Acollaborative clinical and population-based curriculum for medical students to address primary care needs of the homeless in New York City shelters

Ramin Asgary; Ramesh Naderi; Margaret Gaughran; Blanca Sckell

doi:10.1007/s40037-016-0270-8

Acollaborative clinical and population-based curriculum for medical students to address primary care needs of the homeless in New York City shelters

Asgary, Ramin; Naderi, Ramesh; Gaughran, Margaret; Sckell, Blanca 2016-06-09 00:00:00 Perspect Med Educ (2016) 5:154–162 DOI 10.1007/s40037-016-0270-8 ORIGINAL ARTICLE A collaborative clinical and population-based curriculum for medical students to address primary care needs of the homeless in New York City shelters Teaching homeless healthcare to medical students 1,2 3 4 2 Ramin Asgary · Ramesh Naderi · Margaret Gaughran · Blanca Sckell Published online: 9 June 2016 © The Author(s) 2016. This article is available at SpringerLink with Open Access Abstract Background Millions of Americans experience Conclusions Comprehensive and ongoing clinical com- homelessness annually. Medical providers do not receive ponent in shelter clinics, complementary teaching, experi- adequate training in primary care of the homeless. enced faculty, and working relationship and collaboration Methods Starting in 2012, a comprehensive curricu- with community organizations were key elements. lum was offered to medical students during their family medicine or ambulatory clerkship, covering clinical, so- Keywords Curriculum · Health disparities · Homeless · cial and advocacy, population-based, and policy aspects. Primary care · Medical students Students were taught to: elicit speciﬁc social history, ex- plore health expectations, and assess barriers to healthcare; What this paper adds evaluate clinical conditions speciﬁc to the homeless and develop plans for care tailored toward patients’ medical and social needs; collaborate with shelter staff and community Medical providers often lack the skills to address the unique organizations to improve disease management and engage healthcare needs of the homeless with their social condi- in advocacy efforts. A mixed methods design was used to tions that affect clinical encounters. Structured and formal evaluate students’ knowledge, attitudes, and skills includ- integrated curricula to speciﬁcally address the primary care ing pre- and post-curriculum surveys, debrieﬁng sessions, needs of the homeless, with their speciﬁc challenges and and observed clinical skills. barriers, often do not exist. By designing a health dispari- Results The mean age of the students (n = 30) was 26.5 ties clinical and population-based curriculum, we were able years; 55 % were female. The overall scores improved sig- to better prepare medical students to address the multi-level niﬁcantly in knowledge, attitude, and self-efﬁcacy domains barriers to healthcare among the homeless. This piece de- usingpairedt-test (p < 0.01). Speciﬁc skills in evaluating scribes the development, implementation, feasibility, and mental health, substance abuse, and risky behaviours im- assessment of efﬁcacy of such curriculum. proved signiﬁcantly (p < 0.05). In evaluation of communi- cation skills, the majority were rated as having ‘outstanding rapport with patients.’ Introduction Annually, 3.5 million Americans experience homelessness Ramin Asgary and around 630,000 spend each night in the shelter system [email protected] [1]. Overwhelmingly, the homeless have lost their housing due to eviction, inability to pay rent, domestic abuse and Department of Medicine, New York University School of family disputes [2]. Menaged45to 54years, many of Medicine, New York, USA whom are veterans, are at the highest risk [3]. Among NYU Lutheran Family Health Centers, New York, NY, USA this population, age 45 and above, chronic diseases such as Independent Consultant, London, UK heart disease and cancer are consistently the leading causes Touro College of Osteopathic Medicine, New York, NY, USA of mortality, followed by substance abuse [4, 5]. Injuries Teaching homeless healthcare to medical students 155 and other infectious diseases are also common [6]. The Methods rates of smoking and substance abuse are higher than in the general population [6, 7]. The majority of the homeless Curriculum description population belong to racial and ethnic minority groups, and are especially vulnerable to and suffer disproportionately The curriculum was developed by two core faculty (RA from worse health outcomes than other groups [5]. and BS) and offered in the Community Medicine Program Multi-level barriers to access to healthcare exist among of the NYU Lutheran Medical Center between 2012–2014. the homeless, including history of mental illness or sub- Participants were third and/or fourth year medical students stance abuse, fatalistic views about chronic disease, dis- who either elected or were assigned to participate in a one- trust of providers or health systems due to a history of month community medicine rotation to fulﬁl their primary discrimination, and a lack of medical insurance and access care or family medicine clinical rotation requirements. The to primary care [8–12]. Systems-level barriers include lack overarching goals were to improve sensitivity toward, and of a primary care physician, no clinic visit to a physician in understanding of, the impact of fundamental causes and so- the past year, inadequate provider counselling and subse- cial determinants on the health of individuals with a low so- quent misconceptions about chronic disease management, cioeconomic status; awareness regarding healthcare of the lack of insurance, and poor access to healthcare in gen- homeless and their epidemiology and demographics; un- eral [8–12]. Providers often have misconceptions, biases derstanding the implications and the health consequences or subtle prejudice against the homeless and their medical of lack of housing, and assessing strategies to address them needs or priorities [12]. Additionally, providers may lack at the patient and population levels; comfort, efﬁcacy, and the skills to address the unique social conditions that affect effectiveness in developing and implementing a plan of care their clinical encounters; they may have difﬁculty address- for a homeless patient; and knowledge of and skills in uti- ing preventive care for this population within the time con- lizing available social, community, and governmental re- straints of the typical medical visit [12]. The focus of the sources for such patients. Students were encouraged and health system has been, at best, on addressing urgent issues supported to explore and discuss policy and advocacy op- of the homeless, while neglecting primary and preventive tions to improve the health of this frequently ignored pop- care [9, 10, 13]. ulation in the interface of social science, public policy, and Currently, limited health disparities curricula in medical clinical medicine. schools focus on healthcare of the poor or low socioeco- Through a primarily clinical exposure in shelter-based nomic populations in general, and issues faced by refugees clinics and shelter settings, active faculty precepting, and and immigrants [14–19]. Exposure to healthcare of the participating in the primary care model of care at shelter- homeless is often limited or student-driven [20–24]. Struc- based clinics, students were expected to achieve speciﬁc tured and formal integrated curricula to speciﬁcally address learning objectives as presented in Tab. 1 [17–21]. The the primary care needs of the homeless, with their speciﬁc curriculum format included structured reading assignments, challenges and barriers, often do not exist. While global weekly lecture series, weekly case presentations, daily team health has been emphasized in medical school curricula discussion sessions with social workers and staff at shelters over the past decade [25–27] domestic opportunities that and shelter clinics, and clinical sessions with clinical pre- could improve skills in addressing health disparities (which cepting by faculty 3 days a week. are likely transferable to other vulnerable populations, na- The curriculum directors had extensive experience work- tionally and internationally) are often overlooked. ing with underserved populations, including immigrants, We developed and offered an educational model that refugees, and torture survivors; and curriculum develop- originally grew out of a clinical service project introduced ment in medical and public health schools. They also had by the Community Medicine Program at St. Vincent Hospi- collaborated with non-governmental organizations in and tal in New York City, which was later embraced by the NYU outside academic settings. Two core faculty (RA and BS) Lutheran Medical Center, to better serve its largely low-in- incepted the curriculum by meeting regularly over a pe- come and homeless populations. By designing a health dis- riod of 2 years to discuss the educational needs of the parities clinical and population-based curriculum, we aimed programme, as well as challenges and resources, both in to better prepare medical students to address the multi-level the clinical and social settings at the shelters; develop rela- barriers to healthcare among the homeless, as well as the tionships with and elicit interest and feedback from social low-income and poor population. In this piece, we describe service providers at the shelters and collaborating commu- the development, implementation, feasibility, and assess- nity organizations; and evaluate opportunities for hands on ment of efﬁcacy