In his sleeveless T-shirt showing off a prowling panther on one arm and assorted symbols on the other, Michael doesn’t pull any punches when he talks to the UCLA medical students who are trying to help him on the streets of West Hollywood, and what he describes “blows their minds.”
“People drawing up water out of a toilet to inject drugs. Straight men having sex with men for money. It’s a shock to them, but that’s good,” Michael says, his blue-grey eyes gleaming in the waning light on this crisp evening in September. “They’re going to be doctors – they need to deal with things like that.”
Michael speaks from his own experience. Somewhere in his 40s, he has a nearly toothless grin and an engaging and excitable nature. He has been homeless off and on since he was a teenager and says he has shot crystal meth nearly every day for the past eight years. He is struggling to stay clean now so he can be approved for needed heart surgery, and a large measure of his motivation comes from these very students. “Part of what made me start to care was the young people who come here and volunteer, talking to me and treating me properly,” Michael says.
Being listened to. Treated with respect. For a population that is most often shunned – the homeless and transient men and women who populate the city’s backstreets – those two things are worth the world. And when listening and respect come with a healthy dose of medical care, so much the better.
For 10 years, students with the UCLA Mobile Clinic Project have been taking it to the streets, putting up their makeshift M.A.S.H. every Wednesday evening near the same street corner – Sycamore Avenue and Romaine Street – just a few blocks from Hollywood’s historic Walk of Fame. A box truck that the group leases from the university carries folding chairs and tables to set out on the sidewalk. Tarps and poles create spaces for exams that require privacy. Medications – both over-the-counter and prescription – are dispensed from an improvised pharmacy in the back of the truck, and there are supplies of donated clothing, shoes and blankets to hand out to anyone in need.
UCLA’s Coach John Wooden said: “You can’t live a perfect day without doing something for someone who will never be able to repay you.” If ever there was a group of young people who have taken that principle to heart, it is the students who volunteer with the UCLA Mobile Clinic Project.
Jeremy DeMartini is among them. “It’s easy to get caught up in the competitiveness of medical school and forget that the reason you’re going through this is to help people. Every day, our ‘clients’ (they are never referred to as patients) are overlooked and scoffed at by people who pass by them on the streets. I can imagine the frustration and despair this would bring,” says the second-year student in the David Geffen School of Medicine at UCLA. “It is little wonder that they are so appreciative when we give them an outlet to share their experiences, feelings and hopes, which are not unlike everyone else’s.”
Each week, the students see a dozen or so clients, many of whom are initially drawn to the location by the warm meals that are provided nightly by the Greater West Hollywood Food Coalition. In addition to the first- and second-year medical students who, under the watchful eye of an attending physician, provide basic care for acute and chronic issues such as foot problems, respiratory tract infections, hypertension and diabetes, undergraduates act as caseworkers, taking social and medical histories.
All the students are attentive to their clients, taking time to get to know them and learn about not just their health issues, but also their personal lives and the challenges they confront every day. The project has expanded over the years to also include law school students providing legal counseling and has set up services at three other locations in Santa Monica.
Like Michael, many of the clients come back to this West Hollywood street corner week after week. Spencer is 69 and all smiles under a rumpled beige hat, a single braid dangling from his white beard. He’s been coming to the Mobile Clinic Project since it began in 2000, and he happily volunteers to help break in the first-timers. The clinic helped him get his blood sugar under control; now Spencer likes to help teach nervous students how to draw his blood.
Daniel is a middle-aged man who suffers from chronic schizophrenia. He says he experiences headaches when his hypertension isn’t controlled, and he believes the clinic is the one place where he can get his meds. Homeless off and on for the last 15 years, he declares, “I feel safe here.”
Every effort is made to encourage clients with serious chronic conditions to receive ongoing care from a regular physician, often referring them to community clinics that have agreed to work with the project. “We don’t want to take patients away from existing and working systems of care,” says Walter G. Coppenrath III, M.D. ’04, who helped to launch the Mobile Clinic Project’s medical services when he was a student and now is the program’s lead attending physician. For urgent matters, clients are given cab vouchers or bus tokens – and in the most emergent situations, placed in an ambulance – to get to a hospital.
But addressing the clients’s health complaints really is the easy part, Dr. Coppenrath says: “The medicine is simple. The situations are complex.”
For these clients, the context of their lives is as important – sometimes more so – as their medical conditions, Dr. Coppenrath says. To tell a homeless person he or she should apply ice for 20 minutes to reduce swelling is to be blind to his or her living circumstances. Assuming a homeless client is going to follow up on a plan of care is not always realistic.
“The social history is a huge component of providing care in this community,” says Mojdeh Toomarian, medical-student coordinator for the West Hollywood site. “You have to learn about the challenges the client faces in his or her day-to-day living,”
Diffidence is not an option. “At first you’re afraid of offending,” says Lauren Wolchok, a second-year student. “You wouldn’t ask most people, ‘Do you hear voices?’ But in this population, which has a high prevalence of paranoid schizophrenia, people don’t react like you were wrong to ask them. The same applies to sexual history – it’s important, and you can’t be embarrassed to ask about it.”
