Street Medicine Learning Objectives

Background

Street medicine has rapidly evolved as a dynamic and integral part of medical education across multiple disciplines in recent years. From undergraduates to post-graduates, educators and students alike have shown a growing interest in shaping a more structured approach to this field. The need for clear learning objectives, guidance, and a cohesive framework has become evident as both educators and students recognize the importance of this unique area of healthcare. In response, the Street Medicine Institute Educator Coalition Curriculum Committee gathered educators from across the nation to create a set of learning objectives grounded in the ACGME (Accreditation Council for Graduate Medical Education) six core competencies that serve as pillars of medical education, ensuring that street medicine is not only effective but also impactful in shaping the future of compassionate, patient-led care that is rooted in the reality of living without shelter.

Process of Learning Objective Construction

Leaders of the Street Medicine Institute Educator Coalition (Denise Kohl, Corinne Feldman) conducted a series of interviews with experienced street medicine clinicians and street medicine educators across the country using a semi-structured interview targeting specific ACGME pillars. Interviews were analyzed using thematic analysis qualitative technique to inform a series of suggested learning objectives. Using the Delphi model of decision making, members of the Street Medicine Institute Educator Coalition Curriculum committee engaging in a series of moderated consensus building activities to produce the final list of learning objectives for each ACGME pillar. All learning objectives, in their present form, were approved by unanimity by the curriculum committee.

Suggested Use

The presented learning objectives have been created to be relevant to education for a range of learners engaging in street medicine education. Many health professions model their educational framework, competencies, and accreditation standards after some or all the ACGME core competencies: patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. Therefore, the Street Medicine Educator Coalition used these areas as a universal touchstone. These objectives are meant to be inclusive of clinical and non-clinical roles with the understanding that learning objectives should be selected to reflect the individual’s scope of practice. The Street Medicine Educator Coalition also recognizes that street medicine learning may happen in a range of lengths such as a one-hour lecture or a rotation of varying length (e.g. 2-week, 4-week or 6- week, or a one-year fellowship), which influences what is feasible to be taught.

The curriculum committee intentionally created comprehensive objectives for a year-long street medicine fellowship, while also acknowledging its rarity. Educators found it easier to adjust or “right size” the number and depth of learning objectives by having a broad list to choose from, rather than starting with only a few and expanding them if needed. Educators may choose to use these objectives in a range of ways. In traditional use, the educator would select the learning objectives and use them to guide the lecture or clinical experience. However, educators did raise the question of what to do with relatively short clinical experiences (e.g. 1-week rotation). In those cases, where possible, the curriculum committee suggests sharing the list of objectives with the learner and asking them to select 1-2 objectives to focus on during their limited time.

Final Thoughts

Medical education is a creative space and street medicine practice continues to grow and stretch. We encourage feedback and suggestions as these learning objectives are utilized to help them continue to evolve. This is an exciting time to be part of shaping the future of medicine to be a kinder, more socially aware and compassionate place. We look forward to sharing in this journey with you.

Correspondence can be directed to the Street Medicine Institute Educator Coalition Curriculum Chair, Corinne Feldman at  [email protected] or [email protected].

Street Medicine Learning Objectives

Patient Care

1. Contrast health risks for people experiencing unsheltered homelessness compared to sheltered homeless and housed populations.
2. Demonstrate an understanding of cultural and ethical challenges working with unsheltered populations.
3. Describe the relationship between health and social determinants of health including the impact food and water security, sanitation, educational opportunities, environmental overexposure, and health care availability in unsheltered populations.
4. Create and implement treatment plans that recognize, address, and accommodate barriers to health and healthcare experienced by people experiencing unsheltered homelessness.
5. Create culturally appropriate patient-centered, cost-effective, evidence-based treatment plans that utilize harm reduction and trauma-informed principles for people experiencing unsheltered homelessness.
6. Integrate harm reduction strategies, as applied to a wide range of commonly occurring acute and chronic diagnoses, into street medicine care plans.
7. Develop a realistic process for health promotion and disease prevention/preventative medicine (e.g. cancer screenings) for people experiencing unsheltered homelessness.
8. Develop patient centered care plans for the appropriate triage of conditions prevalent in people experiencing unsheltered homelessness including contingency planning for patients who do not want care in an emergency department.
9. Demonstrate the balance of patients' competing needs of medical care with basic needs acquisition such as food, water and protection from the elements.
10. Adapt differential diagnoses to prioritize conditions more likely to occur in people experiencing unsheltered homelessness.
11. Implement a street medicine rounding schedule that promotes continuity of care based on patient resources, lived environment, and team capacity.
12. Facilitate a comprehensive history, which illuminates the lived realities of the patient’s experience from a person experiencing unsheltered homelessness in their lived environment.
13. Discern appropriate, cost-effective pharmacological and non-pharmacological interventions for conditions prevalent in people experiencing unsheltered homelessness.
14. Recommend, order, and interpret diagnostic studies in the street context, taking into consideration personal, environmental and systemic limitations to testing.
15. Demonstrate an awareness of the historical, socio‐political, economic, and context of homelessness as well as the limitations and accessibility of resources that are available to this population.

