Archive for October, 2015

The Great Equalizer

Posted: October 23, 2015 in Uncategorized

Statistics surrounding the number of physicians pursuing MBAs always seems to baffle me. From a distance, I think about how much schooling a physician endures (yes, I do mean endure) and debt incurred. After some time in practice, there is a shift in some to seek higher levels of administrative purpose. Department chair. Service line coordinator. CMO. VP of this, VP of that. Acronyms that I can’t even describe much less understand. Sometimes it is hard to wrap my head around this pursuit of upward mobility. Traditionally physician assistants share a common philosophy: we see patients. We do it in a variety of ways, in a variety of locations. But most PA’s don’t graduate and consider upward mobility as part of their job satisfaction or career plan. While there have been more administrative positions being offered to physician assistants as they gain decades of experience, it is certainly not the norm in most hospital systems. Physicians, however, have different choices to make in this regard.

Over the years, many people have passed through the shelter and soup kitchen based clinics. Often their feedback is similar. This is the way medicine should be. No red tape. No coding. No drama. Just good, simple medicine. We don’t pay any of our volunteers and we don’t beg them either. It is the simplicity of providing truly patient centered care, without time constraints, bundled payments, matrices and check lists, that keeps them coming back. Our philosophy in the clinics is that we are all equal parts of a team. Just like our patient philosophy, everyone matters. If staples need to be picked out of the carpet, the task will not immediately be assigned to the person with the least number of initials behind their name. Folks who aren’t interested in such credential ambiguity usually don’t last too long. For a time, I thought of these Clinics as a great equalizer. Egos in check while the patients get checked. But this isn’t entirely true. Even in the Clinics, titles are still prevalent- doctor, PA, student, nurse, volunteer. There is nothing wrong with identifying yourself (and we must so that patients are clear about who is treating them) but we have to be honest that titles place a degree of separation between us and our patients and often as soon as the words leave our lips, we are trying to find common ground to narrow the separation.

Enter street rounds.

As mentioned in previous posts, most of the rough sleepers of the Lehigh Valley retreat into the woods. Safer. Discreet. Remote. Invisible. While some of the street rounds are done by the LVHN street team on the streets of the Valley, most of them are done in the woods and under bridges (with an occasional storm drain thrown in for good measure). Participants in street rounds have included many interested parties over the last year; none of which are more fascinating than administrators. I don’t dislike administrators. In fact, they are critical to the health care system and to giving real legs (and the necessary teeth) to out-of-the-box programs like Street Medicine. The administrators who have come on rounds knew first hand that to really understand programs and patients like these, you have to see it. And as the saying goes, seeing is believing.

The woods are really the great equalizer. During street rounds, everyone is on a first name basis. No matter what the title or degree held, status is check at the edge of the wood. Maybe the uneven terrain makes us feel vulnerable. Maybe it is the starkness of the humble camps and being acutely aware of how incapable of survival in these conditions we would be. But most likely, it is our street friends who share their stories willingly. The humanistic experience that makes you realize in real-time that we are more similar than we are different. They see the faces and hear the stories of simple unmet needs and complex social histories that lead to what they see. It truly and respectfully on the backs of these survivors that Street Medicine is deemed necessary.

Sitting on a tarmac outside of the Newark NJ airport, I am trying to wait patiently for my plane to take off. I hear mostly white noise as people are shuffling to their seats and stuffing oversized bags into small overhead compartments. I look to my right and see a recent DeSales PA Program graduate sitting a few seats away. In the midst of our boarding process, I hear words being shared about street medicine and homelessness to the unsuspecting middle seat passenger. In 6 hours, Seth could have her convinced to attend the 11th Annual International Street Medicine Conference with us.


While I don’t often spend much time reflecting back on progress over time, I find that preparing for conferences like these tends to send me back to a time when I knew less in both knowledge and people. Two years ago, Brett and I attended our first International Street Medicine Symposium in Boston. We had read so much about the world-renowned Boston Health Care for the Homeless Program (BHCHP) founded and flourished by Dr. Jim O’Connell. I had followed their website for years and had a visit to BHCHP on my bucket list for years. (Hey, some people sky dive, I visit homeless programs.) The opportunity presented itself for this visit with just a few weeks notice. Generous support from both of our sponsoring institutions (to let us go) and family (to keep our kids) allowed Brett and I to travel that Fall to Boston. It was the first time we were able to see a mature and robust healthcare for the homeless program and see first hand how something like that is grown and cultivated over time. Each member of BHCHP seemed to share the vision that had begun more than 20 years before. They were motivated, enthusiastic and committed. At a dinner reception after the first day, Brett and I met Dr. Jim O’Connell for the first time. He was genuinely interested in our small but eager programs. I mentioned that the DeSales Free Clinic has an operational budget of about $18,000. I’ll never forget his response. “You do all of that with $18,000? I have a multimillion dollar budget. It sounds like I have something to learn for you.” I was dumbfounded. You? Learn something from me? It sounded laughable ( and still does) but he was sincere. And a reflection of how all Street Medicine Programs are treated by their peers. This type of interaction has been repeated many times over as street medicine programs come from all over the world, once a year, to learn, share, eat, drink and be merry. Dr. Jim Withers of Operation Safety Net (Pittsburgh, PA) once told me that he thinks that people at this conference and his patients sometimes understand him better than his family. (True)

Now, we are heading to San Jose (CA) for this years conference. Our programs have grown exponentially since that first trip to Boston. So many ideas were illuminated, so many seeds planted. We are travelling with 8 other street medicine team members- 2 University of South Florida SELECT medical students, 2 DeSales University physician assistant students, 2 recent graduates of the DeSales PA Program, LVHN Street Medicine’s new case manager and new clinical coordinator. It is hard to imagine the life trajectories that can change when armed with the knowledge that comes from conferences like these. Brett and I sometimes joke that it feels like you are going away to camp. The time is short, the bond is strong.