"Rewarding and challenging at the same time": emergency medicine residents' experiences caring for patients who are homeless.

OBJECTIVES: The objectives were to examine how emergency medicine (EM) residents learn to care for patients in the emergency department (ED) who are homeless and how providing care for patients who are homeless influences residents' education and professional development as emergency physicians.
METHODS: We conducted in-depth, one-on-one interviews with EM residents from two programs. A random sample of residents stratified by training year was selected from each site. Interviews were digitally recorded and professionally transcribed. A team of researchers with diverse content-relevant expertise reviewed transcripts independently and applied codes to text segments using a grounded theory approach. The team met regularly to reconcile differences in code interpretations. Data collection and analysis occurred iteratively, and interviews continued until theoretical saturation was achieved.
RESULTS: Three recurring themes emerged from 23 resident interviews. First, residents learn unique aspects of EM by caring for patients who are homeless. This learning encompasses both specific knowledge and skills (e.g., disease processes infrequently seen in other populations) and professional development as an emergency physician (e.g., the core value of service in EM). Second, residents learn how to care for patients who are homeless through experience and informal teaching rather than through a formal curriculum. Residents noted little formal curricular time dedicated to homelessness and instead learned during clinical shifts through personal experience and by observing more senior physicians. One unique method of learning was through stories of "misses," in which patients who were homeless had bad outcomes. Third, caring for patients who are homeless affects residents emotionally in complex, multifaceted ways. Emotions were dominated by feelings of frustration. This frustration was often related to feelings of futility in truly helping homeless patients, particularly for patients who were frequent visitors to the ED and who had concomitant alcohol dependence.
CONCLUSIONS: Caring for ED patients who are homeless is an important part of EM residency training. Our findings suggest the need for increased formal curricular time dedicated to the unique medical and social challenges inherent in treating patients who are homeless, as well as enhanced support and resources to improve the ability of residents to care for this vulnerable population. Future research is needed to determine if such interventions improve EM resident education and, ultimately, result in improved care for ED patients who are homeless.