Homeless men, women, and children make up a growing population that is vulnerable to preventable disease, progressive morbidity, and premature death.1,2 Homeless people with multiple and interacting social and medical problems are in need of social medical care. Regarding the provision of care, doctors are trained to help people with their medical problems, to look for a medical diagnosis, and advise on medical care. In the case of homelessness, doctors need to advise on medical care in very difficult social circumstances. In the medical literature, there is little evidence on good practice in caring for homeless people.3 How do doctors perform in these circumstances? Can we make a difference?
For more than 13 years, I have been fortunate to be part of an outreach team for the homeless in Amsterdam. I enjoy working with homeless people and social and medical workers. My patients and colleagues are survivors, fighters, pioneers, and often great storytellers and teachers.
We find pathways to deal with multiple and interacting problems. We wrestle with the consequences of fragmented and disconnected services. We become cross about the lack of information sharing. What is social care about? We flounder. A high morbidity pattern among our homeless patients affects health workers ourselves. We feel paralysed, excluded, and ignorant, overlooked by the rest of the system.
In the literature homelessness and health is described in detail. But information on health workers for the homeless is not readily available. Being a doctor is about knowledge and experience, and the ability to listen and build trust. When providing social medical care for the disadvantaged, these abilities, knowledge, and experience with life and death at the bottom of society must be a core part of the training of doctors.
That does not happen in institutions like teaching hospitals, or when we wait for patients to arrive at our convenience in normal general practice surgeries. There are few lessons about social medical care or the need to diminish health inequalities. We visit ever fewer patients in their homes, far less on the street. Care, when it is afforded, happens in emergency rooms and out-reach clinics, not in primary care. Therefore, there is no continuity of care, no trust building, no interdisciplinary networking, friendship nor teambuilding. No good community practice.
I strongly believe that education and research are the tools to learn about care at the bottom. Given the growing health inequalities between the rich and the poor and the educated and the non-educated, in medical schools social medical care for the poor and homeless should be obligatory within the medical curriculum.4 Alongside the privilege of and adventure in exploring the medical world, doctors should be trained in observing and diagnosing social disease, such as poverty and homelessness, and the care processes needed to integrate social and medical care.5
Medical students are strong advocates against social injustice and eager to learn about social medical care for the disadvantaged.6 By acknowledging the growing populations of poor and homeless people, in response, medical schools should anticipate life out there, society, people and their problems: in the raw! Medical professionals need to be aware of the red tape pathways the poor and homeless have to take along public services and their ever-changing rules, in order to obtain basic care.
Social medical care is about lowering barricades so people can gain access to basic care and integrating services to guide those in highest need. 5,7
Doctors should make a difference!
REFERENCES
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