A CASE STUDY ARTICLE - evidence of a problem
The New York Times
Tuesday, January 8, 2008
Homeless, With A New Loss: Identity
By Elissa Ely, M.D.
There is always plenty to worry about when you are homeless. The most pressing concerns have to do with health and finances, of course. But occasionally there are other worries- deeper, odder, more unexpected. Some are even existential. A while ago, I met a man in a shelter clinic who described the worry that preoccupied him.
The situation was medically straightforward; events should have unfolded predictably. He had a pulled muscle in his shoulder. If he had been working with a primary-care doctor, he would have gone to see him. but he had been homeless for years, floating from city to city and shelter to shelter. So he went, uneconomically but expectantly, to the emergency room.
He waited in a cubicle with a curtain around it. As usual, a nurse took his vital signs, and wrote them in a chart with his name on it. As usual, the doctor came in next. This was business as he knew it. She looked down at the chart.
“I see you were here last October,” she said, as he later told me.
That surprised him. He had never been in this emergency room before. He told her so. She checked the chart, and disagreed.
“No, you were here for an overdose,” she said. According to the chart, he had been transported in a stupor from a shelter across town.
Well, he had certainly stayed at that shelter, maybe even last October. But he was not a drug user, had never overdosed, and had never been to this E.R. He said so again.
She suggested that he had been intoxicated and didn’t remember. The chart had an entry from October with his name, his birth date and an accurate Social Security number. She read them out loud to him. These were facts, but no longer the business he knew.
He asked to see the chart. He wanted to know what he was supposed to have overdosed on, and what his physical description was. Someone must have taken his identification out of his wallet. It’s crazy - especially since they didn’t take the wallet itself - but anything can happen in a shelter.
The doctor wouldn’t give him the chart. She was in the sudden surreal position of being asked to share privileged information about one patient with another patient who might or might not have been the same person. If your identity is being used by someone else, then his overdose is not your business. You have no right to his medical information. This is a violation of HIPAA, the Health Insurance Portability and Accountability Act.
He didn’t care about Hipaa (many of us don’t care much for it), but the doctor had no choice. Though the situation was absurd, her license and a large fine were potentially at stake. She wrote him a prescription for extra-strength ibuprofen and strongly suggested he find a primary-care physician. He was discharged without seeing the chart.
Back in the shelter, he started to worry. Suddenly his shoulder was the least of his problems. Someone had stolen his name and Social Security number. Did the thief have his Medicaid number too, and use it to buy prescription drugs? Could he claim Social Security checks? Where else would the misdoings of an alternate self turn up?
He had not been sleeping well to begin with, and here was something else to keep him awake at night. He came to see us for the insomnia, which was easy enough to treat. But he lingered, prescription in hand, to reflect on the nature of being. “Before my shoulder started hurting, life was easier,” he told me.
“There was only one of me then.”
Elissa Ely is a psychiatrist in Boston.