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At the heart of general practice since 1960

Learning the hard way – how a homeless patient made me confront the limits of a GP

Dr Nishma Manek

As a GP trainee, I often listen to my patients with some form of Sherlock mind-palace filling the space between, as I work out how to help. But listening to Antoni, a guest at a homeless shelter in Westminster, my mind was blank. I could do nothing for him.

Antoni described his daily routine. A picture formed in my mind of a tattered, filthy man weaving his way through the Westminster crowds. Head down, eyes averted, his brisk strides mirror those around him. But unlike them, he has no destination.

All day he walks; the cold descending like an impenetrable suit of armour if he stops. It’s only when evening falls and the pavements empty, that Antoni stands out.

Until six weeks ago he was working as a gardener. Then the work dried up, and his landlord suddenly decided to sell his house. He found himself on the streets.

Antoni told me how his new life has been dissected into disjointed fractions of time, lingering in one public place and then another, as if waiting for trains that never come. Some days he has taken to sitting in a hospital waiting room, five hours at a time, quietly thumbing copies of Reader’s Digest. His presence goes unremarked by receptionists, doctors and patients alike.

He dreads the hour when all the doors close. The hour when he must shed his cloak of invisibility, and eject himself from the world of conversation and lights. The hour when the cold will twist through his bones again, sparking the familiar scrabble of fear.

Antoni explained that he is desperate to work. He described the icy politeness which greets him at the job centre. They ask how he is, but their eyes look right through him to the next person before he’s even met theirs. He is fearful of the character he is slipping into that is so easy to despise.

Silence hung in the air between us.

For patients like Antoni, without being able to address the social determinants of their health, anything else I can do as a GP feels like a sticking plaster.

A recent Lancet review highlighted the extent of the disparity: socially excluded populations have a mortality rate that is nearly eight times higher than the average for men, and nearly 12 times higher for women.[1] That’s double that of US combat troops deployed during the Iraq insurgency between 2003 and 2006. But somehow headlines about the homeless don’t hit quite the same nerve.

There are days in general practice when I can go home riding on a wave of pride that I might have made a small difference to my patients. But there are other days when the impotence is overwhelming. Days when I think about patients like Antoni out there, many of whom I won’t ever see. And I understand why Michael Marmot asked the question: ‘is most medicine just failed prevention?’.

That feeling of impotence interjected any words that formed in my mind on their way to my mouth. I opened and closed it like a goldfish. The silence continued.

But Antoni told me that it was a relief to talk without trying to be heard through the intent of the listener. And that it was the most he had spoken in weeks.

He filled the silence by describing a recent night of walking. At that moment, it seemed he had no past, no memories; that he had been on this stretch of road forever. The loneliness pressed against his chest like a soaking clump of old laundry. He next remembers seeing a pensioner struggling with the gardening. On the margin of stupefaction, he asked to help. The man accepted, and once Antoni had finished, offered him a night on his floor.

It was as though his very witness of Antoni had made him feel real again. That one act of kindness propelled him steadily forward. I took hope from being reminded of the compassion that exists in society.

I imagine Antoni won’t be the first patient to make me question my limitations as a GP. I hope it’s a tension I’ll grow used to… or maybe it won’t get any easier.

For now, he left me with two reflections.

Firstly, that we may look right through the homeless hovering on street corners, their faceless shadows moving in a parallel world on our periphery. But in truth it only takes a bump in life’s road for that edge to be blurred.

Secondly, as a doctor, I’ve spent years being trained how to strategically deploy our ever-expanding arsenal of pamphlets, pills, and procedures. But I drew a blank with Antoni. I wanted to fill in the cracks in the first level of Maslow’s hierarchy, and I couldn’t. Wallowing in that impotence had blinded me to his yearning for the other needs. I didn’t realise that he took my silence as a gift.

I never saw Antoni again. Perhaps he found work. Or perhaps he still walks the nights with plastic bag in tow, all that’s left of his itinerant life.

I often remember him. Sometimes our patients give more to us than we can to them. Even the ones who have so little to start with.

Dr Nishma Manek is a GPST3 in Cambridge

Antoni was a guest seen at the Abbey Centre’s Homeless Welfare Service, which provides a free evening meal service to the homeless for 2 evenings a week in Westminster. It is run entirely by a group of volunteers, and relies heavily on donations to sustain it. If you would like to offer a contribution, however small, please visit their website here

Reference

1. Aldridge, R et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet; Available online 11 November 2017

 

 

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Readers' comments (13)

  • I can't stop the novel leaking out of Dr Manek, but was there anythimy medically wrong with this patient?

    Pills pamphlets procedures...are you suggesting that GPs should also prescribe cash to needy people?

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  • Whilst GP does indeed have limits, it is sadly sold to the population as having none. The college is complicit in this. Hence the ever increasing demand.

    Society has elected politicians who have removed it's safety nets. This is societies fault not GPs.

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  • I had a patient who told me that as a child during the second world war he had been evacuated from London to stay with a family in Devon. He found this family to be abusive and so at the age of 14 he decided to go AWOL. He roamed the countryside and found that looking for help from the clergy, medical profession and the law was counterproductive. He correctly worked out that those professional people were overrun with huge workload and had lost a lot of the compassion that (perhaps) they used to have. He found the best place to go was to find a large farmers house with a barn full of hay nearby to bed down at night. He made sure sure that the Farmer’s wife discovered him in the morning. Most of these women were very kind and of course there was always a plentiful supply of food. This was fine for a couple of days, but of course in the end the farmers wife would notify the authorities. So he went back to AWOL. He managed like this for a couple of years.

    As GPs how many of us have lost compassion (assuming we had some in the first place) due to the excessive pressures of our working environment?

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  • Thank you, Nishma. Beautifully written and comprehensively true.
    All the Very Best,
    Paul

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  • A nice piece of writing but...
    Did he get his sick note and GABA then?

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  • A little heavy on the metaphors...

    I do worry about these consultations, about the way we in which I feel I am being made to medicalise the suffering caused from political decisions.

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  • Vinci Ho

    An ordinary doctor heals a disease.
    A good doctor heals a person ,
    A perfect doctor heals a society/country.
    None of us is a perfect doctor.

    Thank you , Nishma

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  • So what medical problem did he have? We shouldn't have to cover and fill the gaps of society or the job centre. He should get the help he needs from the right sources, and not come to the GP because as you said, there's really nothing helpful you can do for him.

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  • A nicely written post and it hopefully taught the author that's gps can't solve society's social issues. In the real world that would be considered a total waste of my time. One for the eportfplio nishma ;)

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  • An insightful article about a common tragedy which has few safeguards in UK! GP’s are not able to fix poverty and neglect! Wise to realise Our Limitations Early! Then cynicism and burnout can be managed for longer! Thank you for your values- do not lose your compassion for the ill, weak,disadvantaged in Our Society.

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