Learning to Slow Down and Make Medicine Human

By Jacob Watson, MS2 at McGovern Medical School

Growing up in a small town, and then attending undergraduate in a college town at Texas A&M, I had little exposure to the homeless population. Like most of you, I had been approached and asked, “excuse me sir, could you spare a dollar?” but I could probably count the number of times that had happened before I moved to Houston on my 2 hands. I tried to talk to these people and help when I could but being young with no income I felt like there was only so much I could offer. When I moved here in July I hadn’t even been in town for a week when I was approached outside a restaurant and asked for $5 by a man on the street. I told him that I could give him $1 because I didn’t have any money on me just my credit cards and quarters for the parking meter. I wasn’t expecting the response “No I saw inside your wallet, I know you have more in there just give me $5!”. I had to explain to him that I genuinely did not have any extra money on me at which point he stormed off yelling at me in anger. I remember feeling confused in that moment as to why someone would become so angry with me so quickly when I had offered to help, and it made me not want to talk to anyone I met on the street thereafter. Although it was one encounter it started to form an idea in my head of what would happen if I interacted with more of the homeless population, anger and confusion.

Over the next few months I didn’t attempt to investigate these feelings any further, I became acquainted to Houston, made new friends, and began my studies. I attended a Thanksgiving dinner with a group of friends where I met an older medical student who talked to me about her passion for global health, underserved populations, community outreach, and social determinants of health. She told me that she had been working with the homeless population in Houston for almost a year now, and that it was one of the most rewarding experiences she ever had. She told me that her passion really blossomed when she began working at he HOMES clinic at the end of her first year of medical school. Seeing her excitement when she spoke about her passion and plans inspired me to think about my own and ask myself “What do I want to accomplish in medicine?”.

The following Thursday I saw a post on Facebook by a friend of mine “Emergency! I had a last-minute conflict come up and can’t make my HOMES clinic spot this Sunday at 9 AM, can anyone take my spot??”. I thought about it for a minute, and I decided that this would be a great time to practice my full physical exam I had just learned and get some volunteer hours while I was there. I took the spot. I remember being so nervous that morning about how the day was going to go. I checked the address three times and still ended up driving past the parking garage before looping back and finding a spot. I walked down the sidewalk and saw 15-20 people sleeping or laying down against the iron fence around the Beacon. I began to walk down the sidewalk and I remember thinking “are these people going to yell at me too like the first day? There’s the gate let me just get inside quickly”. Of course, the gate I approached was locked. I stood there trying to figure out how to get inside the fence to the clinic for a few seconds when the man on the ground next to me stood up “excuse me sir, are you trying to get to the clinic?’ “Yes” I replied. “Follow me inside, the doors are just over here”. We walked together for a minute, he asked me how my day was, and then he thanked me for coming that morning. I asked him if he was going to come to the clinic today and he told me no, but that everyone there appreciated what we did. That conversation made me feel proud to be there that morning, but more importantly when I look back this is where the trust between the homeless population and myself started to rebuild.

When I walked into HOMES clinic I sat down and began to talk to the other students in the waiting room. “So how does this work, when do we start seeing patients”. I expected to see at least 10-12 patients in the six hours that we were there. “Well we are going to have a quick orientation in a minute, and then we will go out into the beacon for 30-45 minutes to talk to everyone. After that we will split up into teams and probably see 2 patients each. Just ask them how their day is, get to know them, and see if they have any medical problems that they want to be seen for today in the clinic.”. I don’t remember every conversation from my first day at HOMES, but I remember them going something like “Good morning, have you heard about the medical clinic next door, is there anything you would like to be seen for today? Yes? Great go talk to the people in the white coats. No? Okay, have a nice day”. I remember being nervous and feeling like these people did not want to talk to me and I mostly kept to this script.

We returned to our exam rooms where I saw my first patient for the day with my team, a middle-aged man who said that he just needed a medication refill and that he would like a new cane. After talking to him for a few minutes I quickly began to realize that he was quite a complex case and my 4 months of medical knowledge would not be able to handle it. Uncontrolled Diabetes, Neuropathy, a recent significant blow to the head with vertigo for 3 weeks since the blow, a recent fall, and all his medications had been stolen in the past week. I watched eagerly as my clinical student began to engage the patient, waiting to glean any medical knowledge or interviewing skills that I could from him. “Sir I am so sorry that you had your medication stolen and that you lost your cane, I want to do everything that I can today to try and help you”. I watched as the clinical student continued to show patience when listening to our patient’s problem, empathy when he worked to relate and build a relationship with him, and professionalism in how he prioritized this patient as if he was a VIP. What I remember most when I look back on my first day in HOMES clinic is that I could start to answer that question “What do I want to accomplish in medicine?”, and that was to prioritize and make a human connection with every patient as I had just seen done.

Today I have finished my first year of medical school, and just volunteered at HOMES clinic for the 4th time this last weekend. When I look back at the experiences I have had there were some interesting cases, but the most joy I had was talking to the people in the beacon in the morning before we went to clinic. When I approach someone, it is no longer the scripted speech about the clinic next door, but instead a “Good morning sir/mam”, a warm smile, and a handshake before I ask for their name and if I can sit down to start a conversation. I have met some of the most interesting people: military veterans, construction workers who helped build NRG stadium, people who love sports, people who love to garden, and people who probably grew up just like you and me. I have had the opportunity to sit down and pray with a group of people at the Beacon in the morning, and I have sat down and been asked about my passion and goals. Taking the time to slow down and get to know your patients no matter if you are at the homeless clinic or the private hospital in a large medical center not only helps you form relationships, but I believe will also lead to a more fulfilling career in medicine.


Breathing Easy – Reflections from a Project C.U.R.E. Volunteer

By Alyssa Thomason

I’ve been volunteering at Project C.U.R.E. for years with my whole family. What started as my brother looking for some high school volunteer hours evolved into a second career for my mother, who currently serves as Operations Director for the Houston warehouse, uniting her passions for volunteering and management with her interests in healthcare. If you volunteer there, you’ll find her giving orientation talks, driving forklifts, calling embassies, reminding people to hydrate, and doing what she loves.

