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“I had a patient who had a history of trauma, bipolar disorder, substance abuse issues and was living in a homeless shelter at the time,” Alex Paiva, a Licensed Mental Health Counselor from Fall River, Massachusetts said. “At one point, the patient stopped coming.”

“Then maybe a year and a half later, he showed up on my schedule again, he said to me, ‘You gave me info that was pretty straight forward. At the time, I wasn’t ready for that, but I think I am now.’”

Paiva, entering his second year as a medical student at University of Incarnate Word School of Osteopathic Medicine, (UIWSOM) brings 11-years of experience in mental health into his outlook of patient care.

“I’ve learned to not be dissuaded when the patient doesn’t want to engage,” Paiva said, “ultimately, they are going to be the ones who determine when you get let in.”

The osteopathic medical school is located in District 3 of San Antonio’s Southside, an area with a high amount of health disparities. Driven by their local community, UIWSOM’s curriculum, research and service challenges the learner to see patient interaction with sensitivity of unique realities of life, illness and circumstance.

“It all comes back to relationship,” Paiva said.

So, when a message appeared in his inbox about a street medicine group being started on campus, no other program could have sounded more personally aligned to the education Paiva hoped to gain in his medical school experience. And apparently, he wasn’t alone. Founder of Street Medicine San Antonio, (SMSA) Dr. Hans C. Bruntmyer, was surprised to find about 50 students sitting in that meeting room, eager to take medicine to homeless community members.

Across the world, the still-emerging initiative, Street Medicine was helping super-utilizers, with physical, mental and social needs unmet by traditional health care, gain access and trust back into the system. But in Bexar County, the estimated 3,066 individuals living in sheltered and unsheltered homeless conditions was unserved. So, in 2018, Bruntmyer and students started the campus interest group to engage the San Antonio homeless population.

At the start of the year, a cold January night, Paiva and his team took the late shift, 9pm to midnight, it was their first street medicine run, nearly a year after the initial group meeting. SMSA partnered with San Antonio Regional Alliance for the Homeless, (SARAH) to offer medical treatment alongside the annual point-in-time count, a census to gain a number of the city’s homeless population on a given night.

EMT-certified UIWSOM student-doctors spread out in groups around the city. Some searched under bridges and tunnels, while others navigated through woods and rural encampments. Paiva’s team took the dense downtown city parks, breezeways and sidewalks. They carried a backpack full of medical supplies, meant to administer basic medical care like dressing wounds and taking vitals.

When the team came across a man wrapped up in a sleeping bag, Paiva and his partner approached him and found he was willing to talk.

“When’s the last time you saw a doctor?” Paiva asked. The patient had been in and out of homelessness. He had a history of hypertension and diabetes.

“Oh, about 3 weeks ago, when I went to the ER,” the man replied. There, he was treated for hypertension.

“What are you doing for follow up?” Paiva asked.

“Nothing, I have medications, but that’s it.”

As Paiva walked away from his first street patient interaction, he had a sobering feeling, “This person has to rely on going to the emergency room to get help,” he thought, “what’s standing in the way of [primary health care?]”

Sure, the man had medications, but what would he do when they needed to be refilled? What was he doing for follow-up care? Would he have access to a phone to schedule an appointment and what would he do for transportation even if he did have an appointment?

These questions burdened Paiva, knowing that this is the reality of individuals living on the street and where the fringes of health care end. There’s often not someone there, piecing together the gaps in health care access.

“We can be the on those front lines, in the trenches,” Paiva said about SMSA, “regularly showing up to where people are in the city, treating them like a human being, that’s grounding for the person on the other end.”

With street medicine, when medical care providers walk away from their patient, they don’t know if they will encounter that person again, knowing there is not a designated time or place for patient follow-up. There are community partners patients can be referred to, but in order for the continuum of care to function, the initial interaction with street patients demands a different standard for quality of care.

According to Paiva, that sense of accountability “all comes back to relationship.”

“There is an importance of establishing that rapport. Step one- you’re still a person, let’s get that part figured out. And then as we build a trust factor here, we can start addressing medical needs.”

Paiva remembered the patient he counseled before his medical school journey began and before he made house calls on the streets of San Antonio. Throughout the time he worked with the patient, Paiva watched him maintain his residency at a shelter-owned apartment, manage to stay clean for a time period and develop interpersonal skills like how to open up to people, not blow them off, and when to ask for help.

As medical professionals interact with patients, regardless of condition or circumstance, the trust being built is essentially “building trust back into the health care system,” according to Paiva.

“They are going to be the ones who determine when you get let in, and when they will trust your advice- to follow up at a health clinic, to be accept substance abuse support, to enter a shelter,” Paiva said. “The system starts with those on the ground, helping to rebuild the face of health care.”

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