“I get paid back in the end because I have a good day”: A conversation at HOMES Clinic with Dr. Dana Clark
Written by Nicholas Peoples, Mary Fang, & Dana Clark
Introduction
HOMES Clinic (1), which first opened its doors in January 2000, is the only student-managed clinic in Houston and provides free health and social services to people who are uninsured and experiencing homelessness [1, 2]. Countless individuals from across the Texas Medical Center have volunteered their time and industry over the past two decades, but one name has practically become synonymous with the institution itself. That name is Dr. Dana Clark, medical director of Healthcare for the Homeless-Houston (HHH) in its early years and faculty advisor for HOMES Clinic.
For over 20 years – more frequently and longitudinally than any other physician in the history of HOMES Clinic – Dr. Clark has spent her Sundays providing free health services to the Houston homeless population and teaching hundreds of doctors-in-training how to do the same. The weekdays in-between are divvied up between her clinical practice and meetings with the HOMES leadership on how to improve clinic services and grow the organization, which often extend late into the evening. She lead-authored the paper that first introduced HOMES to the world [Clark et al, 2003].
In the clinic environment, Dr. Clark is an incredible role model for empathy and kindness with an uncanny ability to connect with her patients. We decided to sit down with her to understand her remarkable commitment to providing primary care for people experiencing homelessness.
(1) HOMES Clinic, which stands for “Houston Outreach, Medicine, Education, and Social Services,” operates under the umbrella of Healthcare for the Homeless-Houston, a federally qualified health center.
Interview
What was your childhood like?
I grew up fairly poor. My dad was a welder and there were four kids. So you can imagine what that was like.
But we also lived in the Bay Area in California, surrounded by the most colorful and diverse collection of human beings that you could think of – including many that were wealthy or educated beyond our wildest dreams. So going to school felt like a big contradiction. Inner-city poor black kids running alongside the children of Berkeley professors and the like.
But it was because of my upbringing and that multi-cultural, multi-ethnic, multi-socioeconomic scene that I grew up feeling like I could do anything. We accepted everyone. Everyone was a person that had something to offer to make the world a better place. That’s what defined my childhood.
I applied myself and eventually found myself at UCLA’s King Drew Medical center in Los Angeles, in a tumultuously underserved area.
What were the defining features of your medical school experience?
All the gang violence. I was in Los Angeles during the Watts Riots where there were countless killings and shootings. During my surgery rotation, we were pulling bullets out of people the whole time. It was the most heart-breaking experience. I ended up staying there for residency and looking back I know that I received some of the best training possible. I worked with the poorest and most underserved patients in our nation at the county hospital.
I chose primary care and family medicine because I thrived on the challenge of not knowing everything. Again, it goes back to my childhood background of living in community and co-op with radically different kinds of people. Primary care is about thinking about the whole patient and that constantly forces you to think outside the box and see the whole picture.
I would often encounter patients who were experiencing disturbing outcomes. I don’t know if it was provider bias or ignorance or just plain laziness, but I would always find myself asking: “how did this happen? How did this not get addressed in the last five visits?”
For instance, I saw one man with prostate cancer who also had mild intellectual disability. He was just a little slow. His providers had never explained to him his prostate cancer diagnosis in a way he could understand. So the man has metastatic prostate cancer to his back. He was seen at multiple visits in a medical conglomerate. And then he got severe rectal pain, and of course, now it is metastasized to his back. He said, “I wish someone would have told me sooner.” Can I say it’s a bias? Or it’s a lack of care? I don’t know where it comes from. But I saw a lot of things where people have not done their job and then I can come in and do it. That’s one of the things I love about doing primary care – putting all of the pieces of the puzzle together for someone that has a complex situation and being able to help them.
You’ve spent years serving the Houston homeless population, so how did you end up in Texas?
Ironically, the reason I moved to Texas afterward actually had to do with housing. Real estate in California was prohibitively expensive and so we came to Houston for affordable housing and safety. Los Angeles didn’t feel safe for us – there were always the shootings and violence. And if we had stayed in LA, we would not have been able to buy a home. I don’t quite know what to call it, but there is certainly a streak of irony in that given that I later spent a lot of time as a doctor for the homeless.
So the career that we all know you for – is that the path you immediately started on when you left residency?
I actually worked in the private setting for three years because I was having children and starting a family. But I missed the county setting more and more. I saw homeless people on the streets of Houston all the time. I was driving by one of the encampments one day and finally said to myself, “I miss this. I have to get back. This is what I want to do – how do I get here?”
I found my way to Baylor College of Medicine and then HOMES Clinic soon after. And then Dr. Buck (2) started mentoring me. That culminated in becoming the medical director at Healthcare for the Homeless Houston (HHH). I started writing policies and procedures, running meetings, growing the organization. Because at that time it was very small. Now, of course, HHH has several beautiful clinics all over the Houston area providing free health and social services to Houston homeless population.
I did that for four years and I loved it. Over that time, though, I realized my heart was with the patients and the students more than the board meetings. So I stepped down as medical director but kept seeing patients at HHH for years and years and years and put even more of my time into HOMES Clinic.
(2) David Buck, MD, MPH, is Dean for Community Health at University of Houston College of Medicine. He is the founder of Healthcare for the Homeless-Houston and HOMES Clinic. Our interview with him is available in the Journal of Social Distress and Homelessness [3].
