Many students apply to medical school hoping to help underserved populations during both their educational years and their time as practicing physicians. Medically underserved populations, by definition, all face some kind of barrier to accessing health care, be it cultural, economic, linguistic or geographic. Homeless patients, for example, may struggle with multiple barriers to care; this can lead to poor health outcomes. Research supports findings of increased chronic disease loads and mortality among individuals experiencing homelessness versus those who are housed.
The practice of street medicine seeks to provide healthcare to this vulnerable population and fill in the gaps left by traditional medical services. The ultimate goal, according to the National Health Care for the Homeless Council, is to “deliver high quality care in the location of the patients’ choice, rather than withhold care while awaiting their presentation to a fixed clinic site.”
This direct outreach to unsheltered patients has been around globally for decades, but the term “street medicine” was coined officially by Dr. Jim Withers, who has been delivering care to Pittsburgh’s homeless population for over 25 years. Several programs seeking to emulate Dr. Withers’ practice have been founded at medical schools across the United States over the last five years, combining the patient interactions critical for medical education with community service and outreach.
During my tenure as editor-in-chief of in-Training, my goal is to document the experiences of students in street medicine groups at medical schools across the country. I hope to reach students at medical schools who might be interested in setting up a similar program but aren’t sure where to start. Above all, I want to increase awareness of the wonderful work these organizations are doing.
I decided to start with my own institution, the University of Illinois Chicago (UIC) College of Medicine, whose street medicine group is led by co-presidents Philip Ostrov and Kathryn Cushing. I sat down with Philip and Kathryn to talk about their experiences.
How did you become interested in the group? Do either of you have a background in public health?
Kathryn Cushing: Not so much in public health, but I was part of a service-learning group all four years of college. I took social justice classes as well and attended seminars weekly. I found through those experiences that the population I liked to work with the most was the homeless population.
Philip Ostrov: I had done some volunteering with psychiatric patients, but mostly the interest came out of my experience with service learning. [In college] I was the vice president for the University of Wisconsin’s Student Union Directorate and it gave me a lot of freedom to work on individual projects that helped certain groups as well as oversee a lot of the programming. I got a taste for creating new initiatives and seeing them grow on their own. One program I worked on in focused on food education — holding cooking classes, teaching college kids how to cook on a student budget, initiatives to feed the homeless. I wanted to find a project like that at UIC that I knew was a student initiative.
Describe your role within the organization.
KC: Chicago Street Medicine [CSM], the group that originally started this, is now becoming a 501c3 organization. They started student chapters at UIC, [the University of] Chicago, and Northwestern. We’re the co-presidents of the UIC student chapter.
PO: The 501c3 approach is pretty unique to Chicago Street Medicine. A lot of programs in other cities end up being funded directly through one institution. This can streamline a lot of things, but in our case, we decided that CSM could help the patients more and help with medical education if we made it more of a school-chapter, city-collaboration approach.
Are there any challenges you know of that were overcome during the set-up, or that occur during runs?
PO: There are always new challenges. We’re constantly finding things to fix or improve. For example, it’s important to make sure that these patients have as much say as possible in their own healthcare decisions, but that can sometimes be in conflict with what we’re taught and how medicine is practiced in a traditional healthcare setting.
KC: We always have to make sure we’re cognizant of their environment, their ability to give consent, and their trust (or lack of trust) in the medical system. That’s something that’s always on our minds. Structurally, we’re doing things to make sure that all volunteers are well aware of these differences in our patient population.
PO: While we want all new student volunteers to gain valuable experience working with the homeless population, our primary goal is to make sure that the patients are getting the care they need and are treated the best way possible. Those two aspects can be in conflict sometimes.
KC: [laughs] Yeah.
What are the limits of the care you can provide during a street run?
KC: When we go on a run, [the team is] usually composed of three medical students, a resident, and occasionally an occupational therapist or social worker. Having that multidisciplinary team gives us a lot of flexibility in what we can do on the street, and the medical students have people that can provide immediate guidance.
PO: Obviously, we’re not doing surgeries on the street, but for what we can’t do, we make sure to provide as many resources to the patient as possible. Whether or not they follow up is up to them. We’re making new strides to make the follow-up process easier.
KC: One of our recent initiatives is our consult service, which is made up of [University of Illinois Hospital] residents on staff who are aware of homeless patients coming into the hospital as well as those who are inpatients. [The consult service] can monitor them for issues that are specific to homelessness.
PO: If there’s something we can’t provide, or if they need a check-up, or if they need follow-up in a week, let’s say, we give them our card, and they have the number they can call with access to the consult service to directly work with a physician on the staff. Otherwise, there are physicians who are part of Chicago Street Medicine who know to follow-up on their own with patients they have met with previously.
KC: The phone number for the service is manned in two-week shifts by a medical student. We’re also currently working on getting a specific pager within the hospital for these consults. Right now it’s an informal process, but we’ve been working more and more with the hospital to make it an official consult service. That’s more the job of the 501c3 chapter, but they’re keeping us looped in.
How often do you make street runs?
KC: We go on an “open run” twice a month. They’re scheduled to be two hours but usually last longer. We go to [homeless] camps that we know of or camps that we’ve been to before. We work a lot with a photojournalist who has experience working with Chicago’s homeless population. He’s our connection to the community and gives us tips on places to go.
PO: Each month we’ll also have between one and three shorter, focused runs for patients who have called the consult service or who have previously been seen and need to be followed up with. They’re usually 30 minutes to an hour, and we go to where we know these specific patients are. This helps us provide continuity of care, which is one of the big barriers to better healthcare outcomes in the homeless population.
