AMA Journal of Ethics^®

Abstract

This article considers strategies for illuminating health systems’ structural violence toward people experiencing homelessness and for resisting incursion of moral injury to health professional learners. This article also canvasses the nature and scope of educators’ obligations to teach in patient-focused ways that motivate equity and students’ capacity to serve some of the country’s most vulnerable residents in clinical settings or on the streets.

Resisting Education Embedded in Violence

Medical education is at a threshold for much-needed change. Although academic health learning models in the United States have standardized and improved health professional training, the patients served (particularly excluded populations) often just don’t get their health needs met by clinicians and organizations.^1,2,3,4,5,6 Medical education is embedded in structurally violent systems in which the well-being of many patients (eg, those suffering domestic violence, addiction, or homelessness) is largely ignored. Patients experience dehumanization and students may too easily become co-conspirators.^2,3,6,7

The process through which students are desensitized has been referred to as the hidden curriculum and is a form of moral injury.⁸ Medical educators have made efforts to bridge the reality gap between traditional health systems and the real lives of patients through an emphasis on patient-centered care, the social determinants of health, health disparities and equity, narrative medicine, and other frameworks that shift the focus from the health system to those it should serve.^1,3,7,8,9 However, these efforts still fail to provide the transformative experience that a truly immersive setting might provide. In this article, we will discuss how street medicine can serve that role in medical education.

A Classroom of the Streets

Street medicine is an emerging field of practice throughout the world. It is defined as the direct provision of health care to those experiencing unsheltered homelessness.⁴ Teams of health and social service experts regularly visit rough sleepers where they live in campsites, in alleys, along riverbanks, and under bridges. Although a few pioneering programs in Calcutta,¹⁰ Boston,¹¹ Chile,¹² and Pittsburgh¹³ had emerged by the 1980s and 1990s, the grassroots street medicine movement gained momentum only after the turn of the millennium. This movement was catalyzed by the first annual International Street Medicine Symposium in Pittsburgh, Pennsylvania, in in 2005.¹⁴ At that time, the term street medicine was coined to describe this new field of medicine. Participants at this first meeting strongly agreed on 2 specific points. They wanted to continue annual meetings to build the movement, and they wanted to involve and foster their students. The conviction of these leaders was that including students in the care of rough sleeping patients was potentially of benefit to the medical education system. The annual symposium (now hosted by the Street Medicine Institute) has expanded, but the emphasis on medical education has remained strong. Every year students contribute posters, presentations, and workshops. Throughout the United States, academic leaders have incorporated medical education into local street medicine programs.¹⁵ It was usually necessary for them to create the street medicine programs first in order to incorporate medical education secondarily. Wherever medical education is provided in the context of street medicine, it has become affectionately known as “the classroom of the streets.” Let us explore some of the advantages that this unique classroom offers.

Lessons From the Classroom of the Streets

Rehumanization. Students engaged in street medicine are offered a rare opportunity to become deeply immersed in a cultural context that would be otherwise inaccessible. Typically, students encounter rough sleepers in tense—sometimes hostile—settings, such as emergency departments and inpatient hospitalizations.^3,4,16,17 While on street rounds, students are physically able to go to the places where this population lives and experience the “view from the streets.” Street rounds allow students a far more organic, relaxed setting for interactions.¹⁸ Learners see, hear, and even smell the conditions in which rough sleepers struggle to exist. This experience enables students to respond not just as a detached clinician, but as a human being.¹⁵

The change of perspective has deep existential significance for students, as it places them within the reality of the excluded person’s life instead of the converse.^2,5,15,16 The student learns that any healing process must be derived from the phenomenological perspective of the other. The rough sleeper becomes the teacher with whom the student must gain trust to be effective. Coupled with appropriate reflective discourse, students are able to shift their model of the patient-physician relationship from paternalism to solidarity, aligned with the principles of Paulo Freire as described in his seminal work, Pedagogy of the Oppressed.¹⁹ Although this transformation of perspective may be achieved in standard clinical settings, it is greatly enhanced on the streets where paternalism can be challenged. Even after a 1-month street medicine elective, students have later expressed to me that the experience changed forever how they viewed all patients.

The process through which students are desensitized has been referred to as the hidden curriculum and is a form of moral injury. 