I wanted to share the experience of volunteering at Project C.U.R.E. with my peers in medical school, so we partnered with HOMES, and started volunteering with students from BCM, McGovern, and UHCOP. I believe that this organization and the healthcare students of Houston have a lot to offer each other. Even as students, we have more intuition than you’d think for dealing with the supplies that need to be sorted, fixed, categorized, or discarded. As we learn about some of these tools in the warehouse, we recognize and understand them on a different level when we see them in the hospital or clinic – we’ve become more comfortable and familiar with them.

My favorite example of this phenomenon is my personal “pet project” around the warehouse, sorting laryngoscopes (the tool used for placing breathing tubes). The summer before entering medical school, I embarked on the intimidating project of sifting through the piles of parts of varied sizes, shapes, and models to figure out how they fit together, how to trouble shoot when they didn’t work, and which parts were needed for a complete and usable set.

In the classroom, I learned how to use these tools to make sure patients can keep breathing. I saw them in practiced hands in operating rooms and trauma bays and intensive care units. I taught other medical students about them as we practiced with mannequins.

When I see an intubation in the hospital, I think back to the sweaty Houston warehouse that summer, picking apart the handles and batteries and lightbulbs. I think about the once-scattered parts assembled whole in the hands of a doctor who didn’t have one before, oceans and continents away. I think about when my brother was in the hospital and needed a breathing tube after a severe food allergy left his throat swollen shut. I think about the doctors who have plenty of laryngoscopes at their disposal to save kids like my brother every day and send people into surgery safely.

I think about these things as I’m volunteering with HOMES students, teaching them how to pack up kits of complete laryngoscopes. Together, we pick through buckets of parts, testing and re-testing their fit, and finally packaging them into a box. We place the boxes on a growing stack of other boxes waiting to be packed onto a shipping container that will fly or float to its destination, where someone will have the tools to save lives.

Alyssa is a fourth-year medical student at BCM interested in global surgery, currently serving as the Project C.U.R.E. Liaison to HOMES Clinic. 

Alyssa with her mother in the Houston warehouse

Alyssa with her mother in the Houston warehouse

Partially sorted laryngoscope parts.

Partially sorted laryngoscope parts.

A fully assembled laryngoscope and piles of complete laryngoscope kits packed by HOMES students.

A fully assembled laryngoscope and piles of complete laryngoscope kits packed by HOMES students.

Lessons in Women's Healthcare from HOMES Clinic

By Sohini Bandy

Social determinants of health have a profound effect on physical health. Societal issues, such as poverty, unemployment, housing insecurity, stigma, bias, racism, trauma, and lack of education, fuel health inequalities that affect the most vulnerable people in our society. As a medical student, working with homeless patients at Healthcare for the Homeless Houston and through HOMES clinic truly opened my eyes to this – because these patients lack so many basic needs, they experience horrific trauma and shortened life spans. Another example of an issue molded by social determinants of health, which is particularly salient to the state of Texas, is maternal mortality. Texan women are dying from childbirth. Our neighbors are dying. Many of us have heard the statistics: here in Texas there are 34.2 deaths per 100,000 live births, a rate that’s double the national average, worse than several developing nations, and that appears to be increasing. It’s deplorable and shameful. We should all be ashamed of any maternal death that could be prevented - yet what can we do? Here’s my attempt to put the puzzle pieces together to try and figure that out.

For me, it starts at Angela House, a transitional facility for women leaving the criminal justice system, located in Southeast Houston. These women have been through unimaginable trauma – childhood sex abuse, alienation from their families, homelessness, human trafficking, and prostitution - and live with mental health issues as a consequence. Being at Angela House is the first, very important step for them to start to take control of their lives and head down a brighter, less perilous path. I got to know these women while implementing a wellness curriculum I’d designed for them. Over the course of more than a hundred hours with them, one thing became clear to me:

These women have perpetually fallen through the cracks of society and, as a result, their health is suffering. Substance addiction could be from attempting to escape the pain of early childhood trauma and/or sex abuse. Anxiety and depression could be a consequence of living with an abusive partner. Obesity, hypertension and diabetes could be a secondary effect of living in constant, toxic stress on the streets… or from living from paycheck to paycheck supporting a family… or from dealing with constant discrimination as a Black woman… or even from the fear of being arbitrarily punished by a pimp. Viral hepatitis, HIV and HPV infections could be due to unsafe drug and sex practices from being trafficked and prostituted, or from sleeping with others out of necessity to fund a drug habit. Which was instigated by early childhood trauma. And the cycle goes around and around. To me, it became clear that social determinants of health were influencing these women’s health to a greater degree than biological and medical determinants.

Those women at Angela House are not the ones in our maternity wards now, who are suffering while or after giving birth. But they are going through the same issues that the sickest moms are dealing with – obesity, drug use, poverty, STDs, hypertension, diabetes, and mental health issues. I could easily imagine one of these women a decade or two ago, fighting to make it out of the Labor and Delivery unit alive.

 So, what can we do?

For the last month of my clinical training, I helped to care for homeless patients at Healthcare for the Homeless – Houston. There, doctors work hand-in-hand with social workers, psychologists, and housing providers, and next door to legal aid. This team of experts, all in one spot, confidently and compassionately address these patients’ complicated medical histories and tough social backgrounds from all angles and offer them concrete steps to change their situation, if they choose to do so. Observing these direct and effective partnerships gives me hope that, with this model, we can help many more patients reshape their current circumstances to become more healthy and beneficial for their future goals.

These issues are daunting, and wide-ranging – after all, they shape our society. Sometimes just thinking about how deeply engrained, prevalent and messy these problems are makes me want to crawl into bed and never come out. But there are people, organizations, ideas, and organizations like Healthcare for the Homeless Houston that are actively combating social determinants of health that give me hope and make me get up, face the world, and fight again. There is a way forward to chip away at these injustices, and as a Texan physician-in-training, I accept the challenge.

