“Rewarding and Challenging at the Same Time”: Emergency Medicine Residents' Experiences Caring for Patients Who Are Homeless

Abstract

Objectives: The objectives were to examine how emergency medicine (EM) residents learn to care for patients in the emergency department (ED) who are homeless and how providing care for patients who are homeless influences residents' education and professional development as emergency physicians. Methods:We conducted in-depth, one-on-one interviews with EM residents from two programs. A random sample of residents stratified by training year was selected from each site. Interviews were digitally recorded and professionally transcribed. A team of researchers with diverse content-relevant expertise reviewed transcripts independently and applied codes to text segments using a grounded theory approach. The team met regularly to reconcile differences in code interpretations. Data collection and analysis occurred iteratively, and interviews continued until theoretical saturation was achieved.Results: Three recurring themes emerged from 23 resident interviews. First, residents learn unique aspects of EM by caring for patients who are homeless. This learning encompasses both specific knowledge and skills (e.g., disease processes infrequently seen in other populations) and professional development as an emergency physician (e.g., the core value of service in EM). Second, residents learn how to care for patients who are homeless through experience and informal teaching rather than through a formal curriculum. Residents noted little formal curricular time dedicated to homelessness and instead learned during clinical shifts through personal experience and by observing more senior physicians. One unique method of learning was through stories of "misses," in which patients who were homeless had bad outcomes. Third, caring for patients who are homeless affects residents emotionally in complex, multifaceted ways. Emotions were dominated by feelings of frustration. This frustration was often related to feelings of futility in truly helping homeless patients, particularly for patients who were frequent visitors to the ED and who had concomitant alcohol dependence. Conclusions:Caring for ED patients who are homeless is an important part of EM residency training. Our findings suggest the need for increased formal curricular time dedicated to the unique medical and social challenges inherent in treating patients who are homeless, as well as enhanced support and From the Robert Wood Johnson Foundation Clinical Scholars Program,

Screening for Housing Instability: Providers’ Reflections on Addressing a Social Determinant of Health

“…Previous literature highlights challenges providers face in asking about housing status and addressing housing instability. 14,15 Many of the providers studied here said they previously felt ill-equipped to discuss housing instability with their patients due to lack of training or biases about what a homeless patient Blooks like.^These findings support recommendations by Behforouz 19 and others to teach students to obtain comprehensive social histories that include housing, particularly given the impact housing status has on health outcomes. 20 Despite a lack of training and prior experience with asking patients about housing status, VA providers reported routinely incorporating the assessment of a patients' housing stability during the social history following HSCR implementation.…”

“…The few studies examining providers' views toward addressing housing instability have been conducted primarily in emergency department settings and highlight physicians' feelings of frustration and futility in meeting the needs of these patients. 14 Additionally, providers have reported difficulty identifying who is homeless; many do not ask about housing status routinely and express surprise that a patient who did not have the Btypical appearance^of a homeless individual was indeed homeless. 15 Implementation of the HSCR presents an opportunity to ask providers about: (1) their experiences asking about housing, both before and after implementation; (2) their role in addressing housing status in clinical settings; and, (3) their views on how patient housing status impacts clinical decision-making.…”

Identifying Homeless Population Needs in the Emergency Department Using Community-Based Participatory Research

“…A prior study at our institution found that residents identify homeless patients by pattern recognition and stereotype such as poor hygiene or recurrent visits for alcohol use. (40, 41) This approach introduces bias and likely vastly underestimates the true burden of homelessness in the ED. Prevalence of housing insecurity in the ED varies by hospital and is poorly studied, but may be as high as 25% in some urban centers and is universally cited as higher than national estimates.…”

From Their Perspective: The Connection between Life Stressors and Health Care Service Use Patterns of Homeless Frequent Users of the Emergency Department

“…Another study highlighted the similarity of self-reported motives for ED visits between frequent and nonfrequent ED users; these findings are also in line with findings from the present study, including access, convenience, cost, quality, and perceived need for urgent care (Doran, Colucci, et al, 2014). Previously identified interventions to decrease ED use and increase use of outpatient care have included a focus on structural solutions such as insurance coverage and use of community health workers (Hudgins & Rising, 2016), increasing use of formal medical training models for providers to improve screening and understanding of appropriate variations in care and hospital admission decisions for homeless patients (Doran, Curry, et al, 2014;Salhi et al, 2017). Our findings add the perspective of frequent users who are also homeless, a particularly vulnerable patient population with intersecting challenges that make treatment and engagement in services particularly difficult.…”