This month, instead of dashing to a clinic or to the wards every morning to find my patients, I found myself zigzagging through the streets of Boston to halfway houses, racetracks, and even under a bridge to meet patients. For the last 27 years, Boston Health Care for the Homeless Program has provided access to high quality health care to homeless men, women, and children in the greater Boston area. As one of my fourth year rotations, I had the privilege of completing a small corner of my medical training there.
Prior to this rotation, I had limited experience with working with the homeless or transitional population before. At Vanderbilt, I directed a women’s health week clinic where we bussed women from local shelters to our free clinic to receive pap smears and well women care. I was well acquainted with the nightmare of followup for people without stable homes and lives. When a patient had an abnormal result discovered at our clinic, it would take weeks for me to get a hold of the patient by either calling several relatives, driving around to the different shelters, or hanging a flyer near a Narcotics Anonymous meeting room with hopes that a patient would call us back. Furthermore, discovering a pre-cancerous lesion via pap smear at our free event had limited utility. Without health coverage, their access to treatment depended on the generosity of a few incredible Vanderbilt attendings who extracted internal resources to give these women the care they required.
Having completed most of my training in Nashville, Tennessee, I was familiar with the tension of the question, “If you are unable to provide or offer the appropriate care – is it ethical to screen patients for certain diseases?” It is similar to a question well-analyzed in public health, as screening procedures are often valued at the impact of intervention. For example, we do not have excellent cures or treatments for Alzheimer’s Disease. Therefore a screening program would not be valuable to the patient or to society. A similar tension exists in places like Nashville, where many patients do not have coverage to access treatments to diseases. Even public screening for diseases like diabetes or hypertension feels uncomfortable at times for patients without coverage because without access to proper evaluation and consistent care, the impact is minimal, perhaps even negative.
I broached this question to my attending on my first day with Boston Health Care for the Homeless when we saw a patient, “It’s so great that we are able to reach so many homeless people with these screening programs,” I said, “but what do we do if we find something that needs treatment?” The attending gave me a funny look as she replied, “Well, then we treat them.”
In Massachusetts, 98% of the population has health coverage because of an individual mandate. As a provider, working in a place where people are covered is a breath of fresh air or like discovering clean running water. I am so accustomed to bracing myself every time I realize a patient of mine requires something he or she cannot afford. While my colleagues and I have learned to be flexible and creative in acquiring care for uninsured patients, it’s exhausting. This exhaustion is reflected in the burnout that we sometimes see in our upper levels and attendings.
Boston Health Care for the Homeless also has enormous support such as housing and social services. These services walk hand-in-hand with health care. Together, this program is able to provide excellent care to the unlikeliest of populations.
Enrollment on October 1 is essential. I am running a race to raise money for this breath of fresh air. Support me in my effort here!