Addressing the Needs of the Homeless and Underserved
Q&A with Dr. Lipi Roy of the Boston Health Care for the Homeless Program
Lipi Roy, MD, MPH, is an internist with the Department of Medicine at Massachusetts General Hospital and the Boston Health Care for the Homeless Program, as well as an Instructor of Medicine at Harvard Medical School. Dr. Roy completed her residency training in internal medicine at Duke University Medical Center, Durham, North Carolina. Prior to residency, she obtained dual degrees in medicine and public health (a combined MD/MPH) at Tulane University in New Orleans.
Q: What motivated you to become a physician? What is your Specialty?
A: There are very few professions, in my opinion, that offer the diverse array of possibilities that medicine offers. From clinical practice and bench science to biomedical consulting and health policy, the career possibilities are endless. But at the core of medicine, for me, is the relationship between patient and doctor. To be invited into another person’s life and be allowed to listen to him share his deepest concerns is nothing short of a privilege. My patients are my greatest teachers; I learn something everyday. How many people can say that about their careers?
My residency training was in internal medicine (IM). The beauty of IM is that I need to know about all aspects of medicine: cardiology, nephrology, neurology, dermatology, etc. It is tremendously diverse and all-encompassing, and yet it is at the very heart and soul of the art and science of medicine. Sir William Osler, the father of modern medicine and an internist, famously said, “The good physician treats the disease; the great physician treats the patient who has the disease.” Internal medicine training enables me to treat the illness by first knowing the patient in the truest sense.
Q: You are currently a staff physician with Boston Health Care for the Homeless Program (BHCHP); please describe the Program and its mission.
A: The Mission of BHCHP has remained the same for nearly 30 years: to provide or assure access to the highest quality of healthcare for all homeless men, women and children in the Greater Boston area. It is medicine that matters. BHCHP is a community health center that provides comprehensive primary and acute care services in an integrated, team-based manner. Services range from medical and dental to behavioral health, vision, HIV and transgender care. BHCHP staff - who include physicians, nurse practitioners, physician assistants, nurses, social workers and case managers – care for patients in shelter-based clinics, hospital-based clinics (such as the Mass General Hospital and Boston Medical Center), medical respite and on the streets. The Barbara McInnis House is a 104-bed medical respite where homeless men and women receive 24-hour nursing care and daily visits by a medical provider. Each year, over 11,000 patients receive their care at BHCHP.
Q: What led you to BHCHP?
A: Addressing the needs of the underserved is a fundamental aspect of public health, and one that has always been deeply important to me. While at Tulane, not only did I learn about clinical medicine, but my Master’s in Public Health, which focused on International Health, taught me about the disparities in health care; that healthcare delivery can vary with race, geography, education, and poverty. Clinical and public health rotations in India, Nicaragua and, later as a resident, in Haiti highlighted the social determinants of health. Caring for Boston’s homeless population is public health personified. In addition to my global health missions, my experiences caring for displaced New Orleans residents after Hurricane Katrina had a profound effect on me and my understanding of health disparities. These collective experiences, combined with the Mission of BHCHP, confirmed that caring for society’s most vulnerable population was my next calling.
Q: What services do you typically provide? Is there such a thing as a “typical day” for you?
A: I suppose I have “typical days”, but I must emphasize that no two patients are alike.And there is certainly never a dull day! I provide primary and acute care in three outpatient settings: two shelter-based clinics (Pine Street Inn and St. Francis House) as well as the Mass General. At each of these sites, I work with a team of incredible, hard-working and compassionate nurses, NPs/PAs and administrative staff who help me care for our vulnerable patients. After the patient is triaged by nurses, I then listen to his or her story and address complex medical and psychosocial issues. In reference to the Program’s Mission, I help provide fundamental primary care and preventive health services such as mammogram and colonoscopy referrals, and cervical cancer screenings. Depending on the medical concerns, I may order labs, imaging and other tests, and refer to other services or subspecialties.
Q: What are some other common conditions you see that are unique to or complicated by homelessness
A: In addition to the aforementioned services, I also manage a diverse range of medical conditions including but certainly not limited to diabetes, heart failure, chronic kidney disease, lupus, psoriasis and lung cancer. We also treat weather-related conditions such as hypo- and hyperthermia. A great deal of time is also spent in addressing substance abuse (tobacco, alcohol, opioids, etc.) and mental illness. Unfortunately, a significant number of homeless men and women struggle with addiction as well as psychiatric disorders. Connecting these patients with detox and outpatient treatment programs, as well as ongoing psychiatric care, therapy and counseling is a very important aspect of their overall health and wellbeing. We are very lucky to have psychiatric services and substance abuse counseling at BHCHP.
Q: You treat many mentally ill and abused people; is mental illness and abuse common among the homeless?
