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Host: Clarence Fluker
Guest: Sandeep Sharma, MD
Fluker: Welcome to “Beyond the White Coat: Making the Rounds” presented by Community Health Connect — an AAMC program that facilitates conversations on issues related to health disparities, social determinants of health, and other public health concerns in the District of Columbia.
I'm Clarence Fluker, director of community engagement here at the AAMC. I'm joined today by Dr. Sandeep Sharma, the medical director at So Others Might Eat, known to most of the community as SOME.
SOME is an interfaith community-based organization that helps the poor and people experiencing homelessness in our nation's capital. They offer a full range of high-quality health services for adults, including primary care.
Dr. Sharma has been practicing internal medicine for 17 years, with special interest in nutrition, wellness, care for people living in poverty, and geriatrics. He has a traditional internal medicine practice in Maryland and practices primary care in Washington, D.C.
Dr. Sharma will share SOME's experiences with providing services for their clients during the pandemic.
Thanks so much for taking time today, Dr. Sharma.
Sharma: My pleasure to be here. Thank you.
Fluker: So, we'll dive right into the conversation, and my first question for you is, what is unique about providing health care services to people experiencing homelessness?
Sharma: So, the first thing I would say is just our physical access to the patient. Very often, it's difficult to get patients to come in for a visit, just because of lack of transportation. Very often, doctor's offices call the day before to remind patients of visits; our patients don't usually have reliable phone service, they don't have reliable mailing addresses. It's just difficult to get communication to them about a variety of different things. So, physical access is a challenge, communication is a challenge.
Of course, lack of financial resources are a challenge in so many different aspects of providing their health care, whether it comes to getting them home health care services, physical therapy services, sometimes just medication. Despite the fact that they're on programs, there are still, very often, small copayments that patients are unable to afford.
Fluker: I'm going to take a step back now and just ask you to tell me a bit about So Others Might Eat and the types of services that you provide. And can you tell me a little bit about the typical patient that you all see at So Others Might Eat?
Sharma: Sure. So, it's a wonderful organization, number one. They provide medical services to — in terms of primary care, ophthalmology, podiatry, mental health, dental, psychiatry. They also have a case management department, like, mainly run by social services that assists in mental health but also assists, tremendously, with trying to get these patients who are homeless — to try to get them into some type of housing. Because we know once we get them into housing that's affiliated with So Others Might Eat, we're able to provide so much more consistent care in all of those different disciplines: mental health, medical, dental. Because then we're able to access them very easily, we don't lose patients then.
So even if they don't have a phone, it doesn't matter, because we know where they're residing, and there's somebody running the facility, the home where they're residing, the group home, so we're able to get access to them. And they do a tremendous job of coordinating their appointments, their transportation, et cetera.
Fluker: Can you tell us a bit about your typical patients that you might see?
Sharma: Sure. The typical patient is, I would say, probably somewhere between the age of 35 and 50, has chronic medical conditions such as hypertension, diabetes, elevated cholesterol. We do see a good degree of obesity — and that doesn't all mean morbid obesity. These patients also have varying degrees of mental health issues, but the majority of patients have some features of depression, okay?
Now, the severity of mental health, you know, is — there's a wide variety, but the majority of the patients have some type of depression as well. These patients haven't had access to health care in a number of years, and they haven't been able to take good care of their health. And generally, these patients have not been educated about the importance of health care and the importance of prevention — prevention of chronic conditions.
Fluker: Dr. Sharma, you talked a lot about the challenges that already existed for your patients to access health care prior to the COVID-19 pandemic. Can you tell us about how the COVID-19 pandemic has further influenced or impacted their access to health care?
Sharma: Yes. So, COVID-19 made the physical access to health care more difficult. Health care departments' recommendations were to stay inside, stay indoors, avoid social situations. The majority of our patients, just the way they get to the clinic is on a bus, so buses were not an option for them. And then the other thing is, our patients were fearful — appropriately so — about leaving their homes. We're talking about a lot of people who are — actually, when I say leaving their homes, they're usually leaving the shelter in the morning and they're out on the streets. But they're really keeping to themselves, trying to avoid any close situation.
