How Should Clinicians Ally With Patients Whose Health Is Unlikely to Be Improved by Even Numerous Clinical Encounters?

Abstract

Patients experiencing homelessness and mental illness face conditions and circumstances that deserve focused ethical and clinical attention. The first commentary on the case applies insights from qualitative research about social determinants of health to these patients' care and dignity. The second commentary describes 3 kinds of power wielded by physicians-charismatic, social, and Aesculapian-each of which is considered in terms of whether and to what extent physicians' power should be owned, aimed, or shared.Case JJ is a 27-year-old man with schizophrenia, who is brought to the clinic by staff members from a local shelter. JJ does not adhere well to his antipsychotic medication, has experienced several inpatient psychiatric civil commitments and other encounters with numerous clinicians in the region's health care system, and does not have reliable access to shelter, food, water, or hygiene. You, JJ's caregiver in the clinic right now, empathize with him, staff from the shelter, and others trying to help JJ avoid poor health outcomes for which he is at such high risk.You refilled JJ's medication and reviewed his laboratory values, but you know there is little you can do for JJ that can counter the myriad and well-known social determinants undermining the effectiveness of even the most skilled intervention any clinician could offer JJ during a clinical encounter. You wonder how to make the most of this moment you have with JJ on his life journey.