“Them ugly shoes?” *

He celebrated his birthday in the hospital, one single forlorn card from the nurses next to his dinner tray. I was his only birthday visitor, as I came on my morning rounds.

I came to know him well, rounding on him every day for several weeks. At first, he greeted me with gruff monosyllabic answers and distrust, refusing to even look at me. I didn’t take it personally: I would have been surprised if he found it easy to trust a white doctor after years of being a homeless, young, black man in a predominantly white and well-off county. But I did my best to win him over with firm handshakes and large smiles that spread to my eyes despite my surgical mask, trying to demonstrate that I would continue to respect him as much as I did every other patient – regardless of whether he spoke to me or not. I saw a glimmer of hope for our relationship when I introduced myself one day, and said, “Doc Martin, just like the shoes” and he guffawed in spite of himself, saying, “them ugly shoes?”

Slowly, over time, he began to answer my rambling soliloquies with reluctant smiles. Bit by bit, his story emerged. He was raised by a single mom in a tough urban city. His mother had adopted him, and his extended family hadn’t supported the decision. He talked about the sorrow of losing his mother unexpectedly as a teenager, and the inability to grieve as he was shuffled to relatives who viewed him only as an additional responsibility. He talked about a grandmother who promised to love him and offered to let him move in with her in our town. He also talked of the betrayal he felt when that same grandmother decided she couldn’t love him and left him homeless in a town that wasn’t his. Lonely and cold, one rainy night a fellow homeless “friend” invited him into a tent and offered him meth. Feeling as though he had already hit rock bottom, he thought “why not?” From the first hit, he was hooked to the rush of empowerment and fulfillment the meth gave him – if only for a moment.

On the surface, it would seem to an outsider that we had nothing in common. Yet he was only one year younger than me, I am also adopted and raised by a single mom, and we grew up in similarly rough backgrounds in similar cities: I remember what it was like to be afraid to dream. These were the things we could bond over, the foundation of our doctor-patient relationship. Yet life and luck had favored me: I have the privilege afforded me by my skin color, do not wrestle with drug addiction, and can still call my mom at the end of a tough day. An undercurrent of guilt, combined with outrage at the unfairness of the world, meant that each day I drove home with tears in my eyes as I screamed prayers at the Lord, asking over and over again, “Help him. Please. It’s not fair.”

Other people our age are partying, finishing grad school, getting married, having children. Other people our age are still starting their lives. His was close to ending due to a rare pulmonary illness. The rare illness was directly related to his methamphetamine use, which was in turn due to his homelessness, which was directly related to the structural violence and systemic prejudice that so unfairly allocates societal resources. In so many ways, it would have been easier if I hadn’t known his story, which so easily could have been my own story but for the color of my skin or a different family adopting me.

The night before I discharged him from the hospital, I sat on the floor beside his bed, leaning against the wall with my knees drawn to my chest in defeat because I knew I was discharging him to die. He talked about his hopes and fears; we had grown close. With the rare illness he had, there was no chance he would survive on the streets. He was too sick. Even homeless shelters would have killed him during cold and flu season.

But he was also too young for me to accept his death. So, after discussing it with him, I used the diagnosis of meth-induced hallucinations to arrange for him to be admitted to a psychiatric facility. It was the safest discharge plan I could come up with, a Hail Mary that he wouldn’t die. He and I talked about it beforehand, he and I agreed that it was his only chance both to survive his illness, and to get back on his feet. But still, tough as he was, he cried as the transport personnel came to take him to the inpatient psychiatric unit: “this isn’t what I pictured my life to be at nearly 30.”

Once at home, I also cried. I cried for my patient who I knew was going to die. I cried for a broken system where the safest place to send a sick patient was a psychiatric ward. I cried for the structural inequalities that forced him to fail.

In fear, he had asked me to visit him at the psychiatric facility. He had no one else to visit him. I was afraid too, so I agreed to visit, telling myself it would be good to check on his pulmonary status given how easily he could bounce back to the hospital. When I called the crisis stabilization unit the next day, he had already been stepped down to lower level of psychiatric care. After numerous phone calls, I finally tracked down where he had been transferred, and one day after work I drove over to visit.

