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Erin Imler


Preparing to assemble my new bed, I open the wordless instruction manual. The first page shows a picture of a single stick-figure standing there, hands on hips, and sadly regarding a bungled, not-put-together bed; the next image is two happy-looking stick-figures standing with their arms around each others' shoulders, looking at a successfully constructed bed.

Despite the warning, I'm determined to do this by myself. For almost four years, I've slept on my couch, preferring it to my twenty-year-old mattress. Now that I'm starting a new job in a new city, it's finally time for a new bed.

As I put it together, I can't help but think back on my first real job as a family doctor--a post in rural northern California, working at a mobile clinic serving a predominantly homeless population.

I'd come there at age thirty, eager to experience real-life medicine outside of academia.

One of my first patients was Lisa, a petite, blond, twenty-six-year-old woman who had come in for an asthma flare-up.

As we set up the breathing machine for a treatment, she said, "I want to see about getting on methadone."

She was using heroin, she said, and wanted to taper off.

"We have a Suboxone program that I can refer you to," I said.

"No, you can't get high when you're on Suboxone," she answered.

"Well, I'll see what I can find out," I said.

A bit later, she shouted out to me in the hall, "Hey, could I get my birth control shot while I'm here?"

"Sure," I answered. "We just need to do a pregnancy test first."

"I'm not pregnant."

"We need to be certain," I said.

The test was positive.

I walked into Lisa's room. Now breathing much easier, she was playing a game of Tetris on her cell phone.

"Lisa, your pregnancy test is positive," I said.

She said nothing.

After a moment I went on, "You weren't expecting this, and it's a lot to take in..."

Silence. Her eyes did not leave her cell phone screen, but tears started to stream down her cheeks.

"I think it's even more important that we talk about getting off of heroin now," I added.


She nodded briefly.

Finally she spoke. "I live in a tent."

I guess I was gaining the kind of real-life medical experience that I'd wanted. How much more real-life could you get? Only days after starting this job, I found myself inwardly repeating, Meet people where they are.
* * * * *

"Hello Ed, I'm Erin." (None of my patients ever called me "Doctor.")

I extended my hand, but he kept his at his sides, averting his eyes.

"I have an infection, and I don't want to give it to you," he said. The infection blistering his hands, forearms and shoulders came from spending long periods in wet clothing.

Ed wouldn't say much more except, "I'm in a lot of pain from this infection. I take pain meds for my legs, and I'm all out. Can you please give me some pain medication?"

"Okay, I'll give you pain meds for one week," I said. "But you have to promise to come back to see me so I can check on the infection." It was so bad, I gave him two antibiotics.

A week later Ed was back, his infection looking better. Looking me in the eye, he spoke more freely.

He was originally from Virginia, he said. Several years before, his legs had been broken in an altercation; he had rods and screws in both. As a result of this incident, he'd lost his job and his wife. Homeless, he'd wandered across country to the California coast. He'd been taking medication for chronic pain all along, but his pain was worsening.

We decided to get him an appointment with an orthopedist, and I agreed to continue his pain meds until then.

A few weeks later Ed showed up for his refill intoxicated. Tearful and barely coherent, he told me that he'd returned from a walk to find his coat, tent and tarp stolen. Also, he'd received word that the orthopedist wouldn't see him. The problem, an insurance issue, also precluded a visit to a pain specialist.

I try to avoid paternalism, but now I told Ed pointedly, "You need to come back sober before I'll consider continuing your medication."

The next day he limped the two to three miles to our mobile clinic and apologized repeatedly for the previous day's behavior. 

We made a plan: He would take medication for his depression, see the behaviorist and follow strict rules for his pain medication. During the rest of our time together, Ed stuck to the plan.


* * * * *

Cynthia had scabies. Well versed in the housing-assistance programs, she'd looked for shelter and come up empty-handed. To secure a clean place to shower, wash her clothes and treat her scabies, she'd arranged to stay with a man who potentially might take advantage of her.

Seeing my face, she said, "Don't worry, honey. I'll be all right."


Wait, I thought. Aren't I the one who's supposed to reassure you?

* * * * *

John, wheelchair-bound due to a severe low back condition, was also very overweight, with heart disease and chronic kidney disease. Educated and articulate, he'd been approved for disability, but hadn't been able to find wheelchair-accessible housing. He was sleeping in his car, which led to horrible swelling in his legs.

"There has to be a way for you to get housing!" I said, shocked.

"Don't worry if you can't help me," he said. "It's just nice to know that someone cares."

We did help John find permanent housing--but it took hours on the phone speaking with numerous agencies and arranging for the necessary accessibility modifications.

* * * * *

Three months after I arrived, the mobile unit was threatened with closure, and I had to leave. I went to work in a rural clinic in California's Central Valley, living in a hotel for six incredibly lonely weeks before moving on to my current job and home.

Even though I couldn't stay at my first job, I feel grateful for the moments that my patients and I shared. They taught me humility and gave me a broader perspective on the inevitable hardships in life.

Now, when I go to sleep at night, I am very thankful for my bed. And I say a prayer for all those without one.

About the author:


Erin Imler is a family physician with the San Francisco Department of Public Health. "This is my first published piece. Until now, I'd written only privately, but one of my residency mentors, Dr. Jonathan Han, encouraged my writing and introduced me to Pulse. I wanted to write it for two reasons--to tell my patients' stories, and to pay tribute to my wonderful friends and family who supported my moving across the country to follow my heart and take this job."

Story editor:

Diane Guernsey