Time to Team Up

By: Erica Smith

While driving away from HOMES Clinic, an unusual mixture of emotions swells inside me. I notice happiness from sharing conversations in the Beacon and excitement from treating grateful patients. I feel sadness from hearing the challenges of homelessness, accompanied by a sense of determination to address this widespread issue beyond the medical sphere. I think to myself, “What can I do to end homelessness?”

The first time I served at HOMES Clinic as a clinical student, I began the Sunday morning with a bit of nervousness. Being six weeks into third year, I had only completed an Ob/Gyn rotation. With such little experience, I wondered how I would lead the HOMES Clinic team to develop the best possible assessment and plan.

Upon entering Room 1 to prepare for the first patient, I was quickly followed by two pre-clinical medical students and a pharmacy student. “Hi y’all, my name is Erica. I’ll be the clinical student for this room,” I announced. As the other students introduced themselves, I began to feel more at ease. We talked about our different schools and experiences while waiting for the first patient to arrive.

The remainder of the day progressed in a similar manner—at ease and full of dialogue. During the first patient’s history and physical, we worked as a team to create a full assessment. One of the medical students elicited a thorough story from our patient, using questions to fill in any blanks. The pharmacy student deduced the patient’s previous medication based on its purpose and a description of the pill itself. The medical student who performed the physical exam helpfully reported pertinent findings as he worked. Once the patient left the room, we discussed our assessment and plan as a group, working together to optimize the patient’s treatment plan. While I typed the plan we generated, I realized my nervousness had completely vanished throughout the encounter. With a well-equipped team like this, I felt confident that our patient was receiving the best possible care.

My initial interest in HOMES Clinic stemmed from the opportunity to serve those in need, interact with patients, and learn from mentors. However, upon reflecting on my time at HOMES Clinic, I have identified further invaluable lessons from volunteering with this organization. Foremost, HOMES Clinic enables personal interactions with those who are experiencing homelessness. The conversations about daily life and interests are pivotal for understanding the challenges of homelessness and inspiring change in the community.

I have also found that HOMES Clinic provides an exemplary model of how medicine should be practiced in the real world—as a team. The clinic experience enables students from University of Houston College of Pharmacy, Baylor College of Medicine, and McGovern Medical School to learn from each other and develop important skills for working in an interdisciplinary team. This lesson of teamwork especially stands out in the context of homelessness; what better way to address such a pressing and complex issue than as a team? Through teamwork within the community, solutions for the homeless population can be optimized as each person provides a unique perspective. With this in mind, I have a far better question that I should be asking when driving home from HOMES Clinic: “What can we do together to end homelessness?”

Erica Smith is a fourth-year medical student at McGovern Medical School. She is currently serving as the HOMES Clinic Executive Director.

An Exercise in Futility

By: Conor Holton-Burke

“I’m a dead man walking.” Those were his first words. He said it airily, as his cheeks climbed his deeply creased face in a crooked smile that caused his unkempt beard to obscure his eyes: the juxtaposition of jolly and macabre characteristic of those experiencing homelessness. After spending some time with him, I had to agree with his initial assessment. If I were being pedantic about things, I would argue that he wasn’t actually “walking.”

He was in a wheelchair, huddled under a grimy collection of jackets and blankets, which protected him from the uncharacteristically chilly day. He had uncontrolled diabetes, and knew that he was supposed to be taking insulin twice a day, but didn’t know how much or what type. He had recently left an emergency room, where they had helpfully given him a paper subscription for his insulin and patient information pamphlets. They didn’t ask whether or not he knew how to read (he couldn’t), if he knew where to fill it (he didn’t), how he would get to a pharmacy (he couldn’t), or if he had a refrigerator to store the insulin in (I’ll let you guess). Consequently, he hadn’t taken any diabetes medication of any kind, and he was feeling nauseous.

He also had an open wound in his belly that was draining a light brown fluid that smelled like a rotten egg in a dirty sock. He said that a hernia had been repaired several months ago, but the wound had never healed. The fluid wasn’t stool, and the wound was not actively infected, but it was a recipe for disaster. Also, his right scrotum was the size of volleyball. Also, his feet were the color of beets, and he had open wounds along the dorsum of both dripping a fetid, creamy fluid into his yellow, crusted socks. To top it all off, he had suffered a stroke several years back, which had cost him the ability to read and left him completely incapable of navigating the city he lived in.

We would have sent him to the emergency room if he hadn’t been wearing the wristband from the emergency room he had just left. Despite having a blood glucose in the 300’s and the aforementioned ailments, his discharge paperwork said that he “did not have an emergency medical condition,” and they discharged him to The Beacon.

With a healthy amount of skepticism, I checked the Harris County health record only to find to my horror that his story was largely true. A few days prior, he had been to Ben Taub where they had e-prescribed his medicines (because Ben Taub no longer has an in-house pharmacy), scheduled a follow-up appointment in South Houston (that he had no hope of ever making it to because he could not read the directions he was given), and placed him in a personal care home (which he refused to go to). The only thing we could do was try to reschedule his primary care appointment to the only place he knew how to get to in the whole city: Ben Taub. We weren’t even able to do that. Failing to help him in any way, I gave him a water bottle, put a clean pair of socks on his weeping feet, and told him to go to the Ben Taub Emergency Center when he started to feel worse. He was obscenely grateful for these small tokens, but hearing his litany of unsolvable problems left me hollow knowing that this cycle would likely continue until he died.

To the more seasoned clinicians in the audience, please know that I am not hopelessly idealistic. Healthcare professionals can only accomplish so much without some manner of personal responsibility. I know that by refusing to go to the proffered personal care home, his “dead man walking” pronouncement became more of a self-fulfilling prophecy than a victim-of-circumstance situation. I only wish to point out the many inadequacies in our heath care system. Without an in-house pharmacy, illiterate patients are virtually guaranteed not to receive their medications or take them properly.  If we schedule primary care appointments outside of the city, we need more accessible transportation options, especially for wheelchair-bound patients. We also need to reassess how we treat patients with disabling illness. For many, personal care homes and skilled nursing facilities are not tolerable. It’s tempting to tell this patients not to look a gift horse in the mouth, but if we don’t address our patients’ needs we are dooming patients like this one to visiting the ER multiple times a week without receiving any medical or social treatment of value.