Medical Knowledge

1. Identify major causes of morbidity and mortality of populations living unsheltered and how health risks may vary by gender, culture, religion, race, physical differences, and sexual orientation.
2. Demonstrate ability to identify and manage common diseases seen in patients who are homeless including the following conditions: dermatologic infections, acute and chronic wounds, acute and chronic respiratory disease, substance use disorders, mental health conditions, environmental trauma and injuries, malnutrition, tuberculosis, GI bleeding, hepatitis C, HIV and parasitic infections.
3. Demonstrate knowledge of the impact of excessive environmental exposure on acute and chronic conditions across the durations of one’s homelessness.
4. Develop a refined awareness and understanding of the sequela of late-­stage presentations of untreated common illnesses and how to address and prevent these common illnesses.
5. Adapt clinical skills (history-taking, physical exam skills, procedural skills) to the street setting including limited resources for diagnosis and treatment.
6. Implement processes to allow for street-based procedures (e.g. incision and drainage, suture placement and removal) which considers personal, environmental and systemic barriers and opportunities.
7. Demonstrate comprehensive knowledge of behavioral strategies to address the needs of people experiencing unsheltered homelessness.
8. Apply knowledge of the diagnosis, treatment and management of substance use disorder to people experiencing unsheltered homelessness.
9. Apply knowledge of the diagnosis, treatment, and management of mental health diagnoses, including severe mental illness, to people experiencing unsheltered homelessness.
10. Demonstrate discernment in applying pharmacological and non-pharmacological interventions for management of substance use disorders and mental health diagnoses, including severe mental illness.
11. Implement care plans that address sexual health and reproductive health concerns in people experiencing unsheltered homelessness.

Interpersonal and Communication Skills

1. Apply knowledge of your patient’s body language and your own body language to a street medicine encounter including determining the best way to navigate the patient’s personal living space.
2. Demonstrate non stigmatizing, effective, trauma informed approaches to communicating with, and about, patients experiencing unsheltered homelessness.
3. Discuss and clearly, concisely communicate a patient history and physical exam to other providers while recognizing and pointing out unique street-based barriers to care.
4. Integrate harm reduction principles into routine care and communication with people experiencing unsheltered homelessness.
5. Apply the principles of motivational interviewing in the care of people experiencing unsheltered homelessness.
6. Demonstrate discretion when documenting the patient's home environment while maintaining the same HIPAA standard of care extended to all patients regardless of housing status.
7. Integrate a strength-based approach to patient care, documentation, and in communication with the health care system and community.
8. Demonstrate clear communication in the anticipation, recognition and response to conflict and crisis during routine street medicine encounters.

Professionalism

1. Demonstrate a basic understanding of the relationship between health, social justice, human rights and resource unequal distribution of health services and resources.
2. Demonstrate a historical understanding of ethical considerations in working with underserved populations as it relates to treatment of vulnerable patients and research.
3. Recognize and reflect upon personal biases in caring for patients living on the streets and how these biases may affect care and decision making.
4. Demonstrate compassion, integrity, respect, and commitment to professional behavior when working with patients and multi-disciplinary colleagues.
5. Recognize situations that may trigger professionalism lapses and intervention to prevent lapses in self and others.
6. Demonstrate appropriate preparation with respect to personal health and safety, cultural awareness, trauma informed care, harm reduction and expected ethical challenges.
7. Perform patient and team centered tasks in a timely manner with attention to detail in complex situations (e.g. success of task is reliant on successful integration of multiple systems).
8. Independently recognize limits in the knowledge or skills of self or team and models seeking support appropriately.
9. Demonstrate a commitment to self-reflective practices and self-care strategies to optimize personal and professional well-being.
10. Demonstrate sensitive and compassionate delivery of medical information to people experiencing unsheltered homelessness while managing patient values, goals, preferences and competing priorities.
11. Coordinate recommendations from different health care and social service team members to optimize the health and wellbeing of a patient experiencing unsheltered homelessness.
12. Demonstrate flexible communication strategies that value input from all team members, including the patient, when resolving conflict.

Practice-based Learning and Improvement 

1. Appraise the differences in street medicine practice across different healthcare systems and locations.
2. Utilize and critically appraise a range of health resources and literature to support evidence-based, best practices for patients experiencing unsheltered homelessness.
3. Describe the basics of a community needs assessment and situational analysis and how to apply that information to context specific healthcare interventions.
4. Work collaboratively with multidisciplinary care team members to assess, coordinate, and improve patient care practices while demonstrating openness to feedback and input from team members and patients.
5. Present a plan for personal ongoing development and training in street medicine.
6. Self-reflect, analyze, and institute behavioral change(s) to narrow the gap(s) between expectations and actual performance in street medicine.
7. Actively identify areas for quality improvement (QI) and employ an effective QI strategy to implement a change which is assessed for effectiveness.
8. Participate in the education of patients, learners and/or other health professionals in the practice of street medicine.

Systems-based Practice

1. Formulate and explain a well-rounded argument for the necessity of street medicine in mainstream healthcare as a solution to system deficits.
   
2. Appraise the barriers to accessing healthcare faced by people experiencing unsheltered homelessness.
3. Correlate the structural violence exhibited by health care, civil and social service systems to the health disparities seen in people experiencing unsheltered homelessness.
4. Describe individual requirements for successfully receiving government benefits (e.g. medical insurance, nutritional support, social security, and disability).
5. Compare and contrast various payment and sustainability models for street medicine programs.
6. Describe the ways in which street medicine intersects with health care, social and civil services.
7. Demonstrate effective coordination of care between health care, social and civil services for people experiencing unsheltered homelessness.
8. Develop a quality improvement and assurance plan to maximize the effectiveness of street medicine services provided.

Street Medicine Learning Objectives PDF