of this curriculum. teaching. The faculty lobbied extensively with both medi- cal school and shelter directors to address logistical issues; elicited feedback from students who elected a rotation at 156 R. Asgary et al. Tab. 1 Curriculum objectives for participating medical students; shelter-based clinics, New York City, 2012–4 Objectives Format/Venues To describe epidemiology of homelessness, recognize it as a social problem with health implications, and Readings understand the role of fundamental causes of diseases Discussion sessions Lectures To demonstrate skills to investigate and evaluate psychosocial components/stressors of their patients Clinical sessions illness Clinical precepting To develop skills to address biomedical problems speciﬁc to homeless population including but not lim- Targeted readings ited to consequences of substance abuse, living on streets or in transitions or in shelters Clinical sessions Clinical precepting To recognize and address barriers to healthcare access among homeless population (health system level, Targeted readings individual levels, and provider competency level) Discussion sessions Lectures To develop skills to efﬁciently use the primary care setting and its resources to address patient’s so- Targeted readings cio-medical conditions effectively Clinical sessions Team discussion To recognize and apply patient-centred approach considering patient’s priorities Discussion sessions Clinical precepting Lectures To develop skills in efﬁcient use of time in primary care setting and apply evidence-based approaches to Clinical sessions medical conditions of homeless Clinical precepting To demonstrate skills in working collaboratively with community and grass-root organizations that pro- Team discussion vide services to homeless and to learn effective team work with case workers, support staff and shelter Clinical precepting staff To develop skills in recognizing and directing patients to appropriate mental health and substance abuse Targeted readings programmes Clinical sessions Clinical precepting To develop skills in efﬁcient use of time in primary care setting and apply evidence-based approaches to Readings medical conditions of homeless Clinical precepting the clinical sites; and researched and reviewed available To objectively assess students’ performance, anonymous curricula on disparities to inform the content and format pre- and post-curriculum surveys were administered to stu- of the curriculum [14, 15, 19–21]. First, a small number dents at the beginning and the end of the curriculum, respec- of students enrolled in the curriculum to anticipate and ad- tively. Surveys covered ﬁve main domains: (a) knowledge dress logistical challenges and opportunities before it was of regional and national policies and advocacy initiatives open to a larger group. Before each rotation, brieﬁng ses- regarding the homeless population, (b) knowledge about sions were held with students in which the logistics and the demographics and epidemiology of homelessness, and environments of shelters and neighbourhoods, and neces- the fundamental social causes of their illnesses, (c) knowl- sary precautions and processes, were discussed. Students edge of the common physical and psychological conditions were always paired; occasionally, when there was one stu- among the homeless, (d) attitudes and perceptions regard- dent in a shelter, a social worker, support staff, navigator ing working with homeless persons, and (e) skills to assess or a faculty member accompanied the student to and out of and manage homeless healthcare needs, and advocate on the shelter or shelter clinic when needed. Students were en- their behalf. The survey questionnaire included multiple- couraged to help develop or participate in a research project choice questions, selecting one best answer, as well as Lik- related to primary care services for the homeless, and par- ert scale questions regarding attitude and self-efﬁcacy. Data ticipate in future electives. were analyzed using Microsoft Excel 14.0.0, SPSS 20 and QuickCalcs (GraphPad CA, 2014). Parametric or nonpara- metric statistical tests were performed when appropriate us- Curriculum evaluation ing paired t-test measuring mean composite scores within groups (comparing students before and after). Statistical Complementary approaches were used to assess curriculum signiﬁcance was assumed at a p < 0.05. Cronbach’s alpha impact including a) pre- and post-curriculum knowledge, was used as a measure of internal reliability and consistency attitude, and self-efﬁcacy surveys, b) formal clinical skills for questions that were posed on a Likert scale. Electronic assessments by the faculty preceptor, and c) discussion ses- or printed curriculum evaluations were used on 22 students sions with students. in the past 3 years of curriculum implementation. Teaching homeless healthcare to medical students 157 At the ﬁnal session of the curriculum, faculty preceptors the proper introduction to patients, open-ended questions, performed direct clinical skills evaluations that reﬂected el- characterizing chief complaints, asking along a line of rea- ements (12 items) of history taking, physical exam skills, soning, adequate and relevant review of social history, and and communication skills, as well as areas of strengths validating patients’ concerns. Most students scored a 3 in and weaknesses. All students participated in ﬁnal face- all criteria, except 3 students who scored partially com- to-face discussion sessions with the directors to provide plete (2) on some (scale included 1 = incomplete/never, 2 = feedback. General questions were posed as ice-breakers. partially complete/sometimes or 3 = complete/always). All Open-ended discussions focused on experienced or per- students scored either ‘4 = obtained almost all major and ceived challenges, barriers to learning, what and how to minor details of the case’ or ‘3 = obtained most important improve, and which speciﬁc components of the curriculum information-may have missed some minor details.’ The full were more helpful educationally (and why). The majority physical exam included 4 grades and all students performed of these discussions included between 2–4 students over either 4 ‘4 = ﬂuid exam and skilfully put patient at ease and the course of curriculum implementation. Course directors included all relevant components’ or ‘3 = performed exam took individual notes, then compared notes, developed cod- competently, included most important components and was ing schemes, reviewed codes and developed themes using respectful to patients.’ Free text areas included descriptions a qualitative descriptive approach. of individual students’ strengths and weaknesses. This study received the Institutional Review Board ap- Brieﬁng sessions after the completion of the rotation re- proval from NYU Lutheran Family Health Centers. vealed major themes, including characteristics of clinical exposure, exposure to social determinants of health, col- laborative nature of services, and interest in and perceived Results challenges of working with the underserved. Overwhelm- ingly, students found the rotation rich in clinical skill learn- Between 2012 and 2014, 30 medical students participated ing, exposure to important social factors, and collaborating in the curriculum; however, evaluations were available for environment and teamwork at the shelters and shelter clin- 22 students. The eight students participating in the piloting ics. Students reported opportunities to work with mental phase of the curriculum did not receive any pre- or post- health professionals, caseworkers, social workers, and pa- curriculum survey. Mean age was 26.5 years (SD ± 3); tient navigators in shelters and shelter clinics to be very 55 % female; and 65 and 35 % were medical students in informative and enlightening. Some students elaborated their third and fourth year of study, respectively. Ten per- that the experiences provided them with better perspectives cent were dual-degree Doctor of Medicine/Master of Pub- on their own personal and professional lives, and served lic Health students. All but two students were from the as eye openers. A majority of students indicated that they Icahn School of Medicine at Mount Sinai, New York, NY. would seriously consider working with underserved com- Students showed improvement in knowledge, attitude, and munities in their future careers. The main issues regard- self-efﬁcacy questions. The overall scores in knowledge, ing the future career choices of primary care specialties attitude, and self-efﬁcacy domains improved signiﬁcantly, were time constraints and a general lack of system sup- using paired t-test post curriculum (p < 0.01). Speciﬁc port in most primary care settings. Students in general did skills in the evaluation of mental health, substance abuse, not complain about safety or security at shelter or clinic and other risky behaviours improved signiﬁcantly (p < 0.05) sites. Women’s shelters, where survivors of sexual trauma (Tab. 2 and 3). or abuse resided, were in general reserved for female stu- All students were observed and were precepted during dents, and their working environments were often described all of their clinical encounters by faculty preceptors, and as ‘tough’ but ‘manageable’ by the students. participated in devising the plans of care for patients and addressing social conditions that impacted their patients’ Discussion clinical encounters. Final evaluations of communication skills by the faculty preceptors were available from 14 students. Eight students The high number of homeless people in almost every major were not available for a full evaluation of direct clinical city in the US [1] provides a valuable opportunity to train encounter observation by the faculty preceptor due to mul- practitioners in health disparities, and to address the spe- tiple factors, including scheduling problems due to holi- ciﬁc needs of this vulnerable population. Our ﬁndings in- days, sick leave, conﬂict with medical school exams, and dicate that students gained signiﬁcant knowledge, attitude, incomplete evaluations. A majority were rated as having and skills after participating in the clinical and population- ‘outstanding rapport with patients = 3’ on a scale of 1 to 3. based curriculum provided. Despite a high level of base- History-taking skills assessments included items related to line attitudes and self-efﬁcacy, there were still signiﬁcant 158 R. Asgary et al. Tab. 2 Knowledge and attitude among medical students pre- and post-curriculum in New York City shelter clinics, 2012–4 Pre Post P value paired Mean t-test SEM KNOWLEDGE 0.2822 0.422 p < 0.001 Composite score (Yes/No, or one correct answer) 0.0325 0.022 18 15 What is the average number of homeless persons who sleep on street each night in 0.17 0.87 p = 0.001 New York City? 0.09 0.09 a) 20,000 b) at least 10,000 c) 3–4,000 d) I have no idea 18 15 What is the percentage of family homelessness among homeless population in the 0.11 0.33 p = 0.082 United States? 