Cookie Cutter Care Doesn’t Cut It

By: Callie Downs

I walked through a maze of metal fences and empty streets in order to find HOMES Clinic. The Houston Marathon was going on, and the normally busy streets were cleared for all of the runners. Nervous doesn’t even begin to describe how I felt. What could I contribute to patient care as a first-year pharmacy student?

Our first patient was a young woman. Her chief complaint was that she couldn’t sleep. The medical students started by taking her medical history. I was able to chime in and ask about medication history, current medications, and any allergies. The patient was soft spoken and she mumbled occasionally. She slouched on the exam table and wouldn’t make eye contact with us very often. As we were asking questions the fourth-year medical student performed a psychiatric evaluation, but the patient showed no signs of being a threat to herself or to others. The first-year medical students did a physical exam, and then the patient returned to the waiting room.

We presented the case to our attending physician and pharmacist. We selected trazodone as the appropriate treatment for this patient since it was a common treatment for insomnia and it was available in our pharmacy, but then the attending physician asked a question that changed my mind. “Does she feel safe?” I hadn’t thought about it. Trazodone is a sedative. Would you want to sedate a young woman who sleeps on the streets and potentially put her at risk for assault? We didn’t ask if she had a buddy or if she felt safe where ever she sleeps. Furthermore, the physician pointed out that even though she said she didn’t have any thoughts of hurting herself or others it didn’t mean that she was truly okay. People lie. Patients lie. Mental illness is tricky. We wanted to talk to the patient more before deciding on a course of action, so we went to get her from the waiting room.

She was gone. She had told the guys at the front desk that she would be right back. At first I thought she would surely come back, but the longer we waited my hope deteriorated. It was devastating. It felt like I had lost my first patient. I could’ve done something for her; we could’ve helped her. What could we have done differently to provide better patient care? Where did I go wrong?

We helped a second patient that day. We were able to counsel her and give her some medications to help her condition, but I still walked out of the clinic that day feeling as if I had failed as a healthcare provider. I stood there in the empty streets of downtown Houston. The crowds and fences from the marathon had disappeared. Even though it was daytime and I had my phone in my hand, I felt unsafe as a young woman standing alone. My mind flashed to our first patient and my heart broke. She didn’t choose this life for herself. It could have just as easily been me sitting on that exam table.

I think that mental illness and homelessness are more prevalent than we like to let ourselves admit sometimes. HOMES Clinic opened my eyes to tangible evidence of both.  I learned that sometimes clinical guidelines aren’t applicable to patients in specific situations. The medications you would select for someone who was homeless can be different than the medication you would prescribe to someone who had a home and safe environment to return to. Medical treatment plans are customized to every patient’s symptoms, disease states, and medical history, but they are also personalized based on individual circumstances. Every patient, regardless of their demographics, deserves custom care –patients don’t all fit into one cookie cutter guideline. Our patient deserved customized care, and I feel like I failed her. I wanted to make her fit the mold, but I did not consider her circumstances.

I think about her a lot. Did she get the help she deserved? Does she sleep? Is she still out on the streets? I may never know the answer to any of these questions, but I do know that she taught me more than I could have imagined. No patient is the same, and it is our job as healthcare providers to be hypervigilant and aware. You might not be able to save every patient; to change every life you cross paths with. But it is your responsibility to try.

Callie Downs is a first-year pharmacy student at the University of Houston College of Pharmacy.