Letter from a Medical Student: Continuity Clinic

October 20, 2013

Sunday

Now that third year is nearly half over (and I can hardly believe it),

I think it is about time to discuss one of the other aspects of this

year that does NOT involve grades or stressful changing schedules

every week.

All throughout third year, we get the chance to visit a clinic every

other week for an afternoon. It is called "Continuity Clinic,"

although for medical students is is a bit of a misnomer. It is named

for the clinics that residents hold during their rotations, and

continuity refers to the fact that they get to see their same patients

over and over in this clinic, providing continuous care to them in a

primary care setting. For medical students, such continuity would

demand that patients happen to have to come in on the exact weekday

afternoon the student is able to come, although that afternoon may

have no consistency whatsoever. To further complicate things, many

students have chosen a preceptor for continuity clinic that works in

something like Interventional Radiology or the Emergency Room. And I

hope they are not seeing the same patients in the ER that they did two

weeks before - that would be depressing. So I say that continuity for

us refers to the fact that we continually return to the same clinic

over and over.

For my continuity clinic, I have been going to the Addiction and

Substance Abuse Program (ASAP) clinic near Albuquerque's airport.

There, we treat patients who suffer from addictions to a variety of

substances, from heroin to marijuana to pain killers, caffeine and

tobacco and methamphetamine. However, the best medicine we have to

offer right now is in treating addictions to heroin and opiates. The

long-acting medications methadone and suboxone help patients get

relief from the withdrawal symptoms and pain associated with stopping

their drug of addiction, helping them to carry on while trying to

"detox." Mornings at ASAP are specifically for treating patients'

addictions. Most afternoons are a primary care clinic, which means

that the patients come in for more typical family medicine kind of

care: fixing their cholesterol, hepatitis, toe fungus, diabetes, or

simply for their yearly visit; they also just happen to have an

addiction that also needs treatment.

My preceptor is a fiery proponent of health care for this population,

which is so often looked down upon by most of society. We send out

referrals for these patients to see specialists, who sometimes turn

them away claiming that they don't know how to deal with a "methadone

patient," but she does her best to insist that they get decent health

care. However, she can be equally severe with the patients themselves.

I particularly remember one patient who, when my preceptor asked her

how she was doing, she replied, "Not happy to be here. You're going to

yell at me! I gained 5 pounds since last visit." However, unlike many

doctors I have met, I have never heard my preceptor yell - she is

simply passionate that her patients stay healthy. Many times this

means pressuring them to alter their diet, use their pedometer, take

their medications as prescribed (when they can afford the $4 Walmart

price).

I imagine that most people reading this do not read my description and

think, "Wow, if only I could go to that clinic and work with addicted

patients all day long! What a life that would be!" Many of my

classmates can't even stand helping patients control their sugars, let

alone drug cravings. And it's true these patients can be difficult -

they sometimes lie and play down their use (such as when I asked a

patient recently, "When was the last time you used heroin?" and she

replied "Oh, not for a long time...not since yesterday afternoon").

Many times they somehow cannot come up with the $11 daily methadone

payment though they are able to pay for hundreds of dollars' worth of

heroin each week. There is also the fear element, as during one visit

I realized I was actually talking to a drug dealer, and one who had

done very well and had commanded a considerable market. How would I

feel about treating a drug lord? What might happen if they got upset

with the treatment?

One complication of methadone treatment is that when patients first

start, they have to be started on a very low dose of methadone. This

is because we hardly ever really know how much a patient has been

doing on the streets, and there is a risk with methadone that patients

can overdose and die. However, for someone who has been injecting a

heavy amount of heroin multiple times per day, it feels as though we

are offering them a baby aspirin for the worst migraine of their life.

In these first days of withdrawal they become very volatile - they

have made their first step away from their addiction, and do not yet

have the full safety net of their medication to control their

symptoms. Withdrawing from opiates will not kill people, we know, but

it will make them feel as though they are going to die. And what will

they do when the craving gets unbearable? Return to using their drugs,

unfortunately. It takes a tremendous level of support and very close

care to get them through this time.

Sometimes this part isn't as difficult to get through, however. Take

our drug dealer patient. When he was going into withdrawal, he chose

to inject himself with several strips of suboxone. The beauty of

suboxone is that it can only be absorbed under the tongue to achieve a

therapeutic effect. If injected, another ingredient found in the

medication blocks all of a patient's opiate receptors throughout their

body, sending them into an instantaneous and complete withdrawal. This

is an addition that I find extremely clever, although it did make me

feel bad for our patient, who was restless and feeling like he had a

terrible case of the flu.

He was not the only memorable patient I have had while there. I was

also touched to meet one patient who had recently lost her premature

child shortly after birth. Her family blamed her use of methadone and

drugs on the baby's demise, although in her case it was not likely due

to anything she had done or not done. However, because of her loss,

she was convinced to never use drugs again. Her baby, she knew, was

looking out for her, and in her baby's memory she wanted to be a

better person and close a dark chapter of her past. I wonder myself

what that baby must be feeling now. What if it was your entire life's

mission to convince your parent that they needed to change, and then

your life would be over? I hope that that child's spirit recognizes

the powerful impact he or she has made without ever saying a word.

Each time I return to my continuity clinic, I become more and more

convinced that this is where I want to practice. Not necessarily at

ASAP itself, but rather in the field of addiction medicine. I want to

be a family doctor, it's true, but I want to have the training to work

at a methadone clinic and be able to help out these particular

patients. It's not for everyone, certainly, but it is vital that these

people, too, are treated like the children of God that they are, lost

and in trouble as they are. They have taught me so much about

repentance, about perseverance, and about the ways God uses to reach

out to each of us individually.