Into Troubled Waters

Back when he was a medical student, pediatrician Randy Christensen, M95, used to pass through Harvard Square and see the Bridge Over Troubled Waters medical van parked there, ready to welcome homeless patients aboard. “That’s a neat idea,” he thought. Over the past decade, Christensen has extended and remade the notion on his own, working with a small team to treat thousands of homeless children and adolescents adrift on the streets of Phoenix, Ariz., from his mobile doctor’s office in a 38-foot Winnebago.

He’s a busy guy. When he’s not examining patients on the van, Christensen is busy as chair of medicine at Phoenix Children’s Hospital, soliciting funds from philanthropic organizations to support his mission or spending time at home with his family. His wife, Amy, is also a pediatrician, and their three young children have gradually learned to appreciate the nature of their father’s job. “They know that daddy works with homeless kids, and that some of the stories are very sad,” says Christensen, who received a dual M.D.-M.P.H. degree from Tufts. Now he has written a book about his 10-year commitment to working with kids on the street, Ask Me Why I Hurt: The Kids Nobody Wants and the Doctor Who Heals Them (Broadway Books), which came out this spring.

Tufts Now: Tell me about your patients.

Randy Christensen: We take care of patients from zero up to 24 years old who are homeless or at high risk of being homeless. If they come to us and they’re living in a shelter, that’s a perfect patient for us. Similarly, if they come to us and they’ve been in a hotel for the past week and a half because they’ve lost their house—even though they have a roof over their head and they’re paying for it—we think that the next couple of weeks could be so tenuous for them that they could end up being homeless.

What kinds of medical problems do you see?

We see exactly the same things that you would see in a regular doctor’s office—colds, acute injury, asthma, some of those simple things. When patients come to us we do a pretty good background screening and a mental health screening, and we find that, most likely, their problems have been untreated for a while. This means that even though they may be coming in for an earache, it’s not the first day of ear pain for them, and they may have a far advanced ear infection with maybe a rupture of the eardrum. They often haven’t taken any medicines. The complexity of the patients jumps up pretty quickly.

Mental health issues are abundant. We suspect that when it comes to mental health illnesses, homeless patients have about three times the number of mental health diagnoses as the general population. That’s a chicken-and-egg kind of thing. The mental health issues may have gotten you on the street in the first place. Or you may have been out on the street and suffered some traumatic event and then begun to have mental health illness.

Do you see the same patients repeatedly?

The vast majority of our patients follow us. In 2010, we saw about 4,000 medical visits. That’s about 1,500 unique patients, so you can see that they’re all coming back. Some of our clinics we run in schools, so in those cases we just call the nurse and say, “Hey, we’re coming on Wednesday. Make sure that you have Tommy, Billy and Frank there to see us.” We’ve gotten good at follow-up.

We seem to be seeing more and more patients. One of the first questions we ask is, “Where would you go if you didn’t come here?” Many of them say, “I wouldn’t go anywhere.” Some of them say, “I’d go to the emergency room.” When we ask, “How many times did you go to the ER?” they would tell us, “Quite a lot.” Once they start seeing us, the number of ER visits drops quite significantly, in some cases by 50 percent. So that is clearly a cost savings to the community and a time savings to the ER.

In addition to patient visits, we also had another 4,000 educational visits, where patients come in for smoking-cessation programs or exercise programs. We have seen people get off the streets and find a place in society. We actually run a “Health Careers” club that we started a while back, and now we have 22 homeless individuals who are in nursing school or respiratory school or paramedic school. These are people who were formerly living on the street.

How do you handle all the dark stories you hear every day?

The emotional side of things was something I really paid the price for at the beginning. I didn’t talk to my wife about it as much as I should have. But the kind of medicine we do affects the whole team. You try to remain objective when you’re making medical decisions, but these stories are very difficult. The philosophy we’ve all come to embrace is that we can’t change the past, but we are all hopeful that we can affect the future. That said, there are still terrible things that happen, and some of these affect us dearly.

I tried in the book to talk about that experience. You may come home after a long day where you’ve just seen a girl who has been raped and tortured, with all kinds of cigarette burns in the genital area, and that’s been going on for a long time. What do you say to that? How do you come to terms with that? We sort of watch each other on the team. We might pull somebody aside and say, “Hey, it looks like you’re getting too involved with that person. Let me take over for a while.”

How big a role does compassion play in treating your patients?

It’s huge. We tell our patients straight out, “We do care about you. We want you to be careful out there.” We find it works better than a condescending attitude of “If you do this, then you will get this.” That just never seemed to work for our kids. But if we say, “Gee, we think you can get out of homelessness, you can stop using drugs, you can get a job, you can have a happy life and we care about you,” they seem more interested in stopping their behaviors.

You’re saying you’ve had to alter your approach.

That’s absolutely right. It’s been on-the-job training. But I don’t think it has to be on-the-job training for everybody. Some of our experiences can be translated into other models in other cities. People are starting to call me up and say, “Hey, we’re thinking about doing this.” Some of my time is now being spent helping other programs get started, and I love that idea.

What has been your biggest surprise about homeless medicine?

As medical director, I thought I was going to get my patients off the street by taking care of their unmet medical needs. But really what I began to learn is that there were so many other problems out there. My patients had terrible cavities, or their teeth had all been kicked in, or they had such tragic stories that had led to mental health illnesses. They had a lack of education and just weren’t able to deal with many of life’s problems that were being thrown at them.

In other words, you were facing more than just medical problems.

Exactly. That was the biggest thing that I saw. I didn’t know who was going to be responsible for those other issues. I spent a couple of years trying to find where I could send my patients, and it was only after several years of failing that I realized that we needed to make a holistic, comprehensive-type program to deal with the chronic issues of homelessness. It’s only now that we’re starting to see the success we’ve longed for.

Are you saying it’s taken you a while to get plugged into the right support services?

That’s right. It’s all about the partnerships and the collaborations we create along the way. Probably the reason we’ve been successful is that we’ve thought in innovative terms about these collaborations. It’s us and a non-profit agency, us and a for-profit organization, us and the federal government, us and the state government. There are a number of people sitting at the table.

How much does all this cost?

We are an expensive program. It’s about $1.2 million a year to keep it going. Fixed-site care is cheaper than a van. People say, “Why is that? You’re just driving around.” The truth is we’re less efficient in a van. We’ve got to put in gas and cover maintenance. If we get a flat tire, we basically close the clinic. However, with mobile care we’re able to reach a patient population that’s on the move.

What changes have you seen in the homeless population over the past decade?

We’ve started to see more young families that are homeless. In fact, the fastest-growing population is these young families. We know that homelessness tends to perpetuate itself, so if you have a homeless family that has kids, those kids have a higher chance of becoming homeless. Because of this economy, we’ve seen a sort of “new poor,” if you will, where so many families had a job and a house and then they lost everything.

Bruce Morgan can be reached at bruce.morgan@tufts.edu.