Posts Tagged ‘Lehigh Valley Health Network’

Street Medicine has rapidly spread to become a global movement with over 100 programs worldwide on 6 continents. As the Street Medicine Institute prepares for the 13th Annual Street Medicine Symposium this October in Allentown, PA, it’s right to explore why this movement has taken hold and how this innovative healthcare delivery plan has inspired hundreds of overworked medical providers to put on a backpack and work more long hours for free outside the traditional medical establishment. Although the explanation I put forth is in no way comprehensive, may it serve as an offering to explain the “core” of what those associated with the movement are experiencing by going to the people.
One of the first lessons taught to medical providers in their education is not to get emotionally involved in “cases.” This means not getting too close to patients—no crying, no hugs– and not experiencing what they’re experiencing. It’s become a matter of professionalism, that’s it actually UNPROFESSIONAL to care. When people come to us in the midst of some suffering, they are reduced to becoming a “case” so that we may avoid letting emotion crowd our better medical judgement. Inevitably, we come in contact with suffering and are faced with a choice. Humans without a pathological medical condition can’t meet the face of suffering and feel nothing so the choice is to either engage and take on suffering along with the patient, or disengage as a self-protective mechanism leaving the patient to suffer alone. Since the inception of our training we are taught to be professional and this means not becoming emotionally involved, the tendency is to disengage and leave the patient suffering alone.
There is no point in engaging a suffering patient unless you are suffering with them for a reason, suffering with joy. This can’t be accomplished with the goal of social justice or to fulfill a business plan. Justice depends on giving everyone his or her rightful due. This practiced in excess, especially in certain patients, can have disastrous consequences. In order to practice street medicine correctly, we must rise above justice to give everyone MORE than he is rightfully due. This is done through charity, or love.
Approaching street medicine through the lens of charity is essential because patients experiencing homelessness suffer a lot. This suffering is not just from material poverty which we can cure for a moment by offering food. They also suffer from emotional and spiritual poverty from being discarded by society; of feeling unwanted and unloved. If we are going out to cure, which as medical providers we must, then we also must engage with them in their suffering. This means not just giving medicine to relieve bodily suffering, but to cure means relieving the spiritual and emotional suffering they also carry. To accomplish this, street medicine must be approached through charity and love, not justice.
How or why has this approach to patients experiencing homelessness caught on as a global movement? Street Medicine has caught on because it’s been spread through the joy of suffering and giving through charity. This has turned the light on in traditional healthcare institutions and practitioners. When you turn a light on in a room it doesn’t just shine on the ones you love best, not just our patients, but shines on all in the room, like our colleagues and friends in the community.
Street medicine, at its core, is the light that it gives us permission to share the sufferings of our patients with joy, through charity, with the purpose of healing spiritual, emotional and bodily suffering.

~ Brett Feldman

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Last week, I was sitting in a leadership training about effective communication. The instructor started off with an explanation of the ladder of inference. This ladder represents stages of thinking that one goes through, often subconsciously, to determine action or inaction after observing a behavior. When we observe something, we often reflect back on the scenario to make sense of it and in doing so, may not remember all of the details (or even have all of the details). Our minds will fill in the blanks, or infer, what is missing to complete the observation so that it makes sense to us.  We determine action or inaction based on this conclusion. The example given to us was an observation of a quiet exchange between two people which concluded with one person abruptly leaving the conversation and exiting the building. We, of course, came up with a variety of colorful, and sometimes even logical, explainations for what we saw and action that should take place as a result. Sometimes this process leads to workplace drama, other times the inference ladder could be applied to whole populations resulting in dehumanizing sterotypes.

As Brett and I were talking with an old friend this week, we realized that the inference ladder had injected it’s influence on our life in a way that we did not realize until now.  I have written before about the influence of an experience Brett and I had during my PA school education at Midwestern University in which both of us spent time at Hesed House in Aurora, Il providing healthcare for the homeless. It was a meaningful experience that lead to the desire to start the DeSales Free Clinic, and eventually, LVHN Street Medicine. In our minds, Hesed House was providing comprehensive care with tons of hours of accessibility from students and volunteers. When we set out a decade ago to open the DeSales Free Clinic, we modeled it after our recollection of Hesed House. In reality, our blueprint for the vision of the DeSales Free Clinic was not Hesed House at all, but rather, the inference ladder at it’s best. A fill-in-the-blank Mad-Libs version of what we had experienced paired with what we thought was needed for the patients. Turns out inference might not always lead to poor communication or office gossip, but maybe every once in a while, a service to a population who is often dismissed as a result of the same thought process. Tricky tricky little ladder, I’m keeping my eye on you!