I was surprised to pull up to an ordinary blue house in an ordinary neighborhood. I hesitantly walked up to the front door and rang the doorbell. A disheveled stranger answered the door, and without a word let me inside. I nervously wandered through what appeared to be an ordinary house until the counselor welcomed me. She was perplexed to see me, a primary care physician, at the house, but grateful to be able to ask me questions about the complicated medical regimen our shared patient was receiving. When my patient saw me, he visibly relaxed, unclenching his fists and relaxing into his chair, and I felt that I had made the right decision to visit. Any last distrust he had of me melted away now that I had kept my promise to visit. He said he was surprised that I had found him, I told him that so long as he was in this county I would always find him.

Maybe someone was listening to my tearful prayers on those long post-call drives home, because instead of dying he showed up in my office for appointments. Our plan worked. Safe from homelessness, sober from methamphetamines, but groggy from the antipsychotic medications, he would inevitably be sleeping on the exam table when I entered the room. He would sit up, sleepily extend his hand for our ritual handshake, and with a cheeky smile say, “Hi Doc Martin like the shoes.”

Twelve months after discharge, I gave him his year sobriety coin on his birthday and brought him taco bell, his favorite fast food, to celebrate. He opened the envelope and took out the coin, slowly flipping it over in the thickened skin of his hand. Slowly he looked up at me, and said, “Thank you,” with all the power and impact that those words can carry.

Together he and I had had brought him back from a nearly certain death and definite hopelessness. He was stable on medications, was linked in with county services, and had his own apartment with a roommate. He was even talking about taking classes at the local junior college. I began to hope that some of the imbalance of our society could be rectified, and had visions of him leading a normal life full of the milestones that my peers expect.

For a full year, I had been seeing him monthly in my office. First to get him stabilized on the medications, then to make sure he was stable through the cold and flu season that threatened him tenuous pulmonary status. Finally, that spring, a visit came where when he asked “well, when do you want to see me back?” I replied “honestly, whenever you need me again. You’re doing well enough that I don’t think you need regular visits.”

I look back on that moment now and see the flicker of something – Hurt? Fear? - that passed behind his eyes. It was the last time I would see him in my office. Now that he was living on his own, it became more difficult for me to get in contact with him. I called the last psychiatric unit in which he had been living and was told that the last they had heard he had got a new girlfriend that he was “running around with.” Soon after, I began receiving ER reports for “skin picking” and “pulmonary exacerbations.”

One night, I was in the hospital when he happened to come in for an ER visit. Emaciated and working to breath, he was slumped over in the gurney. I could barely recognize him. He struggled to open his eyes as I loudly called his name over the hiss of oxygen. As out of it as he was, he still managed to faintly whispered “Doc Martin” and shook my hand, though his grip was weaker than I had ever felt it. I asked for an ABG to try and get him admitted, but it was normal. I was powerless to do anything but watch as he was given a sandwich and discharged to the street in the middle of winter.

It has been awhile since I’ve received any ER reports.

But I also haven’t received notification of death. I periodically wonder if I will even receive notification when he dies. I have several homeless patients who I know have passed, yet their charts remain alive in our computer, slowly marking their birthdays.

I wonder if anyone will be at his funeral, or if he even will have a funeral.

I told him I would find him if he was in our county. And at first, I did look. I checked the places I knew he used to live on the streets. I let my colleagues know to call me if he came into the emergency room. I asked county outreach workers to message me if they heard from him. But aside from the ER reports, I haven’t heard anything. I wonder if I will be any better at finding his gravestone. I will visit it, because he has nobody else to mourn him. And I will feel as though I failed him.

I keep thinking about that flicker behind his eyes that day that I told him he didn’t need any further appointments. Behind on my schedule, running late to see other patients, I didn’t pause to acknowledge it. I wonder what would have happened if I had. I wonder if by discharging him from my care, he thought I was discharging him from my belief in his ability to succeed, or that I didn’t care anymore. I worry that I had set him up to be too dependent on me. I fear that the same patient-doctor relationship that saved him from death, encouraged him to trust and navigate the system, and gave him hope again… I fear that was the only thing keeping him afloat.

The patient-doctor relationship saved him, and perhaps is what lost him. He allowed himself to trust me, and I allowed myself to love him as my patient. Did he trust me too much? Did I care too much? Regardless, I mourn the loss of his life, and perhaps that has value in itself. The patient-doctor relationship asks the doctor to unconditionally love the vulnerable patient who in exchange gives the doctor his/her trust. From the doctor’s perspective, to love our patients – especially as they wrestle with death – is to willingly open ourselves up to sorrow. And so, I mourn.