Conor Holton-Burke is a fourth year medical student at Baylor College of Medicine. He is an active volunteer for HOMES, serving both in clinic and street outreach. During his third year, he completed the HOMES Pathway for Baylor's LACE program.

Cookie Cutter Care Doesn’t Cut It

By: Callie Downs

I walked through a maze of metal fences and empty streets in order to find HOMES Clinic. The Houston Marathon was going on, and the normally busy streets were cleared for all of the runners. Nervous doesn’t even begin to describe how I felt. What could I contribute to patient care as a first-year pharmacy student?

Our first patient was a young woman. Her chief complaint was that she couldn’t sleep. The medical students started by taking her medical history. I was able to chime in and ask about medication history, current medications, and any allergies. The patient was soft spoken and she mumbled occasionally. She slouched on the exam table and wouldn’t make eye contact with us very often. As we were asking questions the fourth-year medical student performed a psychiatric evaluation, but the patient showed no signs of being a threat to herself or to others. The first-year medical students did a physical exam, and then the patient returned to the waiting room.

We presented the case to our attending physician and pharmacist. We selected trazodone as the appropriate treatment for this patient since it was a common treatment for insomnia and it was available in our pharmacy, but then the attending physician asked a question that changed my mind. “Does she feel safe?” I hadn’t thought about it. Trazodone is a sedative. Would you want to sedate a young woman who sleeps on the streets and potentially put her at risk for assault? We didn’t ask if she had a buddy or if she felt safe where ever she sleeps. Furthermore, the physician pointed out that even though she said she didn’t have any thoughts of hurting herself or others it didn’t mean that she was truly okay. People lie. Patients lie. Mental illness is tricky. We wanted to talk to the patient more before deciding on a course of action, so we went to get her from the waiting room.

She was gone. She had told the guys at the front desk that she would be right back. At first I thought she would surely come back, but the longer we waited my hope deteriorated. It was devastating. It felt like I had lost my first patient. I could’ve done something for her; we could’ve helped her. What could we have done differently to provide better patient care? Where did I go wrong?

We helped a second patient that day. We were able to counsel her and give her some medications to help her condition, but I still walked out of the clinic that day feeling as if I had failed as a healthcare provider. I stood there in the empty streets of downtown Houston. The crowds and fences from the marathon had disappeared. Even though it was daytime and I had my phone in my hand, I felt unsafe as a young woman standing alone. My mind flashed to our first patient and my heart broke. She didn’t choose this life for herself. It could have just as easily been me sitting on that exam table.

I think that mental illness and homelessness are more prevalent than we like to let ourselves admit sometimes. HOMES Clinic opened my eyes to tangible evidence of both.  I learned that sometimes clinical guidelines aren’t applicable to patients in specific situations. The medications you would select for someone who was homeless can be different than the medication you would prescribe to someone who had a home and safe environment to return to. Medical treatment plans are customized to every patient’s symptoms, disease states, and medical history, but they are also personalized based on individual circumstances. Every patient, regardless of their demographics, deserves custom care –patients don’t all fit into one cookie cutter guideline. Our patient deserved customized care, and I feel like I failed her. I wanted to make her fit the mold, but I did not consider her circumstances.

I think about her a lot. Did she get the help she deserved? Does she sleep? Is she still out on the streets? I may never know the answer to any of these questions, but I do know that she taught me more than I could have imagined. No patient is the same, and it is our job as healthcare providers to be hypervigilant and aware. You might not be able to save every patient; to change every life you cross paths with. But it is your responsibility to try.

Callie Downs is a first-year pharmacy student at the University of Houston College of Pharmacy.

The Value of $5

By: Sally Huang

This afternoon after class I contemplated studying in one of my favorite coffee shops. In an effort to save money, I had recently made a plan to only study at school or at a local university library on weekdays and limit my coffee shop excursions to just the weekends. I hadn’t been adhering well to this plan, and subsequently I found myself wavering towards the library.

I approached the stop light that would force me in one direction or the other (coffee shop or library). After selecting my lane I noticed a man standing in the middle of the road. He was a tall, well-built African-American man who looked to be in his 40’s. He had short graying hair and wore a plain cotton navy blue sweater over belted khaki slacks and tennis shoes. His glasses had round wire rims, making his round face look small. He looked tired, but not tattered; disheveled, not destitute. His portly stature and erect posture suggested a recent departure from white collar favor. Even in the shelter of my car I could feel the penetrating force of sunlight on my light skin; here was a large, older dark-skinned man standing outside covered head to toe in thick clothing. His cardboard sign read: “NEED GROCERIES FOR 2.”

I was about two lanes over from him. I took out my wallet and counted my bills: 3 $20’s, a $10, and a $5. Two quarters – change from oatmeal this morning. I mulled over the money for about five seconds and decided to give him the $5.

In the short time it took for me to take my wallet out and count my money, the man had made his way to the cars parked behind me. The light was still red. He had just started to make his way back when the light turned green. I was dismayed but didn’t want to fight the oncoming traffic behind me. I took my foot off the brake and moved on.

After passing through the intersection I drove to the coffee shop, bought a coffee for $2.95, and sat down to write.

This cup of coffee – if I bought just one less every week and instead gave it to someone else who could really use it – what kind of difference would that make?

What can $5 buy? It is one or two cups of coffee (depending on where you go). Three Snapple from the vending machine at school. Two morning oatmeals. 0.5 times parking in the ridiculously (over)priced garage next to school. One visit to an exhibit at the Asia Society.

What else can $5 buy? A box of strawberries. One large can of Bush’s vegetarian baked beans. Five bags of chips. Water. If spent wisely, one full loaf of bread and a large jar of peanut butter from the grocery store. Apples for the week.

What is the value of $5? It is a shared meal for two. It is the alleviation of churning hunger, at least until the next morning. It is an arbitrary amount, the act of giving which tells the receiver, “I care. I want to help. You are not alone.”

