The Education of Psychiatry – Caring for Patients Experiencing Homelessness
Malia E. Haddock, MS, PMHNP-BC
Although trainees incidentally care for patients experiencing homelessness throughout residency and beyond, intentional didactic and clinical experiences with homelessness create unique opportunities to increase interest, confidence and ability among resident psychiatrists in the care of underserved patients.
It is well known that individuals with unstable housing have disproportionally high rates of severe psychiatric and substance use disorders compared to their housed counterparts. Indeed, untreated psychiatric and substance use disorders are cited as primary causes of homelessness, and once homeless, psychiatrically-symptomatic individuals face additional barriers to accessing psychiatric care. Common obstacles include lack of affordable or reliable transportation, variable access to telephone/internet, and systems barriers such as scheduled appointments and attendance policies. However, intangible barriers such as provider discomfort with homelessness may further distance patients from psychiatric care.
The Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI) is a validated 19-item instrument designed to “assess medical students’ and physicians’ attitudes towards homeless persons and to measure their level of interest and confidence in their ability to deliver health-care services to the homeless population” (Buck et al., 2005). The impetus for this inventory traces back to a 1985 publication on access to care among individuals with unstable housing. The report’s author, Elvy, writes, “The disinclination of the homeless to seek care may be due in part to the ways in which many health-care workers respond to them. A less investigated but possibly equally important circumstance is the attitudes that health-care professionals have toward the homeless” (as cited in Buck et al., 2005, p. 2). More contemporaneous academic discussions also play a role in HPATHI’s inception, particularly those involving the role of humanism and Social Determinants of Health curricula in undergraduate and graduate medical education (Buck et al., 2005).
Opportunities for Psychiatry
In “A Survey of American Psychiatric Residency Programs Concerning Education in Homelessness” McQuistion et al. found that while 60% of programs offered optional clinical and/or didactic experiences, only 11% of programs reported mandatory rotations in the care of patients experiencing homelessness. Lack of widespread mandatory programming was attributed to several factors, most notably lack of attending psychiatrists with expertise in caring for patients experiencing homelessness; lack of funding and/or logistical support to create programming; and perceived lack of homelessness in suburban and rural areas (2004).
Given the prevalence of severe psychiatric illness and substance use disorder among individuals experiencing homelessness, psychiatry trainees have much to gain from intentional exposure and training in this area. Over time, measurable improvements in interest, confidence and ability among learners may result in more accessible and culturally attuned care for this population.
Why HPATHI in Medical Education?
- Acknowledges the impact of provider attitudes and behaviors on engagement with underserved patients
- Raises awareness among educators and learners of the unique needs of patients with unstable housing
- Establishes baseline data on attitudes, interest, confidence and ability in caring for patients experiencing homelessness
- Uncovers experience and knowledge gaps that can be specifically addressed through curriculum development
- Over time may lead to structural changes in both educational practice and care delivery to meet the needs of learners and underserved patients
Buck, D.S., Monteiro, F., Kneuper, S. et al. Design and validation of the Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI). BMC Med Educ 5, 2 (2005). https://doi.org/10.1186/1472-6920-5-2
McQuistion HL, Ranz JM, Gillig PM. A survey of American psychiatric residency programs concerning education in homelessness. Acad Psychiatry. 2004 Summer;28(2):116-21. doi: 10.1176/appi.ap.28.2.116. PMID: 15298863.