Social justice. The learning environment of a typical street medicine program offers other advantages. While global education is well recognized as providing cultural awareness and the opportunity to compare the American health system with other health systems, street medicine constitutes a significant cultural plunge and a chance to see the shortcomings of the American health system from the margins. It also can be practiced in convenient locations. Street medicine naturally incorporates an analysis of inequity in social determinants of health, such as poverty, addiction, mental illness, racial and gender injustice, housing, and the effects of the criminal justice system. In the street medicine context, these are not just abstract topics but immediate challenges that can be addressed through the principles of street medicine practice, including harm reduction, advocacy, health systems coordination, and continuity of care across a range of settings (streets, department accompaniment, inpatient street medicine consultations, respite care, and aftercare when housing is achieved). Unlike in the clinic-based practice environment, the social determinants of health are apparent, and usually the persons served are open to honest discussions about them. Street teams intimately experience the barriers to care, and students witness how to seek out and creatively engage with partners in the community. Academic street medicine programs often incorporate a rich mix of professionals, such as nurses, social workers, experts who formerly experienced homelessness, and others, all working together on the streets. These transdisciplinary teams naturally integrate to transcend their traditional professional boundaries.

Street Medicine Education

Traditional academic medicine has only recently embraced street medicine in its formal curricula. This is likely due to the nascence and novelty of the street medicine educational movement. Nonetheless, academic leaders and medical student groups have been quietly developing programs for the past 20 years. These range from highly developed programs like the Boston Health Care for the Homeless Program¹¹ to small student-initiated programs like Street Medicine Detroit.²⁰ Most academic street medicine programs have physician champions who work with the students on the streets and represent them at the faculty level within the institution. Generally, there is a community nonprofit partner that provides the street guides and social services, such as housing and addiction and mental health services.

Regarding safety, the Street Medicine Institute leadership is not aware of any instances of physical harm experienced by membership organizations’ volunteers. In addition, a recent extensive review of the legal literature revealed no malpractice suits associated with the practice of street medicine (T. B. Hershey, P. Govil, unpublished data, 2019). Admittedly, it would be difficult for those experiencing homelessness to bring a malpractice suit in the context of street homelessness.

It is notable that students have often been the initiators of well-established programs. For example, the University of Rochester’s Street Outreach Program²¹ was created by Emma Lo when she was a medical student, (She is now an assistant professor of psychiatry practicing street psychiatry at Yale University.) The Street Medicine Institute Student Coalition boasts 535 student members, 37 established US programs, 11 developing US programs, and 9 international programs at the time of this writing.²² Residencies are integrating street medicine as a longitudinal component of their training. Most recently, UPMC Mercy Hospital, in collaboration with Pittsburgh Mercy, established the world’s first (nonaccredited) street medicine fellowship in 2019,²³ with another postgraduate street medicine fellowship being initiated at Integrative Emergency Services/JPS Health Network in July 2021.²⁴ To guide these diverse educational efforts, the Street Medicine Institute has formed the Street Medicine Educational Consortium.

Ethical Implications for Medical Education

Street medicine is a powerful and much-sought learning environment for health care students. My students in Pittsburgh often remark that street interactions are so “real.” After a 1-month elective, one student described her experience by saying, “I got my common sense back this month!” The divorce of clinical practice from patient reality is no longer acceptable to many of our best students. For them, it is painful and demotivating to witness the traumatic effects of a health system that largely serves itself and transfers blame for poor health to those who are excluded.¹⁵ As awareness of health disparities related to race, community trauma, poverty, gender, and other factors grows, the hypocrisy of looking away becomes intolerable and incompatible with the ethical foundations of our profession. The best students hunger not just for technical skills, but for meaningful engagement with the deeper forces that create the suffering that they witness. Such students understand that if health care is to be extended to those who have been excluded, we need to meet them in their own reality.²⁵ Street medicine students are energized and often become leaders in health care advocacy. For them, the marriage of social justice with medical education is long overdue. Academic medicine must not ignore the passion of such students. They will shape the future of our profession, but they need settings in which they can help reinvent health care to truly serve our communities. Street medicine can be a template for the meaningful, reality-based, and transformative kind of classroom needed to make the changes we need to make.