Finding Healing Together

“I’ve missed you,” I said as I took Juan’s hand and sat next to him. There was a new sallowness in his face, appearing to have aged years since I last saw him. I fell silent, unsure of what to say next. The din of the busy hospital ward filled the space. I wondered how many more times I would sit with him after he had attempted to take his life.

I first met Juan 3 years ago as an intern in our medicine-pediatrics primary care clinic. He was 66 years old and recently diagnosed with advanced hepatocellular carcinoma. He greeted me with a boyish grin, and we immediately took a liking to each other. Pointing to his abdomen where he had tumors growing in his stiffened liver, he described unyielding pain as his greatest concern. He proudly announced he was “8-and-a-half years clean” from a long history of heroin and cocaine addiction. We discussed treating his pain while supporting his substance use recovery and planned to follow up in a few weeks.

Juan did not make it to his follow-up appointment nor many other visits over the next few years. His cancer turned out to be a less acute concern than his PTSD, bipolar disorder, and chronic homelessness. His complexity made timely care all the more important but challenging to deliver. I often left him voicemails after a missed appointment, knowing his phone would go uncharged for weeks. Despite the long gaps in contact, we developed a close relationship. I found myself thinking of him often between visits, worrying about his whereabouts and safety, despite my efforts to draw professional boundaries. “Ah, my favorite Doc! I missed you,” he would say after months of absence. “I missed you too,” I started to let myself say in return.

Such spottiness is common in our community clinic situated in the poorest neighborhood of Springfield, Massachusetts. In a city riddled with resource insecurity and nearly 30% of citizens living below the federal poverty line,¹  our patients’ troubled social situations often sabotage continuity and adherence to care despite best intentions. When I asked why he wasn’t coming to appointments or taking his potpourri of pills, Juan described wandering the streets all day and having his medications stolen at the shelter. I became fixated on his homelessness, thinking everything else would fall into place if we could find him stable housing.

Addressing Juan’s homelessness was complicated by his sparse contact and the critical lack of affordable housing. During one of his many hospitalizations, the social work team miraculously placed him in a medical foster home. I went to his room to share the news. We hugged, his eyes twinkling with tears of joy. “I can’t believe it! Somewhere with my own bed?” I went home elated, picturing him laying his head on a soft, clean pillow at last.

Two weeks later, Juan was back in the hospital. He had abruptly left the foster home, along with all his medications, and returned to the street. When I asked why he left, he provided a list of grievances: arbitrary rules, rude staff members, and roommates he couldn’t trust. After numerous such iterations, Juan has taught me about the complex decision-making of those who have been chronically unhoused—an arithmetic of counterintuitive tradeoffs I would never fully understand but would have to respect.

Most recently, Juan was accepted into the city’s newest medical respite home. A couple weeks later, he chuckled and said, “I’m doing really good, Doctor.” He was taking his medications and made friends in the house. At the end of the visit he said, “Guess what? Tomorrow is my birthday! I haven’t celebrated in years. I’m buying everyone a pineapple upside-down cake to share with me.” Later, his respite nurse shared that she had bought him a cake to spare his wallet. I gushed my thanks and reflected on how this was the most hopeful I had felt for Juan in a long time.

Despite my initial relief, I was wary of thinking this was happily-ever-after for Juan. There was a thorny existential suffering burrowed deep within him, impervious to medications. His pain and hopelessness created the perfect storm to resuscitate a buried demon: addiction. After being abstinent for nearly a decade, Juan’s urine started testing positive for cocaine and fentanyl. Recently he was found slumped over at a bus station, barely breathing. He later reported he had attempted to overdose on heroin to finally end his pain. Statewide referrals to psychiatric treatment facilities were denied due to his supplemental oxygen requirement, which precludes admission to many psychiatric facilities and homeless shelters. He was discharged a week later.

I’ve come to reckon that Juan will never be entirely free of pain. Now I find myself caught in a dilemma: should I keep prescribing his narcotics? For some, the answer is clear, and his prescriptions would have been suspended long ago. To me, the ethics and safety of his situation are kaleidoscopic. As my mentor once put it, “You’re damned if you do and damned if you don’t.” While he remains at the respite home with his medications stored in a locked box and given under supervision, I continue to refill his controlled substances. I know that refusing to treat his pain would undoubtedly drive him to self-medicate with more street drugs, playing Russian roulette with each hit of fentanyl. I give thanks to my mentors who empower me to embrace this approach of radical compassion and harm reduction.

Juan is but one man, yet his struggles are emblematic of the traps and failings of our society that leave some people lurching in the dark corners where few dare or care to look. I see that we live in a world rife with medical advancements but scarred by poverty, cyclical trauma, and institutionalized neglect of certain populations. I see our safety nets tearing under growing masses, Juan’s body falling through the holes into the cold void, over and over, like a macabre Groundhog Day. I find myself running to catch him, usually arriving too late or with arms too weak to hold him. Each time, my heart sinks and I wonder if things will ever get better for him.

As I prepare for a career dedicated to complex and vulnerable patients, I am mindful of my sentimental approach, which often embroils me in the emotional turbulence of patients’ lives instead of allowing me to focus solely on the medical mechanics. I once nursed this as a vulnerability that needed patching up, for the sake of professional decorum and longevity in this trying career. But Juan has taught me that there can be strength, for physician as well as patient, in letting oneself care deeply. Because when the room is dark and I hold Juan’s hand, quiet and out of solutions, I take to heart when he musters a crooked smile and says, “I’m glad you’re here.” In these moments, I feel powerless as a doctor but warmed by the pure, gentle light of our shared humanity. In these moments, I find healing and know there is always a way forward.

The author would like to thank Cecily Wiswall, MD, Sharon Wretzel, MD, Kathryn Jobbins, DO, Karissa LeClair, MD, and Nicole Seo for their support, mentorship, and helpful edits on this essay.