A sea of reluctant faces stared intently as I entered the Nurses' Clinic at Pine Street Inn for the first time in early July of 1985, barely two days after finishing my residency in internal medicine at Massachusetts General Hospital (MGH). During the month of June I had served as the senior medical resident in charge of the Bigelow Intensive Care Unit, the bustling hub that cares for the hospital's most complex and desperately ill patients.
Buoyed by the sense of invincibility that accompanies such passages, I strode into New England's oldest and largest shelter, containing over 700 beds and located barely six blocks from the hospital, with a swagger that drew a stern grimace from Barbara McInnis and the other nurses. After four years of medical school and three years of residency, I had thought my training was finally over. My education in homelessness and poverty was just beginning.
This tepid reception by the nurses took me by surprise and left me deflated. Barbara welcomed me to the nation's only independently licensed nursing clinic, begun almost fifteen years earlier by volunteer nurses from the Accident Floor of Boston City Hospital (BCH). Exasperated by the growing number of homeless persons seen emergently for a host of preventable conditions, the nurses resolved to go directly to the shelter to offer timely care and treatment. Barbara, a nurse with the Massachusetts' Department of Public Health, was assigned to Pine Street Inn in 1972 to help with the control of tuberculosis and other infectious diseases. The shelter's clinic flourished over the years, the silence and apparent indifference of hospitals and physicians notwithstanding.
"Pardon our skepticism, but we've been burned too much and don't trust doctors to take good care of our folks. But you will do just fine if you listen to us and do what we say. You'll have to forget much of what you were taught in residency. Nothing changes in the life of a homeless person unless you slow down and take the time to earn trust and develop a lasting relationship. Consistency and presence are essential. Never judge. Remember that people have lived through hell and listen carefully to their stories. With that as bedrock, delivering health care might just be possible."
Each guest was invited into the clinic and addressed by name. Most homeless persons wander our urban landscapes for days without ever hearing someone call them by name, and the response was exuberant. Eyes opened, heads lifted, scowls became smiles.
Virtually all visits to the Nurses' Clinic began with a footsoak. The waiting area had ten chairs, all occupied by shelter guests soaking their feet in buckets of warm water mixed with an antibacterial called Betadine. This ritual was instituted by the nurses not only for comfort and hygiene, but also as a sign of service and respect. Barbara informed me that my apprenticeship would begin with a couple months of learning the art and skill of soaking feet. She set aside my stethoscope and doctor bag. No medical questions, no chief complaints, no review of systems, no diagnosing.
"Just tend to the feet and ask what else you can do to help."
I dutifully soaked feet for almost two months while observing devoted nurses such as Bob Johansen, Betsy Kendrick, Sheila Healey, Randy Bailey, Mary Hennessey, and so many others, work their magic among weary but grateful pilgrims. In keeping with the obvious biblical allusion, the footsoak inverts the usual power structure and places the caregiver at the feet of each patient and far from the head. This gesture of respect for the literal and figurative personal space of each homeless person is critical and a marked contrast to how I was taught to take charge during clinical encounters, invading privacy each time I placed a stethoscope on the chest, peered at a retina, or examined a throat. After wandering the city for hours, suffering exposure to the extremes of weather, and then standing in a series of queues awaiting entrance to the shelter, a bed ticket, and the evening meal, homeless persons relished the chance to sit and rest while someone cleansed and soothed their feet.
Barbara asked me to concentrate on an elderly gentleman with schizophrenia and massively swollen legs. I knew this man well from the MGH emergency room, where he was brought several times a month by EMS. Despite our efforts, he never followed our instructions and refused all medications. The diagnosis in his chart read: "chronic schizophrenia, paranoid type, treatment resistant." His feet were so badly swollen that we needed separate buckets to soak each foot. After about a month, he looked down quizzically at me, smirked, and addressed me for the first time:
"I thought you were supposed to be a doctor. What the hell are you doing soaking my feet?"
Dumbfounded, I couldn't think of anything better to say than, "I do whatever the nurses tell me to do." A few nights later, he told me he was having trouble sleeping at night and would appreciate some help. I remember struggling with how to best respond and offering him a very low dose of the anti-psychotic haloperidol (Haldol), which is quite helpful for sleep. A few days later he came to the clinic and was happy that he was sleeping better, but he asked for a higher dose so that he could sleep longer. Over the next few weeks he opened up to me, accepting my offer of medication to help with his mood and his auditory hallucinations. Three months later he was placed in a group home --after 25 years on the streets and in the shelters. Barbara just smiled, no I-told-you-so's.
I came to this job buoyed to make a difference. Barbara taught us to forget plans — "plans get executed" — and live in the present. She had no pretenses about changing the world and eschewed any titles or leadership roles.
"Follow your heart, just do whatever needs to be done next."
From Stories from the Shadows: Reflections of a Street Doctor by James O'Connell. Copyright 2015 by James O'Connell. Excerpted by permission of BHCHP Press.