0.08 0.13 a) 15–25 % b) 30–40 % c) 50–70 % d) I have no idea 18 15 What is among some of the most common complaints in dropping centres? 0.08 0.62 p = 0.015 a) Headache b) abdominal pain c) cough d) feet swelling 0.08 0.15 13 13 The highest cost of homeless to society comes from? 0.79 0.92 p = 0.081 a) Social services b) food and housing c) outpatient care d) hospital admission due to 0.11 0.08 mental illness 14 13 What is the ethnicity/race with highest rate of homelessness among chronically home- 0.53 0.80 p = 0.040 less in New York City? 0.12 0.11 a) Black b) Hispanic c) Whites d) other e) all are equally at risk 17 15 ATTITUDE 3.35 3.65 p < 0.001 Composite score 0.063 0.056 18 15 I am comfortable being a primary care provider for a homeless person with major 2.81 3.94 p = 0.001 mental illnesses 0.22 0.11 22 16 I feel comfortable providing care to different minority and cultural groups 4.10 4.38 p = 0.029 0.22 0.18 22 16 I feel generally overwhelmed by the complexity of the problems that homeless people 3.33 2.56 p = 0.003 have 0.17 0.18 22 16 I enjoy learning about the lives of my homeless patients 3.90 4.63 p = 0.003 0.17 0.13 22 16 I generally believe caring for the homeless is not ﬁnancially viable for my career 2.95 2.56 p = 0.096 0.18 0.26 22 16 I feel comfortable to provide care to a homeless person with depression 3.14 4.13 p = 0.0001 0.19 0.09 22 16 I feel comfortable to provide care to a homeless person with other mental illnesses 2.90 4.13 p = 0.0001 0.19 0.09 22 16 I feel comfortable to provide care to a homeless person with substance abuse 2.81 3.81 p = 0.0001 0.16 0.14 22 16 I feel comfortable to provide care to a homeless person with alcohol abuse 2.76 3.94 p = 0.0001 0.15 0.14 22 16 I feel comfortable to help uninsured or underinsured persons to better navigate health 2.33 3.25 p = 0.021 system 0.20 0.19 22 16 I feel comfortable to negotiate plan of care with homeless patients considering their 3.05 4.00 p = 0.006 constraints and expectations 0.18 0.20 21 16 Likert scale: Strongly Disagree (1) Disagree (2) Neither agree/disagree (3) Agree (4) Strongly Agree (5) Teaching homeless healthcare to medical students 159 Tab. 3 Self-efﬁcacy among medical students pre- and post-curriculum in New York City shelter clinics, 2012–4 SELF-EFFICACY Pre Post P value paired Mean t-test SEM Composite score 3.317 3.695 p < 0.001 0.067 0.061 18 12 I believe that I can assess depression in a homeless person 3.33 4.44 p = 0.0002 0.20 0.13 21 16 I believe that I can apply Depression score/questionnaire to assess depression in a home- 3.62 4.69 p = 0.0009 less person 0.18 0.12 21 16 I believe that I can obtain and assess psychosocial issues from a homeless person 3.43 4.25 p = 0.0004 0.15 0.14 21 16 I believe that I can assess substance abuse in a homeless person 3.43 4.06 p = 0.014 0.18 0.19 21 16 I believe that I can assess alcohol abuse or dependence in a homeless person 3.48 4.19 p = 0.002 0.16 0.14 21 16 I believe that I can obtain and assess sexual history from a homeless person 3.95 4.44 p = 0.0004 0.08 0.13 21 16 I believe that I can assess smoking history and provide smoking cessation to a homeless 3.86 4.56 p = 0.0003 person 0.13 0.13 21 16 I believe that I have skills in directing homeless persons to potential psychosocial re- 2.24 3.57 p = 0.002 sources 0.14 0.22 21 16 I believe that I have skills in directing homeless persons to potential and accessible 2.24 3.38 p = 0.0001 biomedical resources 0.15 0.18 21 16 I believe that I can work collaboratively with social service providers and community 3.95 4.38 p = 0.047 organizations that provide services to the homeless 0.18 0.13 21 16 I believe that I have clinical skills to detect and address most medical problems speciﬁc to 2.95 4.06 p = 0.0001 the homeless population 0.16 0.11 21 16 How has your experience here at Community Medicine Program changed your career 3.11 3.56 p = 0.078 choices to go to: Primary care residencies (Emergency Medicine, Internal Medicine, Pae- 0.11 0.16 diatrics, OBGYN, Preventive Medicine, Family Medicine, General Surgery) 9 16 How has your experience here at Community Medicine Program changed your career 3.22 4.13 p = 0.011 choices to work with the underserved? 0.22 0.15 19 16 Likert scale: Strongly disagree (1) Disagree (2) Neither agree/disagree (3) Agree (4) Strongly agree (5) increases in these educational domains. The curriculum’s Lessons learned unique approach for skills building used a population case- based health disparities focus, highlighting the process by Overall, the curriculum was a positive experience for the which social determinants of health intersect medical, pub- students. They gained an understanding of epidemiology lic health, and social systems and improving comprehensive and demographics of the homeless, appreciation for the learning. health consequences of lack of housing, knowledge and skills regarding appropriate social and community resources for the homeless, and skills in addressing them at the in- dividual and population levels. Students gained clinical 160 R. Asgary et al. skills in identiﬁcation, diagnosis and management of com- dents, using paired analysis of pre- and post-curriculum mon medical and psychosocial conditions, as well as sub- responses for each student helped demonstrate statistically stance abuse issues and the identiﬁcation and assessment of signiﬁcant improvements in educational domains. We used the broader socioeconomic and policy factors affecting the a combination of quantitative and qualitative approaches to healthcare of the homeless. better elicit feedback, and faculty preceptors directly evalu- Students rotated through multiple shelter clinics and ated students’ skills at the end of curriculum. While differ- were exposed to a wide variety of special shelters, in- ent batches of students participated in the training over the cluding those speciﬁc for signiﬁcant mental health issues, period of curriculum implementation, and have been evalu- substance abuse problems, or post incarceration facilities. ated by different faculty preceptors, the direct observations This provided an opportunity for better development of and assessments by faculty preceptors may have been prone skills in interviewing and taking care of individuals with to grade inﬂation. The speciﬁc setting and context of our ex- more precarious situations, which will ultimately improve periences and the inner city urban setting in the city of New their ease and comfort with subsequent homeless patients York, have likely inﬂuenced the experience and challenges during their career. For patients, it likely fostered better of our patients, but also the content of the curriculum, expe- patient-provider trust and rapport with student providers. riences of our student participants, and the success of our To our knowledge and experience, the strength of this programme. The majority of the homeless in New York curriculum was in its setting and complementary mod- City are from ethnic and racial minority groups, and may els of teaching clinical and population-based medicine at face both health system challenges and opportunities that the intersection of social science, which provided unique are different from other states, countries, or suburban or clinical and non-clinical learning opportunities. Students rural areas. The demographics of our students, the urban appreciated the triangulated teaching approach of structured health system setting, and the challenges and availability readings, clinical precepting, and the discussion sessions of social service agencies are also likely to vary in other with medical and social service providers. This created an settings. Our assessment of the curriculum only evaluated opportunity for group learning and collaborative teamwork its short-term impact, and it was not designed to assess its with professionals from other disciplines. The location long-term impact and attainment of educational skills. of our clinics, which were based at the shelters, and the close partnership with community organizations, shelters, Challenges and neighbourhood entities, along with a robust social and medical service referral system with the