I know what people, even those close to me, might say about panhandlers: that they are lazy scamming leeches that can’t be bothered to help themselves. At one time in my life I believed this; these thoughts made it easier for me to ignore the suffering right before my eyes. But after working with this population through a student-run homeless clinic and a Street Medicine Outreach team, I know how inaccurate – and how harmful – the rhetoric of blame can be. And in my own experiences with depression, I know the despair that isolation brings. In the same way that my problems feel like more than I can handle when I think I am carrying them alone, their struggles – to find food, access healthcare, get housing, stay safe in the streets – are only exacerbated by the feeling that the world is deaf to their suffering. Most of them want to help themselves, but they need some help from others along the way.

I paid for my coffee with a $10 and received two $1’s and a $5 back. I’m saving the Lincoln for him.

Sally Huang is a second year student at BCM. She is currently serving as one of the BCM representative for HOMES Clinic.

The Little Things

By: Nadia Haj-Ismail

“Does your leg hurt you?” I asked a patient with a bandage on his leg while managing at HOMES Clinic.

“No, not at all. But when I was walking past a few people sitting outside of the Beacon, one of the guys said, ‘What is that awful smell?’ It hurt me right here.” He pointed to his heart with a sad smile on his face.

I felt my own heart shatter into a million pieces. I couldn’t think of what to say to him; no words could encompass the amount of sadness that I felt when I looked at the expression on his face. As I continued to talk to this patient, I realized that in addition to dealing with the daily struggles of homelessness, he was also trying to properly care for chronic ulcers on his leg. For an individual with a home, caring for an ulcer may be as simple as buying some gauze and bandages and changing the dressing on a daily basis. For a homeless individual, however, the process is more complicated when the individual doesn’t have access to a shower, transportation to get to a store, or money to buy the necessary supplies.

Beyond each of these challenges, this patient had also had hip surgery in the past; as a result, he was physically unable to bend his leg to reach his bandages. The only time that he was able to change the dressing was when he had a doctor’s appointment or used some sort of urgent care center such as an emergency room. He told me that on the previous day, he had gone to an ER where the physicians had decided that changing his bandages wasn’t a necessary service. Instead, he was instructed to wait another two days until Monday, when he could be seen in a clinic.

It has been nearly two years since the first time I volunteered at HOMES Clinic. Every time I am at the clinic, I hear another story about the unimaginable struggles that our homeless patients face as they drift along the streets, unsure what each new day will bring. Some of the patients have been homeless for a considerable time, their rugged faces reflective of all they have seen. They know what resources are available to them, where to sleep, and where to get food. Other patients are newly homeless, evident from the uneasy look in their eyes and the flailing optimism in their voices.

The patient was not exaggerating regarding the smell of his bandages. The look on the faces of the other patients in the waiting room made it obvious that the odor was very strong, and anyone who opened the door to the patient’s room was greeted with a powerful gust of the unpleasant smell. Our attending said that there was little to no concern about infection of his leg, and the patient had an appointment to see another doctor the very next day. Regardless, the team decided to address the patient’s concerns and change his bandages.

He was so extremely grateful for our help, thanking everyone for doing such a huge favor for him. However, the reality is that changing his bandages was not much trouble at all. I’m still bothered by the fact that the ER chose not to change his bandages for him. I know that the ER is not supposed to be a place for non-emergent or routine care, but for someone who is homeless like our patient, there aren’t many alternatives. We usually don’t get to learn what happens to patients after they leave our clinic, but hopefully, this patient is able to find himself somewhere stable to live—a home that will enable him to properly care for his chronic wounds and establish long-term care with a primary care physician. In the meantime, hopefully HOMES Clinic can continue to address his and other homeless individual’s needs.

Nadia Haj-Ismail is a third year medical student at UT Houston. She is currently serving as one of the Associate Directors of Operations on the HOMES Clinic leadership team.

Street Medicine Conference 2015

By: John Tucker Sigalos

If a tree falls in the woods and no one hears it, does it make a sound? This classic cliché sums up the main take away that I had from the Street Medicine Conference I attended this past October. Before I explain why, let me set the stage. My name is John Tucker Sigalos, and I am an MS2 at Baylor College of Medicine (BCM), a manager at H.O.M.E.S Clinic, and a Board member for the clinic as one of the BCM representatives. When I, along with six other medical students representing both BCM and UT Houston, arrived in vibrant San Jose, we were prepared to learn from the experts how we might better serve the homeless population at our student run clinic, and to gain insight into how we could start a street outreach program that would bring healthcare to the hidden urban populations.

Over the first two days of presentations, lectures, talks, breakout sessions, and sharing of ideas, we listened to heartbreaking personal stories, heard about the services that were being provided to homeless individuals around the world, and learned about the challenges that were overcome to provide these services. An undercurrent throughout these learning opportunities was the issue of being a healthcare provider with very limited resources, due to having an antagonistic or dismissive relationship with those who control the resources. Stated bluntly, there was bubbling frustration that, “Nobody cares about homeless people and their well-being.”

This led me to two questions. How do we as students, physicians, social workers, and all others who would like to see progress made on improving the health of our poorest citizens actually make effective change, and who has the ability (power) to make change? The second question is a bit easier to answer. Our government, hospital administrations, and insurance companies make a lot of the decisions on how resources are allocated. With this group of people in mind, one might picture well-dressed men and women sitting in a boardroom making decisions about money that will drastically affect people’s lives whom they haven’t even met. This impersonal and money based approach irks the moral sensibilities of those passionate about making change and providing care to the underserved. The argument from those out there on the streets helping homeless people is that, “I cannot believe that anyone who could see these people and hear their stories could not feel a moral obligation to help them.” In order to spread awareness and inspire people to care about the problems of the homeless, there have been documentaries produced describing their plight and the deplorable acts of government in films such as Lost Angels: Skid Row Is My Home and Exodus From the Jungle. Yet, despite being interesting and thought provoking films, it is easy to see that providers, students, and activists are speaking a different language than the resource brokers.

