Microsoft Word - It'snotaboutthefeetcover.docx Published by University of Minnesota Libraries Publishing It’s not about the feet Erik A. Wallace, M.D.; Nikki D. Bloch, B.A.; Heather Cassidy, M.D. DOI: https://doi.org/10.24926/jrmc.v2i4.2160 Journal of Regional Medical Campuses, Vol. 2, Issue 4 (2019) z.umn.edu/JRMC All work in JRMC is licensed under CC BY-NC Erik A. Wallace, M.D.; Associate Professor of Medicine, Associate Dean for Colorado Springs Branch, University of Colorado School of Medicine Nikki D. Bloch, B.A.; Medical Student, University of Colorado School of Medicine Heather Cassidy, M.D.; Assistant Professor of Medicine, Assistant Dean for Community-Based Medical Education, University of Colorado School of Medicine Corresponding author: Erik A. Wallace, M.D.; Associate Professor of Medicine, Associate Dean for Colorado Springs Branch, University of Colorado School of Medicine, 4863 N. Nevada Ave., Room 426 Colorado Springs, CO 80918; 719-255-8084; Erik.Wallace@cuanschutz.edu All work in JRMC is licensed under CC BY-NC Volume 2, Issue 4 (2019) Journal of Regional Medical Campuses Perspectives It’s not about the feet Erik A. Wallace, M.D.; Nikki D. Bloch, B.A.; Heather Cassidy, M.D. Abstract The authors at a regional medical campus reflect on the positive impact of implementing a free foot care clinic at a local homeless shelter. Although basic foot care services were provided, the humanistic conversations between medical students providing the care and the people who were homeless had a profound impact on both parties. Medical students connected with a patient population that they have little in common with and were enlightened and rewarded through these conversations. In the satirical video “It’s not about the nail,”1 a woman confides in her partner that she is suffering from a terrible headache. The partner, noticing a nail protruding from her forehead, offers to remove the nail to relieve her pain. The woman snaps back, “It’s not about the nail…you always try to fix things when what I really need is for you to just listen.” Embedded in the absurdity, the video illustrates how our human impulse to solve “problems” can overshadow other unique and critical human abilities: listening and empathizing. This solution-finding impulse is perhaps even more profound among clinicians, who are often called to the profession from a deep desire to heal. Yet while focusing intently on the most obvious problem at hand, we risk overlooking the person bearing the “problem.” While our patients may be looking for solutions, they are also looking to be heard and for their experiences to be witnessed and validated. In our rush to fix the “problem,” do we risk rendering our patients invisible? And what do we do when our patients’ challenges are much greater than our capacity to solve? For people experiencing homelessness, their “nails” are manifold. These wounds often go unnoticed as they are forced into the fringes of society, met with the downturned faces of a public too disturbed by—or judgmental of—the reality of their misfortune to acknowledge it. They suffer from physical, mental, and emotional ailments; we focus on “solving homelessness,” epidemics of homelessness, and wars on homelessness (or the homeless)…all while we hope for the “problem” of homelessness to simply disappear.2 Homelessness can be borne from illness and will foster illness. As Kushel et. al described, “Homeless people have higher rates of premature death, a greater burden of acute and chronic physical health conditions, a higher prevalence of psychiatric and addictive disorders, and a higher risk of being sexually or physically assaulted than do people who have a home.”3 Access to health services by people experiencing homelessness is limited, and repeated mistreatment by the healthcare system has caused them to lose their trust in us; the imperative to secure food and shelter may outweigh traveling to a scheduled clinic appointment. Unique to the medical management of people experiencing homelessness are the pathologies of their feet. People who are homeless spend hours each day on their feet as their primary mode of transportation: learners participating in our medical school’s Poverty Immersion in Colorado Springs (PICOS) quickly discovered that several miles separate our community’s central homeless shelter, soup kitchen, and social services center. Despite the critical role feet play in survival, basic foot care is often impeded by the tyranny of the moment; daily and urgent survival needs can lead to chronic neglect of minor and major foot problems. Nail pathologies, blisters, corns, tinea pedis, and foot deformities are all common among this population; limited access to hygiene and ambulating in ill-fitting shoes or wet socks can lead to ulcers, infections, frostbite, and amputations, especially in people with underlying diabetes and diabetic