Nameless. Faceless. Invisible. It’s estimated that during the life of a homeless individual in the United States, many go up three months without being called by their name. The physical and social barriers between the housed and the unhouse are immense. For the homeless, it can seem to be an endless maze of closed doors. Like the old rat experiment from my Introduction to Psychology course- teach the rat what to do and what not to do by shocking it with a quick zap at deter unwanted behavior. For the homeless, they stand too long in the doorway of a business- zap! They go to a doctor’s office without insurance – zap! They ride the bus for too long- zap! Nowhere to go, nowhere to be and no where to feel safe.
But what happens when these souls pass on from this world? Most of the bodies of our friends who have lived their lives on the streets will remain in the county morgue waiting for someone to claim them. Usually no one comes. Unclaimed and unnoticed even after death. Most are cremated and buried in an unmarked grave, unceremoniously passing from the land of the living to the land of the dead. No memorial service, no sign in book, no slideshow of memories to cherish. Even the cause of death seem somewhat generic. The majority of the time the homeless who die on the street have died of “natural causes”. There’s no family to request an autopsy or discussion as to why or how someone died. They just simply die. The injustice against these souls does not end at the moment in which they take their last breath. Over the last 11 years, I’ve had the privilege of knowing many of our rough sleepers in the Lehigh Valley. Some have resided outside for more than a decade, others have floated between the streets, shelters and single room occupancies that scatter our cities. My experience has taught me their lives are anything but forgettable. Their survival to the moment in which they left this world is nothing short of remarkable. Many of our street friends have endured things that no human should ever experience. Abandonment, untreated mental illness, an astounding amount of physical and psychological trauma. And while each of us, homeless or housed, have undeniable autonomy over our choices, we cannot ignore how previous experiences affected growth, development and decision-making capacity of those who are unsheltered. They have taught me and those who have shared their lives with them the remarkable resilience of a person and how a community of strangers can grow to love one another when they share each other’s burdens. They are some of the funniest, kindest and truest souls I have even known who had a way of sharing their reality with me so I understood their wisdom.
As we ring in the beginning of winter this week, many cities across the United States remember those men and women who have died on our streets with a memorial service. So that their lives, even after death, can attempt to have some humanism attached to it. This year, a memorial wall has been erected in downtown Allentown. Located at 707 Hamilton St so that all who pass by will remember that the Lehigh Valley is not insulated from the harsh realities of homelessness and the fact that some of our own citizens die while struggling with homelessness. It is an attempt to remind us that we are all connected. The seen and unseen. The named and the nameless. So while we gather with those who we hold so dear during this holiday season let us remember those who passed in silence and offer them some compassion, some memory, and some honor.

A few weeks ago, Lehigh Valley Health Network and the Street Medicine Program hosted two events with Dr. Jim Withers, a pioneer of street medicine in the United States, to raise awareness about homelessness to different groups in the Lehigh Valley. The first night was a small gathering of donors at a local country club with Dr. Withers as the featured panelist along with Brett and Dr. Motley, chair of the Community Health Department at Lehigh Valley Hospital.  It was a fascinating discussion about how street medicine in many cities has uncovered an ugly truth; that healthcare itself is very, very sick.  Often times the Street Medicine provider straddles two worlds. A world of middle class America and a world of extreme poverty and isolation. In terms of Maslow’s hierarchy of needs, we expect all patients to be functioning at the top of the pyramid in a place that Maslow defined as self-actualization. That is the place where people are achieving or are on their way to achieving their highest potential.  Because this is the basic assumption for all of those interacting with the healthcare system, it is no wonder that conscious or unconscious bias seeps in to our everyday patient interactions.  The traditional healthcare systems gets frustrated with those patients who just don’t or can’t follow through. We label them as non-compliant and design policies that allow us to dismiss patients from our practices after two no call no shows or after being late for an appointment a few too many times. Because after all, our clinical time is important and if we allow ‘them’ to be late then we are just enabling them.