A: Yes, unfortunately, many homeless men and women have experienced abuse and suffer from mental illness. Often there is a correlation, but not necessarily. It is important to connect patients with the appropriate care, whether it be a therapist, psychiatrist, substance abuse counselor, or if the illness is quite severe (e.g. patient is actively psychotic or suicidal), then they may require inpatient psychiatric hospitalization.
Q: What are some of the challenges or frustrations that you face at BHCHP?
A: In a world of rising healthcare costs, I think all healthcare institutions are facing financial constraints. Certainly, community health centers are no exceptions. However, BHCHP has been very fortunate to receive ongoing support at the city, state and federal levels, in addition to generous private and corporate donations. Our work in caring for the city’s otherwise neglected homeless population is clearly recognized by governing bodies, and we are very grateful for this. Some of the frustrations I feel revolve around addiction. The number one cause of death in our population is from prescription drug overdose; as a Program, we have incorporated a wide number of interventions to address this growing problem. Alcohol and tobacco abuse are also significant problems that I address on a daily basis. Other challenges include lack of time and an abundance of paperwork; however, these ‘cons’ are far, far outweighed by the ‘pros’ of being a doctor to this very special group of people.
Q: Can you share a success story?
A: I have many success stories that I would be proud to share!
One of my favorite patients is a 50-something man with diabetes, obesity, and uses alcohol and tobacco who comes see me at MGH. Over the past two years, with persistence and hard work – peppered with positive encouragement – he has managed to stop drinking, eat healthy, exercise and lose significant weight. He is also spending more time with his son. I am so proud of him, and tell him every time I see him. Another one of my favorite patients is a homeless vet who spent 9 years in Special Forces. He struggled with severe depression and has been hospitalized several times for attempting suicide. Poorly controlled diabetes and peripheral vascular disease resulted in below-the-knee amputations of both legs. In spite of all of these obstacles, he not only survived but thrived: through regular medical and mental health visits, referrals to Endocrine and Cardiology, compliance with medications and ongoing positive reinforcement, this wonderful vet is now in housing, quit smoking, takes his meds regularly and has completed a college diploma. Stories like this remind me what a privilege it is to care for these brave individuals.
Q: Are there any other interests or research that you are pursuing?
A: One of my greatest passions is preventive health, specifically addressing obesity, nutrition and fitness. In order to reach a larger audience, a few years ago, I combined my passion for healthy cooking with my love of caring for patients by creating a healthy spices blog called Spices for Life MD. On this site, I write articles about the evidence-based health benefits of spices (including paprika, garlic and turmeric and cinnamon); recipes that contain these spices; and health conditions that would benefit from a healthier diet such as hypertension, diabetes and colon cancer. My goal is to educate and thus empower people to make healthy lifestyle decisions. Recently, I added the category, ‘Health and the Homeless’, where I write short vignettes about what it means to be a doctor to the homeless population.
Q: What advice can you give to a healthcare professional interested in pursuing a career in (or volunteering for) a healthcare for the homeless program, community clinic, vulnerable population, etc.?
A: I whole-heartedly encourage anyone interested in pursuing a career in caring for the homeless/underserved population to spend time with the organization, and get to know the people. This could entail shadowing a physician in clinic or volunteering at a shelter or health fair. There are endless ways to get involved. The key is to have the desire, the passion to make a difference in another person’s life.
Q: How has working at BHCHP and its vulnerable patient population affected you as a physician and as a person? What do other providers need to know about what you do? What does the public/government need to know?
A: Caring for the City’s homeless population has had a profound effect on me. When I hear about a 19-year-old girl’s struggle with heroin addiction or an experienced veteran’s repeated episodes of post-traumatic stress, I am in sheer awe of their strength and perseverance. These courageous individuals work hard to overcome obstacles, every moment of everyday. To me, each day is a reminder of how fortunate I am because I learn so much from my patients. Through this position, I have learned about compassion, teamwork, patience and respect. I have also learned to be open-minded and not pass judgment when a person is sitting on the sidewalk, asking for money. He or she has a lifetime of stories and struggles that led to that moment. Thus, I would ask the public to keep an open mind and an open heart when they come across a homeless man or woman sleeping under a cover on the street or asking for money. Most of them have endured events and/or traumas that we can barely fathom.
One of my mantras is to appreciate all the small things in life. No matter how stressful life can get, always try to take a step back, take a deep breath and realize how lucky you are. And cherish your health - physical, mental, emotional and spiritual. Without it, nothing else matters!
To learn more about Boston Health Care for the Homeless Program (BHCHP), go to http://www.bhchp.org/
To follow Dr. Roy’s blog, Spices for Life MD, go to www.SpicesforLifeMD.com
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