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Last month I gave a lecture to first-year medical students on a topic that is foundational to their future practice of medicine. No, it was not on the Krebs cycle. It was a lecture on homelessness, something that impacts nearly 600,000 people on any given night in the U.S. and that has profound negative health effects, up to and including premature mortality.
This lecture, part of a series on population health in the first-year curriculum at NYU Grossman School of Medicine, marked a milestone: it was the first time a lecture on homelessness was required for all first-year medical students at our institution. Responses to a tweet I wrote about it were enthusiastic, suggesting that others see the value of teaching medical students about homelessness.
The relevance of homelessness for medical education is abundantly evident from the fact that homelessness is associated with myriad negative health outcomes. People experiencing homelessness have higher than average rates of most chronic medical conditions. Preventive healthcare in some cases becomes an impossibility; how do you do a bowel prep for a colonoscopy, for example, when you are homeless? People experiencing homelessness also have higher than average rates of substance use and mental illness, which in turn can be exacerbated by homelessness itself. Risks for infectious diseases are amplified, whether in crowded shelters or in unsheltered locations with inadequate hygiene resources. Homelessness is associated with environmental risks including hypothermia, hyperthermia, and exposure to violence. Homelessness is even associated with premature aging.
I aimed to help students gain a basic understanding of the prevalence, causes of, and solutions to homelessness. Importantly, we covered the fact that the primary drivers of homelessness are structural -- lack of affordable housing paired with low wages and an inadequate social safety net. We discussed how structural racism puts some groups at disproportionate risk for homelessness. It is on top of these larger structural factors that individual vulnerabilities such as substance use disorder, lack of family support, or a mental health crisis can serve as a tipping point into homelessness.
To prepare for the lecture, students were encouraged to watch A Deep Dive: Homeless Services and Housing, from the National Alliance to End Homelessness. This video's first 20 minutes give a concise, evidence-based overview of the causes of homelessness and its solutions presented by Marybeth Shinn, PhD, and Jill Khadduri, PhD, authors of In the Midst of Plenty: Homelessness and What to Do About It.
My lecture focused on realistic steps students can take in their future clinical practice to improve their care of patients experiencing homelessness. First, we talked about the importance of asking patients about their housing situation. Too often, healthcare providers rely on stereotypes about "what homeless people look like," a losing proposition considering there is no single face of homelessness. Indeed, one in four people living in a U.S. homeless shelter are children. By understanding patients' housing situations, providers can tailor their care plans appropriately -- for example, by avoiding medications requiring refrigeration or by having a lower threshold to keep patients in the hospital (or referring them to a medical respite program) when they have a medical issue that cannot be safely managed while homeless. While medical students and physicians generally cannot immediately solve a patient's homelessness, we can and should ensure that the medical care we provide is appropriate, in addition to offering social work assistance or referrals to local community resources. We can also use our voices to highlight the interconnectedness of housing and health, and advocate for needed solutions such as expansion of housing choice vouchers and permanent supportive housing.
Importantly, I also provide students with advice from people who have been homeless themselves, who shared their insight to the question, "what do you wish healthcare providers knew about homelessness?" via a Facebook support group run by Mark Horvath, founder of the nonprofit Invisible People. Their responses -- which I share with permission -- are eye-opening. Experiences of stigma in healthcare settings were underscored by comments like:
"I wish they wouldn't look down on us."
"We are intelligent human beings with legitimate concerns: act accordingly."
"Please don't assume that I am drunk or high or just looking for shelter. My friend died weeks after one of you turned him away."
For those interested in learning more from people who have experienced homelessness themselves, the Health x Housing Lab (which I co-direct) and the Health & Housing Consortium, Inc. host a series of Flipping the Script events, where people with lived experience of homelessness speak about how homelessness has impacted their health and healthcare.
A single lecture is surely not enough to prepare students for the challenges of providing quality medical care in the setting of widespread homelessness. Research has shown, for example, that medical trainees' attitudes toward homelessness actually seem to get worse over the course of their medical careers -- and effective educational interventions to improve attitudes toward and care of patients experiencing homelessness have been elusive. While a lecture early on in their medical training can help lay a foundation of awareness -- including knowledge of the fact that homelessness is caused by structural factors rather than personal failings -- this is, of course, just one small step.
Ultimately, I hope that one day I don't have to teach a lecture on homelessness to our medical students because we have garnered the political will to implement the policies and mobilize the resources that can end homelessness as we know it. In the meantime, we should ensure that medical students are well-prepared to provide care that is appropriate, competent, and minimizes stigma for patients experiencing homelessness.
Kelly Doran, MD, MHS, is an assistant professor in the Departments of Emergency Medicine and Population Health at NYU Grossman School of Medicine. She is a practicing emergency physician and co-directs the Health x Housing Lab.