Episode 136: Street Med 2 - a podcast by Rio Bravo Family Medicine Residency Program

Episode 136: Street Med 2.      

Future Dr. Bedi presents the history and purpose of street medicine and shares why she became interested in this topic. Dr. Saito tells his personal experience and shares the particular challenges of unhoused patients.

Written by Indudeep Bedi, OMS III, MSIII, Western University of Health Sciences. Comments by Steven Saito, MD. 

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Indu: I want to talk about street medicine in some general terms, as well as Tracy Kidder's article published in the NYT this year, called "You have to learn to listen," which is based on Kidder's book Rough Sleepers, on Dr. Jim O'Connell's work with the Boston homeless community.  

Dr. Saito: Let's start by talking about street medicine in general. What exactly is street medicine? 

Street medicine was a term coined by Dr. Jim Withers, from Pittsburgh, who has been practicing the art since the 90s. He founded the Street Medicine Institute (SMI) in 2009, which strives to connect providers worldwide to address homelessness. Providers practice healthcare, of course, but first and foremost, it is about building relationships and demonstrating you are one of them instead of the power differential that usually exists in our system. It requires a paradigm shift, and it's a shift in thinking. Dr. Jim Withers himself, for example, began to wear ragged clothes and put dirt in his hair to show these vulnerable individuals that he was accepting of who they were and respected them for it. In return, they respected him. 

Dr. Saito: Do you know of other programs which exist? 

There are a bunch of programs now that have spurred up, such as Doctors without Walls, San Francisco's community health center, of course, are very own CSV, and the Boston Pine Street shelter, which I will talk about more. The SMI publishes an annual report, and there are about 50 independent street medicine programs nationwide. Many global programs have sprung up, too. An international street medicine symposium was founded in 2005. In general, this is an excellent community of providers who can share best practices regarding this unique population. Even a student coalition at the SMI helps get student-run programs off the ground. 

Dr. Saito: What is one of the homeless community's biggest problems? 

That is a tricky question because of the complexity surrounding this issue. I will tackle this by answering that housing is one of the most considerable problems. The housing may be either transitional or permanent. Transitional operates to get the individual immediately off the street. In contrast, permanent housing takes longer to find, but many charities have bought real estate to create permanent housing. Permanent housing also includes the individual being vetted, in a lot of cases, to make sure that they will do okay if they have a place of their own. Are they able to be independent? Can they pay rent? Do they have a job? In 2009, however, a new program was implemented known as Housing First. This social program provided "a no-strings-attached" housing to the homeless population with substance use and mental health problems. What was great about this program is it was found that the relapse rate was much lower in this population when compared with other programs. In 2018, however, due to gentrification and rent increases, there was a very steep rise in homelessness in cities on the west coast, such as Seattle, San Francisco, and Los Angeles. To combat this, many state-wide programs were established that work with healthcare providers to provide these individuals with the help they need. 

Dr. Saito: What is the article "You have to learn to listen" about?

I would first like to read a short excerpt from the article: "In American cities, visions of the miseries that accompany homelessness confront us every day — bodies lying in doorways, women standing on corners with their imploring cardboard signs dissolving in the rain. And yet, through a curious sleight of mind, we step over the bodies, drive past the mendicants, return to our own problems. O'Connell had spent decades returning, over and over, to the places that the rest of us rush by." 

Dr. O'Connell completed his IM residency at Mass General in Boston and was about to move on to an oncology fellowship when he was approached by some colleagues with a request to take a position as a physician for one year in a grant-funded program from the city of Boston to address homelessness in the 1980s. The program operated outside of Pine Street Inn homeless shelter. One of the initial experiences that Kidder describes Dr. O'Connell having was his first day of being there, being surrounded by stern-faced nurses who obviously knew more than he did about this niche population. He really had to prove himself to them and the individuals who were homeless. Soon after he joined, Dr. O'Connell met a nurse by the name of Barbara McInnis, who told him, "I really think we want doctors, but you've been trained all wrong. If you come in with your doctor questions, you won't learn anything. You have to learn to listen to these patients." Nurse McInnis also taught Dr. O'Connell a common practice at their shelter, which was to soak patients' feet by filling a tub and pouring in betadine, as a lot of the population did not have footwear. This reflection of "placing the doctor at the feet of the people he was trying to serve" is beautiful. That is precisely what street medicine is about. 