parent hospi- We faced common barriers in developing and implementing tal, fostered a more effective collaborative environment in a customized health disparities curriculum within a primar- which students, faculty, and clinic/shelter staff, casework- ily service-oriented programme, including a lack of fund- ers, and community organizations shared ideas and worked ing, difﬁculties coordinating and accommodating faculty closely to improve the health of each individual homeless and trainees’ busy schedules [14, 15], devoting speciﬁc di- patient. dactic weekly sessions on an uninterrupted basis, consistent Over the past ten years, there has been a greater inter- networking with grass-root and advocacy organizations, and est and movement toward social responsibility in medicine coordinating students’ clinical and didactic sessions with and global health, which includes the appreciation of the clinical preceptors. Other challenges included securing ad- effects of social determinants of health, [28, 29] the issues ministrative support from the parent institutions to assure of social justice, the right to healthcare and greater health that the training experience and clinical services were unin- equity, and the reduction of health disparities [30]. An terrupted. The course directors provided all administrative overwhelming number of homeless people in our shelter support and primarily used personal relationships to over- clinics are from racial and ethnic minority groups, which come most of these challenges through close negotiations helped students improve their cultural competency skills with the clinics, shelters, and community organizations. No in identifying and addressing the effects of racial and eth- funding was provided to reimburse course directors, collab- nic factors on their patients’ healthcare. This experience orating organizations or shelter staff. To our experience, has undoubtedly helped our students to better recognize the taking the steps to create a formal supervised exposure socioeconomic context of their patients’ illnesses, and to re- for medical students during their ambulatory blocks, ex- alize vividly the context of health disparities in the United pert faculty, existing collaborative work with community States. organizations, and maintaining institutional support during Some important limitations of our curriculum evaluation training are essential components. The body of knowledge include the self-reported nature of pre- and post-curriculum in regard to health disparities and domestic global health ex- surveys, and the possibility of socially desirable responses periences and competencies has signiﬁcantly improved in and feedback. Despite a relatively small number of stu- recent years. Extensive core faculty experience in popula- Teaching homeless healthcare to medical students 161 creativecommons.org/licenses/by/4.0/), which permits unrestricted tion-based medicine, curriculum development, and working use, distribution, and reproduction in any medium, provided you give with the underserved, immigrants, refugees, and the home- appropriate credit to the original author(s) and the source, provide a less, along with available literature resources [9, 13–15, 20, link to the Creative Commons license, and indicate if changes were 21], helped to set objectives, and to design and implement made. the curriculum. References 1. National Alliance to End Homelessness. The State of Homeless- Conclusions ness in America. Washington D.C. USA: Homelessness Research Institute; 2013. The signiﬁcant increase in interest among medical students 2. 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Cancer Epidemiol Biomarkers Prev. 2002;11:431–8. root organizations, and garnering institutional support and 11. Zlotnick C, Zerger S. Survey ﬁndings on characteristics and health departmental commitment are crucial components. status of clients treated by the federally funded (US) Health Care for the Homeless Programs. Health Soc Care Community. Acknowledgment Authors thank the leadership at the NYU Lutheran’s 2008;17:18–26. Community Medicine Program (CMP), Dr. William Pagano, Bar- 12. Wen CK, Hudak PL, Hwang SW. Homeless people’s perceptions of bara Conanan, and Aaron Felder. Authors specially thank physician welcomeness and unwelcomeness in healthcare encounters. J Gen providers, Drs. Mark Rabiner, Miranda Vondornum, Jacqueline Perez, Intern Med. 2007;22:1011–7. Mira Batra, Ambika Deb and Jonathan Keith Joseph as well as staff at 13. Asgary R, Sckell B, Alcabes A, Naderi R, Adongo P, Ogedegbe G. the CMP program for their invaluable contribution and support of this Perceptions, Attitudes, and Experience Regarding mHealth Among project. Homeless Persons in New York City Shelters. J Health Commun. 2015;27:1–8. nd The abstract of this study has been presented in the 142 Annual Meet- 14. Asgary R, Saenger P, Jophlin L, Burnett DC. Domestic global ing of American Public Health Association, November 2014, New Or- health: a curriculum teaching medical students to evaluate refugee leans, LA. asylum seekers and torture survivors. Teach Learn Med. 2013;25: 348–57. Conﬂict of interest R. Asgary, R. Naderi, M. Gaughran and B. Sckell 15. Asgary R. Bring global health and global medicine home. Acad state that there are no conﬂicts of interest. Med. 2013;88:908. Ethical standards This study received the Institutional Review Board 16. Doran KM, Kirley K, Barnosky AR, Williams JC, Cheng JE. De- approval from NYU Lutheran Family Health Centers. This work was veloping a novel poverty in Healthcare curriculum for medical stu- carried out in accordance with the Declaration of Helsinki including, dents at the university of michigan medical school. Acad Med. but not limited to, there being no potential harm to participants, that the 2008;83:5–13. anonymity of participants was guaranteed, and that informed consent 17. Bonafede K, Reed VA, Pipas CF. Self-directed community health of participants had been obtained. assessment projects in a required family medicine clerkship: an ef- fective way to teach community-oriented primary care. Fam Med. Open Access This article is distributed under the terms of the 2009;41:701–7. Creative Commons Attribution 4.0 International License (http:// 162 R. Asgary et al. 18. McNeal MS, Buckner AV. Using mini-grants and service-learning 26. Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. projects to prepare students to serve underserved populations. J Educational effects of international health electives on U.S. and Health Care Poor Underserved. 2012;23(2 Suppl):20–6. Canadian medical students and residents: A literature review. Acad 19. Iles-Shih M, Sve C, Solotaroff R, Bruno R, Gregg J. Health and Med. 2003;78:342–7. illness in context: a pragmatic, interdisciplinary approach to teach- 27. Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner ing and learning applied public health within an urban safety net P. Global health in medical education: A call for more training and system. J Public Health Manag Pract. 2011;17:308–12. opportunities. Acad Med. 2007;82:226–30. 20. Weinstein LC, Lanoue MD, Plumb JD, King H, Stein B, Tsemberis 28. O’Neil E. Awakening Hippocrates: A Primer on Health, Poverty, S. A primary care-public health partnership addressing homeless- and Global Service. Chicago: American Medical Association ness, serious mental illness, and health disparities. J Am Board Press; 2006. Fam Med. 2013;26:279–87. 29. Parsi K, List J. Preparing medical students for the world: Service 21. Omori JS, Riklon S, Wong VS, Lee DF. The Hawai’i homeless out- learning and global health justice. Medscape J Med. 2008;10:268. reach and medical education project: servicing the community and 30. Farmer P. Pathologies of Power: Health, Human Rights, and the our medical students. Hawaii J Med Public Health. 2012;71:262–5. New War on the Poor. London, England: University of California 22. Goodier R, Uppal S, Ashcroft H. Making international links to Press; 2005. further interprofessional learning: a student-led initiative for the homeless population. J Interprof Care. 2015;29:265–7. Ramin Asgary is a clinical educator and health services researcher 23. Andell C, Profﬁtt B, Disco M, Clithero A. Street outreach and shel- with extensive experience in health disparities curriculum development ter care elective for senior health professional students: an interpro- for medical students and residents. fessional educational model for addressing the needs of vulnerable populations. Educ Health (Abingdon). 2014;27:99–102. Ramesh Naderi is a health services researcher with extensive experi- 24. Batra P, Chertok JS, Fisher CE, Manseau MW, Manuelli VN, Spears ence in health disparities research J. The Columbia-Harlem Homeless Medical Partnership: a new model for learning in the service of those in medical need. J Ur- Margaret Gaughran is a medical student with interest and experience ban Health. 2009;86:781–90. in working with underserved communities. 25. Panosian C, Coates TJ. The new medical ‘missionaries’ – groom- Blanca Sckell is a clinical educator with extensive experience is work- ing the next generation of global health workers. N Engl J Med. ing with underserved communities and curriculum development. 2006;354:1771–3. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Perspectives on Medical Education Springer Journals http://www.deepdyve.com/lp/springer-journals/acollaborative-clinical-and-population-based-curriculum-for-medical-PfyTsLmG0U

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Publisher: Springer Journals
Copyright: Copyright © 2016 by The Author(s)
