A Street Psychiatry Rotation for Medical Trainees: Humanizing the Care of People Experiencing Homelessness

Abstract

Despite an epidemic of homelessness in the USA, with approximately 568,000 people experiencing homelessness on a given night in 2019, medical trainees are often poorly equipped to address the needs of this population [1]. Trainees will inevitably encounter these individuals in their practice, but evidence shows that altruism decreases as trainees advance in their medical education and attitudes toward people experiencing homelessness become more cynical [2]. Only half of psychiatry residency programs offer clinical rotations with specific exposure to homelessness, and only 20% of residents actually participate in these [3]. A recent call to action frames the lack of medical training specific to homelessness [4]. Clinical electives offering community-based exposure to people experiencing homelessness are necessary to fill this important gap in medical education. Educational experiences have the potential to improve trainee attitudes toward people experiencing homelessness. The Health Professionals Attitudes Toward the Homeless Inventory (HPATHI) assesses healthcare professionals’ attitudes, interests, and confidence about working with individuals experiencing homelessness through a series of validated 5-point Likert scale questions. Family medicine residents demonstrated significant increases in the “social advocacy subscale” of the HPATHI after participation in clinical and enrichment activities related to homelessness [5]. Health professionals and trainees with more than 1 year of experience working with people experiencing homelessness had significantly higher HPATHI scores [6]. Physician assistant students who had worked previously with people experiencing homelessness scored higher on the HPATHI than those who did not [7]. In another study, a larger proportion of residents in one program entered a public psychiatry fellowship after a rotation about homelessness was implemented, suggesting that trainees may even steer their careers toward community work after these rotations end [8]. “Street Psychiatry” is a model of mental health and addiction treatment delivery that brings services directly to those who make their homes on the street, who may lack access to mental health treatment through traditional routes. Mental health professionals have long understood the need to meet people with serious mental illness in the community, and Street Psychiatry aligns philosophically with the “Assertive Community Treatment (ACT)” model and other evidencebased community outreach models. Street Psychiatry specifically targets people experiencing unsheltered homelessness— those who sleep outdoors—due to their disproportionate vulnerabilities. This group suffers from mortality rates ten times higher than the general population, a high burden of serious mental illness and substance use disorders, and significant barriers to obtaining care [9–12]. Through regular engagement with a Street Psychiatry team, a trusting relationship creates a more welcoming, respectful, and collaborative space—both literally and figuratively on the patient’s terms [13]. Street Psychiatry experiences have been implemented at several health professions training programs and existing educational offerings at Vanderbilt School of Medicine in Nashville, TN, Janian Medical Care in New York, NY, House of Hope in Providence, RI, and other programs were reviewed [14–17]. The Yale Street Psychiatry Elective, a rotation based at the Connecticut Mental Health Center in New Haven, CT, is a clinical experience for psychiatry residents, public psychiatry fellows, and other trainees. The learning objectives include developing familiarity with health systems, addressing social determinants of health, advocating for social justice, and enhancing empathy for marginalized peoples (see Table 1). We describe the Yale Street Psychiatry Elective’s implementation and its evaluation through a pilot postexperience survey of early participants. * Emma Lo [email protected]