I would also say that it was difficult for us to educate our patients because we didn't have access to them. And very often, at So Others Might Eat, we get access to these patients not only in our clinic or in our outreach programs, but we have a soup kitchen that's across the street where we very often have community outreach from the staff at our medical clinic that go there and inform patients of different screening events and things that are going on in our clinic. So COVID just really affected our ability to communicate with our patients, so that's definitely been a challenge.
Fluker: And can you tell us a bit about how, for a nonprofit like So Others Might Eat that provides clinical services for people experiencing homelessness, can you tell us a bit about how you probably had to shift how you do operations during this time?
Sharma: Yes. So, one of the things that we started doing was much more access to telehealth visits. So now, basically, telehealth is — we're communicating with patients via phone and, usually, it's via FaceTime. That's the preferred method, so we can actually, you know, after they're describing the issue that they're having, we can actually at least physically — not physically see them, but at least through video, we can see them.
So, there's been much more access, on our end, to telehealth. The challenge has been, not all of our patients have phones that have FaceTime, 'cause not everybody has a smartphone, and not — our patients also, like, although they're scared to come into the clinic, they're not necessarily up to speed on the effectiveness of telehealth.
Because telehealth actually can be an effective way to triage patients and treat patients as — you just have to — as a clinician, you have to use your skills in a different way. You're not able to touch the patient, but you're able to listen to the patient; you have to talk a lot more to the patient. So, that's something that's definitely changed. And as time goes on, more patients are becoming aware of it, more patients are trying it, so it is something that's expanding.
Fluker: So, it's interesting that you talk about using telehealth for this population, where you said some people don't necessarily have iPhones or have smartphones, which would allow them to do a video call. Do you see or have patients that may not have a phone at all?
Sharma: So, there are definitely patients who don't have a phone at all, and unfortunately, what very often happens is that we lose track of these patients. And we may lose track of these patients for six months, nine months, sometimes even longer than that.
Now, the patients who don't have, say, a smartphone — what we'll do is we'll just do a pure phone consultation. Now, that's definitely more difficult, because, you know — for example, you know, there's a trust that develops when you see a physician or a nurse practitioner and you see them face-to-face. Now, they know us, so even when they see us through a video visit, they're not able to see us face-to-face, but they know us, they've seen us before.
Through a phone without a video, it's more challenging, so you have to spend a longer amount of time, and it's hard to gauge what the patient is understanding. 'Cause if I'm educating a patient, let's say, about diabetes, whether I'm – I mean, in person is definitely better, but even through a video visit, just by reading their face and reading their eyes, you can get a sense of whether or not they're understanding the education that you're providing. But without seeing them, you're just hoping — you're hoping that they're understanding your message, so you just try to reiterate it.
Fluker: Earlier, you talked about a number of your patients who may live on the street, or some who may live in congregant group shelters or all sorts of different types of living arrangements. Can you talk to me a bit about how you engaged, or what kind of guidance was being provided to group shelters in the district, from the medical community?
Sharma: So, I think that the local health departments are doing the best job they can possibly do to provide guidance to the shelters. The guidance that the local health departments use — whether it's, you know, District of Columbia, Maryland — it's based primarily on the CDC guidelines. And the CDC guidelines for homeless shelters are basically requiring them to categorize patients. So, we have patients who are completely asymptomatic, so they don't have a cough, they don't have a runny nose, they're not feeling weak, they're not having a fever, and they will be put in one section of the shelter, okay? And then, there will be a place for anybody who is under suspicion, so a person who's, you know, having a cough or shortness of breath, but not so much that they would require an emergency room visit, right?
