It was a Friday morning at 4:30 a.m. and I was rushing to the hospital for pre-rounds. I was on my neurology rotation, and my pockets were heavy and stuffed with tools. My preceptor had texted me the room numbers of the patients I was to visit that morning. I had three patients to see in the hour before rounds — the first two patients I had been following every day this week and a third patient was a new admit from overnight.
When I finally made it to my third and new patient, I had 20 minutes left before rounds. I gently knocked twice on the patient’s door and slowly creaked it open to expose a dimly lit room. To my surprise, the patient was already awake and eating some Lorna Doone cookies while sitting up in bed. At the end of her bed was a purple backpack that looked like it was stuffed to its limits and bulging at the seams. The patient’s name was Joy. I introduced myself and told Joy that I was a medical student on her team.
Joy was an 18-year-old Black female. She explained that she had been experiencing headaches every day for a month. These headaches had been getting worse, but Joy could not identify a particular trigger. She described the pain as stabbing and as a 10/10 that was generalized all around her head and radiated to behind her eyes. She said that she had sensitivity to sound and light and experienced episodes of flashing lights and ringing in her ears. However, she did not have a headache at the moment. Joy had no past medical history, no surgical history, no allergies and was not on any medications. Joy had received her GED at the age of 17 and was now working as a barista. She told me about the city where she grew up and about her mother, father and younger brother. Joy said she had been sexually active with both men and women. When it came to the physical exam, there were no significant clinical findings.
As I neared the end of obtaining the patient’s history and completing her physical exam, there were several things that left me perplexed: the confusing HPI Joy had described, the overstuffed backpack at the foot of her bed and the fact that she had been awake and eating so early in the morning. I knew that Joy’s description of her headaches was not quite pathognomonic for any specific headache category and that she appeared in no acute distress despite her severe complaint. However, I couldn’t yet determine whether Joy was truly experiencing extraordinary headaches or if there was something else driving this visit. I felt unsure, but it was now 5:57 a.m., and I had three minutes to get upstairs. I told Joy that I would be back later to speak with her with the rest of the team. Joy told me, “I like your rainbow flag pin,” pointing to my white coat as she showed me her rainbow lanyard. We waved goodbye and I scurried out the door.
After another medical student and I finished presenting our patients, we began rounds with the larger team, consisting of a neurologist, physician assistant and pharmacist. The last patient on our census for the day was Joy. when we finally made it to Joy’s room, I led the way through the door. I waved hello and Joy smiled back. My preceptor then took over and began questioning her about her headaches. I could see his eyes glancing at the overstuffed backpack and her entirely cleaned breakfast tray. After some time, my preceptor motioned to the other group members to leave the room.
It was just the three of us now. My preceptor began asking Joy more specifically where and with whom she lived. Joy became red and then quickly clenched her head as if she were experiencing another headache episode. The doctor apologized to Joy for her being in pain and gave her a minute of silence. When her hand lowered back down and she opened her eyes back at us, he asked Joy more about her backpack, inquiring if it was stuffed with schoolwork, perhaps? He asked if she would show us what she was working on. Joy was very hesitant and so he backed off again. My preceptor then said, “many of our patients here are experiencing homelessness or don’t have all the resources they need outside of the hospital, and sometimes we can help with this. Do you think we can be of any help in this way for you?” Joy was silent for some time, and then she began to tear. She folded over to grab her backpack and opened it up. It was full of clothes. My preceptor told Joy that she does not need to be ashamed and that she was not alone. He told her that we were going to have the social work team come by to help her with accessing any resources she may be needing.
We ultimately learned that Joy had left her family home because they did not accept her for being a member of the LGBTQIA+ community after she decided to come out to her parents. She had been experiencing homelessness for the past two weeks and had come to the hospital because she was no longer feeling safe in the place that she was staying and because she was hungry. He asked if we could visit her again tomorrow and Joy agreed. I was feeling sadness, grief and empathy for Joy. I now felt some sense of greater understanding about Joy’s situation, which came both with relief in this cathartic moment for Joy, but also with much concern.
Taking part in Joy’s care changed my outlook in medicine; this interaction solidified my passion and the meaning I found in the path I was pursuing. I also learned numerous lessons that day including the importance of taking a good patient history, and especially, a thorough social history. I saw that sometimes patients may not always be up-front and honest about their history as a means of self-preservation or embarrassment, and it is important to investigate potential sources of secondary and tertiary gain to best help our patients. After talking with my preceptor, I learned that homelessness may be suggested subtly by way of an overstuffed bag or by exhibiting avoidance, anger or embarrassment when asked about one’s address. It can also correlate with psychiatric conditions and alcohol and substance use. In children, homelessness may be suggested by lack of continuity in education, poor hygiene or lack of health/immunization records.
Lastly, the experience reinforced the importance of allyship. I believe that by wearing my LGBTQIA+ pride pin, I was displaying my support of this community and that helped to provide a safe space for Joy. When so many individuals are disapproving of this community, visual representation of support can be powerful and comforting. Some patients have verbalized negativity towards my pin, which has given me hesitancy about wearing it on my white coat, but my interaction with Joy reminded me about the patients for whom I am choosing to wear it and the importance of continued support especially in the face of critique. I believe that Joy has made me more curious about my patients and more empathetic, and I will use the lessons I learned from her case to better inform my future interactions with patients.
*The patient’s name has been changed to respect HIPAA and for patient privacy.