We agree with Sandra Scott Simons, MD, that far more societal resources are needed to solve homelessness and that EDs are the canaries in the coal mine in seeing the harmful effects of societal disinvestment in safe, affordable housing. (“Homelessness is a Diagnosis EPs Can't Fix,” EMN. 2020;42:24; https://bit.ly/3mHGPty.)
Obviously, solving homelessness is not a responsibility that can or should be shouldered by EPs alone. Yet EPs in collaboration with local and national homelessness and housing organizations can choose to add their powerful voices to advocate for the policies and programs that are needed.
Dr. Simons' article does a disservice to people experiencing homelessness by spreading harmful myths that further stigmatize them. We know from rigorous research that homelessness is associated with higher rates of chronic illness and strikingly high mortality at much younger ages than comparable housed individuals.
The chronically homeless patient in the ED is probably more likely to die in the next year than the housed patient in the ED with chest pain. The idea that patients experiencing homelessness present to the ED primarily for secondary gain, that they just want a sandwich, is incorrect and dangerous. The suggestion that EPs write “malingering” on their charts is particularly troubling. People experiencing homelessness should receive the same consideration of their medical complaints as other patients.
The compassion fatigue that Dr. Simons mentioned is real. Recognizing that our patients experiencing homelessness have valid medical needs—medical needs that we are equipped to assist with as physicians trained not only in resuscitation but in emergency medicine—goes a long way toward preventing compassion fatigue. Giving them that sandwich or pair of socks when needed doesn't hurt either.
Kelly M. Doran, MD
New York, NY
Maria C. Raven, MD, MPH
San Francisco, CA
Drs. Doran and Raven are the authors of “Homelessness and Emergency Medicine: Where Do We Go From Here?” (Acad Emerg Med. 2018;25:598; https://bit.ly/36gTo8M.)
Dr. Simons responds: I agree 100 percent that patients experiencing homelessness have high rates of medical issues that must not be ignored. No, we should not write “malingering” on their charts. The introduction of my article verbalizing that malingering often ends up on their list of diagnoses was to demonstrate the problem and was in no way an affirmation of this practice. The point of the article was to draw attention to the need for social work resources in the ED. We are doing these patients a disservice if we only focus on medical needs and ignore their multitude of social needs.