Dr. O'Connell has been managing the street medicine program at Pine Street since then, and that oncology fellowship remains forgotten. The program he is a part of now has 19 other shelters in order to tackle Boston's growing homelessness problem. However, it was apparent to Dr. O'Connell a few years in that these shelters were not really making a difference in terms of curbing the amount of homelessness. That problem was still continuing to grow. In addition, many other systemic issues were leading to the rise in homelessness, such as the AIDS epidemic around the time, lack of welfare programs, gentrifications, etc. But the difference was being made in the sense that these individuals who had been pushed to the margins, who were overlooked, and who were in essence burned by the healthcare system in one way or another and highly suspicious of providers for that reason, were now able to be coaxed into receiving and accepting the help they needed. This was done by, as said previously, placing the physician at the feet of the people he was trying to serve.

Over the years, the program continues to grow and even created a new clinic with beds, offering housing vouchers, but it also faces other problems, such as funding and efficiency. A significant focus for the homeless community is housing options. And most people will do really well after being housed, while for others, finding housing brings more troubles with it when they need to be continuously moved from home to home to avoid eviction. I think a lot of it has to do with the lack of resources that come with housing. Homelessness is so complex that finding a home is simply not enough, and these individuals can again fall through the cracks if those other issues are not addressed. While street medicine does a lot of good, it is a harsh reality that individuals have a low life expectancy and will die of this homelessness because of the other issues that remain a constant in their lives, such as substance use, HIV, AIDS, and mental health issues. 

Dr. Saito: How did you come to be interested in this topic?

I have been interested in street medicine for a while now. I volunteered in some projects that exposed me to the perils facing the population, especially for addiction. For example, I had an excellent opportunity to work with an organization that would put up tents to test the communities for HIV and connect them with resources if needed. We would specifically go to the areas where people who were homeless or of low SES tended to congregate. I really started to think about it more recently when I encountered a patient on the Infectious Disease service who was incredibly complex in an immunocompromised state due to AIDS, with multiple hospitalizations and pretty much every infection under the sun. He was what we commonly refer to as non-compliant because of substance use, and whenever we found placement for him upon discharge, he would run away from that home. I think, as providers, we are very quick to judge and label patients as non-compliant without pausing to understand the nuances of their condition. He would later continually return to the hospital in an acute exacerbation of his illness. With each hospitalization, his baseline continues to worsen. And I was deeply saddened to come across such a patient and also recognized within myself this frustration with the system in which we operate. I am a bit despondent about his outlook, and the work of the CSV team is critical to these rough sleepers. 

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Conclusion: Now we conclude episode number 136, “Street Med 2.” Future Dr. Bide recounted the experience of Dr. O’ Connell and some of the challenges faced by our unhoused patients. Dr. Saito added his personal experience and reminded us that compliance with medications may be difficult in unhoused patients. Here in Clinica Sierra Vista, we are proud of our street medicine program, and we hope many more volunteers would join us in our mission to bring “health for all.”

This week we thank Indudeep Bedi, Steven Saito, and Hector Arreaza. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

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References:

1. Meyers, T. (2022) Understanding the practice of Street Medicine, Direct Relief. Direct Relief. Available at: https://www.directrelief.org/2022/02/understanding-the-practice-of-street-medicine/.
2. Balasuriya, L. and Dixon, L.B. (2021) Homelessness and mental health: Part 2. The impact of housing interventions. Psychiatry Online. Available at: https://ps.psychiatryonline.org/doi/10.1176/appi.ps.72504.
3. Atherton, I. and Nicholls, C.M.N. (2012) Housing first as a means of addressing multiple needs and homelessness. European Journal of Homelessness. European Observatory on Homelessness. Available at: https://dspace.stir.ac.uk/handle/1893/9035#.ZCRWKBXMKdY.
4. Kidder, T. (2023) You have to learn to listen: How a doctor cares for Boston's homeless. The New York Times. Available at: https://www.nytimes.com/2023/01/05/magazine/boston-homeless-dr-jim-oconnell.html.
5. Street Medicine Institute Annual Report (2021). Street Medicine Institute. Available at: https://stmi.memberclicks.net/assets/AnnualReport/Street%20Medicine%20Institute%202021%20Annual%20Report.pdf.
6. Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

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