Early in my fourth year of medical school, I had the opportunity to rotate through the Unhoused Consult Service, a medical student-founded and -led initiative that supports people who are unhoused or housing insecure. The primary medical student rotating on service carries the pager and collaborates with the other student volunteers. Not sure what to expect coming onto the service, my main objective was to approach each encounter with empathy, curiosity, and lack of judgment. Patients deserve to feel comfortable disclosing potentially sensitive topics during our interviews and when offered resources. To that end, I endeavored to put them at the center, asking questions about access to clean food and water, where they often slept, if they had ever been incarcerated, and if they had any source of income. Based on their responses, I would then help them find food and housing resources, apply for financial aid, offer clean clothing and hygiene supplies, and in some cases, provide a pre-paid smartphone to facilitate follow-up and access to services.
What I had not anticipated was how the experience would highlight the extent of my own good fortune, and what that fortune says about the distance between my experiences and those of the patients I was meeting. It’s common knowledge that many medical students come from relatively well-resourced backgrounds. A survey study by Shahriar et al. found that over 50% of U.S. medical school applicants came from the top quintile of household incomes. Though I was raised in a modest home in a rural region, I was always afforded the opportunity to focus on academic endeavors and partake in whatever extracurricular activities piqued my interest. My brother and I never had to think about the roof over our heads or the food on our plates. It wasn’t a conscious thought, but I had always felt somewhat protected from, and maybe even a little blind to, the situations many of the patients I met on the service were navigating. That façade of certainty completely crumbled when I met Joe.
One Tuesday morning, I received a consult to see Joe, a patient admitted to our hospital. Joe had been identified as experiencing homelessness by his admitting team. He had been sleeping outdoors in a tent for over a year and was struggling with substance use and co-occurring mental health conditions. When I entered the room, Joe greeted me with a friendly smile, sitting in bed, flipping through cable channels on the hospital TV. I introduced myself and explained my role, and we began the interview. Over the course of our conversation, Joe shared his story with surprising openness and candor. He had once lived with a family member, but when that person had suddenly passed away, Joe no longer had a place to stay. Following that loss, he experienced a deep depression, disrupting his ability to maintain a steady job and ultimately precipitating his housing insecurity. Joe and I talked more about his journey to this point, and he talked about how losing his career had affected his sense of self-worth and identity. As the consult was wrapping up, he asked me if I knew of anyone looking for tutoring. He had previously tutored graduate students and was looking to take on new clients. He then handed me a business card; beneath his name were letters denoting an advanced degree.
Indeed, sitting across from me was someone who had completed years of higher education, dedicating thousands of hours to studying through hard work and discipline, just as my peers and I had. Taken by surprise, I asked about his degree, and we began talking about his academic path and what had inspired him to pursue it. In that moment, I saw a reflection of myself in Joe. I realized just how quickly any person can find themselves in similar circumstances. That truth is a lesson in humility, gratitude, and grace.
Admittedly, before joining the Unhoused Consult Service, I hadn’t closely examined my unconscious biases around this population. I had believed my education and career path would shield me from such instability — that my choices alone could guarantee my security. I was wrong, and I am exceedingly grateful for meeting Joe. His story showed me where my biases lay, and underscored for me the importance of taking a comprehensive social history. Though I knew Joe was unhoused because of the nature of the consult service, his story didn’t align with my schema of an unhoused person — which showed me that anyone could be unhoused, and that it was important to consciously ask about a patient’s resources/housing status and see if they had a safe dispo plan in place. As a result of our interaction, I now personally ask every admitted patient about housing (who they live with, where they live, how long they’ve been living there, etc.) and if they have access to a reliable telephone, as care coordination is near impossible without one. If these quick screening questions raise concern, I then press further. I try to make that bit as conversational as possible, and it is usually well-received regardless of the patient’s socioeconomic status.
Ultimately, my experience with patients like Joe has challenged me to grow and more consciously recognize the humanity of those most often overlooked in society. For medical students at institutions with programs like the Unhoused Consult Service, I strongly encourage spending time on those services. Most, if not all of us will care for patients experiencing housing insecurity throughout our careers, and unless forced to confront it, we may never know what unconscious biases we harbor.
Have you ever had a patient who made you examine your own unconscious biases? Share your experience in the comments.
Hannah Harrelson is a fourth-year medical student at the University of Virginia with plans to pursue ophthalmology. She is interested in health policy and advocacy and hopes to integrate community health initiatives into her career. In her free time, she teaches fitness at a local community studio and sings karaoke with friends.
Name and identifying details have been modified to protect patient privacy.
Illustration by Diana Connolly
