I'll settle for small steps

December 3, 2004

How this young internist helped a reclusive man begin to re-enter society.

When I first saw the hotel, I felt like turning around and getting right back on the subway.

It was a hulking, dilapidated structure in a drug-infested section of Brooklyn, one of many "welfare hotels" in the city where down-and-outers lived in dirt-cheap single rooms. I stood across the street, feeling small, white, and very young.

I was supposed to go in, knock on all the doors and try to talk to the residents of this place-I'll call it the Graylock Hotel-about sexually transmitted diseases. My first job out of an internal medicine residency program was working in a homeless clinic in New York City. To make extra money, I had taken an evening job leading health discussion groups in the Graylock and several other welfare hotels. If some of the residents decided to visit my clinic for care, all the better.

That's where I met Aaron (not his real name). On my first couple of trips to the Graylock, Aaron would talk to me only through his closed door.

"Hi, Aaron, it's Dr. Kevin," I said, using my first name to dilute the formality.

"Hi, Dr. Kevin. I can't make it to your group tonight."

The first time he cracked open the door, several weeks after we met, a mix of stale and fresh cigarette smoke wafted into my face. Aaron wanted to get a peek at me. But he wouldn't let me see him. "How are you, Dr. Kevin? Maybe I'll come to your group next week."

One day, he finally opened the door. Aaron receded into his room and sat on a bare mattress. The room was dark, filthy, and filled with dirty dishes, dirty clothes, and broken stereo equipment. Aaron was morbidly obese and had several disfiguring keloids on his face. His toenails were two and a half inches long, curving. Pain and rejection were written all over his body.

"I have a rash," he said. I had a pretty good idea where it was going to be before he had closed the door and pulled down his underwear. He had an angry tinea cruris and was very uncomfortable.

"Aaron, you have jock itch. Here's a prescription for a cream that you should use twice a day. Why don't you come see me in our clinic sometime?" I had firmly promised myself that I would never write prescriptions while I was doing outreach for my groups, and here I was breaking my own rule a few weeks into the job. But I was facing an exceptional circumstance. This reclusive man had built up his courage to let me see him and his rash. I knew I had to step up to the plate. His rash went away. Over the next few weeks, Aaron called the clinic and made appointments, but he would not show up. When I saw him at the Graylock, he always had some excuse. "I didn't have the subway fare. I was too tired."

However, he now routinely let me into his room. There were old albuterol canisters next to the overflowing ashtrays. Lots of empty junk food bags. Now that I could get a good look at him, I couldn't help but notice that he had massive peripheral edema with stasis dermatitis.