Subject: Education; Medical Education
ISSN: 2212-2761
eISSN: 2212-277X
DOI: 10.1007/s40037-016-0270-8
pmid: 27277430
Publisher site: See Article on Publisher Site

Abstract

Perspect Med Educ (2016) 5:154–162 DOI 10.1007/s40037-016-0270-8 ORIGINAL ARTICLE A collaborative clinical and population-based curriculum for medical students to address primary care needs of the homeless in New York City shelters Teaching homeless healthcare to medical students 1,2 3 4 2 Ramin Asgary · Ramesh Naderi · Margaret Gaughran · Blanca Sckell Published online: 9 June 2016 © The Author(s) 2016. This article is available at SpringerLink with Open Access Abstract Background Millions of Americans experience Conclusions Comprehensive and ongoing clinical com- homelessness annually. Medical providers do not receive ponent in shelter clinics, complementary teaching, experi- adequate training in primary care of the homeless. enced faculty, and working relationship and collaboration Methods Starting in 2012, a comprehensive curricu- with community organizations were key elements. lum was offered to medical students during their family medicine or ambulatory clerkship, covering clinical, so- Keywords Curriculum · Health disparities · Homeless · cial and advocacy, population-based, and policy aspects. Primary care · Medical students Students were taught to: elicit speciﬁc social history, ex- plore health expectations, and assess barriers to healthcare; What this paper adds evaluate clinical conditions speciﬁc to the homeless and develop plans for care tailored toward patients’ medical and social needs; collaborate with shelter staff and community Medical providers often lack the skills to address the unique organizations to improve disease management and engage healthcare needs of the homeless with their social condi- in advocacy efforts. A mixed methods design was used to tions that affect clinical encounters. Structured and formal evaluate students’ knowledge, attitudes, and skills includ- integrated curricula to speciﬁcally address the primary care ing pre- and post-curriculum surveys, debrieﬁng sessions, needs of the homeless, with their speciﬁc challenges and and observed clinical skills. barriers, often do not exist. By designing a health dispari- Results The mean age of the students (n = 30) was 26.5 ties clinical and population-based curriculum, we were able years; 55 % were female. The overall scores improved sig- to better prepare medical students to address the multi-level niﬁcantly in knowledge, attitude, and self-efﬁcacy domains barriers to healthcare among the homeless. This piece de- usingpairedt-test (p < 0.01). Speciﬁc skills in evaluating scribes the development, implementation, feasibility, and mental health, substance abuse, and risky behaviours im- assessment of efﬁcacy of such curriculum. proved signiﬁcantly (p < 0.05). In evaluation of communi- cation skills, the majority were rated as having ‘outstanding rapport with patients.’ Introduction Annually, 3.5 million Americans experience homelessness Ramin Asgary and around 630,000 spend each night in the shelter system [email protected] [1]. Overwhelmingly, the homeless have lost their housing due to eviction, inability to pay rent, domestic abuse and Department of Medicine, New York University School of family disputes [2]. Menaged45to 54years, many of Medicine, New York, USA whom are veterans, are at the highest risk [3]. Among NYU Lutheran Family Health Centers, New York, NY, USA this population, age 45 and above, chronic diseases such as Independent Consultant, London, UK heart disease and cancer are consistently the leading causes Touro College of Osteopathic Medicine, New York, NY, USA of mortality, followed by substance abuse [4, 5]. Injuries Teaching homeless healthcare to medical students 155 and other infectious diseases are also common [6]. The Methods rates of smoking and substance abuse are higher than in the general population [6, 7]. The majority of the homeless Curriculum description population belong to racial and ethnic minority groups, and are especially vulnerable to and suffer disproportionately The curriculum was developed by two core faculty (RA from worse health outcomes than other groups [5]. and BS) and offered in the Community Medicine Program Multi-level barriers to access to healthcare exist among of the NYU Lutheran Medical Center between 2012–2014. the homeless, including history of mental illness or sub- Participants were third and/or fourth year medical students stance abuse, fatalistic views about chronic disease, dis- who either elected or were assigned to participate in a one- trust of providers or health systems due to a history of month community medicine rotation to fulﬁl their primary discrimination, and a lack of medical insurance and access care or family medicine clinical rotation requirements. The to primary care [8–12]. Systems-level barriers include lack overarching goals were to improve sensitivity toward, and of a primary care physician, no clinic visit to a physician in understanding of, the impact of fundamental causes and so- the past year, inadequate provider counselling and subse- cial determinants on the health of individuals with a low so- quent misconceptions about chronic disease management, cioeconomic status; awareness regarding healthcare of the lack of insurance, and poor access to healthcare in gen- homeless and their epidemiology and demographics; un- eral [8–12]. Providers often have misconceptions, biases derstanding the implications and the health consequences or subtle prejudice against the homeless and their medical of lack of housing, and assessing strategies to address them needs or priorities [12]. Additionally, providers may lack at the patient and population levels; comfort, efﬁcacy, and the skills to address the unique social conditions that affect effectiveness in developing and implementing a plan of care their clinical encounters; they may have difﬁculty address- for a homeless patient; and knowledge of and skills in uti- ing preventive care for this population within the time con- lizing available social, community, and governmental re- straints of the typical medical visit [12]. The focus of the sources for such patients. Students were encouraged and health system has been, at best, on addressing urgent issues supported to explore and discuss policy and advocacy op- of the homeless, while neglecting primary and preventive tions to improve the health of this frequently ignored pop- care [9, 10, 13]. ulation in the interface of social science, public policy, and Currently, limited health disparities curricula in medical clinical medicine. schools focus on healthcare of the poor or low socioeco- Through a primarily clinical exposure in shelter-based nomic populations in general, and issues faced by refugees clinics and shelter settings, active faculty precepting, and and immigrants [14–19]. Exposure to healthcare of the participating in the primary care model of care at shelter- homeless is often limited or student-driven [20–24]. Struc- based clinics, students were expected to achieve speciﬁc tured and formal integrated curricula to speciﬁcally address learning objectives as presented in Tab. 1 [17–21]. The the primary care needs of the homeless, with their speciﬁc curriculum format included structured reading assignments, challenges and barriers, often do not exist. While global weekly lecture series, weekly case presentations, daily team health has been emphasized in medical school curricula discussion sessions with social workers and staff at shelters over the past decade [25–27] domestic opportunities that and shelter clinics, and clinical sessions with clinical pre- could improve skills in addressing health disparities (which cepting by faculty 3 days a week. are likely transferable to other vulnerable populations, na- The curriculum directors had extensive experience work- tionally and internationally) are often overlooked. ing with underserved populations, including immigrants, We developed and offered an educational model that refugees, and torture survivors; and curriculum develop- originally grew out of a clinical service project introduced ment in medical and public health schools. They also had by the Community Medicine Program at St. Vincent Hospi- collaborated with non-governmental organizations in and tal in New York City, which was later embraced by the NYU outside academic settings. Two core faculty (RA and BS) Lutheran Medical Center, to better serve its largely low-in- incepted the curriculum by meeting regularly over a pe- come and homeless populations. By designing a health dis- riod of 2 years to discuss the educational needs of the parities clinical and population-based curriculum, we aimed programme, as well as challenges and resources, both in to better prepare medical students to address the multi-level the clinical and social settings at the shelters; develop rela- barriers to healthcare among the homeless, as well as the tionships with and elicit interest and feedback from social low-income and poor population. In this piece, we describe service providers at the shelters and collaborating commu- the development, implementation, feasibility, and assess- nity organizations; and evaluate opportunities for hands on ment of efﬁcacy of this curriculum. teaching. The faculty lobbied extensively with both medi- cal school and shelter directors to address logistical issues; elicited feedback from students who elected a rotation at 156 R. Asgary et al. Tab. 1 Curriculum objectives for participating medical students; shelter-based clinics, New York