Maria Powell is an Internal Medicine Resident (R1) at the University of Calgary who graduated from medical school at Memorial University of Newfoundland in 2017
Admittedly, my social histories used to consist of the same three questions: Do you smoke? Do you drink alcohol? Do you use recreational drugs? I would occasionally ask if the patient worked outside the home, or what they did for income, but the question rarely came up when reviewing consults with resident and staff physicians so I did not routinely ask about it. One thing I am sure of: I never asked whether or not the patient had a home.
During my first two years of medical school, I had lectures on the social determinants of health, and I thought I understood their importance. Yet, it was not until I did a “Health of the Homeless” elective in downtown Toronto that I truly appreciated the impact of the social determinants of health.
The definition of homeless in the literal sense is to be without a home. This can refer to people living with friends, in homeless shelters, or on the street . Within this definition, there are three subgroups: chronically homeless, cyclically homeless, and temporarily homeless . A recent Canadian study estimated that 235,000 different Canadians will experience homelessness in a year, and over 35,000 Canadians are homeless on any given night . Yet for every person that is homeless, there are 23 that are vulnerably housed and at risk of becoming homeless .
During the first week of my Health of the Homeless elective, I met a very sick woman in a homeless shelter. She had been diagnosed with some form of cancer years back and had received treatment. However, she was lost to follow-up secondary to mental illness, substance misuse, and homelessness. Some years later she presented to the emergency department with severe pain, which was found to be due to pathologic bone fractures from tumor metastases. The day I met this woman, my perspective of medicine changed forever. There are so many others with similarly tragic stories, only some of which I would go on to hear during my elective. One man with NYHA class IV congestive heart failure because of metabolic syndrome caused by long-term psychiatric medications and no access to proper monitoring or follow-up; another with HIV and CD4 counts less than 50 who was not taking antiretroviral medications. I immediately realized how naïve I was. This was an entire group of people that I did not “see” on my other rotations or learn about in medical school. My limited understanding of the social determinants of health became strikingly apparent. How was I not asking about homelessness before? I am sure there were patients that I had encountered on my other rotations who were homeless or vulnerably housed, and I am sure it impacted their health, but somehow I had failed to connect the dots.
To find out if I was alone in my ignorance, I reviewed the literature. In general, my suspicion was supported: exposure to healthcare of the homeless population in medical school is often limited or student-driven [4-7]. In general, our medical education system takes a disease-based approach to the study of medicine. Yet, up to 70% of illness is related to the social determinants of health . The different patients I saw and stories I listened to during my elective put these determinants in context for me. Homelessness is a significant contributor to disease. Mortality rates of homeless individuals are more than four times that of the general population . Homeless persons have an increased incidence of psychiatric illnesses and substance misuse , are five times more likely to be HIV positive , and are almost ten times more likely to have tuberculosis . Living conditions affect our health and increase our risk of disease. But despite these risks, homeless persons often fail to receive the healthcare that they need, even under the Canadian Medicare system .
I believe that more exposure to homeless persons in the healthcare setting through learning modules and service-learning initiatives that emphasize the social determinants of health may help address this issue. These could include interactive presentations from healthcare providers that serve these population, clinical skills scenarios in first and second year medical school centered around homeless persons, or clinical placements/training rotations in environments where healthcare is provided to homeless populations. Studies have shown that students who have had the opportunity to work with vulnerable populations such as the homeless through service-learning [13,14], electives [15,16], or self-directed projects during medical school  had improved knowledge, attitudes, and clinical skills relating to this population. Such experiences may lead to a better awareness and appreciation of the impact of the social determinants of health. Furthermore, it may empower students to advocate for vulnerable populations that they encounter in the future. The more I learned about homelessness, the better I was better able to appreciate the social determinants of health, and the more I felt empowered to help those in need. These kinds of experiences may not motivate every medical student to work directly with this population, but at the very least they will help students to be more mindful of the social determinants of health when caring for patients.
Note: The patient cases mentioned here are composites. Patient confidentiality has not been compromised.
- Begin, P., Casavant, L., Miller, N., & Depuis, J. (1999). Homelessness. Ottawa, ON: Parliamentary Research Branch.
- Gaetz, S., Gulliver, T., & Richter, T. (2014). The State of Homelessness in Canada. Toronto: The Homeless Hub Press.
- Hwang, S. (2010). Canada’s hidden emergency: The ‘vulnerably housed.’ http://www.theglobeandmail.com.
