Homelessness and Medical Care: Can Professional Attitudes be Changed?

Homelessness, if not “living”, attempting to survive without a home has not been an uncommon state throughout human history. As noted in an article on homelessness in Wikipedia there is an estimation of 100 million people, worldwide, being homeless. They “lack housing, because they cannot afford, or are otherwise unable to maintain, regular, safe, and adequate shelter.”

There will certainly be more individuals and families who will become homeless associated with the current recession throughout most of the world including the United States. The problems, including social, legal, political and medical associated with the condition of homelessness are enormous. How should society look on these people and react to their plight and their behaviors? Are additional descriptive names such as “vagrant, tramp, hobo (U.S.), transient, bum (U.S.), bagman/bagwoman, baghuman, street walker, urban outdoorsmen, or the wandering poor” fairly describe and treat the homeless? What part of society, if any, should feel responsible for what has happened to them and take responsibility to attend to them and help to restore them? Should the legal system look at the homeless as outliers of the public who must be forced to conform to accepted social standards or otherwise removed from public view one way or another? How do politicians look upon the homeless? Do they consider them as much a constituent as those who can live their lives and their days away from the streets or away from living under some transient roof? And what about the medical system and how healthcare providers look at the homeless problem, the homeless themselves and what role healthcare plays and should play in the lives of those without homes? What attitudes should healthcare providers including physicians hold toward the homeless patients?

Those visitors to my blog who frequently scan my threads here may recognize that I have used the American Medical Association’s Virtual Mentor website as a resource to develop medical ethics topics.

I have used that resource again, this time, the January 2009 issue, for the topic regarding medical care for the homeless. There are a number of articles there dealing with the subject and which can be obtained free in a PDF format by clicking on this link.
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Homeless patients entering the medical system provide a challenge to all who serve them. Many arrive in later stages of untreated diseases or diseases for which they were previously diagnosed but because of various reasons have not followed the therapeutic prescriptions and repeatedly return still ill or worse. Many, because of their illicit drug habituation, complicate their conditions. These homeless patients through their appearance, their demands, their non-compliance, their behavior and other factors may be looked upon as “difficult patients” by the physicians who attend them. But it is not unlikely that these patients seem “difficult” also because the physicians simply have not been trained to understand and therapeutically relate to those deemed “homeless”. This negative attitude of physicians in practice toward the homeless is suggested to be a reflection of the lack of constructive educational experience with the homeless during their early years of medical training. As a participant in the teaching of medical students, I recognize that this expectation is probably correct. Constructive and humanitarian educational experience represents the key words regarding what the students need.

An example of such an educational experience is described in the Virtual Mentor education article "Medical Student Self-Efficacy and Attitudes toward Homeless Patients" by David S. Buck, MD, MPH, and Benjamin T. King can be accessed through the above PDF link. The authors conclude: “As educators, we must change the way physicians and other health care professionals are taught. We must design substantial and effective ways of transmitting professional, empathic, and culturally sensitive attitudes that will improve relationships with estranged patient populations. We must remove the barriers to care that negative perceptions create and promote active advocacy. Students need more exposure to the economic, behavioral, social, and environmental determinants of health. Research has shown that these dynamics are best learned through an experienced-based curriculum within a positive, supportive, and rewarding environment and that these can eventually outweigh the negative experiences so common in the current system. Making students better able to serve the “difficult” patient will make them better physicians.”

What do you think about the homeless in the medical care system and how they are cared for? What do you think about negative physician attitudes about the homeless? What are your suggestions regarding solutions for this general social but also personal problem that afflicts many? ..Maurice.

Graphic: Photograph from Wikipedia taken by Eric Pouhier and digitally modified by me using Picasa 3.