City, 2012–4 Objectives Format/Venues To describe epidemiology of homelessness, recognize it as a social problem with health implications, and Readings understand the role of fundamental causes of diseases Discussion sessions Lectures To demonstrate skills to investigate and evaluate psychosocial components/stressors of their patients Clinical sessions illness Clinical precepting To develop skills to address biomedical problems speciﬁc to homeless population including but not lim- Targeted readings ited to consequences of substance abuse, living on streets or in transitions or in shelters Clinical sessions Clinical precepting To recognize and address barriers to healthcare access among homeless population (health system level, Targeted readings individual levels, and provider competency level) Discussion sessions Lectures To develop skills to efﬁciently use the primary care setting and its resources to address patient’s so- Targeted readings cio-medical conditions effectively Clinical sessions Team discussion To recognize and apply patient-centred approach considering patient’s priorities Discussion sessions Clinical precepting Lectures To develop skills in efﬁcient use of time in primary care setting and apply evidence-based approaches to Clinical sessions medical conditions of homeless Clinical precepting To demonstrate skills in working collaboratively with community and grass-root organizations that pro- Team discussion vide services to homeless and to learn effective team work with case workers, support staff and shelter Clinical precepting staff To develop skills in recognizing and directing patients to appropriate mental health and substance abuse Targeted readings programmes Clinical sessions Clinical precepting To develop skills in efﬁcient use of time in primary care setting and apply evidence-based approaches to Readings medical conditions of homeless Clinical precepting the clinical sites; and researched and reviewed available To objectively assess students’ performance, anonymous curricula on disparities to inform the content and format pre- and post-curriculum surveys were administered to stu- of the curriculum [14, 15, 19–21]. First, a small number dents at the beginning and the end of the curriculum, respec- of students enrolled in the curriculum to anticipate and ad- tively. Surveys covered ﬁve main domains: (a) knowledge dress logistical challenges and opportunities before it was of regional and national policies and advocacy initiatives open to a larger group. Before each rotation, brieﬁng ses- regarding the homeless population, (b) knowledge about sions were held with students in which the logistics and the demographics and epidemiology of homelessness, and environments of shelters and neighbourhoods, and neces- the fundamental social causes of their illnesses, (c) knowl- sary precautions and processes, were discussed. Students edge of the common physical and psychological conditions were always paired; occasionally, when there was one stu- among the homeless, (d) attitudes and perceptions regard- dent in a shelter, a social worker, support staff, navigator ing working with homeless persons, and (e) skills to assess or a faculty member accompanied the student to and out of and manage homeless healthcare needs, and advocate on the shelter or shelter clinic when needed. Students were en- their behalf. The survey questionnaire included multiple- couraged to help develop or participate in a research project choice questions, selecting one best answer, as well as Lik- related to primary care services for the homeless, and par- ert scale questions regarding attitude and self-efﬁcacy. Data ticipate in future electives. were analyzed using Microsoft Excel 14.0.0, SPSS 20 and QuickCalcs (GraphPad CA, 2014). Parametric or nonpara- metric statistical tests were performed when appropriate us- Curriculum evaluation ing paired t-test measuring mean composite scores within groups (comparing students before and after). Statistical Complementary approaches were used to assess curriculum signiﬁcance was assumed at a p < 0.05. Cronbach’s alpha impact including a) pre- and post-curriculum knowledge, was used as a measure of internal reliability and consistency attitude, and self-efﬁcacy surveys, b) formal clinical skills for questions that were posed on a Likert scale. Electronic assessments by the faculty preceptor, and c) discussion ses- or printed curriculum evaluations were used on 22 students sions with students. in the past 3 years of curriculum implementation. Teaching homeless healthcare to medical students 157 At the ﬁnal session of the curriculum, faculty preceptors the proper introduction to patients, open-ended questions, performed direct clinical skills evaluations that reﬂected el- characterizing chief complaints, asking along a line of rea- ements (12 items) of history taking, physical exam skills, soning, adequate and relevant review of social history, and and communication skills, as well as areas of strengths validating patients’ concerns. Most students scored a 3 in and weaknesses. All students participated in ﬁnal face- all criteria, except 3 students who scored partially com- to-face discussion sessions with the directors to provide plete (2) on some (scale included 1 = incomplete/never, 2 = feedback. General questions were posed as ice-breakers. partially complete/sometimes or 3 = complete/always). All Open-ended discussions focused on experienced or per- students scored either ‘4 = obtained almost all major and ceived challenges, barriers to learning, what and how to minor details of the case’ or ‘3 = obtained most important improve, and which speciﬁc components of the curriculum information-may have missed some minor details.’ The full were more helpful educationally (and why). The majority physical exam included 4 grades and all students performed of these discussions included between 2–4 students over either 4 ‘4 = ﬂuid exam and skilfully put patient at ease and the course of curriculum implementation. Course directors included all relevant components’ or ‘3 = performed exam took individual notes, then compared notes, developed cod- competently, included most important components and was ing schemes, reviewed codes and developed themes using respectful to patients.’ Free text areas included descriptions a qualitative descriptive approach. of individual students’ strengths and weaknesses. This study received the Institutional Review Board ap- Brieﬁng sessions after the completion of the rotation re- proval from NYU Lutheran Family Health Centers. vealed major themes, including characteristics of clinical exposure, exposure to social determinants of health, col- laborative nature of services, and interest in and perceived Results challenges of working with the underserved. Overwhelm- ingly, students found the rotation rich in clinical skill learn- Between 2012 and 2014, 30 medical students participated ing, exposure to important social factors, and collaborating in the curriculum; however, evaluations were available for environment and teamwork at the shelters and shelter clin- 22 students. The eight students participating in the piloting ics. Students reported opportunities to work with mental phase of the curriculum did not receive any pre- or post- health professionals, caseworkers, social workers, and pa- curriculum survey. Mean age was 26.5 years (SD ± 3); tient navigators in shelters and shelter clinics to be very 55 % female; and 65 and 35 % were medical students in informative and enlightening. Some students elaborated their third and fourth year of study, respectively. Ten per- that the experiences provided them with better perspectives cent were dual-degree Doctor of Medicine/Master of Pub- on their own personal and professional lives, and served lic Health students. All but two students were from the as eye openers. A majority of students indicated that they Icahn School of Medicine at Mount Sinai, New York, NY. would seriously consider working with underserved com- Students showed improvement in knowledge, attitude, and munities in their future careers. The main issues regard- self-efﬁcacy questions. The overall scores in knowledge, ing the future career choices of primary care specialties attitude, and self-efﬁcacy domains improved signiﬁcantly, were time constraints and a general lack of system sup- using paired t-test post curriculum (p < 0.01). Speciﬁc port in most primary care settings. Students in general did skills in the evaluation of mental health, substance abuse, not complain about safety or security at shelter or clinic and other risky behaviours improved signiﬁcantly (p < 0.05) sites. Women’s shelters, where survivors of sexual trauma (Tab. 2 and 3). or abuse resided, were in general reserved for female stu- All students were observed and were precepted during dents, and their working environments were often described all of their clinical encounters by faculty preceptors, and as ‘tough’ but ‘manageable’ by the students. participated in devising the plans of care for patients and addressing social conditions that impacted their patients’ Discussion clinical encounters. Final evaluations of communication skills by the faculty preceptors were available from 14 students. Eight students The high number of homeless people in almost every major were not available for a full evaluation of direct clinical city in the US [1] provides a valuable opportunity to train encounter observation by the faculty preceptor due to mul- practitioners in health disparities, and to address the spe- tiple factors, including scheduling problems due to holi- ciﬁc needs of this vulnerable population. Our ﬁndings in- days, sick leave, conﬂict with medical school exams, and dicate that students gained signiﬁcant knowledge, attitude, incomplete evaluations. A majority were rated as having and skills after participating in the clinical and population- ‘outstanding rapport with patients = 3’ on a scale of 1 to 3. based curriculum provided. Despite a high level of base- History-taking skills assessments included items related to line attitudes and self-efﬁcacy, there were still signiﬁcant 158 R. Asgary et al. Tab. 2 Knowledge and attitude among medical students pre- and post-curriculum in New York City shelter clinics, 2012–4 Pre Post P value paired Mean t-test SEM KNOWLEDGE 0.2822 0.422 p < 0.001 Composite score (Yes/No, or one correct answer) 0.0325 0.022 18 15 What is the average number of homeless persons who sleep on street each night in 0.17 0.87 p = 0.001 New York City? 0.09 0.09 a) 20,000 b) at least 10,000 c) 3–4,000 d) I have no idea 18 15 What is the percentage of family homelessness among homeless population in the 0.11 0.33 p = 0.082 United States? 