- Arndell, C., Proffitt, B., Disco, M., & Clithero, A. (2014). Street outreach and shelter care elective for senior health professional students: an interprofessional educational model for addressing the needs of vulnerable populations. Educ Health (Abingdon), 27(1), 99-102. doi:10.4103/1357-6283.134361
- Asgary, R., Naderi, R., Gaughran, M., & Sckell, B. (2016). A collaborative clinical and population-based curriculum for medical students to address primary care needs of the homeless in New York City shelters : Teaching homeless healthcare to medical students. Perspect Med Educ, 5(3), 154-162. doi:10.1007/s40037-016-0270-8
- Batra, P., Chertok, J. S., Fisher, C. E., Manseau, M. W., Manuelli, V. N., & Spears, J. (2009). The Columbia-Harlem Homeless Medical Partnership: a new model for learning in the service of those in medical need. J Urban Health, 86(5), 781-790. doi:10.1007/s11524-009-9386-z
- To, M. J., MacLeod, A., & Hwang, S. W. (2016). Homelessness in the Medical Curriculum: An Analysis of Case-Based Learning Content From One Canadian Medical School. Teach Learn Med, 28(1), 35-40. doi:10.1080/10401334.2015.1108198
- Younger, D. S., & Moon-Howard, J. (2016). Assessing the Public’s Health. Neurol Clin, 34(4), 1057-1070. doi:10.1016/j.ncl.2016.06.007
- Nordentoft, M., & Wandall-Holm, N. (2003). 10 year follow up study of mortality among users of hostels for homeless people in Copenhagen. BMJ, 327(7406), 81. doi:10.1136/bmj.327.7406.81
- Fischer, P. J., & Breakey, W. R. (1991). The epidemiology of alcohol, drug, and mental disorders among homeless persons. Am Psychol, 46(11), 1115-1128.
- Robertson, M. J., Clark, R. A., Charlebois, E. D., Tulsky, J., Long, H. L., Bangsberg, D. R., & Moss, A. R. (2004). HIV seroprevalence among homeless and marginally housed adults in San Francisco. Am J Public Health, 94(7), 1207-1217.
- Bamrah, S., Yelk Woodruff, R. S., Powell, K., Ghosh, S., Kammerer, J. S., & Haddad, M. B. (2013). Tuberculosis among the homeless, United States, 1994-2010. Int J Tuberc Lung Dis, 17(11), 1414-1419. doi:10.5588/ijtld.13.0270
- Omori, J. S., Riklon, S., Wong, V. S., & Lee, D. F. (2012). The Hawai’i Homeless Outreach and Medical Education Project: servicing the community and our medical students. Hawaii J Med Public Health, 71(9), 262-265.
- Packer, C. D., Carnell, R. C., Tomcho, P. M., & Scott, J. G. (2010). Development of a four-day service-learning rotation for third-year medical students. Teach Learn Med, 22(3), 224-228. doi:10.1080/10401334.2010.488467
- Baribeau, D., Ramji, N., Slater, M., & Weyman, K. (2016). An advocacy experience for medical students. Clin Teach. doi:10.1111/tct.12495
- Jain, S., & Buchanan, D. (2003). A curriculum in homeless health care was effective in increasing students’ knowledge. Med Educ, 37(11), 1032-1033.
- Bonafede, K., Reed, V. A., & Pipas, C. F. (2009). Self-directed community health assessment projects in a required family medicine clerkship: an effective way to teach community-oriented primary care. Fam Med, 41(10), 701-707.
Rudy Ramchandar MD
This is a unique topic and an excellent work based on first hand experience, investigative journalism, and literature search. The author is to be commended for publication of this report. Furthermore, medical school curriculum developers should take note and incorporate her experience as highly recommended experience in the mid clinical years before the “glamorous” residency choices have been made.
Dr Iain J Robbé
Dear Dr Powell: thank you for sharing your thoughtful reflections and conclusions about homelessness, the importance of the social determinants of health, and learning opportunities during the MD program.
I agree with your analyses and you made a particularly cogent point about the opportunities for health advocacy by MD learners and residents. Your narrative had resonances with Dr Daniel Bierstone’s CMAJ blog in September 2016 (1) and I was reminded of my comments to him.
I wondered if you had also been inspired by the work of Andermann et alia (2) and by the importance of curiosity (3)? The emphasis on the medical expert area in the CanMEDS competency framework still dominates MD programs despite their alleged modernisation (4).
However the insights that you have shown in your article demonstrate your awareness of others areas of competence and the centrality of the social determinants of health especially for vulnerable populations, for example, people who are homeless.
Thank you again.
Best wishes, Iain
Dr Iain J Robbé
Clinical Medical Educationist
(2) Andermann, A., et alia. (2016). Evidence for Health I: Producing Evidence for Improving Health and Reducing Inequities. Health Research Policy and Systems,14:18 DOI 10.1186/s1296 1-016-0087-2
(3) Fitzgerald, F.T. (1999). Curiosity. Annals of Internal Medicine,130:70-72.