Understanding the Practice of Street Medicine

One of Dr. Pete Cathcart’s first days practicing street medicine, on a blazing-hot Nashville summer day, wasn’t about blood pressure checks or wound care. Instead, it was about building relationships.

Toting a “heavy” Direct Relief emergency medical pack, he and a patient navigator made their way from site to site in the heat, looking for people experiencing homelessness who might need medical care. When they finally stumbled across an occupied encampment, they introduced themselves to the people there, got a tour, and promised they’d be back.

“The next time when they saw us, that we had actually come back and held to our word, they allowed us to treat them for medical issues,” he recalled.

Neighborhood Health, a community health center in Nashville where Cathcart works as a physician, began its street medicine program during the pandemic. The health center, like providers around the country, had moved many of its services online because of Covid-19, and its leaders quickly noticed that many homeless patients weren’t accessing telehealth services.

Sending a team into the street to dress wounds, monitor chronic diseases, and provide mental health services was a way to make sure their most vulnerable patients were still receiving health care.

Today, the street medicine team includes doctors, nurse practitioners, registered nurses, a van driver, and a patient navigator whose role is to connect people to other services, such as housing. Along with medicine, they bring tents and sleeping bags to distribute to homeless patients.

For Cathcart, the trust he’s earned from patients living on the streets is key. Many don’t trust the medical establishment and were initially suspicious of doctors who showed up out of nowhere, offering help. “Now, that level of trust is there,” he said. “Our patients readily seek us out now. They even come to our clinic.”

One patient, whom Cathcart began treating for a skin infection during street medicine rounds, has now been housed – Cathcart attested that the man’s cat was an emotional support animal – and comes to see the physician during clinic days.

He’s gained much-needed weight, said Cathcart, and is managing a long-term spinal cord injury with the help of physical therapy. “He doesn’t have the stressors he once did,” he said. “He looks like a different person.”

Good medicine

Dr. Jim Withers isn’t the first person to practice street medicine – he credits the work of physicians like Jim O’Connell, Jack Prager, and Joe Greer as inspiration and influence – but he’s the one who coined the term.

“Street medicine” refers to medical care, aimed primarily at people experiencing homelessness, that takes place outside the walls of a clinic. “This was a field of medicine without a name, and it needed to be promoted,” Withers said.

For Withers, the need for a U.S.-based street medicine movement became clear when he was working as a physician in Pittsburgh. Emergency departments would regularly call in the middle of the night, reporting patients whose unmanaged illnesses had turned into crises. “People were ill, disconnected, traumatized,” he recalled.

As a member of the medical establishment, Withers felt like part of the problem. “I wanted to take off the white coat and just be able to liberate myself from the structure, the power dynamic,” he said. “People came in, and they were so traumatized that they didn’t trust you at all, and [even] with your best feelings and dreams toward them, you knew that you were part of the structural violence” that homeless patients regularly experience.

So on the advice of a man named Mike, Withers began dressing in ragged clothing, rubbing dirt into his hair, and going out to spend time with people experiencing homelessness. “Very quickly I realized I couldn’t just be that observer. I needed to dress that wound, I needed to get that blood pressure,” he recalled.

In 2008, Withers founded the Street Medicine Institute, an organization that today connects practitioners working around the world to treat homeless patients. “It’s innovative, it’s rewarding, it’s needed, but honestly, it’s kind of countercultural,” he said of the medicine he practices. He regularly runs into people who fear the social ramifications of practicing street medicine – or just plain don’t approve.

Although unsheltered individuals have many of the same medical issues that the general population confronts – chronic diseases, mental health concerns – Withers said that practicing street medicine means letting go of some of the conventions of the doctor-patient relationship.

For one thing, whatever you have in your backpack is all you can use, he said. For another, a patient struggling with alcohol or substance use disorder, or an unmanaged chronic disease, might be unwilling to change some behaviors. The goal is to provide them with the best care possible while understanding that their goals may be different from a physician’s.

“Street medicine is good medicine,” Withers said. “It’s the only medicine these folks are going to get” if they’re unwilling to go to a clinic or doctor’s office.

Housing and health

Sometimes, said Dr. Danielle Williams, the unreliability of street medicine poses an additional, extraordinary challenge.

Williams heads up the street medicine team at Roots Community Health Center, an Oakland, California-based health center. She regularly practices primary care and treatment for mental health issues and substance use disorders on the street. But in addition, her team, like Cathcart’s, works directly to get people into housing. Her team also routinely brings food and water to unsheltered patients.

For Williams, getting patients into housing – an essential factor in overall health – is a top priority. Since the pandemic, she’s been able to refer a patient directly to housing. “Honestly, the hardest part is finding the patient again sometimes and letting them know they were accepted,” she said. That can also be an issue when treating substance use disorders. “I can offer suboxone, but I have to be able to find that patient regularly, and I haven’t found that to happen,” she said.

She explained that keeping track of medications can be difficult for many of her patients. Many struggle with back issues or arthritis “from having such a hard life.”

“I think focusing on housing is more important,” she said.

The delicate balance between addressing immediate needs and creating a healthier future for a homeless patient is something that street medicine practitioners regularly confront, Withers said. Many have the “hidden agenda” of getting patients into housing and high-quality, regular primary care, but they understand the need to meet patients where they are rather than dictate a course of care for them.

It’s important to be aware that many homeless patients “are tired of having more people take power from them,” he explained. That’s why the work of physicians like Williams, Withers, and Cathcart, who build trust with their patients, treat them appropriately, and listen to their needs, is so essential.

“It’s like harm reduction. You’re going to make the best connections when you just respect people,” Withers said.

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