This thought process leads me to the conclusion that in order to effectively help the homeless, those in the medical community need to hold their treatment and resource allocation to the same standard that we do everything else. Plainly, we need to do more research. Research and action through evidence based medicine is the way that healthcare providers prove we are doing the best possible job for our patients. I believe that through this method we will be able to show that helping the homeless and those in need is not only morally responsible, but fiscally responsible as well. Think about this scenario: A homeless man is on the street without access to healthcare and has uncontrolled high blood pressure. How much money will it cost to give him Lisinopril for a year? After searching online I found that the average price for a thirty day supply is roughly ten dollars. Over a year, let’s round up much higher and say it would cost two hundred dollars to supply this man with his medication. Without this medication, let’s consider the scenario in which this man has a stroke as a result of his untreated hypertension, presents to the emergency department, and must remain in the hospital for weeks. Now, how much has this man cost the hospital and the government supporting the hospital? Thousands? More than a hundred thousand? I am not an expert on hospital cost structure, but it makes sense that you could prevent similar tragic events and treat a lot people for much less just by reducing the heavy burden of acute, late stage, and preventable health care costs. Even though this thought experiment makes intuitive sense, we are not doing the high quality research necessary to prove that providing sustainable, chronic healthcare to patients without access is actually beneficial to society, including the resource brokers who make the decisions. The physicians and other people on the ground are doing great work and providing great services, but instead of doing research and documenting how we are being effective and how we can improve, we are only making documentaries.

The scenario I detail above was tackled on the last half day of the conference by Dr. Sheryl B. Fleisch, a psychiatrist at Vanderbilt. Dr. Fleisch is in the midst of generating ground breaking work that proves her way of providing mental health services to the homeless with chronic treatment is saving money for Vanderbilt’s medical center and improving lives. For her, and for those of us in the medical community who want to make sure that all those in need receive medical care, “money and cost” don’t have to be dirty words that create boundaries to care. With research and simple documentation, we can speak the language of those with decision making power and build a coalition that allows physician care to break through their current four-walled boundaries and extend into the streets and the community.

So, if a tree falls in the woods (if a caring physician helps a homeless patient in need), and no one is around to hear (and we do not do research to document our success as leverage for more opportunities to help), does it make a sound (are we really being as effective as we can be in our mission)?

John Tucker Sigalos is a second year student at Baylor College of Medicine. He is an active volunteer for H.O.M.E.S Clinic, serving as a clinic manager and a BCM Representative on the leadership team.

“Everyone who has ever done a kind deed for us, or spoken one word of encouragement to us, has entered into the make-up of our character and of our thoughts, as well as our success.”

By: Truong Lam
Quote: George Matthew Adams

“Hi, do you have some change… just 50 cents is fine.” How many times has each of us been approached with that line, especially in the Texas Medical Center? Most times, how do you respond? Now, I’m guilty of this too, but most of us continue to amble on, pretending not to notice, or say, “I’m sorry. I don’t have any money.” Not that this is always the wrong answer, but is there a better answer?

Back in September 2013, I helped to form a group at Rice University called OwlsHelp Consulting as the first step towards finding a better solution to this problem. OwlsHelp Consulting was born out of a need to bridge the gap between the homeless population and the many benefits, resources, and opportunities readily available for the financially disadvantaged, as well as to connect students to the reality of poverty for these individuals and families. When we were first formed, the idea was to expose students in a very intimate, real way to the daily struggles of being homeless in Houston. Today, we represent an organization (transitioning to nonprofit status) working to bring comprehensive stability to homeless individuals by tackling all of their problems simultaneously, rather than temporarily putting a band-aid on them.

In the next few paragraphs, I’d like to share a few anecdotes, some insights I’ve developed along the way, and suggestions I have for bringing genuine, influential relief to the homeless of Houston.

Lisa Garcia is a single mom of five kids. This family was the first to receive our assistance, and we continue to work with them today. When we first met Lisa and her family, we looked at them, looked at ourselves, and said, “We’re a team of bright, hard-working, enthusiastic Rice students. I’d say we solve EVERYTHING in a few months.” Boy, have we ever been so wrong! I think when we view homelessness, we see it almost as a “choice,” or rather, something that individuals can escape from at any given time, yet they choose not to. For some people, it may be a matter of “choice.” But for the many displaced and disenfranchised, it’s a matter of surviving. For 10 years, Lisa has been in a vicious cycle of poverty that she has not been able to escape. The reality is every time she tried, she would just hit another wall. If she wanted her daughter, who is resolutely resistant to attending school, to go to school, she’d have to drag her daughter to school by bus, provided that she had money for the bus fare for the both of them. But oftentimes, that would mean she would have to miss a morning job interview. If she had a job interview lined up, she would set up the interview with a certain phone number that she would no longer have when they would like to follow up because she could not afford the phone bills. If she had a spot reserved for housing, she was told that she could not move in since the oldest son has a charge of “attempted burglary” on his record. If she wanted to stay in a motel temporarily, she would be told she is on the MCO list (Must Check Out) because her alcoholic husband has been cited for public disturbance at almost every motel/inn they stay at. And this is really just the beginning.

Another woman, in her thirties, has six kids and is with a supportive husband. They traveled down to Houston from Tennessee looking to start a new life. The move seemed obvious because her sister lives in an apartment here close to downtown. While the woman and her husband were on the job hunt, they stayed in the sister’s apartment. On one occasion, the sister promised to help relocate the family to another apartment, where she said she would pay for all expenses while they continue to look for work. Unfortunately, the sister took the moving van with all their possessions and left without a trace. When our organization was made aware of their situation, they had already been living in a park close to my apartment for almost a week! What’s more is that this was in the middle of December and the youngest of the six children was only four months old.

Interestingly, this family was brought to my attention by a very caring, selfless individual. He had been living in the same park for many years, but saw his job as helping bring assistance to those who are even less fortunate than himself. He’s nearly 50, and when he told me his story, it caught me a little off guard as to how he became homeless. He attended a public university in Utah on a football scholarship, which paid for his tuition and fees. While there, he pursued a degree in accounting. Not too long after his freshman year, his grandfather fell gravely ill and died. His grandfather had raised him throughout his life and had helped to prepare him for college. He was very close to his grandfather and immediately fell into depression. Without the only adult figure he considered to be a role model in his life, he eventually dropped out and descended into a downward spiral that drove him into inevitable poverty. Now, he finds satisfaction in being able to provide food, blankets, clothing, and other basic goods to other homeless individuals—a part of his personality, he says, he owes to his grandfather’s kindred spirit.

