A group of doctors has made it their mission to make medical care more accessible to homeless patients, and in the process they are rediscovering their empathy
Most days if you are looking for Dr. Rebecca Karb you will find her in one of Rhode Island’s emergency departments. An emergency medicine doctor, Karb often pulls overnight shifts at Rhode Island and the Miriam hospitals where she sees everything from minor injuries to “crazy TV stuff.”
But on Wednesday evenings, Karb is often found far from traditional clinical settings: in the backs of cars, public restrooms of fast-food restaurants and outdoor tents.
Her patients are nomads, people without permanent homes, who live in encampments and makeshift shelters — and outside the mainstream of the health care system. But a growing group of physicians has made it their mission to take medical care to them.
Leading the effort is Karb, who is co-director of the Comprehensive Stroke Center at Lifespan, the state’s largest health care provider. Last spring, Lifespan in partnership with House of Hope and Project Weber Renew, two nonprofits that offer social services, launched Rhode Island’s first street medicine program. The Rhode Island Foundation provided a $133,925 grant in December 2022 to fund it, and so far 20 doctors from various specialities have signed up.
The program seeks to tear down the barriers that keep homeless people from accessing health care. Sara Melucci, director of outreach at House of Hope, says the standard health care system is not designed to accommodate this group of people.
“When your life is just in a constant state of crisis, keeping an appointment time often doesn’t work well,” Melucci said.
Patients who often miss appointments may get penalized and taken off patient lists. Transportation is another hurdle — homeless people may not have bus passes and even if they did doctors’ offices are not always on public transportation routes. They, too, may hesitate to leave their personal belongings unattended to go to the emergency room, even if they have a serious wound that needs tending.
Both Karb and Melucci say many homeless people also have had traumatic experiences in clinical settings. An unpleasant remark from a provider over a patient’s body odor or appearance can leave a lasting impression. Psychiatric settings where doors lock automatically and security is tight may make formerly incarcerated people — and those who have been in the foster care system — feel uncomfortable.
“For many of our folks, the health care system is … a place where you feel powerless again,” Melucci said.
Meeting patients out in the streets tears down these barriers. Away from the frenzy of emergency rooms doctors, can take their time with each patient and discuss their health concerns and explain discharge instructions. With each visit they build trust where it may have frayed.
“When you’re outside and you meet people — you’re wearing regular clothes, they’re wearing regular clothes. It’s in their space. It just feels like all of those barriers are kind of taken away, and you get to just talk to people as people,” Karb said.
Though the program is still in its early stages, the doctors say they are already seeing positive changes. Karb estimates that they have been able to reduce emergency room visits by intervening before a wound or a condition requires hospitalization. In some cases their interventions have likely saved patients’ lives.
The program also has proven an effective way to screen for infectious diseases, such as hepatitis C, which often go untreated among this patient population. But getting access to medication and treatment for such diseases is not always easy. Multiple appointments and tests are often required, and attending these may not be easy for the homeless. Karb and her colleagues are now working to get easier access to this care for their outdoor patients.
Melucci says a major goal the program is accomplishing is to bring homeless people back into the mainstream of the health care system. Lifespan has created a database to track homeless patients, so when doctors see them they can update their charts, which is helping physicians manage chronic illnesses. Doctors who have had patients lapse in their visits also can ask the street medicine team to follow up with them.
But street medicine is not without its challenges. The doctors often have to deal with patients who are reluctant to seek more specialized care in clinical settings. Coaxing them to go to the hospital requires trust between physician and patient, which takes time to build. The doctors also are limited in how much they can treat in the field. There are some wounds and conditions that simply require hospitalization.
The health care system, too, can improve to become more accessible to the homeless population. Offering bus passes would help patients keep appointments, and having a walk-in day could make it easier for those who may have trouble keeping a scheduled appointment time. Melucci says that even the way doctors describe patients in their medical charts can improve a patient’s experience in the hospital.
In some ways, it is changing the way doctors involved in the program practice medicine. Karb, for example, says she has become a more passionate advocate for her patients in the emergency room who may need additional services such as treatment for a substance use disorder. Dr. Natasha Rybak, an infectious diseases specialist who is part of the street medicine outreach, says physicians can get frustrated with patients who miss appointments but meeting homeless patients has helped her understand why they might do so.
“I’ll never think that way again, because I actually was able to physically see all the barriers that those people had,” Rybak said.
For Karb the program is an opportunity to try a different way to deliver care for a patient population that is often overlooked and marginalized.
“I just think that there’s no particular model of medical care that works for everybody. And it’s not like a failure to adapt and create a new model to fit the needs of people, especially folks that have not been well served by the current medical system,” Karb said.
She also sees the program as having a salubrious effect on the mental and emotional health of physicians. Many health care workers have faced burnout after the COVID-19 pandemic, which has eroded their capacity for empathy. But working with homeless patients has rekindled Karb’s.
“One thing that this has done for me at least is it allows me to bring that [empathy] back, and I would hope that patients can see that,” Karb said.
Jonny Williams is a staff writer for the Rhode Island Current.