The final year of my internal medicine residency at Massachusetts General Hospital (MGH) took an unexpected turn when the chief of medicine, Dr. John Potts, summoned me to his office. Alongside Dr. Tom Durant, a respected figure throughout the hospital, they presented me with an unusual “request.” They were part of a citywide coalition dedicated to providing care for homeless individuals. This coalition, composed of community members and homeless people themselves, strongly advocated for a full-time, paid physician to collaborate with nurses. Despite their efforts, they hadn’t found a doctor willing to commit. Drs. Potts and Durant proposed that MGH should contribute a physician to this vital program, and they believed I was the right person. They framed it as a meaningful year of service, akin to an “urban Peace Corps.” Having graduated college in the late 1960s, I was receptive to the idea of social responsibility and saw it as a worthwhile endeavor for a year. Dr. Potts generously agreed to defer my oncology fellowship, assuring me it was a delay, not a cancellation of my career path.
This conversation marked the genesis of the Boston HealthCare for the Homeless Program (BHCHP), funded by a grant from the Robert Wood Johnson Foundation. This “year of service” has become my full-time commitment for over two decades. I also maintain my role as an attending physician at MGH, and BHCHP has operated a daily clinic at MGH since 1985. While many clinicians volunteer to assist underserved, indigent, or homeless patients, I am fortunate to be paid for work I am deeply passionate about.
The Complexities of Healthcare for the Homeless
Working with homeless individuals quickly reveals the intricacies of their medical needs. One of the initial observations is the prevalence of chronic illnesses that have been neglected for extended periods. Conditions like hernias left untreated for years, uncontrolled hypertension, and undiagnosed or unmanaged diabetes are common. Early in my practice, the HIV epidemic began to significantly impact the homeless population. Having previously practiced medicine in an academic teaching hospital, I was surprised by the profound engagement and fulfillment I found in this new field.
Soon after recognizing the chronic health issues, I became deeply interested in the social determinants of health and illness. When caring for someone without a home, shelter, or secure place to store medication, the barriers to effective treatment become immense. This reality compels you to advocate for policy changes and obstacle reduction for this vulnerable population. However, the issue of homelessness reflects broader societal failures across education, corrections, healthcare, and social services. Deficiencies in each of these systems contribute to individuals falling into homelessness. Addressing this multifaceted problem is a monumental task, where a single physician’s voice can feel small.
Many healthcare professionals experience discouragement when confronted with these systemic challenges. The desire to help is often met with the feeling of fighting an uphill battle. Yet, after several months, a shift occurs. You begin to see your patients as extraordinary individuals with incredible resilience, facing unimaginable circumstances, and relying on you as their doctor. This is when the work truly captivates you. I realized profoundly and quietly that I had become deeply connected to the people I was caring for, and my path had diverged from academic oncology. My focus shifted to addressing their immediate suffering and, where possible, mitigating the societal factors contributing to it.
Common illnesses are often amplified by the conditions of homelessness. Consider diabetes, a prevalent condition in primary care. Standard management involves exercise and dietary control. However, individuals living in shelters often lack the ability to manage their diet effectively, as provided meals are typically high in calories and carbohydrates. Furthermore, shelters in Boston often prohibit needles, complicating insulin administration. We have had to adapt diabetes treatments to accommodate the realities of our patients’ living situations. This exemplifies how a common illness becomes significantly more complex when compounded by homelessness.
Tuberculosis is another stark example. One shelter experienced an outbreak of 100 active cases of pulmonary TB. This event underscored the public health dimension of my work, where the health of one individual directly impacts the health of others in the shelter community.
In 1985, we encountered our first case of HIV/AIDS in the shelter. Within a year, the number escalated to 100, and continued to rise. In those early years, effective treatments were non-existent. Our understanding of the virus was limited, and we could only manage the complications. It was a disheartening battle, with a high mortality rate. The sheer difficulty of managing this illness only strengthened our resolve.
We also observe conditions like pellagra and vitamin deficiencies, such as scurvy, in our patients, conditions rarely seen in populations with consistent access to nutritious food. However, the conditions most emblematic of homelessness are frostbite and hypothermia. While much frostbite care is managed outside of hospitals, every winter we treat numerous individuals with frostbite, often leading to auto-amputation of fingers and toes. With patient consent, I have documented this grim process to educate medical students and colleagues. It is a regrettable reality that I have become an expert in frostbite care, a condition entirely preventable, yet resulting in significant bodily harm. It is a recurring tragedy in major cities across the Northeast and likely throughout the country each winter.
