relationships each have their own tenor and particular rhythm. With this particular person, I sit on the floor, play with the dog, and we chat about much more than her health, always bearing in mind that this is a professional relationship, a helping relationship of therapeutic value. In this type of work, we sometimes walk a fine line, the boundaries blurring, but building relationships is what it's all about, after all. Without those warm bonds, it's nothing but clinical rapport, which to me is a chillingly stiff boundary which holds little interest for me.

So yes, these folks admittedly live in a corner of my head both night and day, but the value which I derive from these relationships repays me for my labors in the larger scheme of things---the karmic and dharmic bank, if you will. It's the calculus of caring, the mathematics of the calculation a mystery, and the final result so much more than the sum of its parts.
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