neuropathy.4 The feet of those experiencing homelessness hold stories. However, for those of us living with the privilege of stable housing, putting on our socks and shoes may simply be a reflex, our thoughts limited to the color coordination of our socks, matching shoes to the day’s tasks or outfit. Long nails or mild lesions might easily be addressed by the supplies in our medicine cabinet, or via access to a podiatrist. Our feet usually don’t tell a compelling story. For people who are homeless, their feet speak of their daily lives and struggles. They tell of the last time shoes were removed—sometimes weeks or months ago. They tell of the miles walked, the weather endured, the pain withstood. They tell of deprivation, prioritization, and impossible choices. DOI: https://doi.org/10.24926/jrmc.ADDHERE Journal of Regional Medical Campuses, Vol. 2, Issue 4 Perspectives Dedicated foot care clinics provide the opportunity to uncover the narratives hidden beneath the well-worn shoes of people who are homeless; the privilege to peer past their soles and into their souls. Although foot care clinics for homeless individuals are not new, they are not common in our communities. Trimming nails, filing calluses, and applying athlete’s foot powder might seem like small solutions for small problems, but, similarly to preventive dental care, diagnosis and treatment of minor foot problems can avoid major pain, disability, and costs down the road. While these medical services may be rendered at primary care clinics or even in emergency departments, traditional settings cannot consistently afford the time and personal attention to make connections and unravel stories. Dr. JJ O’Connell, in his book Stories from the Shadows: Reflections of a Street Doctor, reflects on his own experiences providing foot care for the homeless: “the footsoak inverts the usual power structure and places the caregiver at the feet of each patient and far from the head. This gesture of respect for the literal and figurative personal space of each homeless person is critical and a marked contrast to how I was taught to take charge in clinical encounters.” 5 Unlike addressing foot complaints in most traditional clinical settings, when running a foot care clinic for the homeless, it’s not about the feet. During our quarterly foot clinic at a local homeless shelter, medical and allied health professional students undergo training and supervision from local volunteer physicians and podiatrists. The students arrive apprehensive, with outsized nerves: here is a new clinical skill to master AND the unknown of engaging with a person experiencing homelessness. Students welcome each guest by name, settling the patients in chairs while they take their places on stools at the guests’ feet. They ask about their feet, inquire about their likes and dislikes, and hear about their worries. Quickly, students’ attentions shift from apprehensions about how to correctly trim toenails and choose appropriate tools for shaving a callus, to the surprising ease of conversation with their guests. Stories unfold. There is listening and empathy. Human connection is forged. Humility is discovered, and humanity is restored. Over the course of a two-hour clinic, the room shifts from awkward quiet to the ease of warm chatter and laughter. The students, most of whom had little previous desire to care for feet, wear profound, unselfconscious smiles by the end. After thirty minutes of cleansing, care, and lotion application, each guest leaves with fresh feet, a new pair of socks, and a smile. Sure, there is a cost, and cost-savings, to providing foot care to people who are homeless. Basic foot care can improve quality of life by avoiding future pathologic foot complications. However, the true value in these clinics rests in the opportunity to listen and empathize. The privilege to hear stories and in doing so provide visibility to a population that too often goes unseen. To reaffirm their dignity and humanity though the simple act of service, and for them to reaffirm our own. Ultimately, it’s not about the feet. References 1. Headley J. It’s not about the nail. Accessed at https://youtu.be/-4EDhdAHrOg on August 7, 2019. 2. Gellafante G. Are we fighting a war on homelessness? Or a war on the homeless? New York Times. Accessed at https://www.nytimes.com/2019/05/31/nyregion/ho melessness-shelters.html?searchResultPosition=3 on August 7, 2019. 3. Kertesz SG, Baggett TP, O’Connell JJ, Buck DS, Kushel MB. Permanent supportive housing for homeless people – Reframing the debate. N Engl J Med. 2016;375(22):2115-17. (DOI: 10.1056/NEJMp1608326) 4. To MJ, Brothers TD, Van Zoost C. Foot Conditions Among Homeless Persons: A Systematic Review. PLoS ONE. 2016;11(12):1-14. (DOI: 10.1371/journal.pone.0167463) 5. O’Connel JJ. Stories from the Shadows: Reflections of a Street Doctor. Boston MA, USA: BHCHP Press; 2015.