Like, not someone who's, like, acutely short of breath, because that person is going to be sent to the emergency room because they're going to need an urgent evaluation. But someone who can still be managed in an outpatient setting but still has mild symptoms, they're going to be segregated from those homeless people who do not have any symptoms at all. That's the guidance that's coming from CDC, and it's very — homeless shelters are being — the recommendations to homeless shelters are very similar to the recommendations that are being provided to other institutions that have patients — some with symptoms, some with no symptoms — such as, like, a long-term care facility, nursing home-type facilities.
Fluker: There are a lot of people right now who are part of the movement that say "housing is health" or "housing is health care." Along that line of thinking, what do you see is the role of physicians and health care administrators and academic medicine in housing for all and housing as health? What do you think our role is? Or is there a role, do you think?
Sharma: I think there is. I think an easy role is to advocate, that's number one. But the other thing is, I think, data accumulation and data analysis. I'm not aware, specifically, but it would be an interesting research project to look at patients with similar age, similar clinical comorbidities, and even similar access to health care to see if there's a difference in outcome by one person having a home versus another person not having a home.
Because there's been a number of situations that I've encountered with patients, and they've just had their medications stolen, because, you know, they're staying somewhere and, you know, they leave for a few minutes, and, you know, their bag's taken, medications are gone.
The other thing is, we have a lot of diabetic patients at our clinic, and a lot of our diabetic patients are on insulin. Insulin has to be refrigerated. We have so many patients whose insulin goes bad because of inadequate refrigeration. And very often, the patients feel guilty. So, rather than come back to the clinic and say, "This is what happened," basically, they just go without their insulin.
And we don't actually know what's going on with their diabetes at that time, because if you're going without your insulin, very often, you're not going to be checking your blood sugars. And if you are checking your blood sugars and the blood sugars are high, you're not able to do anything about it, because you don't have the insulin to bring it down. So, I think that would be an interesting research project, and I think that there would be significant differences in clinical outcomes by the same exact patient, one being homeless and one not.
Fluker: What do you think we've learned about the health care system from the way this pandemic has played out?
Sharma: So, I don't wanna be overly negative, but I definitely think there was a lack of preparedness in terms of dealing with the pandemic. In terms of PPE, we weren't prepared, didn't have readily available access to all health care professionals. I don't think we had a good alternative plan in place for when ICU beds were completely full, possibly lack of ventilators — we just didn't have an alternative plan in place. I also think that there was a significant lack of education to the health care workers. I can tell you that, prior to COVID-19 — and I've been practicing for 17 years — I cannot recall, even in medical school, about a pandemic in terms of preparing for one or what actually happens. Historically, the Spanish flu may have been mentioned, and I don't even remember it, but it may have been mentioned, but there was a lack of education for all of us.
Now we expect, you know, a layperson to, you know, not know that much about a pandemic, prior to COVID-19, but I myself — I was unprepared. You know, I was looking for guidance from our local health department, I was on the phone very frequently with, you know, different directors and epidemiologists, and this was just all new. Now the virus itself, it's a novel virus, it's new, but our preparedness should've been better, I feel. And I think it will, going forward.
Fluker: We've talked a lot about the patients. I'd be interested in knowing, from your perspective as the physician, what have been some of your lessons learned about working with this population during the pandemic? What are some lessons that you will take away with you, that you'll think about in the future?
Sharma: Well, that regardless of situation, at the end of the day, we're all human beings and we all wanna thrive. So, these patients, regardless of their situation — and there are times in probably every day that they lose a bit of hope, but overall, their underlying feeling is that of optimism, that, "I wanna get better. I wanna be safe. The future is going to be better." That's an important lesson, I think, that I've learned, because these patients have unbelievable challenges on a day-to-day basis. They don't have shelter, they don't have consistent food, but still, within them, there's still an optimism that, if not tomorrow, next month is gonna be better.
Fluker: Dr. Sharma, thank you for joining us today on “Beyond the White Coat: Making the Rounds.” The work that you and your colleagues are doing every day speaks to the AAMC's mission of improving the health of people everywhere, and we appreciate your work.
Sharma: Thank you — appreciate being here.
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