What did you find so energizing about providing healthcare for the homeless that you didn’t find in private practice?
The thing I love about working with underserved populations is the ability to impact truly sick patients. They have heart failure, kidney failure, poorly-managed diabetes, hypertension, and a million other things. A lot of them are homeless. It’s a high level of care.
If you work in a private practice you have “cost restraints.” Insurance won’t pay for a lot of basic things and the patient can’t afford it. But in academic medicine, I can do the appropriate workup I need to do. I can take care of the patient the way they should be taken care of. Not because they can’t afford it or someone says, “that’s too expensive.”
“That’s what I really like – you don’t have to compromise your ethics. You just do what the patient needs. And leave money out of it.”
“That’s what I really like – you don’t have to compromise your ethics. You just do what the patient needs. And leave money out of it.”
What have you learned from your years of experience providing primary care to people experiencing homelessness?
“Empathy. Because when you put yourself in the patient’s position, then you can ask the right questions.”
You imagine what it’s like to be in their shoes. But then you can feel what it’s like and grow.
And then you learn how to make your own situation better too.
The empathetic doctor will realize, “Oh, that person barely made it in here. Maybe they need a walker.” But many trainees and providers won’t even think about that. They’re too focused on the heart failure that the chart says the patient is coming in for – never mind that they could barely “come in” in the first place.
So now build on that with homeless patients. Think about when it’s so cold outside! When it has beenraining, wet, and 30 degrees. You have to feel what that was like for that person when they walk through your door. And then you know to ask them if they need a blanket. That’s probably the single most important thing they need. Or some dry shoes. Forget the other things. Through empathy, you put yourself into the whole situation.
My patients have taught me a lot about resilience. I always tell the students as a doctor you can go to a lot of places you’ve never been – but you have to listen to your patients to get there.
“Empathy. Because when you put yourself in the patient’s position, then you can ask the right questions.”
What are the challenges you’ve faced trying to do this work?
The corporatization of medicine. Medicine has changed. It’s becoming a machine. Family medicine doctors are being told to see too many patients a day now. With the implementation of the EMR you can come home and chart for three plus hours on the same patients you see that day. So if you work 40 hours a week, it’s 80 hours. Whatever you’re told you’re making per hour, you’re making half that because the hours are twice what you signed up for.
Medical training now seems to be heavily focused on teaching providers to get through the patients. Maybe not doing a full chart review, for instance. I was trained on quality – striving for perfection. But corporate medicine is striving for production. And if you miss a few things? Just keep it moving. That’s the mentality. I think this takes all those gifts out of gifted providers and they just become producers.
And how can you find time to speak out and advocate for change? How can you write an op ed? How can you take the time to practice the empathy I was just talking about? You’re just fighting to get the dishes done when you get home.
We’re supposed to be teaching new providers about the social determinants of health and practice-based leadership and culturally competent care. But trainees rarely have time to ask any social determinants of health questions. I’ve only had one student in the last three years ask a question like that. She said, “The gentleman I just saw in Exam Room 3 was in jail. Is there anything we should do to help with his transition?” No one else ever asked me a question like that. But we don’t even have time to get to any of that. We’re supposed to be training leaders, but where are they getting the training?
That’s another thing that makes HOMES Clinic so special. It’s a place where students can experience and learn about the social determinants of health in limitless ways. We need leaders. The whole country needs leaders. And medicine needs leaders. When the students come to HOMES they can express their creativity (3). They can be supported and work independently and altruistically outside of the mold. They’re really coming over because they are empathetic and want to help. Your class is a new generation. You guys bring so much to the table, but it’s still a mostly untapped resource because the schools still don’t realize how smart you all are. We need a “leadership track” in medical school to really allow students to realize their leadership potential and help medicine evolve in the right direction.
(3) For interested readers, several recent student accomplishments at HOMES Clinic are reviewed in the following article: Peoples N. (2022). Making our own “New Normal” in a COVID-19 world: Progress Notes on HOMES Clinic’s first year back. Accessible from: homes-clinic.org.
What are your parting thoughts?
Medicine is a discipline of questions. You can ask a patient anything. But first you have to establish a relationship with them. And then they’re happy you asked. If you don’t ask, you’re not going to get the answer.
My upbringing taught me to always place myself in the other person’s position. We would have a better world if we could all practice empathy. The more you can put yourself into the other person’s shoes the more you can see that they are human too.
“In fact, that’s the only way I can get through the day. I block out the insanity from the corporate board and I go to a totally human area, regardless of the pressure put on me with high patient volumes and limited time. The corporate overlords would just have me saying to each patient: “Get in here. Sit down. What the heck do you need?” But by taking that time to walk in that person’s shoes, I get paid back in the end. Because then I have a good day.”
References
Clark DL, Melillo A, Wallace D, Pierrel S, Buck DS. A multidisciplinary learner-centered 302 student-run clinic for the homeless. Fam Med. 2003; 35:394-397.
Peoples N, Fang, M., Clark, DL. HOMES Clinic offers a “House of Yes” for Houstonians Experiencing Homelessness During Coronavirus Pandemic. But Where Are the Rest of Houston’s “Student Run” Free Clinics? TMC Pulse. 2021
Peoples N, Fang M, Buck D. Healing the homeless, fixing a broken aid industry, and challenging the status quo. Journal of Social Distress and Homelessness. 2022.
