Street Medicine
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Street Medicine

Authors

Sriram Venkatesan, FAWM
Medical Student
Sri Ramachandra Medical College, India
Vice Chair, EMRA Prehospital & Disaster Medicine Committee
EMRA Rep to the ACEP Tactical & Law Enforcement Medicine Section

Alexis Kimmel, MD
University of Cincinnati Emergency Medicine Chief Resident
Chair, EMRA Social Emergency Medicine Committee
EMRA Rep to the ACEP Social Emergency Medicine Section

Faculty Editors

Chad Holmes, DO, FACEP
John Peter Smith Hospital
Street Medicine Fellowship Director

Edward J. Egan, MD
UPMC Mercy
Street Medicine Fellow

INTRODUCTION

Description of the specialty
Street medicine is the practice of providing medical care “outside the walls” of a medical facility to unsheltered people experiencing homelessness. Care is typically provided in encampments, parks, under bridges, and along streets and sidewalks.1,2

Individuals experiencing homelessness, particularly those who are unsheltered, face a unique set of challenges and barriers to obtain medical care. Many lack transportation to a hospital, some fear theft or destruction of unattended personal property, and others simply may need to prioritize basic human needs (finding food, shelter, restrooms, etc.).3 Unsheltered patients are often overlooked by traditional primary care facilities, leading to decreased access to primary and preventative care for this population. Additionally, many studies have demonstrated that the life expectancy of rough sleepers is several decades shorter than that of the general population.4,5,6

It is important to note that the practice of street medicine is difficult to define, given the variability across regions and programs. Homelessness itself has a broad definition, ranging from temporary unstable housing to chronic homelessness. Patients experiencing homelessness may face concomitant health concerns, including mental health conditions, substance use disorders, physical or developmental disabilities, and histories of trauma or abuse.

The inability of this population to access primary and preventative care can add to the financial strain on the entire health-care system through increased emergency department utilization. Furthermore, lack of care in the early stages of illness may lead to advanced disease presentations. Street medicine addresses this issue by bringing services out of the clinic and directly to the streets or encampments, preventing medical conditions from deteriorating to the point of needing emergency care. As street medicine continues to expand, so does the scope of practice. In recent years, street medicine teams have been able to provide full-service primary care directly on the streets, from dispensing medications, drawing blood, performing ultrasounds, and treating behavioral health and substance use disorders.7

History of the specialty/pathway
The early formation of street medicine can be traced to 1992, when Dr. Jim Withers, an attending physician at the University of Pittsburgh Medical Center Mercy Hospital Internal Medicine Residency Program, dressed in plain clothes, grabbed his backpack filled with medicine, went out one night and started treating the unsheltered in his community. He became the first person to coin the concept of “street medicine.” What started out as one man’s mission has grown over the past 25+ years into the Street Medicine Institute (SMI), an international organization that aims to advance street medicine as a distinct health-care discipline. Working through SMI, physicians from every continent, in partnership with academic centers and rural health clinics, are now innovating and defining best practices for the care of unhoused patients.8

Soon after, Dr. Philip Brickner, a New York-based internist, faced a similar situation. When he and his colleagues realized that their hospital was getting a flurry of sick, elderly men in its emergency department every night from a nearby rundown hotel, they established a free clinic at the hotel. They formed teams consisting of a doctor, nurse, social worker, and electrocardiograph technician to staff this clinic and even made daily house calls on the sickest patients.9

In 1984, Dr. Jim O’Connell began similar work in Boston. After finishing his internal medicine residency at Massachusetts General Hospital, he took the lead on a pilot health-care project, the Boston Health Care for the Homeless Program (BHCHP), caring for unhoused patients in the city. Policymakers and public health advocates eventually took notice, and in late 1984 the Robert Wood Johnson Foundation launched a $1.4 million national pilot project on health care for the homeless. Dr. O’ Connell was tasked with leading Boston’s efforts. Years later, he and his team created the country’s first medical respite unit, where unsheltered people who were too ill for the streets but not sick enough for hospitalization could recover. The unit began with only 25 beds in the corner of a state-run shelter, but soon expanded to an old nursing home in Boston’s Jamaica Plain neighborhood, where it tripled in size. Today, BHCHP’s mission remains the same, and its resources are exponentially greater. BHCHP has a staff of more than 400, including 15 physicians, and an annual budget of about $50 million (funded largely through federal and state reimbursements).10,11

Why residents choose this career path
Residents choose this career path when they are interested in impacting their larger community and policy through community outreach, research, health policy, clinical services, and education.