0.08 0.13 a) 15–25 % b) 30–40 % c) 50–70 % d) I have no idea 18 15 What is among some of the most common complaints in dropping centres? 0.08 0.62 p = 0.015 a) Headache b) abdominal pain c) cough d) feet swelling 0.08 0.15 13 13 The highest cost of homeless to society comes from? 0.79 0.92 p = 0.081 a) Social services b) food and housing c) outpatient care d) hospital admission due to 0.11 0.08 mental illness 14 13 What is the ethnicity/race with highest rate of homelessness among chronically home- 0.53 0.80 p = 0.040 less in New York City? 0.12 0.11 a) Black b) Hispanic c) Whites d) other e) all are equally at risk 17 15 ATTITUDE 3.35 3.65 p < 0.001 Composite score 0.063 0.056 18 15 I am comfortable being a primary care provider for a homeless person with major 2.81 3.94 p = 0.001 mental illnesses 0.22 0.11 22 16 I feel comfortable providing care to different minority and cultural groups 4.10 4.38 p = 0.029 0.22 0.18 22 16 I feel generally overwhelmed by the complexity of the problems that homeless people 3.33 2.56 p = 0.003 have 0.17 0.18 22 16 I enjoy learning about the lives of my homeless patients 3.90 4.63 p = 0.003 0.17 0.13 22 16 I generally believe caring for the homeless is not ﬁnancially viable for my career 2.95 2.56 p = 0.096 0.18 0.26 22 16 I feel comfortable to provide care to a homeless person with depression 3.14 4.13 p = 0.0001 0.19 0.09 22 16 I feel comfortable to provide care to a homeless person with other mental illnesses 2.90 4.13 p = 0.0001 0.19 0.09 22 16 I feel comfortable to provide care to a homeless person with substance abuse 2.81 3.81 p = 0.0001 0.16 0.14 22 16 I feel comfortable to provide care to a homeless person with alcohol abuse 2.76 3.94 p = 0.0001 0.15 0.14 22 16 I feel comfortable to help uninsured or underinsured persons to better navigate health 2.33 3.25 p = 0.021 system 0.20 0.19 22 16 I feel comfortable to negotiate plan of care with homeless patients considering their 3.05 4.00 p = 0.006 constraints and expectations 0.18 0.20 21 16 Likert scale: Strongly Disagree (1) Disagree (2) Neither agree/disagree (3) Agree (4) Strongly Agree (5) Teaching homeless healthcare to medical students 159 Tab. 3 Self-efﬁcacy among medical students pre- and post-curriculum in New York City shelter clinics, 2012–4 SELF-EFFICACY Pre Post P value paired Mean t-test SEM Composite score 3.317 3.695 p < 0.001 0.067 0.061 18 12 I believe that I can assess depression in a homeless person 3.33 4.44 p = 0.0002 0.20 0.13 21 16 I believe that I can apply Depression score/questionnaire to assess depression in a home- 3.62 4.69 p = 0.0009 less person 0.18 0.12 21 16 I believe that I can obtain and assess psychosocial issues from a homeless person 3.43 4.25 p = 0.0004 0.15 0.14 21 16 I believe that I can assess substance abuse in a homeless person 3.43 4.06 p = 0.014 0.18 0.19 21 16 I believe that I can assess alcohol abuse or dependence in a homeless person 3.48 4.19 p = 0.002 0.16 0.14 21 16 I believe that I can obtain and assess sexual history from a homeless person 3.95 4.44 p = 0.0004 0.08 0.13 21 16 I believe that I can assess smoking history and provide smoking cessation to a homeless 3.86 4.56 p = 0.0003 person 0.13 0.13 21 16 I believe that I have skills in directing homeless persons to potential psychosocial re- 2.24 3.57 p = 0.002 sources 0.14 0.22 21 16 I believe that I have skills in directing homeless persons to potential and accessible 2.24 3.38 p = 0.0001 biomedical resources 0.15 0.18 21 16 I believe that I can work collaboratively with social service providers and community 3.95 4.38 p = 0.047 organizations that provide services to the homeless 0.18 0.13 21 16 I believe that I have clinical skills to detect and address most medical problems speciﬁc to 2.95 4.06 p = 0.0001 the homeless population 0.16 0.11 21 16 How has your experience here at Community Medicine Program changed your career 3.11 3.56 p = 0.078 choices to go to: Primary care residencies (Emergency Medicine, Internal Medicine, Pae- 0.11 0.16 diatrics, OBGYN, Preventive Medicine, Family Medicine, General Surgery) 9 16 How has your experience here at Community Medicine Program changed your career 3.22 4.13 p = 0.011 choices to work with the underserved? 0.22 0.15 19 16 Likert scale: Strongly disagree (1) Disagree (2) Neither agree/disagree (3) Agree (4) Strongly agree (5) increases in these educational domains. The curriculum’s Lessons learned unique approach for skills building used a population case- based health disparities focus, highlighting the process by Overall, the curriculum was a positive experience for the which social determinants of health intersect medical, pub- students. They gained an understanding of epidemiology lic health, and social systems and improving comprehensive and demographics of the homeless, appreciation for the learning. health consequences of lack of housing, knowledge and skills regarding appropriate social and community resources for the homeless, and skills in addressing them at the in- dividual and population levels. Students gained clinical 160 R. Asgary et al. skills in identiﬁcation, diagnosis and management of com- dents, using paired analysis of pre- and post-curriculum mon medical and psychosocial conditions, as well as sub- responses for each student helped demonstrate statistically stance abuse issues and the identiﬁcation and assessment of signiﬁcant improvements in educational domains. We used the broader socioeconomic and policy factors affecting the a combination of quantitative and qualitative approaches to healthcare of the homeless. better elicit feedback, and faculty preceptors directly evalu- Students rotated through multiple shelter clinics and ated students’ skills at the end of curriculum. While differ- were exposed to a wide variety of special shelters, in- ent batches of students participated in the training over the cluding those speciﬁc for signiﬁcant mental health issues, period of curriculum implementation, and have been evalu- substance abuse problems, or post incarceration facilities. ated by different faculty preceptors, the direct observations This provided an opportunity for better development of and assessments by faculty preceptors may have been prone skills in interviewing and taking care of individuals with to grade inﬂation. The speciﬁc setting and context of our ex- more precarious situations, which will ultimately improve periences and the inner city urban setting in the city of New their ease and comfort with subsequent homeless patients York, have likely inﬂuenced the experience and challenges during their career. For patients, it likely fostered better of our patients, but also the content of the curriculum, expe- patient-provider trust and rapport with student providers. riences of our student participants, and the success of our To our knowledge and experience, the strength of this programme. The majority of the homeless in New York curriculum was in its setting and complementary mod- City are from ethnic and racial minority groups, and may els of teaching clinical and population-based medicine at face both health system challenges and opportunities that the intersection of social science, which provided unique are different from other states, countries, or suburban or clinical and non-clinical learning opportunities. Students rural areas. The demographics of our students, the urban appreciated the triangulated teaching approach of structured health system setting, and the challenges and availability readings, clinical precepting, and the discussion sessions of social service agencies are also likely to vary in other with medical and social service providers. This created an settings. Our assessment of the curriculum only evaluated opportunity for group learning and collaborative teamwork its short-term impact, and it was not designed to assess its with professionals from other disciplines. The location long-term impact and attainment of educational skills. of our clinics, which were based at the shelters, and the close partnership with community organizations, shelters, Challenges and neighbourhood entities, along with a robust social and medical service referral system with the parent hospi- We faced common barriers in developing and implementing tal, fostered a more effective collaborative environment in a customized health disparities curriculum within a primar- which students, faculty, and clinic/shelter staff, casework- ily service-oriented programme, including a lack of fund- ers, and