Image result for maslow's hierarchy of needs

The homeless population and their interaction with the healthcare system is an example that can be applied to many other vulnerable populations who are expected to be functioning at the tip of Maslow’s pyramid. Domestic violence, gender dysphoria, substance abuse, financial instability and recent prison release are all examples of people are struggling to have their basic needs met. It was interesting to see and talk with the attendees at the conclusion of the panel discussion. Many of them have lived in this area their entire lives and never fully understood how and why this type of human condition was lurking in their own backyards. Perhaps the best part of the evening came from the country club bartender who spoke with me, Brett and Dr. Withers after the room had mostly cleared.  He shook our hands and told us that in his job, he listens to a lot of very boring presentations (and I believe him) but he was so grateful to have listened to this panel discussion.  He felt he had learned so much and went on to tell us about the homeless people he had known in his life and how he thought they may have ended up that way. Of all the people in the room, it seemed that perhaps the unsuspecting bartender had been one of the main benefactors of the event.

The following day, Dr. Withers gave grand rounds at the Hospital. Over 200 people RSVP’d to the event and the crowd was primarily full of short and long white coats.  At the conclusion of Dr. Withers discussion, a panel of currently or formerly homeless Lehigh Valley residents shared their stories of living on the streets, surviving on the streets and in our institutions and candidly shared how things could have been better.  One panelist has been unsheltered for over 9 years and shared that the Street Medicine team are the only people he knows that are not homeless.  This spoke to me particularly as I was reminded of the isolating nature of homelessness and the sense that the world can become ‘us’ and ‘they’ with seemingly very few bridges between. As I sat and listened, I noticed how absolutely silent it was in the room.  There was not a single pager ringing, phone buzzing or hushed side-conversation. Several hundred people who usually conversate all day were hanging on every single word these brave men and women shared.  I thought about how intimidating the room must have looked from the panelist table and that for years, the patients felt like no one listened to them. And yet, here we were, begging in earnest for them to tell us their stories. The power of this paradox is in its irony. Healthcare providers have an opportunity every day to listen to our patients stories. Not just the story of their symptoms. But THEIR story. We feel pressured to rush, to ‘work lean’, to make in through but in the end, that isn’t what anyone wants. Each time I see a room full of such talent hear the message of street medicine and the stories of its patient’s, I can’t help but feel the pull of a tide. That perhaps we are closer than we think to a return to the roots of good medicine and real connections with all of our patients.

“The woman declared that she was all for the building of a drug and alcohol rehab center next to her city apartment except that the proposed height of the building would cast shade on her kale plants and ruin her plants.”

Portland, Oregon was the host of the 2016 National Healthcare for the Homeless Conference and Policy symposium.  I found it to be a fascinating mix of liberal residual hippee mentalities mixed among upscale microbreweries.  A blue city residing in a largely rural red state. The first thing that struck me about Portland was how clean the city was. It’s beautiful to look at with its detailed architecture, Mount Hood peering over you in the background and the Willamette River hugging some of the neatest reformed parts of town. Freshly potted plants sprinkle the windowsills and front door steps of many residential and commercial properties. One afternoon I watched teams of volunteers artistically arrange flowers and potted plants in fancy designs in a local square just for the viewing pleasure of the many young professionals who eat their lunches on the squares surrounding steps. In general there was a sense of calm in the city.

But there was one obvious difference that somewhat shatters the beautiful façade of Portland. Every 6 to 10 feet I encountered a person experiencing homelessness. A man, a woman, a child just sitting on the street. Some of them were clearly high, but many of them were not. One woman sat with a pad of paper and pencil in her hand but was stuck in a catatonic state of waiting for inspiration.  Some of them were panhandling, many of them were not. Children were coloring while their parents made signs displaying their person plight. Many people were laying with their pets. The thing that struck me every day was that for the size of Portland, the number of homeless is unbelievable. Most numbers estimate between 3400-3600 people sleep on the streets of Portland every night. The lack of affordable housing and the lack of enough shelter caused the governor of Oregon to declare a state of emergency which allows homeless to sleep on the street safely without being disrupted by police, business owners or residents. The city has seemed tolerant of this and understanding of the fact that there is simply no where to shelter all of these people.  It does beg the bigger question though.  Why are there so many?

