Street Medicine: An Example of Reality-based Health Care

Abstract

Jim Withers, MD S Medicine, an emerging field of medicine in the United States, is the provision of health care directly to those living on the streets of our communities. As such, it represents a trend in both health care delivery and medical education in which the reality of those we serve is central. While initiatives such as patient centered care, the medical home and motivational interviewing strive to build health care around the individual, Street Medicine is a more radical attempt to create a care relationship on the terms of those who have been largely excluded from our system of organized health care. The unsheltered homeless living under our bridges, in our alleys, and along our rivers have arguably the worst medical care in the U.S. in terms of continuity and effectiveness. Many receive care in Emergency Departments or not at all. The life expectancy of a homeless person is approximately 47 years.1 For those who do not generally use shelters, it is even shorter. In addition, there is growing evidence that the chronic street homeless population incurs a disproportionate amount of cost due to frequent and prolonged hospitalizations and emergency room visits.2 If ever there was a case of a system not fitting a population, the chronic street homeless are that case. The American health care delivery system has become a victim of its’ own success. While the system’s scope and efficiency are impressive, this has come at the cost of flexibility. Patients are forced to come to the structure of health care delivery and mold themselves to the needs of that system. Indeed, many people never make it into our health care institutions at all, despite having very real needs. Barriers of culture, economics, and other circumstances create gaps between a growing number of citizens and the health care industry. The result is a divorce between established medicine and reality. Our rigid structure prevents us from reaching people. The antithesis would be the traditional house call, in which the physician literally came to the patient in their own world, on their terms. Dismissed as a quaint historical legacy, the house call deserves a serious second look. By going directly to the patient, the nurse or physician immediately establishes the centrality of that person’s reality. This creates trust, and an acknowledgement that any health care plan will be grounded in a shared recognition of real circumstances. The person is honored for who they are. Even if this occurs only one time, the patient will forever value the respect they were given and are more likely to work in partnership with us. Equally important is the insight we gain about the actual determinants of the patient’s health. We see the forces at work in their lives and health. Without such information we are working with incomplete data. This is illogical if our goal is truly