Homeless patient

The incident

A homeless patient in his 50’s. He has a gangrene-induced ulcer of the shank (infested with worms). After regular treatment (medication, vasodilator, wound dressing) the patient gets well. I would like to discharge him, but the patient, instead of saying thank you for my work, insults and scolds me because he has to go.

1. Identities of the actors in the situation

Medical doctor: Female in her early 30s living in Budapest, in a housing estate (private owned flat). Native tongue: Hungarian. Nationality: Ukrainian. Came to Hungary to marry her husband 3 years ago. Husband: policeman. First job in Hungary, no child yet.

The patient: Man in his late 50s (in bad physical condition), no family. He has been homeless for at least 10 years, no knowledge about his previous life or on how he got onto the streets. Most of the time he is a street-dweller, in and out of temporary asylum places. He was hospitalised two months ago (he was kept in hospital longer than necessary for humanitarian considerations).

There is a clear hierarchical relationship between the doctor and the patient; however both of them have experiences of belonging to a minority meeting (sometimes) with discrimination.

2. Context of the situation

The situation happens in a specialised medical institution, reserved for homeless patients. For the doctor, it was a conscious choice to work with homeless people, she is knowledgeable in this area of work. This is not the first time she has been insulted by a patient but for some reason this hurt her most as she made a special effort to make sure the patient received proper treatment.  He was kept in hospital for longer, considering the cold weather (the incident happened in February). The patient was informed well before time that he was to be discharged.  However, previously, on several occasions he was told that he would have to leave shortly.

3. Emotional reaction

Bitterness, shocked by the “ungratefulness” of the patient, deception, desperation, anger. At second thought: feeling disempowered (“I cannot do anything for him any more”), lack of awareness. At third thought: feeling a huge discomfort discovering that actually she would find gratitude normal.

4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock.
  • Homelessness: contrary to many middle class Hungarians she does not think homelessness is a moral tar and homeless people are responsible for their state. She believes it is a structural problem and homeless people deserve assistance (that is why she chose to work with them).
  • Medical profession: it her duty to help people, no matter what their conditions are. There is however a strict line between social work and the medical profession (that is why there are social workers in the institution). Doctors’ competences stop at treating medical problems.
  • Definition of the situation: She is aware that discharge for the patient would mean going back onto the streets and although she is sympathetic, this is out of her remit.
  • Self-image: As a person she esteems herself as socially sensitive and in this situation she believes she had done everything in her power, and beyond that. She is not expecting gratitude for her work but she would be happy to be recognised for her support (certainly not as an enemy). The incident makes her conscious that although she is not working to be recognised, she would find it normal that patients are “grateful” to her.
5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatized", positive, very positive, real, unreal) etc?

Mixed feelings: anger first – the man is seen as ungrateful, irrational and aggressive. At the same time: pity and (partial) understanding – which does not mitigate the negative effect on her self-comfort.

6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator.
  • The “Street” means going home for him, although not in the same way asa person in a different situation. He did not choose to be on the streets but he has got used to it. However,as it is now cold outside and he hasgot used to being warm and safe, he is scared to go back.
  • The Hospital is now his temporary home, it means protection, care and warmth.
  • The doctor is now the closest person to him (always showing willingness to help, he expects her to understand him).
  • Definition of the situation: the discharge means betrayal (He thinks that the doctor should know that this would put him in danger.
7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?
  • The “helping” relationship is a tricky one. Giving usually means putting the other in a position of obligation and it is rewarding to the self. In institutional helping relationships, often this hierarchy is resisted by clients who deny the obligation expected.
  • A very large power distance inverts the usual (and universal) reciprocity rules: the “takers” do not have the obligation to return. To the contrary, they have the right to remain permanently in the taker’s position without returning (see Mauss)
  • Professionals working with very low class clients should be empowered (trained) in order to avoid identity shocks inherent in disturbed gift relationships of this kind.

Empowerment should also include better team work, where health professionals can better count on partner professions, like social workers, psychologists, and so on.