It seems that no part of the city with has been spared by number of visibly a visible homeless. During our travels, we took an informal poll. People working at donut shops. our taxicabs driver, local lifetime residents etc. We simply asked “Why do you think there are so many homeless in Portland?”   Interestingly they all gave the same answer. They thought that because Portland was such an understanding and homeless friendly community, the people (particularly youth) were seeking out Portland as a counterculture experience. There is a pervasive feeling that these that the majority of the homeless in Portland wanted to be homeless for the experience. While many of those that we informally polled recognize that the legalization of recreational marijuana probably his added to the appeal of coming to Portland, none of them could say for certain the size of that effect. The locals seem particularly bothered that there were so many people with seemingly no end in sight. While they admitted that they felt ‘bad for the people’, they were relatively unsympathetic because they felt that this was a situation that has occurred by personal choice. When I attended a breakout session with people representing homelessness from all over the state of Oregon, I told them what the locals told us about the homeless problem in Portland. I asked if they felt that it was true; that there was a counterculture experience occurring and Portland happen to be the perfect place for it to occur. All of those representing Portland on the panel adamantly denied that any of what the common feeling was true. One CEO of a local if you federally qualified health center commented that while the summers are mild, the winters are very cold and rainy and no one would choose to be homeless and stay in Portland. I would say the same for people who are homeless in New England, in Pennsylvania, in Michigan. Many people endure these harsh winters and yet they don’t leave (which has puzzled me for years). There’s no migratory patterns for the homeless to fly south for the winter. While the truth likely lies somewhere in the middle of these two polarized viewpoints, this creates a particularly large problem for philanthropy. People do not donate to a cause in which they feel the misery of poverty is by choice. Frankly, the sympathy factor goes way down and when there’s no sympathy there’s no money. Perhaps some of the most important (and challenging) steps that Portland must take is changing public perception. Porland seems prime for the picking to lead the country in inovative solutions to minimize homelessness.  A combination of finances, a youthful open minded population with well-established social and healthcare services. I look forward to watching this city’s story unfold.  Press on Portland, press on.

I’ve never given a eulogy before. While preparing for his, I realized I really didn’t know much about him, but felt I understood him. The two words that best described him were courage and character. Not usually the first two words that come to mind when picturing a man who made his home in a drainage pipe for almost 5 years. He never left because he said, “It was a good spot.” In fact, none of the homeless providers knew who he was until the day he came into our hospital complaining of abdominal pain. At the time, it seemed like his life was finally turning around. He had a job. After months of trying, he got a job which required an almost 10 mile walk each way daily. He was saving his money and had an apartment picked out closer to his work so he could, “walk to it,” which always made be chuckle when he said it.

“Courage” describes him so well because the day I met him (in the hospital) was the day I told him he had a terminal illness and only a few months to live. He smiled his crooked smile that I would see so much over the next few months, shrugged his shoulders, and said, “Well, I guess that’s the way it goes….. What do I do now?” At first I wasn’t sure he understood what I just said so I repeated it and his reaction made me understand that he did understand, and simply had a degree of bravely rarely seen. He asked me what they would do with him after he dies. I honestly wasn’t sure so I asked what he would like us to do. He said all he wanted was a box with a cross on it but nothing else. He also told me he was Catholic but hasn’t attended church in about 15 years and wanted to know if it was ok to see a priest.

We told some of the local landlords about his situation and helped with getting an apartment for $250 a month so he wouldn’t have to spend his last days in the drainage pipe, no matter how good of a spot it was. He saw me at least weekly in the soup kitchen and was visited by our hospice nurse much more often in his new apartment. We also arranged for him to go into our inpatient hospice unit whenever he wanted, even if it meant his stay could last months, which isn’t the normal procedure for an inpatient hospice unit. He said he would stay out as long as he could so the people who were sicker than him could have the bed. By making that decision, it meant he would continue to struggle finding food daily, walking miles to different soup kitchens even as he grew weaker. I soon learned that his weekly walk to see me at the soup kitchen was the barometer he used to tell him when it was time to enter the hospice unit.