community organizations shared ideas and worked ing, difﬁculties coordinating and accommodating faculty closely to improve the health of each individual homeless and trainees’ busy schedules [14, 15], devoting speciﬁc di- patient. dactic weekly sessions on an uninterrupted basis, consistent Over the past ten years, there has been a greater inter- networking with grass-root and advocacy organizations, and est and movement toward social responsibility in medicine coordinating students’ clinical and didactic sessions with and global health, which includes the appreciation of the clinical preceptors. Other challenges included securing ad- effects of social determinants of health, [28, 29] the issues ministrative support from the parent institutions to assure of social justice, the right to healthcare and greater health that the training experience and clinical services were unin- equity, and the reduction of health disparities [30]. An terrupted. The course directors provided all administrative overwhelming number of homeless people in our shelter support and primarily used personal relationships to over- clinics are from racial and ethnic minority groups, which come most of these challenges through close negotiations helped students improve their cultural competency skills with the clinics, shelters, and community organizations. No in identifying and addressing the effects of racial and eth- funding was provided to reimburse course directors, collab- nic factors on their patients’ healthcare. This experience orating organizations or shelter staff. To our experience, has undoubtedly helped our students to better recognize the taking the steps to create a formal supervised exposure socioeconomic context of their patients’ illnesses, and to re- for medical students during their ambulatory blocks, ex- alize vividly the context of health disparities in the United pert faculty, existing collaborative work with community States. organizations, and maintaining institutional support during Some important limitations of our curriculum evaluation training are essential components. The body of knowledge include the self-reported nature of pre- and post-curriculum in regard to health disparities and domestic global health ex- surveys, and the possibility of socially desirable responses periences and competencies has signiﬁcantly improved in and feedback. Despite a relatively small number of stu- recent years. Extensive core faculty experience in popula- Teaching homeless healthcare to medical students 161 creativecommons.org/licenses/by/4.0/), which permits unrestricted tion-based medicine, curriculum development, and working use, distribution, and reproduction in any medium, provided you give with the underserved, immigrants, refugees, and the home- appropriate credit to the original author(s) and the source, provide a less, along with available literature resources [9, 13–15, 20, link to the Creative Commons license, and indicate if changes were 21], helped to set objectives, and to design and implement made. the curriculum. References 1. National Alliance to End Homelessness. The State of Homeless- Conclusions ness in America. Washington D.C. USA: Homelessness Research Institute; 2013. The signiﬁcant increase in interest among medical students 2. The US Department of Housing and Urban Development Ofﬁce of in social responsibility and addressing the social determi- Community Planning and Development. The 2011 Annual Home- less Assessment Report to Congress 2012. nants of health has not been matched by adequate prepara- 3. Culhane DP, Metraux S, Byrne T, Stino M, Bainbridge J. The age tion and structured clinical and population-based exposures structure of contemporary homelessness: evidence and implications to underserved populations. This relatively novel curricu- for public policy. Anal Soc Issues Public Policy. 2013;13:228–44. lum, focusing on the healthcare of the homeless, who are 4. Baggett TP, Hwang SW, O’Connell JJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year overwhelmingly from racial and ethnic minority groups, period. JAMA Intern Med. 2013;173:189–95. was designed to teach medical students about the impact of 5. The health of homeless adults in New York City; A report from lack of housing and other social determinants on the health New York City Departments of Health and Mental Hygiene and of the individual and the population. Considering the sheer Homeless Services. 2005. 6. Kim DH, Daskalakis C, Plumb JD, et al. Modiﬁable cardio- number of homeless people, we believe there are opportuni- vascular risk factors among individuals in low socioeconomic ties to teach health disparities to medical students in virtu- communities and homeless shelters. Fam Community Health. ally every large city in the United States and abroad. Further 2008;31(4):269–80. doi:10.1097/01.FCH.0000336090.37280.2e. emphasis should be placed on incorporating and discussing 7. Lee TC, Hanlon JG, Ben-David J, et al. Risk factors for cardiovas- cular disease in homeless adults. Circulation. 2005;111:2629–35. the interface between clinical medicine, social factors and 8. Khandor E, Mason K, Chambers C, Rossiter K, Cowan L, Hwang advocacy opportunities at the population and policy lev- SW. Access to primary health care among homeless adults in els in medical schools. Triangulating teaching methods Toronto, Canada: results from the Street Health survey. Open Med. with targeted readings, structured and supervised clinical 2011;5:94–103. 9. Asgary R, Garland V, Jakubowski A, Sckell B. Colorectal cancer exposure, and interactive case-based discussion with social screening among the homeless population of New York City shel- service providers; and creating and maintaining a working ter-based clinics. Am J Public Health. 2014;104:1307–13. relationship with service providers, using available com- 10. Chau S, Chin M, Chang J, et al. Cancer Risk Behaviors and Screen- munity resources and working collaboratively with grass- ing Rates Among Homeless Adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev. 2002;11:431–8. root organizations, and garnering institutional support and 11. Zlotnick C, Zerger S. Survey ﬁndings on characteristics and health departmental commitment are crucial components. status of clients treated by the federally funded (US) Health Care for the Homeless Programs. Health Soc Care Community. Acknowledgment Authors thank the leadership at the NYU Lutheran’s 2008;17:18–26. Community Medicine Program (CMP), Dr. William Pagano, Bar- 12. Wen CK, Hudak PL, Hwang SW. Homeless people’s perceptions of bara Conanan, and Aaron Felder. Authors specially thank physician welcomeness and unwelcomeness in healthcare encounters. J Gen providers, Drs. Mark Rabiner, Miranda Vondornum, Jacqueline Perez, Intern Med. 2007;22:1011–7. Mira Batra, Ambika Deb and Jonathan Keith Joseph as well as staff at 13. Asgary R, Sckell B, Alcabes A, Naderi R, Adongo P, Ogedegbe G. the CMP program for their invaluable contribution and support of this Perceptions, Attitudes, and Experience Regarding mHealth Among project. Homeless Persons in New York City Shelters. J Health Commun. 2015;27:1–8. nd The abstract of this study has been presented in the 142 Annual Meet- 14. Asgary R, Saenger P, Jophlin L, Burnett DC. Domestic global ing of American Public Health Association, November 2014, New Or- health: a curriculum teaching medical students to evaluate refugee leans, LA. asylum seekers and torture survivors. Teach Learn Med. 2013;25: 348–57. Conﬂict of interest R. Asgary, R. Naderi, M. Gaughran and B. Sckell 15. Asgary R. Bring global health and global medicine home. Acad state that there are no conﬂicts of interest. Med. 2013;88:908. Ethical standards This study received the Institutional Review Board 16. Doran KM, Kirley K, Barnosky AR, Williams JC, Cheng JE. De- approval from NYU Lutheran Family Health Centers. This work was veloping a novel poverty in Healthcare curriculum for medical stu- carried out in accordance with the Declaration of Helsinki including, dents at the university of michigan medical school. Acad Med. but not limited to, there being no potential harm to participants, that the 2008;83:5–13. anonymity of participants was guaranteed, and that informed consent 17. Bonafede K, Reed VA, Pipas CF. Self-directed community health of participants had been obtained. assessment projects in a required family medicine clerkship: an ef- fective way to teach community-oriented primary care. Fam Med. Open Access This article is distributed under the terms of the 2009;41:701–7. Creative Commons Attribution 4.0 International License (http:// 162 R. Asgary et al. 18. McNeal MS, Buckner AV. Using mini-grants and service-learning 26. 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N Engl J Med. ing with underserved communities and curriculum development. 2006;354:1771–3.

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Acollaborative clinical and population-based curriculum for medical students to address primary care needs of the homeless in New York City shelters

Acollaborative clinical and population-based curriculum for medical students to address primary care needs of the homeless in New York City shelters

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Acollaborative clinical and population-based curriculum for medical students to address primary care needs of the homeless in New York City shelters

Acollaborative clinical and population-based curriculum for medical students to address primary care needs of the homeless in New York City shelters

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