Toward better health care for the homeless
NFA. Those three letters are a mainstay of physician shorthand in the Toronto hospital where I work. I learned them as most physicians do — early in my years of clinical training. They stand for “no fixed address,” a description applied to patients who have nowhere to call home. But the acronym unofficially means more than being unhoused. It carries the negative connotation of someone who might be combative, disagreeable, infested with lice or bed bugs, or incoherent.
The other week, I was asked to see a patient who routinely took shelter in one of Toronto’s many parks. The nurses and doctors at our hospital knew him well. He would come to the emergency room every now and again with the ailments we often see in people without easy access to food and water, clean clothes, or a bed: malnourishment, hacking coughs from pneumonia, infected skin sores. But it had been a few months since we had seen him.
It was after a particularly stormy night, and someone had found him lying on one of the main paths in a city park. The paramedics wheeled him into the emergency room on a stretcher, and the staff recorded his vitals, ordered an initial volley of tests, and admitted him. Then they called me.
When I approached him, he was lying on his side, his knees folded so tightly into his chest he was no larger than the pile of blankets that lay on top of him. Scanning him for any sign of injury, I noticed he was favoring his right shoulder. Had he sprained it? Was something broken? I wondered.
I shifted his gown and gasped. The skin over his back had been scraped off almost to the bone, exposing pink and gleaming tissue: the muscles of his scapula. He had been sleeping on hard pavement. Night after night, the pressure had literally worn him down.
Patients who are homeless visit hospitals frequently. Research conducted last year at the National Health Service in the United Kingdom counted a visit by someone who was homeless almost every seven minutes. Sometimes those patients flare into loud or even violent outbursts. But most of the time, they don’t.
In the United States, government figures estimate that approximately 653,100 people were homeless on any single night last year — the highest estimate since the US Department of Housing and Urban Development began tracking that number in 2007.
Canada is no exception, and in Toronto we are seeing more and more homeless patients in our emergency rooms, especially during winter. Too often, in our effort to treat what is acute — sepsis, dehydration, potentially life-threatening alcohol or drug withdrawal — we fail to recognize what caused the patient’s homelessness in the first place: the layoff, the injury, the fallout, the escape, or the eviction that began the unraveling of a life. We fix what we know how to fix.
By treating our most vulnerable patients independent of their circumstances, we project our own biases onto them. In flows prejudice, which has a way of creating a false narrative that is difficult to dislodge and which makes it easier for us to hurry these patients out the door.
In my patient’s case, I could have easily overlooked a small note buried in his chart that provided an important clue to his current struggles: He’d lost the house he had shared with his sister, who had been moved into a long-term care facility after a dementia diagnosis. I suspected that my patient, who was forgetful and recalled little about his sister, might have inherited the same condition. Had I not found that note in his chart, I might not have thought to refer him to a neurologist for an assessment. A genetic test later confirmed the diagnosis.
The health needs of the unhoused cannot be fixed with a pill. They need a more comprehensive type of healing. For doctors, whose emotional stores are still drained from the maelstrom of the last few pandemic years, this means opening our hearts and minds to our patients’ experiences. When we do that, we not only fight against the stigma attached to our patients but directly improve their health.
Studies have shown that patients respond to their physicians’ empathy by having greater faith in their care and by better adhering to their treatments. It may even lower their mortality risk. Patients with type 2 diabetes, for example, who are treated by empathetic providers have a lower risk of heart attacks and other cardiovascular events, improving their chances of living longer and better despite their disease.
Some in the health care field are already trying to meet unsheltered people where they are. Last fall, the US Centers for Medicaid and Medicare began allowing insurers to reimburse health care providers for medical services given outside a clinical setting — a form of care known as “street medicine.” In Toronto, where I live and work, a new initiative allows clinicians to “prescribe” housing to unsheltered, ill patients — government funding pays the rent for apartments built by a partnership between a major health network and the city.
Such interventions may help mitigate the harms of the infections, cancers, heart disease, substance use disorders, brain injuries, and other conditions that disproportionately affect those without stable housing. And they are premised on what should be every doctor’s highest ideal: understanding.
We can’t eradicate all of the indignities and perils that our patients with no fixed address face, but we can see to it that they are not dismissed.