Bioethics Discussion Blog: Homelessness and Medical Care: Can Professional Attitudes be Changed?

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Saturday, January 24, 2009

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.

6 Comments:

At Monday, January 26, 2009 1:08:00 AM, Blogger Mandy said...

In some respects this question is similar to others about 'who is whose responsiblity'...I think society (as a whole) needs to take responsiblity.

I don't know about the US but in the UK there is an element of things being over there, as in somewhere else, and not relevant when it comes to the homeless, mentally ill, the old (well anyone who isn't 'useful')

I think homeless charities provide some access to medical care...but usually that is at specific times. Such as Christmas when they open centres for a short while.

I want to big up the Sally Army. I am not religeous, rather the opposite, but I think they do alot of good work for the homeless.

I think some chickens are going to come home to roost with the recession. Some would see it as an opportunity for people to understand each other better, due to the levels of poverty that will be experienced. However, as Germany's history has shown. Often in extreme situations, extreme and hateful responses lead to horrific happenings.

With the UK government thinking about printing money..you really have to wonder (again looking back over history and the levels of inflation that bought) where this is going to end. Scary times.

Gone off on a tangent but if we look at 'Care in the Community'. As in real care...with designated community resources...that would, in part, support people who are homeless and other vulnerable people too. That is if the rescources are relevant rather than tokenistic. I doubt, in a recession, government's will be providing that level of care and perhaps society won't be able to afford it, even if they did. Hmmmm?????

 
At Tuesday, February 24, 2009 2:26:00 AM, Anonymous Dr. Fouzia Shersad said...

It is not the fact that homeless people do exist that is under discussion here. It is the attitudes of physicians towards such people that has to be debated in this forum. We need to inculcate positive attitudes towards socio-economically challenged people and take care of them with the same compassion and care with which we would treat the so-called "sophisticated and respectable patient" with the same condition.

Having lived a comfortable life, away from the poor and weak strata of the society, many medical students look at these patients with sympathy rather than empathy. Dedication and sincerity towards their studies may not extrapolate to good clinical attitudes, if this aspect has not been emphasized early in the course.

Medical students should be taught to develop high levels of tolerance to non-compliance and rude behaviour of patients. Rather they should anticipate such situations and deal with them tactfully. The best way of developing this skill would be by doing an elective at a general hospital where these patients come for treatment.

Medical schools should clearly articulate the requirement for such attitudes in their course objectives to prime medical students regarding a need to develop a compassionate attitude to all sections of the community.

 
At Tuesday, February 24, 2009 8:00:00 AM, Blogger Maurice Bernstein, M.D. said...

My first and second year medical students as well as those in the third and fourth years are fortunate to have most of their training in a major County hospital where they have the opportunity to attend and learn from patients who meet the patient class that is what this thread is all about. In the first two years, without formal patient responsibilities and with teachers such as those of us stressing taking humanistic approaches to the interaction with the patient, I fear much may be lost in the later years of medical training when the students enter the "hidden curriculum" taught by others in a stressful environment of patient responsibility, patient overload and time limitations. In that environment humanistic and attempts at empathetic understanding may wane and some of the students may end up with cynical attitudes for their "difficult" patients. ..Maurice.

 
At Tuesday, April 21, 2009 3:44:00 PM, Anonymous Anonymous said...

Paula Jenny Cranfill pjc04@fsu.edu

I don't know, it is a tough issue: brings up a lot of questions about equal treatment etc. I don't want to comment further because I will sound like a hypocrite. BTW I don't find the graphic offensive

Paula Jenny Cranfill
pjc04@fsu.edu

 
At Tuesday, April 21, 2009 5:38:00 PM, Blogger Maurice Bernstein, M.D. said...

Paula, I would be most interested to know what you think about "equal treatment etc". Comment.. to enter a discussion about an important subject, you can express your views on a topic without disclosing your own personal behavior. You won't "sound" like a hypocrite if you are not disclosing facts about yourself.
On the other hand you should yourself feel comfortable about taking that view about others. ..Maurice.

 
At Wednesday, July 01, 2009 11:01:00 PM, Blogger Jean said...

One physician said with exasperation that he just hated being lied to. Most of us, in all walks of life, detest our best efforts being wasted as happens far too often with health services to homeless people in their addictions. One EMT saved a heroin addict's life and was paid with a punch; the man was angry that his high was ruined. But I have seen some health practitioners actually extend a healing touch to homeless addicts. Each little touch helps.

 

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