Teaching Students about Health Care of the Homeless

Objective: The Association of American Medical Colleges lists altruism as an attribute that students should possess at the time of graduation, but studies have shown a trend of increasing cynicism as students progress through school. Students and residents who rotated through homeless clinics have been shown to have more positive attitudes toward caring for the indigent and were more likely to volunteer at those sites later. Few opportunities exist for students to rotate through clinics serving the homeless during their clinical years. Our objective was to create an elective for students to learn innovative skills in caring for homeless patients, work with community role models, and encourage future altruism through positive clinical experiences with homeless people. Description: The course is a two-week clinical elective offered yearly to fourth-year medical students. It consists of a lecture series, clinical work, and site visits. Enrollment is limited to five students due to the number of sites required for clinical work. The following lectures are included in the course: an overview of homelessness, homelessness and health care, chronic disease management, disease prevention, and challenges to caring for the underserved. We also gave lectures on medical topics common in homeless patients, including tuberculosis, HIV infection, substance abuse, mental illness, and skin disorders. Lecturers are asked to provide realistic approaches to these conditions that incorporate the social context. For five half-days each week, students gain clinical experience rotating through clinics in homeless shelters, community clinics, and clinics operated by the City of San Francisco and the VA Medical Center. The students perform outreach to homeless people living on the street, working with faculty who have experience providing this care. They also visit sites providing services to homeless people to learn innovative ways to provide care. Current site visits include tours of a homeless shelter and its adjoining medical clinic, a methadone-maintenance program, a needle-exchange program, a respite hotel, and a long-standing free clinic. Discussion: This course has been offered for two years. The student's satisfaction was assessed via our institution's standard evaluation form. Students have given the course a rating of “outstanding” for all domains on the evaluation. Outcomes were qualitatively assessed though a written survey and focus groups. All students “strongly agreed” with the statements “This course has provided me with role models in the health profession” and “This course has taught me innovative ways in which care can be delivered to indigent patients.” Students' comments about what they liked most about the course have included the following: “I was given the chance to see community services and talk to people who run them”; “I was able to talk to homeless people in their own milieu”; “I was exposed to corners of the city's indigent which would otherwise be overlooked in our training”; “This course is our school's best kept secret!” In the future, we plan to assess students' knowledge by pre- and post-tests. We also plan to expand the course to internal medicine residents next year.