How do I know if this path is right for me?
It is advised that you have experience rotating or working in street medicine in order to determine if this is the right career path for you. This path typically appeals to providers who have an interest in population health and/or serving vulnerable populations. Emergency physicians are often well-suited for this career path because of our adaptability, resourcefulness, and ability to quickly establish rapport with patients. Street medicine often involves a strong sense of connection with patients and communities, and a degree of longitudinal and preventative care.

Career options
Most emergency physicians working in street medicine have full-time emergency department appointments at academic or community institutions. Depending on the phase of the individual street medicine program, physicians may have protected time to build programs, fill medical directorship roles, complete street medicine rounds, and perform administrative and educational tasks (precepting medical students, residents, and non-physician practitioners, giving presentations, community engagement, etc.). Others contribute to street medicine outside of their full-time departmental commitments.

IN-DEPTH SPECIALTY INFORMATION

Number of programs

Preparing for a Career in Street Medicine
Research requirements
There is no research requirement to become involved in this field. However, completing research — especially research with ties to social determinants of health, population health, health equity, social justice, etc. — during residency is highly recommended for applicants considering this fellowship.

Suggested rotations to take during residency
It is recommended that you have experience with street medicine before applying for a fellowship position. Whether at your home institution or another program, your experience will help you to decide if this specialty is right for you. Street medicine teams often integrate knowledge from primary care, psychiatry, addiction medicine, wilderness medicine, and public health. Rotations that augment these skills would be useful, but are not required.

Suggestions on how to excel during these elective rotations
Demonstrate your dedication, interest, and knowledge base. Read every day about relevant topics. It is always a good idea to arrive early and stay late if needed, especially to ensure all patient care has been completed. Be courteous to everyone you encounter.

Should I complete an away rotation?
If you are interested in one of the two programs, it may be worth considering an away rotation at their institution, if available. Be aware that this rotation will be a way not only for you to get to know the program, but also for the program to get to know you. As with any audition rotation, strive to be at your best, and treat every day as an interview day.

How can I make my CV stand out from the crowd?
Your resume should clearly display your interest in street medicine by listing multiple supporting activities. Strive for leadership positions where you have meaningful involvement. Seek training through conferences, workshops, and online training modules to better educate yourself, and then subsequently educate others about your niche. Learn the administrative skills that are needed to design and manage a street medicine team. Involvement in your program’s social emergency medicine interest group or similar organization may provide additional opportunities for involvement.

Should I join a hospital committee?
If there is a hospital committee in which you are interested and could have a meaningful role, then you should definitely participate. Possibilities could include “high utilizer” or “complex care” committees, if available. Hospital programs with community outreach involvement would be ideal to help prepare for fellowship. Experience with community paramedicine groups may also be beneficial and may offer ride-along experiences for physicians.

Publications other than research
This is highly encouraged! There are many opportunities for submitting articles in medical newsletters, magazines, journals, and blogs. You could also consider working on a podcast. This is an excellent opportunity to expand your own and the audience’s knowledge base on a particular topic and also to bolster your writing skills. Perhaps the best way to accomplish this is to reach out to your targeted publisher. You will be surprised by how many doors open simply by asking!

Books to consider reading

  • O'Connell JJ, Swain SE, Daniels CL, Allen JS. The Health Care of Homeless Persons: A Manual of Communicable Diseases and Common Problems in Shelters & on the Streets. Boston, MA: Boston Health Care for the Homeless Program with the National Health Care for the Homeless Council; 2004.
  • Alter HJ, Dalawari P, Doran KM, Raven MC. Social Emergency Medicine: Principles and Practice. 1st ed. Cham, Switzerland: Springer; 2021
  • Kullberg P. On the Ragged Edge of Medicine: Doctoring Among the Dispossessed. Corvallis, OR: Oregon State University Press; 2017.

Important skills to practice during residency
Technical skills that are often used in prehospital and austere medicine are adaptable to working in a low-resource setting like street medicine. Principles of motivational interviewing and trauma-informed care are also important to use with this patient population.