As time went on he grew so weak he could no longer make the walk to see me, was vomiting all food and drink, and was even having trouble getting around his apartment. Also, the heat broke in his apartment—in January—which he said didn’t bother him because he still had a bed and 4 walls, which is more than he had the last 5 year. With his nurses help, we convinced him to go to the hospice unit and he agreed. He wouldn’t go until he cleaned his apartment, packed up all his belongings, and took it to the shelter to give them to someone who needed them. We tried to talk him out of the strenuous task of cleaning when he was barely able to walk but he wouldn’t hear of it. The landlord was so nice to rent to him at such a low price he couldn’t leave the apartment dirty, he said. When I think of his strong character, I consider that for a man who had so little in life, and was now so close to death, his biggest concerns was for the sicker people in the hospital than he, the other homeless who were more in need of clothes than he, and not violating the trust of his landlord who first showed trust in him.

While delivering my eulogy I looked out in the full seats in the funeral home and was struck by how many people he brought together. All of his caretakers and an old acquaintance from high school came to say goodbye with a priest presiding in front of his beautiful box with a cross adorning the top. In the end, he got all he wanted, and we received a lesson of a lifetime.

-BF

Whew.

Remember when you were in middle school and your parents sent you off to camp for two weeks for the first time? Personally, I dreaded that day. Two weeks seemed so long. And. let’s face it,  there were an endless number of spiders that could be encountered in 14 days. But off you went and when you returned, you were different. And suddenly, you had lived more in those 14 days and learned more about life, yourself, spiders, archery and basket weaving than you could ever have imagined. Multiply that by a gazillion, and that is what the first three months of full time street medicine in this household has been like.

As you may remember, Brett became full time street medicine on October 1, 2014 as a result of a grant from the Pennsylvania Department of Health. The support and the rate at which the Program has been growing in 12 short weeks is baffling, even by my standards. At the start of the Program, there was a shelter based clinic (Safe Harbor- Easton, PA) and a soup kitchen based clinic (St. Paul’s- Allentown PA) in addition to the separate (but closely related) DeSales Free Clinic at the Allentown Rescue Mission.  In three months, there are now street rounds twice per week – one day in Allentown, one day in Easton, a new clinic at the 6th and Chew St Winter Shelter, involvement of medical students, internal medicine residents, development of a homelessness screening tool, ground work for the opening of new clinics in the Ecumenical Soup Kitchen (Allentown), Salvation Army Hospitality House (Allentown) and New Bethany Ministries (Bethlehem). Not to mention the training for the new Network wide electronic medical record, meeting quarterly requirements of the grant and endless other tasks. In addition, I and DeSales University have taken to a new project by opening a clinic at the Truth Home for Women (Bethlehem) which provides free medical care to women who are recovering from human/sex trafficking.

I have had some time to reflect on these last few months during a much needed break from my teaching responsibilities. However, all that time I envisioned playing board games with my kids and organizing closets were erased by the passing of my dear uncle, the hospitalization of our 7 month old son (who is back to blowing raspberries and trying endlessly get his toes into his mouth), the declining of my most favorite sassy lady- my 92 year old Nana and a slew of other unforeseen life events. In those wee hour moments while rocking a sick baby back to sleep, I get my clearest visions and thoughts.

Life itself is without protocol. I remember being a PA student desperately trying to grasp the concept of electrolyte replacement and management. I remember begging for a protocol. Yes, I know protocols are really just suggestions. Yes, I know we treat people and not number. Yes, I understand that every case is individual. BUT GIVE ME THE PROTOCOL. Mostly, I thought, so I don’t kill someone out of my own stupidity. I needed place to start. Homeless medicine is an amorphous area of medicine. Most people who start out in this field are drawn to the social justice of it all, the simplicity of the system. But they are nervous, scared even. It is so far outside of how we normally practice medicine. Think of a typical office visit- there are front office staff, there is a scheduled appointment, there are people to room the patient. You see the patient and practice within well defined (mostly) evidence based standards of care. You fill out a bill, maybe write out a prescription that will need a prior authorization. Which will then be denied requiring you to either spend an hour on the phone arguing or change the prescription. It may be a pain in the butt, but traditional medicine has structure. It has protocol.

As we are training new providers to volunteer, open clinics and screen patients, I am reminded that this new way of thinking about medicine can invoke a sense of agoraphobia. There are no walls. No documented peer-reviewed standards of care. No protocol. In fact, it is the very opposite of protocol. It is creative, sprawling, think-outside-the-boxy, just-because-its-never-been-done-doesn’t-mean-you-shouldn’ty. This is the origin of the (my) addiction to street medicine.