Caring for unhoused people offers key lessons to Family Medicine interns at the Keck School of Medicine of USC
By Wayne Lewis
Medicine isn’t a first career for USC resident Will Fang, MD. But his earlier experiences as a teacher in San Diego very much inform his calling.
There, he sometimes witnessed students’ learning being sabotaged by the difficult realities that underserved communities are forced to confront. For instance, a straight-A student might miss a week of class to care for an ailing mother who had alarming symptoms but was too worried about the risk of deportation to seek medical aid.
“Those scenarios shouldn’t be happening in health care,” Fang said. “It’s part of what drove me into medicine, trying to solve that disparity in some way — or at least prompting our system to understand that there are a lot more people in need of help.”
After he earned his medical degree, that ethos carried him to the Keck School of Medicine of USC for his postgraduate education.
“What drove me into medicine, trying to solve that disparity in some way — or at least prompting our system to understand that there are a lot more people in need of help.”
– Will Fang, MD
Fang is among the first cohort in a new residency program in the Department of Family Medicine that requires first-year trainees to work with the Street Medicine team. They provide care to a population in need — the tens of thousands of people experiencing homelessness in Los Angeles. Recognizing that unhoused people face difficulties accessing brick-and-mortar clinics, the Street Medicine program brings care directly to them, wherever they reside.
“The people we serve have largely been excluded and forgotten by society,” said Brett Feldman, MSPAS, PA-C, clinical assistant professor of family medicine and director of Street Medicine in the Keck School of Medicine of USC. “We feel strongly that they shouldn’t get less care.”
The discipline is distinguished from mobile and RV medicine, in which care is delivered within a van — and not only because of the superficial difference in settings.
“We want to care for people in their environment, where they feel most comfortable, rather than bringing them into our RV, where we feel most comfortable,” he said. “Intentionally flipping the power dynamic in the patient’s favor, to the point where they can lead us, is an important lesson residents learn.”
The program’s mission resonates deeply with participants such as Matt Sayre, MD.
“This residency gives me an opportunity to serve the underserved,” Sayre said. “That’s all I ever wanted to do. In fact, that’s why I went into medicine to begin with.”
A commitment to health care access
The new three-year Street Medicine track within the Family Medicine residency is the first of its kind nationwide. Trainees gain firsthand experience in an extraordinarily patient-centered approach to care, according to Corinne Feldman, MMS, PA-C, clinical assistant professor of family medicine and director of the Street Medicine track.
Trainees gain firsthand experience in an extraordinarily patient-centered approach to care
“We value the human connection in Street Medicine,” she said. “It keeps us safe on the street. It allows us to come back the next day or the next week. And it also makes people happy to see you after you couldn’t locate them for a while. They look at you and say, ‘I knew you would find me.’”
USC’s Street Medicine program launched in 2018 when the Feldmans were recruited from Allentown, Pennsylvania, where the two physician assistants had built a large program in the same vein over the previous eleven years. The scope of L.A.’s crisis was a strong motivator.
“Part of the reason we came was the vision that everybody sleeping on the streets in L.A. has access to basic health care,” Brett said.
That vision has galvanized a cadre of Trojans to care for unhoused Angelenos. Today, the team includes physicians, physician assistants, nurses, USC community health workers, physician assistant students, a doctoral resident in occupational therapy, HIV fellows from Los Angeles County + USC and as many volunteers as the program can logistically handle.
“No other residency program is doing anything like this.”
– Matt Sayre, MD
The program has had substantial, measurable impact. Today, nearly three-quarters of unsheltered patients coming from LAC+USC have seen a primary care provider through USC Street Medicine, up from little more than a quarter. At LAC+USC, the readmission rate for patients seen through the Street Medicine program has dropped precipitously since 2018, from over 30% down to 7%.
For Sayre, the fact that a rotation in Street Medicine is a requirement made the Keck School stand out.
“The first thing I thought was, no other residency program is doing anything like this,” he said. “That really intrigued me.”
Likewise, Fang saw the compulsory rotation as a compelling reason to learn at USC.
“Knowing that they really value health equity, for all patients, attracted me to the program,” he said. “That proactive approach of reaching out to the community, instead of waiting for people to come to you, really drew me in.”
Unique lessons for doctors-in-training
The activities of the Street Medicine program regularly extend beyond medical care. Team members may travel as far afield as assisting patients with housing aid, obtaining personal identification or finding transportation.
“Whatever we’re called to do in that moment on behalf of the patient, that’s what gets done,” Brett said.
Of course, the systems behind such services can be challenging to navigate. But there is no one else to punt duties to, and no single person can do it all. So the team embraces a “beehive approach,” in which collaboration is at a premium and team members regularly stretch beyond their comfort zones. There’s simply no room to get caught up in job descriptions or hierarchies.
“I tell my students, ‘Sometimes you drive the bus; sometimes you’re sitting in the front seat; sometimes you’re all the way in the back; and sometimes you have to get out and push — and that can be all within one patient encounter,’” Corinne said. “That is a really valuable lesson to learn early in developing your professional identity as a physician.”
Putting the patient so elementally at the center of health services is a lesson in itself. In Brett’s view, caring for a patient in Street Medicine means really caring.
“USC is building love and solidarity into its medical curriculum.”
– Brett Feldman, MSPAS, PA-C
“As medical students, our residents may have been taught that maintaining distance is a matter of professionalism, to avoid clouding their clinical judgment,” he said. “I hope the lesson they’re learning with us is the importance of loving your patients, and that that’s OK. It means a lot that a school such as USC is building love and solidarity into its medical curriculum.”
No matter the ultimate setting of residents’ careers, Corinne believes the Street Medicine training will make them into better physicians, who are better able to help people for whom health care access and outcomes have lagged.
“The residency is not only for the care of people who are experiencing unsheltered homelessness,” she said. “There are so many transferable skills, learned streetside, that help physicians take care of different types of people experiencing health inequities for a variety of reasons.”
Indeed, the first interns to enter the program see the opportunities for growth in bringing care to those who typically lack access, as part of a team accustomed to stretching scant resources.
“Family medicine calls us to treat everything under the sun, essentially,” Sayre said. “I’m learning a translational practice in that sense. In a resource-poor setting, with me and a backpack, how can I deliver the best possible health care?”
Fang recognizes echoes of his earlier work as a teacher, in the responsibilities, quandaries and rewards of the residency.
“I still remember the first, and last, time I said, ‘the students.’ My principal corrected me, ‘No, these are your students,’” he said. “Well, in Street Medicine, these are our people. And at the end of the day, it feels amazing to help them.”
Learn more about Street Medicine at the Keck School of Medicine of USC at the program’s website.