What Wolchok and other students quickly learn is that most of the clients – accustomed to being ignored by the people who pass them daily on the streets – welcome the opportunity to open up about their lives. At the end of one night, a client gave Toomarian a bracelet he had found as a token of his thanks. “He said, ‘It was really nice that you talked with me for two hours,’” Toomarian recalls. “That’s when I realized that although we are limited as to how much medical care we can provide, we do a lot simply by listening.”
The rapport built with clients through these conversations serves another important purpose. “This is a population that used to be called service-resistant,” says Dr. Coppenrath, a family-practice physician. “That’s a misnomer. They’re resistant to the types of services they’ve had in the past.” Virtually every Mobile Clinic Project client has had unsettling experiences with the healthcare system – whether it has been waiting 24-to-36 hours to be seen in the emergency room or having a physician tell him or her to lose weight and stop doing drugs, oblivious to their daily challenges.
Part of the project’s mission is to provide a bridge for the population to reconnect with the network of social, legal and medical services that are available to help them. That step is done by gaining trust and lowering the barrier to the service. So when a medical-student volunteer shows up wearing a freshly pressed white coat, he or she is quickly told to lose it. “A white coat out here creates a barrier,” Dr. Coppenrath says. “When you remove that cloak, it changes the relationship. It becomes people helping people: ‘I have knowledge, you have stories to tell me, let’s work together.’”
Harm-reduction is at the core of the project’s approach. “We don’t judge or criticize,” says Jessica Howard-Anderson, medical-student coordinator for one of the project’s clinics at a service-access center for the homeless in Santa Monica. Instead, students work with clients to reduce their risk factors. Substance abusers, for example, aren’t coaxed to quit but might be counseled on the importance of using sterile needles. As clients learn that the students aren’t there to scold and are interested in building a relationship unconditionally, they become more trusting and likely to return for follow-up visits.
Because the clinic doesn’t refuse care to clients who are under the influence or otherwise belligerent, there can be uncomfortable moments. A hand-lettered sign entreats: “Mobile Clinic is a safe place. Please keep weapons, drugs & alcohol at least 2 blocks away.” Safety precautions are in place, as is a de-escalation protocol that all volunteers learn before going to a site. Whenever a volunteer feels unsafe or threatened, he or she asks for the “blue thermometer,” setting off a chain of events in which the student is removed from the situation and a veteran coordinator intervenes. But such cases are rare. “The population is self-policing,” says Koy Parada, Ph.D., who was a doctoral student in the UCLA School of Public Health, where the concept for the project originated, and today remains involved as a faculty adviser. “If there’s a problem, long-time clients often will defuse the situation themselves before it escalates.”
At the end of the evening, the students and their supervisors gather under their portable lights for a debriefing. The group invariably includes at least one student who is beaming in the aftermath of a meaningful client interaction. It is a powerful, formative experience that will help to shape many of these students’s future careers.
“This makes me to want to become a physician who will listen when others do not,” DeMartini says.
Ele Lozares-Lewis, M.D., hasn’t forgotten her experience as a project volunteer six years ago. It was pivotal in her decision to pursue a career in family medicine working with underserved populations. Dr. Lozares-Lewis is currently a third-year resident at Santa Rosa (Calif.) Family Medicine Center. Working with the homeless population as a student “wasn’t easy emotionally, but it felt comfortable,” she recalls. “The population was so grateful for any help we could give them.”
For Dr. Lozares-Lewis, the experience also had a significant dose of déjà vu. She had been planning on studying film production when her life spiraled out of control in the 1990s. Hooked on speed, she lived for five years out of abandoned warehouses and ate from soup kitchens in San Francisco as she struggled to put her life back together. She vowed that if she succeeded, she would do something to give back to the community. She did succeed and came to study neuroscience at UCLA, where the Mobile Clinic Project gave her that opportunity.
Her story is emblematic of a reality that comes as a surprise to many medical students interacting for the first time with the homeless population: “They learn that a lot of the clients they see are not all that different from them or their family members,” Dr. Lozares-Lewis says.
But if interacting with some of society’s most neglected individuals reminds students not to lose their empathy amid the rigors of medical school, it can also force them to grapple with the reality that despite their best efforts, dramatic success stories are all too rare. More typical, sadly, are the stubbornly self-destructive clients who struggle with mental illness or fight a losing battle with sobriety, if they fight at all. Many are severely depressed. It’s heartening for the project volunteers when they are able to find shelter for clients in need, but there are also times when the system fails, and a bed with a roof over it is nowhere to be had.
“With this population, you have to change your frame of reference,” Dr. Coppenrath says. “We can’t fix all of their problems in one visit. We can give them a good night, and maybe a good week. We can try to give them a good month and work toward getting them a good year.
“But you need to start small,” he says. “If you go out thinking you’re going to be able to save every person in a single encounter, you’re not going to get very far.”
Dan Gordon is a regular contributor to UCLA Medicine.