In addition to the stories I have mentioned here, I have encountered many different homeless individuals in the medical center and throughout downtown Houston who have very similar stories. Most times, it is the story of someone who is left by the wayside to fend for him/herself, when there is no hope, no direction, no support, and no one to tell them, “It’s going to be okay.” As the previous entries have so eloquently described, we are all human. We have the same desire to succeed, to make our parents proud, to care for our kids, and to give back to our communities. But, to me, what that really means is that we all have the moral obligation to help fellow man and to support each other in times of need.

The problem is here and around us. We cannot turn a blind eye to something that is so deeply entrenched in our daily lives. We see it every day, yet as the problem gets larger, we develop more and more excuses as to why we shouldn’t help “those people.” My request for you is this: when someone asks you politely for change, take some time to listen to their story. Now there are some unstable and violent individuals as well, but if you are in a crowded place and the individual is courteous with you and does not try to impose on you, stay there for a few minutes and ask him/her a few basic questions. “Why are you in this situation?” “Where are you from?” “Do you have family here?” It is beautiful how a few lines can develop a connection that was not there before. Once you have developed this trust, you can then direct homeless individuals to much needed assistance by handing them a “HELP card.” The HELP card is a wonderful resource sheet created by the Houston’s Coalition on Homelessness. I normally carry a few of these on me, so that if I do run into someone who needs food, shelter, mental help, or rental assistance, I can direct them to the appropriate services by pointing out these resources on the HELP card.

I know that this isn’t easy, but it is necessary if we want to make a difference to the status quo. In closing, I’d like for you to think back to before medical school, before today and the success you’ve accumulated up to this point. Think of all the people in your life, the support you had, and the environment you were in to ensure that you would become the person you are today. Now imagine all of it gone, completely absent from your life. What would have happened? Who would you be today? Many homeless men, women, and children lead the lives they lead not because they choose to, but because this is the only outcome they know of due to the lack of basic necessities for succeeding and striving for their dreams. Remember that when you give someone change or a few dollars, you sustain a caged life entirely dependent on the earnings of others. But if you take a few moments to cast aside the stigmas and open your heart, you’ll be simply greeted with the greatest gift any human can give to another—love.

Truong Lam is currently a research assistant investigating molecular mechanisms of lipid metabolism in the skeletal muscle. He is applying to medical school and would hope to one day use his experiences with his case management work to adopt better and more comprehensive medical practices for the homeless. If you are interested in learning more about OwlsHelp or the work that he is doing, feel free to email him at Truong.N.Lam@uth.tmc.edu.


“Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.”

By: Shawdon Molavi
Quote: Leo Buscaglia

As a clinical student at HOMES for the first time, I felt late to the game. I was unfamiliar with the format of the patient encounters and had no idea what to expect. I was admittedly more nervous than I had ever been on any rotation.

By this point, I had spent plenty of time in the hospitals with patients, but I always had mixed feelings about my role. Most of my patients had spent entire days waiting in the E.R., had been seen by countless doctors, nurses, and other providers, and were often fasting as they waited for procedures. After all of that, who would want a student to come see them? I know this is how all physicians learn, and I have been lucky that most of my patients have been tolerant and supportive of my learning process. However, with so many other doctors around, it often felt like I was going through the motions, not accomplishing anything other than inconveniencing my patients.

Carrying this view when I first went to HOMES, I was very much surprised at the crowd that quickly gathered after we entered the Beacon to triage patients. In just a few minutes, there were twice as many people asking to be seen than we had capacity for. Some had chronic issues that had been continually worsening; others had just been injured the night beforeregardless, all were eager to be helped. It quickly became apparent that this was not just another learning experience for students, but a much needed and sought after service. That worry of being a nuisance because I was a student was gone, and my only focus was to make sure I did everything I could to provide quality care to these patients.

HOMES Clinic provides a unique opportunity through which you can have a meaningful impact, even as a student. My experience was an affirmation of the main reason I wanted to become a doctor in the first placeto help others. Homelessness can be an isolating and dehumanizing experience. With such limited resources, the homeless often struggle to find people willing to help. That is probably why being able to provide such a needed, basic service felt all the more fulfilling that morning. HOMES is certainly not a solution to the wider needs of all the homeless in Houston, but it does show that a few caring individuals can make a difference.

Shawdon is a fourth year medical student at Baylor College of Medicine. He is currently applying to residencies in General Surgery.

"No ray of sunshine is ever lost but the green that it awakens takes time to sprout, and it is not always given the sower to see the harvest."

By: Kristin Tang
Quote: Albert Schweitzer

Growing up and attending college in Houston, I wasn’t unaccustomed to seeing the occasional panhandler on the corner or seeing people sleeping on the streets of downtown. My first real encounter with homelessness was at a downtown pizza joint the year before I started medical school. A girl my age placed a crumpled dollar bill and several coins on the counter. She asked the cook if she had enough for a slice of pepperoni pizza. After visibly trying to ignore her, he finally looked up with disdain and said, “Wait in line until you get to the cashier. We deal with money there.” “But do I have enough for a pepperoni?” she repeated. “I can’t count. I’m having a hard time getting something to eat today.” The man, irritated, looked at the coins and said gruffly, “No. You can only get cheese. There’s only $2.50 there. Pepperoni is $2.75.” He walked away. Realizing this girl was homeless, I volunteered to buy her slice. Her name was Mary, and she asked if she could eat with me. Hesitantly, I said yes.

As we swapped stories, Mary’s mood changed every few minutes, going from deep gratitude for my good deed to borderline ecstasy upon learning that I could read, to crying in despair at her living situation, to anger at social workers for putting her in foster care, to irrational paranoia that shelters were scamming her, and finally to hopeful, saying she too would become a doctor. Meanwhile, there I was, thinking all I wanted out of this was to do a good deed. As I observed her, I was surprised at how sobered I felt by Mary’s reality. I felt guilty and helpless, feelings I had never before experienced after aiding others. These feelings kept me up that night. Was I prepared to deal with this in my future career?