How do I stand out from the crowd in the interview/hiring process?
Your goal during the interview is to be engaging, confident, and personable. Be courteous to everyone you meet, and treat every event/interaction as part of the interview. Make sure your application is complete and you fulfill all requirements in a timely manner. Communicate a clear vision about how your future career will include street medicine.

What types of questions are typically asked?

  • What are your 5- and 10-year career plans?
  • What specifically was your street medicine training during residency?
  • How do you plan to expand our department’s involvement and education in street medicine?
  • What are your strengths and weaknesses?
  • Tell me more about the [fill-in-the-blank] leadership opportunity that you list here on your resume.
  • Why do you seek employment at our institution?

How many recommendations should I get? Who should write these recommendations?
Each potential future employer will have its own policies regarding the number of recommendations required. Seek letters from physicians who know you well and will advocate strongly for you. Letters from program directors and/or department chairs would be favorable. If you have a mentor within the niche of street medicine, a letter from him or her would be ideal. Letters that display your knowledge of and competence in street medicine will help support your cause for a career that allows you to continue to build and expand upon your street medicine training.

CONCLUSION

Additional resources

Journals and Journal Articles

  • Enich M, Tiderington E, Ure A. Street medicine: A Scoping Review of Program Elements. International Journal on Homelessness. 2022:1-49. doi:10.5206/ijoh.2022.2.15134

Blogs/Podcasts

National organizations

Conferences

How to find a mentor
There is no central website that links interested physicians with mentors in the field of street medicine. Consider reaching out to the Street Medicine Institute, individual programs to find networking opportunities, or mentors within that program or hospital system. You could also reach out to the EMRA Social EM Committee or sign up as a mentee in the EMRA Mentorship Program for guidance.

 References

  1. Street medicine: Medical outreach for unsheltered people. https://nlihc.org/sites/default/files/NHCHC_What-is-Street-Medicine.pdf. Accessed April 9, 2023.
  2. Goldstein A. Street medicine in California: ‘Go to the People.’ California Health Care Foundation. Published December 12, 2022. Accessed May 30, 2023. https://www.chcf.org/blog/street-medicine-california-go-people/
  3. Leafe M. Street medicine: Removing barriers and providing care. Angels in Medicine. https://medangel.org/street-medicine-removing-barriers-and-providing-care/. Published June 3, 2021. Accessed April 9, 2023.
  4. Roncarati JS, Baggett TP, O'Connell JJ, et al. Mortality Among Unsheltered Homeless Adults in Boston, Massachusetts, 2000-2009. JAMA Intern Med. 2018;178(9):1242-1248. doi:10.1001/jamainternmed.2018.2924
  5. Brown RT, Evans JL, Valle K, Guzman D, Chen Y-H, Kushel MB. Factors associated with mortality among homeless older adults in California. JAMA Internal Medicine. 2022;182(10):1052. doi:10.1001/jamainternmed.2022.3697
  6. Levins BH, Levins H, Weiss BM, et al. Older middle aged homeless dying at higher rates. Penn LDI. October 24, 2022. Accessed June 4, 2023. https://ldi.upenn.edu/our-work/research-updates/the-older-middle-aged-homeless-population-is-growing-and-dying-at-high-rates/.
  7. Doohan NC, Mishori R. Street Medicine: Creating a “Classroom without walls” for teaching Population Health. Med Sci Educ. 2020;30(1):513-521. doi:10.1007/s40670-019-00849-4
  8. Pawlak K. Street Medicine Institute: Our Story. Accessed June 4, 2023. https://www.streetmedicine.org/our-story.
  9. Dr. Philip Brickner: A doctor who made house calls to the poor. Kazantoday.com. Accessed May 30, 2023. https://kazantoday.com/WeeklyArticles/dr-philip-brickner.html
  10. Jim O’Connell. Boston Health Care for the Homeless Program. April 7, 2023. Accessed June 4, 2023. https://www.bhchp.org/institute-team/jim-oconnell/.
  11. Marketing Communications: Web, University of Notre Dame. The Call of the Streets. Notre Dame Magazine. Accessed May 30, 2023. https://magazine.nd.edu/stories/the-call-of-the-streets/
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