The inadequacy of 20 dollars.

DOI: 10.1200/JCO.2012.43.6220 A man in his midfifties and tanned from years working in the sun sat with his hands folded in his lap, his legs dangling off the edge of the salmon-colored examination table. As we talked, he occasionally rubbed his fingers, which were swollen from arthritis. He had been my patient for some time, and I’d come to know him well over the years. He had no family and no permanent home. He worked on farms and often slept in the barn or a spare bedroom of the farmers who employed him. He was uninsured and lived paycheck to paycheck. Our social workers had managed to enroll him onto our hospital’s indigent care program, allowing him to have medical treatment and receive medications for nearly free. Not completely free but almost. He had a low-grade follicular lymphoma but one that had caused him significant symptoms at initial presentation. I had treated him with bendamustine and rituximab almost 18 months prior. He achieved a remission with the therapy, and he had been on maintenance rituximab since then in an effort to prolong his remission. Recently, he missed an appointment for the maintenance rituximab infusion—something that he had never done before. When he did not show up for the infusion or for his clinic visit with me, I knew something was wrong. It was unlike him to fail to show for an appointment, to not even call to cancel or reschedule. A manual laborer with a strong work ethic, he arrived for his medical appointments early, often an hour before the scheduled time, and he complied with every piece of medical advice he was given. As he sat on the examination table for this visit, I asked him about any lymphoma symptoms— fevers, night sweats, weight loss, any new pain or enlarged lymph nodes—and about the rest of his life. Other than difficulty sleeping and chronic arthritis pains in his hands that sometimes interfered with his ability to work, he was feeling well. However, he admitted, he had recently lost his job. He explained that the availability of farm work in our area, rural northern Florida, was hard to come by, given the local economy, and that the farmer he worked for had let him go a month earlier. With the loss of that steady income, and thus the roof over his head, he would be homeless within the week. He told me this in a straightforward, direct manner, but I could almost hear the swell of panic rising in his voice as he told me more of the details. He had been through this before, but this time was worse. Plus, he needed two prescriptions, one for his arthritis pains and another to help him sleep, but he couldn’t fill them because he had no money. “You don’t have any at all?” I asked. “None,” he said, solemnly. He looked me directly in the eyes when he spoke, but then he looked away, turning his gaze downward to his suntanned and calloused hands folded in his lap. I turned away from him and stared at the computer screen, where I had his medical chart pulled up. I scanned through the various screens of his chart as if I were hunting for a critical piece of medical information that would aid in my diagnosis or treatment of this problem. Homelessness was out of the realm of my expertise. It would have been far easier for me to deal with recurrent lymphoma. That, I could handle. But this? I was flustered, and I felt incompetent. I hid those feelings and my awkwardness from him by focusing on his chart, on his list of diagnoses, drug allergies, prior surgeries, and documented family history. Not surprisingly, I did not find any of the answers I was looking for in his medical record. “Where will you go next?” I asked, turning back to him. “I can go to the homeless shelter, but I’m only allowed to stay one week. After that, I don’t know,” he said. I was at a loss for words. I do not know anything about being homeless. I grew up poor, but I had a solid home and two hard-working parents who always told me that, while we did not have much money, we were “rich in love.” Even when we could only afford powdered milk and boxed macaroni and cheese, there was always a meal on the table at dinnertime. I wracked my brain, trying to think of possible solutions. How could I fix this problem? As a physician, I am used to fixing problems. As an oncologist, even when cancer is not curable, I can often fix the symptoms. I can make people feel better in one way or another. Could I hire him to do yard work at my JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 30 NUMBER 28 OCTOBER 1 2012