Centering Houselessness

Medical students’ experiences listening to people who are houseless

By Caroline King, Cameron Fisher, Jacob Johnson and Arum Chun

This year, the four of us – Caroline King, Cameron Fisher, Jacob Johnson, and Arum Chun – came together to ask this question: what can medical students do to help support people who are houseless in our city?

We started by thinking about all of the ways we might help support people: through the direct delivery of care, research, advocacy, and other mechanisms. We decided that we could use community research as a mechanism to help us answer this question.

We started by working with Street Roots, Central City Concern, Sisters of the Road, Operation Nightwatch, and other community-based organizations to ask if and how we could start to identify appropriate, community-defined roles for medical students. We created two panels of advisors: one of people who work for Street Roots, a local newspaper that supports people who are houseless, and one of community organizations who serve people who are houseless.

We started by asking both of our panels what was important to them: What makes you feel safe? What do your patients care about? How can we help? We took the feedback we received and drafted a survey together. After we received approval from the institutional review board, we surveyed folks at Operation Nightwatch on the weekend evenings, and at Street Roots on the weekend mornings, about their experiences with houselessness and what we could do to be supportive.

Each of us was profoundly impacted by this work in different ways.

Cameron reflects, “There have been many opportunities to reflect on the care of marginalized groups throughout medical school. I have attended a countless number of group small group sessions, talks, and workshops on the matter. I think it is wonderful that OHSU provides space for current and future providers to reflect on these topics, but when I stepped into the houseless community here in Portland for the first time I immediately realized I had barely scratched the surface. Over the last year I have spent time with people affected by houselessness outside of the medical context. I have interviewed folks in the role of a researcher, and I have also had lunch with folks as a friend. Spending time in this population without the hierarchical and at times oppressive roles that medicine gives us, has led me to a greater understanding of their lived experience and interactions with the healthcare system than any of the aforementioned activities ever could.”

Similarly, Caroline notes: “Community-defined research is an opportunity to refocus medicine and public health to amplify the voices of those impacted by decisions they are too often left out of. I am so grateful to have had a chance to design and pursue this project through the OHSU-PSU School of Public Health, and to take time outside of medical school to listen to folks who generously shared their time, energy, and stories with us. This project has strengthened my commitment to becoming a primary care provider; I know I will take this work forward with me throughout my training.”

Jacob was also deeply impacted by this work. “This way of getting to know people on their terms, in their words, in their spaces, went so far beyond the healthcare encounters we train to perform. It was about having a human encounter. It was about the simple, disarming act of asking people what they need and listening. My experiences have convinced me to challenge all the defenses that keep us from seeing people who are houseless as people who don’t get to have a say in how we treat them. I’m so grateful to have had the opportunity to be part of this work.”

Finally, Arum writes, “During this experience, I deeply felt the privilege of being a medical student, to be listened to, to be allowed into a community, and to have the resources to relay the messages of the houseless community to the medical community the best we can. I will carry this privilege and the awareness of its existence with me into my career in providing community centered and structurally competent care that I learned from this experience.”

At the end of the project, we summarized our experiences and presented the results back to the community. We were surprised by what we learned. Across the board, when we asked folks “what can medical students do to support people who are houseless,” participants asked us to destigmatize houselessness and substance use disorders among our peers. While many folks had positive experiences working with OHSU, they also helped us realize how the hospital, up on the hill overlooking the city, can feel inaccessible.

Moving forward, we are working with the School of Public Health to identify ways to partner with community members and bring change to conversations about substance use disorders and houselessness in medical school. Below, we include comments from three of our community partners – Richard, John, and Barbra – who agreed to share their thoughts about our work and what medical students can do for this article.

John encourages providers to humanize what is already a really tough process. “[Providers] should have an idea of what the homeless go through. No one chooses this, not really. People don’t know what it’s like to be ignored and [to feel] invisible. The last time I was struck with pneumonia in the winter, I was very sick. I was afraid of embarrassment because I was hallucinating and soiled myself because I couldn’t get out of my car. I was so embarrassed, but I was choosing between embarrassment and death so I called the ambulance.”

We asked John why it was important to share this story. He told us, “People need to know the realities of how hard things can be when you are houseless. I hope my story helps people know that nobody chooses this.”

Barbra was one of the first people we met working in the community. We asked her about what she wants health professional students to know about treating people who are houseless. She said “[Healthcare professionals] have to be ready for anything and lead compassionately and not [be] judgmental. When people go into the emergency department they are judged for how they look or smell, and without asking any other questions medical professionals assume things. The symptoms are beyond what you can actually see. And I’ve seen this happen over and over again. Health professionals need to be more open and not go in with what your eyes tell you.”

We also asked Barbra how she feels about our project this year. She told us that she “can’t wait for this project. Honestly, I think there can be a real partnership here. You go into the ER and you say the ‘h word’ you’re in trouble already.

“But if you’re going into this to treat people out in the community then you’re ready for anything. There’s no four walls that can explain it. You have to be out here and see it.”

Finally, Richard is a member of our advisory team who helped us better understand community research and our role in it this year. We asked him what he wants students to know. He said, “We’re not all the same. From my perspective, we’re not a homogenous group. The strains on these individuals depends on the assortment of stressors they experience, which are going to be different from the usual patients. You can’t even assume that a person got a good night’s sleep. Students shouldn’t assume that all houseless people are dishonest, or lacking capacity.

“Connecting the dots is really difficult and people need to understand this. It’s so easy to say ‘why don’t you just get a job?’ but say that to someone who has only two teeth showing. Just looking at the math – that person is going to be turned away from jobs. There are obstacles that people don’t even think about.”

We asked Richard what he thought about our work. He said, “I just think it must be very difficult to maintain such optimism and motivation in helping and hopeful fields these days. I don’t know – it just seems that things are very chaotic and this is a very stressful time to stay focused on a particular thing. The range and depth of that really takes something.”

We’re looking forward to continuing this work in the months and years ahead.

Caroline, Arum, Jacob and Cameron would like to thank Dr. David Bangsberg, Dr. Paula Carder, and Dr. Peter Sullivan for their support and guidance in this work.

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