Establishment of a Fellowship in Street Medicine.

Abstract

The American Medical Association recognizes street homelessness as a significant barrier to the provision of high-quality care.1 Traditional medical training provides inadequate preparation for physicians to manage persons experiencing unsheltered homelessness (PEUH). Street medicine is the direct provision of health care and social support to PEUH,2 who experience high barriers to needed care and tend to use acute hospital-based care at high rates.3We established a street medicine fellowship to enable physicians to acquire the requisite clinical and organizational skills to become leaders in improving outcomes in this vulnerable population.The UPMC Mercy Street Medicine Fellowship is the first of its kind. This one-year, one fellow per year program was initiated in 2019 by UPMC Mercy, Pennsylvania. The fellowship accepts applications from physicians who have completed a residency in internal medicine, family medicine, emergency medicine, or psychiatry, and who seek to develop expertise in caring for PEUH while also participating in multidisciplinary care to enable them to serve as future leaders in this field. At the end of the fellowship training a survey is sent to learners.Fellows are instructed in comprehensive management of PEUH. The program uses the “go-to people” approach to health care as promoted by the Street Medicine Institute. Fellows are challenged to set aside the mindset of the “office approach,” which often does not embrace unique social determinants of health, and round 3 to 4 times per week on the streets, on the riverbanks, and in homeless encampments, including general rounds, targeted case management rounds, and specialty rounds (eg, psychiatric, harm reduction, intimate partner violence, etc). They participate in additional outpatient clinics, 3 half days per week, which have been established for PEUH and for those who have transitioned from street homelessness into housing. Fellows maintain this continuity group of patients throughout the fellowship year. Home visits are also conducted for newly placed patients.Fellows apply the concept of “community united” so that changes initiated in one community are spread to others. They utilize multidisciplinary mentors and engage in productive communication with experts in street medicine. They conduct a formal comparative analysis of 2 communities in which street medicine is practiced to further develop insight into improvement opportunities as well as attend the annual International Street Medicine Symposium as a learning activity and for academic presentation as applicable.Fellows are assessed monthly according to the Accreditation Council for Graduate Medical Education's Core Competencies. Fellows also complete a monthly evaluation of their assigned experience. Lastly, fellows are surveyed at the completion of the year (Figure).Our first fellow now carries a university faculty position in another city. She teaches in the outpatient setting and has integrated clinical street work with community initiatives, a street medicine interest group, and a peer outreach group. Our second fellow is practicing emergency medicine in another city and incorporating her skills to improve care in that setting for PEUH.Although our program is young, our graduates have affirmed that formal fellowship training in street medicine is a viable yet heretofore unexplored avenue toward more effectively addressing society's responsibility toward PEUH.