Okay, so this morning I want you to think about something with me. I want you to be honest, as honest as you can, as I will be with you too. Deal? We can’t move forward until you agree.

Right.

What do you feel when you’re driving along, you come to the next busy intersection, stop for the red light, and see that homeless guy? You know the very one I’m talking about. That homeless guy with his grimy, almost blackened clothes, week’s growth of beard, and the cardboard sign that says, “Will work for food?”

Nope, nope, nope, come back here. You said you would be honest with me, and I’m not going to let you weasel out of this one that easily. Your second cup of coffee can wait.

You don’t know this man. You don’t know his story. You don’t know if he’s a scammer (you really think that likely he is), a deadbeat dad (how could he not be, you think, dressed like that and begging?), or just a really, really lazy person (of course he is, I work for food every day. It’s called a job!).

Do you look at him critically, looking for clues to his story in that brief minute that the light is red? Do you look on him with compassion, feeling a sense of urgency to help? Do you look at him with a sense of guilt, knowing that if you don’t help him, right now, that nobody else is likely to for the rest of this day?

Now, take that feeling that you had at the red light, or those feelings, because my hunch is of you’re like me you had a smattering of all of them, and sit with them a minute. How do they hit you? Do they make you feel empowered? Sad? Angry at society? Helpless? Energetic? Depressed. Full of empathy? Disengaged?

Take those feelings and multiply them by a hundred, a thousand, ten thousand. Doesn’t feel so good, does it? Feels downright bad. You want to stop feeling that way. You want to get back to feeling good again, driving away from that intersection and going shopping and spending your money and hugging your children and smelling the fabric softener in your clean clothes.

Indigent patients, truly indigent patients, hit us like that in the emergency department hundreds or thousand of times each month. They are the truly poor, the truly needy. The ones who will be with us always, no matter the party in power or the stock market close. Homeless, down on their luck, no job, no money, no place to stay. Using drugs. Coming in with blood alcohol levels of three, four hundred. Dirty. Smelly. Reeking of alcohol and sweat and vomit and street grime.

I’m sorry, but my part of this bargain is to be honest with you since you stuck around with me.

We all know that being a doctor is glamorous, right? It’s all about Patch Adams and House and ER and Marcus Welby and Grey’s Anatomy. It’s about quickie sex in the supply closet between exciting traumas. It’s about magic tricks and starched white coats and throwing your weight around because you’re a star surgeon who saves lives. It’s about sterile environments and bright lights and making that once in a lifetime diagnosis that gets you noticed and makes you a hospital legend.

Come on. You know better.

ED medicine is about grueling hours and long shifts and inexhaustible waiting rooms full of patients with chest pain and bleeding and suicide attempts and drug overdoses. It’s brutal, folks. A lot of the time it’s just brutal. I hate to burst your bubble, but there it is.

Indigent patients are one of those special groups I was telling you about the other day.

I got to the office yesterday and saw that there had been about a dozen psychiatric consults remaining to be seen when my colleague had gone off shift at midnight the night before. From midnight until 8am the next morning, another thirteen or so had *dinged* into the work queue. Twenty-five patients with their own stories. A good number of them that guy. The one holding the sign at the intersection, or someone a lot like him.

How can we show compassion to the old, tired, smelly guy with the sign when we are tired before we even get started with the day’s shift? When we see the never-ending line of misery staring back at us on the computer screen and we just want to hit the gas and burn rubber and drive off?

I’ll tell you how.

First, we don’t go into this line of work unless we really want to help people. Sounds all rose colored glasses and kittens and sparkles and unicorns, but it must be true. It has to be. You don’t put up with this shit unless you want to be a doctor.

We train and train hard for a reason. We learn our craft and how to do it backwards, forwards, upside down and sideways, blindfolded and with one hand tied behind our backs. We take long hours of call, we work days on end with little rest and we see patients back to back to back so that we develop toughness. When the fifth indigent patient comes in with the same-old same-old story at midnight on a Saturday when we are so bone-tired that we can’t see straight, we give him the same ear and the same critical workup we’d give the lady with full insurance coverage who drove herself to the ED in the Lexus to have her arthritis checked out. If we’re good doctors we do, that is.

We care for each patient as a person, a person with worth. I don’t care if you’re down on your luck, if you have no money, if you have no job, and if you curse me for everything I’m worth as I tell you I’m going to commit you for your own safety after you drunkenly sliced your wrists opened and guzzled a mixed drink of Tylenol and scotch. I’m going to take care of you the way my excellent mentors taught me to, the same way I would want my own mother or daughters to be taken care of.

Being indigent is not a crime.

Being an arrogant, thoughtless, cold, uncaring doctor should be.

Greg Smith is a psychiatrist who blogs at gregsmithmd.