Careers in Medicine: Clinics in Underserved Communities
A NextGen Pathways in Medicine Article
From an Interview with James O' Connell, M.D., Boston Health Care for the Homeless Program
Increasingly, the delivery of health care is being regarded not only as an issue of economics but also as an issue of social justice. While there is much partisan debate as to whether universal health care coverage is an aim that should be pursued by the federal or state government, many organizations have already devised innovative methods of delivering high-quality medical care on a local scale to populations that normally fall through the cracks of the U.S. health care system. One such organization, the Boston Health Care for the Homeless Program (BHCHP) associated with Boston Medical Center (BMC) and the Massachusetts General Hospital (MGH), is led by Dr. James O'Connell. He explains that "These people [the homeless] are our neighbors and are part of our society — because of the challenges they face each day to survive, they are shut out of the health care system. They can't schedule things two weeks in advance. They need to live for today." Dr. O'Connell's program is unique in that it does not rely on volunteer work. Instead, it hires physicians, nurse practitioners, physician assistants, social workers and nurses to bring medical care to Boston's homeless population at three hospital clinics and over 70 shelter and outreach clinics. BHCHP has "one foot firmly planted in the community, the other in the hospital," and "delivers consistent, good-quality, continuous care to people living in shelters and on the streets."
Dr. James O'Connell
Unlike some other career paths in medicine, there are no fixed or common paths toward treating the marginalized and no formal requirements for clinical work with the underserved, which include the homeless, rural communities, and urban populations in specific neighborhoods. Dr. O'Connell describes himself as an "accidental pilgrim," originally en route to a fellowship in oncology until he was approached with a job offer as a full-time physician directing the integration of care for homeless people in Boston with the mainstream health care system. At first, Dr. O'Connell was concerned that, like many physicians participating in early efforts to serve marginalized populations, he in turn would be marginalized by the medical community, which had not yet mobilized to confront the issue of delivering medical care to all. Fortunately, BHCHP was designed as a joint effort of Boston City Hospital (now Boston Medical Center), Lemuel Shattuck Hospital, the Massachusetts General Hospital, state and city agencies responsible for serving homeless individuals and families, and community activists. The highly joint nature of the program allows Dr. O'Connell and the other physicians to focus their clinical work on homeless patients on the streets and under the bridges of Boston while participating as members of an academic medical community within MGH amd BMC. At these hospitals, physicians can practice clinical medicine, attend and teach residents and medical students on the inpatient services, and conducting research. While not all organizations and clinics follow this model, Dr. O'Connell asserts that this problem of marginalization is less prevalent now than it was in the 1980's, though many doctors who start their clinical work in underserved communities find themselves will little time to participate in functions of academic medicine.
The experience of clinic work for the underserved varies with each organization and each patient population, but there are common characteristics. Dr. O'Connell notes that these are "populations with special needs - you need to learn to address those needs. Medical milieu differs. You need to adapt to local issues." Dr. O'Connell also emphasizes that it's important to understand the people and how they live: "When I look at my life, I'm like an old-time country doctor who visited patients where they live. Homeless persons are often very, very sick when they come to see you - they have competing priorities such as finding meals and a safe place to sleep. Some are very sophisticated about health care issues; some start with little understanding about health care basics. The guiding principle imparted by the people out in the community is that nothing is going to work in the program unless we build one-to-one relationships between the doctors and patients [instead of sending patients to hospitals where they might see a different doctor each time]." Working with homeless patients is also very different from working in a clinic in the developing world: "Compared to third world countries, there is a relatively better life for homeless people here. However, in those countries, people have family support. In Boston and other U.S. cities, most homeless persons are alone and without family support. They are devastated by losses in their lives, and most of the time suffer alone. They've lost contact with family and friends, and there is a poverty of spirit that is striking since they don't have the support or family to gather around them at hard times." This lack of support networks often prompts physicians to tests the fine line between being a doctor and being a friend or surrogate family for a homeless patient: "We're [often] the most consistent and reliable presence in the lives of our patients." Many of these situations and questions regarding the nature of the doctor-patient relationship and end-of-life, nursing home, and hospice care are raised in the care of these patients and other underserved communities.
Serving the marginalized communities has its fair share of rewards and challenges. "[It is a] real blessing being able to practice as a doctor for people who are very appreciative of my care. The medical problems are complicated and challenging, and this group of people has fascinating and compelling stories. You realize the courage with which they live their lives of desperate poverty and overwhelming challenges." On the other hand, "[You] always feel downstream, taking care of people who have no hope of getting out of that situation (i.e. severe learning disabilities, HIV, etc.). When you start out, you can't help but get wrapped up in the greater societal issues that create homelessness in the world's richest country. At first you desperately want to fix homelessness for each patient, but after 6 months or so, you are humbled by the magnitude and complexity of the problem of homelessness in modern America. Doctors can't change it alone, but they need to cooperate and work with other sectors of our society, including housing, labor, welfare, corrections, and education. You realize you cannot change society alone, but need to be a part of a much larger mosaic of a solution. Sometimes I feel our most powerful role is that of advocate and witness, and we are free to become completely absorbed in the care of each of our patients. 'I'm a doctor, and my job is to ease their suffering today, to accept each person without judgment, and not try to change people.'" Nonetheless, physicians like those at BHCHP continue to strive to make an even stronger impact: they bear witness to the consequences of homelessness and poverty and serve as advocates as they show policy makers and legislators the evidence and need for creating inroads to mainstream society for underserved communities. To young physicians hoping to help improve the lives of marginalized populations, Dr. O'Connell advises, "Get yourself as well trained as possible: you're going to need excellence in your clinical skills as the foundation for your practice. Also, take some time working in a program to see what the lifestyle is like, if it turns you on. There are opportunities in every city around the country and in rural areas. If you have a love of medicine and are interested in both the science and the art, finding populations that are not well-served by our current system is an enriching challenge." 
Lester Leung is the founder of the Next Generation and a member of the Harvard College Class of 2006.
James O'Connell, M.D. is president of the Boston Health Care for the Homeless Program.