During my first week of medical school, I learned of the HOMES Clinic and jumped at the opportunity to make a difference and explore a new side of homelessness. Fate must have played a part on my first day as a volunteer, because sitting there in the waiting room was Mary. Upon recognizing each other, we shared a warm embrace. This time our encounter was only a few short minutes, because Mary wasn’t my patient and I had others to attend to. I learned that Mary had come to clinic because a dog bit her leg. She told me she was living in the woods. Her demeanor was still a little off the mark. After clinic, I learned that Mary often came to HOMES Clinic thinking she was pregnant. I left the clinic wondering if she would be okay on her own.

I let the thought of Mary slip away as I got further into my medical studies. Early one morning during surgery rounds, as I was deeply entrenched in my patient’s chart, my vision was suddenly obscured by a piece of notebook paper held out by a patient. On the paper, a couple of flowers and the following message were drawn in crayon: “This is to say thank you to all the doctors and nurses taking care of me!” The patient holding the card was a young, disheveled woman in a gown. She was walking unsteadily with her IV tower, grinning from ear to ear, and ranting about how great the hospital was. I took the card and thanked her, commenting on how beautiful it was, while a nurse quickly ushered the woman back to her room. I heard the patient objecting down the hall as I continued rounding with my team. It was strange; she looked so familiar, yet I could not match a name or situation to her face. Twenty minutes later, I realized the woman was Mary. It had been over two years since our last meeting. Now I was left with even more questions and that same lingering feeling of helplessness. What was her situation now? Why is she in the hospital? Why, with so many services available to and being utilized by her, does Mary still seem to be struggling with the same predicament after all this time? Have we failed her?

Because my team wasn’t taking care of Mary, I thought it would be unethical to search for her and meddle in her services at the hospital. The brief encounter in the hospital hall was the last I heard from her. Although most of my experiences treating the homeless have had positive and rewarding outcomes, my encounters with Mary bring to light the stark reality of homelessness. According to a report from Houston’s Coalition for the Homeless, 1 in 5 homeless individuals identify as chronically homeless, and 1 in 4 have mental health issues. People like Mary are falling through the cracks, and there’s no reliable safety net for them. It’s evident that our medical system is flawed in many ways. Often, we don’t even know what happens to our patients after they walk out the door. We succeed with some patients and fail with others. One can easily become overwhelmed with all the imperfections that we see. But like many things in life, it’s the little things that count—the small areas in which we can help, the kind gestures we offer to those we care for. I’m not sure what more we can do as healthcare providers or how to turn things around for our homeless. I’ve since come to terms that perhaps a slice of pepperoni pizza and a sympathetic ear is a good place to start. Maybe people like Mary will make their way back to health and social services because they know they will find our smiling faces and giving hearts.

Kristin is a fourth year medical student at UT Houston. Last year, she co-led a project at HOMES Clinic through the Albert Schweitzer Fellowship. She and former HOMES Clinic Executive Director, Winnie Zou, worked to introduce preventative medicine and social work aspects of healthcare using a community-based participatory approach.

“We Shall Never Know All the Good a Simple Smile Can Do.”

By: Ashley McMullen
Quote: Mother Theresa

I remember my first day at HOMES Clinic – I was about three months into med school with hardly a wrinkle on my short white coat. I remember awkwardly going through the motions of the physical exam, trying to keep my hands from shaking as they palpated the skin of my first real patient. I watched a pharmacy student sail through her patient presentation like a champ, and then stammered through my own like I had just learned English the night before. Some of that Sunday I wouldn’t mind forgetting – but one thing that will certainly stick with me is how I felt that morning at the Beacon.

The Beacon is a community center where homeless individuals can receive services like a hot meal and a shower. Each Sunday, HOMES volunteers spend time next door with Beacon patrons before starting clinic. That morning when I took off my coat and sat down with my coffee, the homeless guy next to me, with the strange body odor, became John – the man who was thrown in jail two weeks prior because he was caught sleeping in his car inside a private lot. He was released in the middle of the night with no money, no car, and no one to call. So he made his bed on the concrete just a few blocks from where we were sitting. The homeless lady to my right, with the facial tic, is Sarah – a woman probably around my age. She left home as a teenager to escape repeated sexual abuse and never finished high school. Sarah had her psychiatric meds stolen at the last shelter she resided, so she prefers to stay outside. What I felt then was not so much pity or shock, but a strong sense of solidarity and understanding. These were individuals like me, with unique stories and experiences that shaped the trajectory of their lives.

We often tend to view the needy and medically underserved through this veil of “otherness” – where we focus so much on our differences that we fail to recognize the shared humanity that unites us. Until you can appreciate where a person comes from, it’s difficult to put yourself in their shoes and effectively comprehend their needs. This is the beauty of HOMES Clinic. We learn to listen to and understand people who are different from us, while acknowledging our own biases – this is what makes us better physicians, pharmacists, and healthcare providers. After four years of being a part of HOMES, I have left clinic feeling inspired, annoyed, overwhelmed, and everything in between. Yet I can say with ease, it’s been one of the most influential experiences of my med school education.

A few months ago as I was getting up to leave the Beacon, the gentleman I’d been talking to that morning said to me, “Doc, you don’t know what it means just to have someone smile at you.” I’m not sure where to begin bridging the gap of inequality in our healthcare system, but I suppose a smile is a good place to start.

Ashley recently graduated from UT Houston Medical School. She will be starting residency soon in Internal Medicine/Primary Care at University of California, San Francisco.


Welcome to our new blog!

The HOMES Clinic Student Blog was created to allow student volunteers to reflect on something passionate to them that stems from their time at the clinic. Students will be writing about a variety of topics revolving around HOMES Clinic, including their specific experience at the clinic, accounts of the history/beginnings of the clinic as they remember it, how their time here helped them in residency or in their journey to become a physician, and much more! So volunteer, get inspired, and share with us!