What’s your favorite thing about working with this patient population?
PO: That’s a good question.
KC: For me there’s kind of this… wall, or distance, when you first meet with a patient that’s experiencing homelessness, which makes sense, right? We’re coming into their homes, we’re coming into their community, and it’s reasonable for them to be suspicious. Once you start to sense trust and a relationship, and they begin to work with you on their medical care, that’s just such a rewarding process. There was a patient specifically that I worked with who I saw on the street and followed up with in the hospital. Watching her begin to share more about her life with me, feeling like she could confide in me about her drug use — that I wasn’t upset by that, or trying to pull her towards methadone, but rather just listening, trying to take care of her health — that was a very rewarding process for me, to feel that wall being taken down bit by bit. Sometimes it goes back up, and sometimes it comes back down. Even being able to convince patients to go to a hospital is very rewarding.
PO: We’re all here in medical school because we have an interest in helping people, and some of us have a specific population that we feel close to or connected with. I always felt like there are obvious ways to help a lot of different types of people, but there’s no clear gateway to help — not fix, but support — the homeless population in America that seems to be growing. I felt like this was the first time I could use some of my expertise or my skills to help people in a more impactful way than just bringing a can of soup somewhere. There’s a place for all different types of help, but this is something that I felt I could actively contribute to.
Emma Martin: A service that medical students specifically can provide.
KC: Exactly. One that gets tangible results.
PO: Well, we’re not necessarily fixing anything, but–
KC: Sometimes you do fix things, though! Sometimes you have a patient with an abscess, you help convince them to come to the hospital, you give them antibiotics, and the abscess is fixed. You may not be fixing their homelessness, but you’re making their life easier.
What supplies do you take with you on a run?
PO: When we were first founded, the process was a lot less organized, but luckily you talked to us at a time when we’ve made improvements. We have these huge, bright red backpacks that we take on runs.
KC: Like EMT backpacks.
Images courtesy of Philip Ostrov.
PO: They’ve got everything that you could possibly think of.
KC: Supplies for wound care and Narcan [naloxone], especially. Those are our bread and butter.
PO: We also carry a glucose monitor, blood pressure cuff, basic stuff for vitals. Over-the-counter medications like ibuprofen as well, plus socks, mittens, bottles of water and hygiene supplies. We also get donations from the [UI Health] Pilsen Food Pantry to take out to patients during runs.
KC: They’ve been wonderful. A super generous organization to work with.
PO: We want to make sure, though, that when we bring out food with us that it doesn’t feel like an exchange of services to the patient. We don’t wanna say “if you talk to us, we’ll give you food.” That’s not the goal here.
KC: Sometimes new volunteers can become frustrated if we go to a camp that has twenty tents and only three people come over to see us. It’s important to understand that if you’re in your home and someone starts banging on your door, you don’t have to answer them. We have to understand that, and we need to respect their space.
During your tenure as co-presidents, how would you like to see the group grow or change?
PO: There are a few different aspects. One goal is better patient care, and another is better education for the medical students. The second one is easier to address. I’d like to bring more lectures to the medical curriculum to teach a broader audience about how to work with these patients. I think it should be permanently added to the curriculum, especially since UIC sees a lot of this patient population compared to other hospitals.
KC: The more that we can have a multidisciplinary approach on the street, the more holistically we’ll be able to treat the patient, and the more aspects of their care we’ll be able to address. We’ll be able to make bigger changes [in their quality of life]. Social work is a big factor that we’re working on expanding right now — getting patients set up with insurance, if that’s something they’re interested in, is very difficult if they don’t have an ID or don’t know their social security number. Social workers can be instrumental in helping with that. Having them on our street runs could bridge a huge gap — we can’t provide every facet of care as medical students.
PO: We’re actively exploring collaborations with the UIC School of Social Work as well as with Mile Square, the [federally-qualified health center] that we refer patients to for services beyond what we can provide. We want to make sure our runs are less about the medical students providing as much as they can through street medicine and more about the patients getting the most out of a visit from street medicine teams. We don’t want overlap.
EM: You don’t want redundancy, which can be frustrating for patients.
PO: Exactly. Our goal isn’t to be the same thing as the night ministry, or other organizations that also work with this population.
KC: They all serve wonderful purposes, but too much overlap just means more unnecessary work for each organization and more confusion for the patients.
If a student is thinking of setting up a similar organization at their own medical school, what advice would you give them?
KC: Looking at what the Street Medicine Institute [in Pittsburgh] did to get started and modeling that approach could be helpful. They have like the ultimate program there — they have an actual clinic!
PO: To add on that, you can ask students at other schools for help setting up your own program, and I’m sure they’d be happy to help. The Street Medicine Institute does a lot of medical student collaboration.
KC: They also hold a research conference every year that students can attend. It’s a growing field, once you look into it — a lot of people working toward the same thing.
PO: Finding a mentor at your own school is really the first thing to do, though. They don’t have to be in any one specific field. In my experience here and in undergrad working in a similar role, there’s always money somewhere, and there are always people who want to help. You just have to find them.
Philip Ostrov is a second-year medical student at the University of Illinois Chicago College of Medicine. He received his undergraduate degree from the University of Wisconsin Madison in 2016 and got a masters degree in physiology at the University of Illinois at Chicago in 2017.
Kathryn Cushing is a second-year medical student at the University of Illinois Chicago College of Medicine. She received her undergraduate degree from Villanova University in 2018.