A True Exam Room

I recently accepted an opportunity to work in a new clinical setting. I now spend one day a week at a harm reduction site that serves people who are currently using or have used drugs within the past 12 months.

To my surprise, I’d passed by the nondescript brick building housing the site countless times. Clients come in to a room known as the “exchange”—a large space where they can make a cup of coffee or a bowl of oatmeal, grab some snacks, trade used needles or pipes for clean ones, or pick up a hygiene kit or a new T-shirt. Social workers make the rounds to assist folks with these tasks; as the clinician, I meander and chat with the clients, introducing myself as a doctor and offering to help them with any medical questions.

Often clients’ eyes pop open as they proclaim, “Yes! I need to talk with you.” I typically respond, “Would you like some privacy? We can meet in an exam room in the back.” Curiously, the energy that had been growing between us then falls flat. Eyes moving nervously, clients mumble about having to be somewhere soon. “Maybe another day,” they say. I then re-engage them while staying put in the exchange, and the energy of the interaction reinflates.

When clients do agree to be seen in an exam room, the dynamic shifts. The exchange is their territory, but the exam room is mine. Ghosts of prior medical trauma waft around us. The exam room is too quiet, too unchaotic, and the sudden focus on the client as an individual feels too pressured and intense, generating a vulnerability that feels intolerable. Painful emotions shoved deep inside threaten to bubble up and puncture the hard shell our clients have constructed to help them survive. The time a client allots for a medical visit can expire at any moment; I act swiftly when visit opportunities present themselves.

Truthfully, the exchange is the true exam room. It is where I observe clients carefully and tune in to their energy and their body language to note what they might need. So much vital medical care transpires in the exchange—offering a popsicle, listening to a story about a tattoo, answering general medical questions, complimenting someone, giving a smile and a hug.

When I notice a finding that would likely benefit from a prescription or a procedure, I’ll gently suggest to that client that we meet in an exam room. And then I follow their lead.

Pam Adelstein
Newton, Massachusetts