The Success Story of Boston HealthCare for the Homeless Program
BHCHP’s foundation was built upon a coalition of homeless individuals, community activists, and shelter providers who initially held skepticism towards the medical establishment. When grant funding became available in Boston, they feared that medical professionals would dictate the program’s direction without community input. The coalition insisted on having a central role in shaping the program, advocating for healthcare as a matter of social justice, not mere charity. They opposed relying on volunteers, emphasizing the need for consistent care from full-time doctors who would be readily available, mirroring the accessibility we expect from our own primary care physicians. They also stressed the importance of integrating the program within the mainstream healthcare system. The principle was clear: when I treat someone under a bridge, I am an MGH doctor, and that individual becomes an MGH patient. This community-driven insistence on integration, I believe, has been crucial to BHCHP’s unexpected growth and impact.
Initially, I resisted aspects of this plan, particularly the restriction on using medical students. The coalition viewed medical students caring for homeless individuals as akin to experimentation. They mandated a system where full-time clinicians worked in teams, including doctors, nurse practitioners, physician assistants, nurses, and social workers, to ensure a stable and reliable infrastructure. Crucially, they emphasized that meaningful change requires health professionals to develop genuine one-on-one relationships with their patients. The core mission of the program became outreach – bringing clinicians out of traditional settings to meet homeless individuals where they are, building trust, and leveraging those relationships to deliver effective primary and preventive care. Looking back, their demands were remarkably insightful. I am grateful that I wasn’t solely responsible for designing the program; I would have undoubtedly created something fundamentally different.
Today, BHCHP comprises 17 doctors, 35 nurse practitioners, and 60 nurses, primarily full-time. We operate three hospital-based clinics and 75 clinics situated in shelters and community locations familiar to homeless individuals. We have dedicated street and “racetrack” teams to reach individuals in diverse settings. Everyone operates on the same electronic health record system, and individuals we encounter in outreach automatically become patients of Boston Medical Center or MGH upon initial contact.
A vital component of our program is the McInnis House, a medical respite care facility named in honor of Barbara McInnis, a nurse who served as our inspiration. In 1985, shelter rules often required individuals to leave early in the morning and not return until late afternoon. Homeless advocates highlighted the immense difficulty for those unwell with flu or back pain to spend the day on the streets until shelter re-opening. They tasked us with creating designated shelter beds for individuals needing daytime rest due to illness.
When we launched the respite program in 1985, we collaborated with Dr. Janelle Goetcheus (founder of Christ House) and David Hilfiker (later founder of Joseph’s House) who were engaged in similar initiatives in Washington, D.C. In that era, patients undergoing coronary artery bypass grafts (CABG) typically remained hospitalized for 1 to 5 weeks. Today, the average hospital stay post-CABG is just 3.6 days. As hospital stays shortened, the complexity of “home” care escalated, and demands on our respite program grew. We continually adapted to meet these evolving needs. Many surgical procedures once requiring hospitalization are now performed as day surgery. For homeless individuals lacking a safe place to recover or receive pre- and post-operative care, our respite programs bridge this critical gap. We admit patients the day before surgery, facilitate their hospital transfer, arrange post-operative pick-up, and provide continued care at McInnis House.
In 1992, we acquired a former nursing home to accommodate the increasing need for respite care, expanding gradually from 52 to 72, and then 90 beds. In 2008, we moved to a renovated facility, increasing capacity to 104 beds. The respite program has established a unique position for BHCHP within Boston’s medical community. Hospitals across the city refer patients to McInnis House for ongoing care or from emergency departments when admission is not desired, but discharge to the streets is unsafe. If I encounter someone on the street at risk of frostbite, I can admit them to McInnis House for 24-hour medical and nursing care. McInnis House has become a national leader in the development and evolution of medical respite care for vulnerable homeless populations, facilitating the integration of medical, mental, and oral healthcare for this community.
Educating Future Doctors to Care for the Homeless
During my medical training at Harvard from 1978 to 1982, community service opportunities were limited and required significant initiative to find. Over the past 10 to 20 years, medical schools have made remarkable strides in community engagement. However, time for community involvement during medical school and residency remains constrained. The key is to integrate service into the core curriculum, recognizing and expecting it as a fundamental aspect of physician training. While progress has been made, there is still much to achieve.
Some students who rotate through BHCHP may feel uncomfortable in shelter environments, while thriving in other settings, such as community health centers serving Latino communities. It is crucial for each individual to find their area of comfort and passion. Numerous rewarding opportunities exist. Students should hold onto their initial motivations for pursuing medicine and resist pressures to solely prioritize specialties with limited hours and high financial rewards. Profound satisfaction can be found in caring for vulnerable populations who deeply appreciate your efforts and welcome you into their lives. Some are drawn to international or global health, while others flourish in community health centers and programs for the homeless. I encourage students to explore diverse service avenues and discover where their hearts and minds find resonance.
