Identifying Gaps in Homeless Health and Addiction Education in a Medical School Curriculum

by Lizzeth N. Alarcon, MD; Sarah Stumbar, MD, MPH; Florida International University, Herbert Wertheim College of Medicine, Miami, FL

Background

Housing is an important social determinant of health. The clinical assessment of an unhoused individual requires a unique understanding of their psychosocial circumstances, and this knowledge should be integrated into their care plan. Unhoused individuals face higher rates of mental health and substance use disorders (SUD) relative to their housed counterparts.¹Florida is among the top three states with the largest homeless population.² Florida International University’s Herbert Wertheim College of Medicine (FIU HWCOM) is located in Miami and approximately 47% of FIU HWCOM graduates attend residency programs in Florida.³ Therefore, preparing our medical students to care for individuals facing homelessness and/or a SUD is imperative.

Methods

We examined the existing curriculum to determine in what capacity homelessness and SUD are already taught. The terms searched in FIU HWCOM’s electronic curriculum map included homeless, unhoused, housing insecurity, undomiciled as well as substances, addiction, recreational, injection drug use, overdose, and recovery. The course directors for all courses and clerkships were also emailed. We performed a literature review to determine best practices regarding undergraduate medical education learning objectives on homeless health and SUD.

Results

We assembled a list of learning objectives based on guidance from expert societies and national organizations.^4-8 We identified gaps between practiced and recommended education at FIU HWCOM, largely in the absence of objectives covering homeless health, as well as SUD objectives addressing harm reduction strategies and community-based supports aside from abstinence-based models. More details are in Tables 1 and 2.

Conclusion

Curricular gaps in important health topics in undergraduate medical education can be identified using a systematic approach to a curricular review including communication with course and clerkship directors, a literature search to identify recommended learning objectives, and communication with institutional leadership.

Next Steps

Our findings were presented to FIU HWCOM Strand Leaders Committee, which oversees integration of curricular content at our institution. The committee approved recommendations to address the identified gaps in the existing curriculum. The authors will work with the course directors of the Community Engaged Physician Course, which focuses on the social determinants of health, as well as the Clinical Skills Course to implement new curricular activities.

Table 1. Proposed Learning Objectives and Identified Curricular Gaps at FIU HWCOM: Homeless Health

By the end of medical school, students should be able to:	Included	Not Included
1. Define homelessness by federal standards.		x
2. Describe the epidemiology of homelessness in the United States, Florida, and Miami.		x
3. Understand the prevalence of severe mental illness, substance use, intimate partner violence as common comorbidities among individuals facing homelessness.		x
4. Recognize common skin conditions of individuals facing homelessness and treatment options.		x
5. Describe management of exposure-related conditions seen in hot conditions: heat exhaustion, heat stroke.		x
6. Identify challenges to chronic disease management due to homelessness and use them to develop patient-centered care plans.		x

Table 2. Proposed Learning Objectives and Identified Curricular Gaps at FIU HWCOM: Substance Use Disorders

By the end of medical school, students should be able to:	Included	Not Included
1. Understand the pharmacology of opioids, hallucinogens, stimulants, nicotine, alcohol, and marijuana.	x	(Stimulants)
2. Describe the neurobiology and the psychosocial model of addiction.	x
3. Describe the epidemiology of substance use in the United States and Florida	x
4. Use validated screening strategies to detect risky substance use.	x
5. Describe the diagnostic criteria for substance use disorders.	x
6. Utilize motivational interviewing and shared decision-making to understand patients’ perspectives and goals for decreasing use of a substance.	x
7. Identify indications for referral to treatment and community support for substance use disorders.	x
8. Explain harm reduction strategies related to substance use disorders.		x
9. Conduct patient risk assessment related to opioids to treat chronic noncancer pain.	x
10. Increase self-awareness on personal attitudes towards individuals facing substance use disorders.		x

References

1. Gutwinski S, Schreiter S, Deutscher K, Fazel S. The prevalence of mental disorders among homeless people in high-income countries: An updated systematic review and meta-regression analysis. PLOS Medicine. 2021;18(8):e1003750. doi:10.1371/journal.pmed.1003750

2. States With the Most Homeless People. U.S. News. Accessed July 19, 2023. https://www.usnews.com/news/best-states/articles/states-with-the-most-homeless-people

3. Florida International University Herbert Wertheim College of Medicine Office of Student Affairs Statistics, 2022.

4. Core Competencies Curriculum - National Health Care for the Homeless Council. Published August 2, 2019. Accessed July 19, 2023. https://nhchc.org/clinical-practice/homeless-services/core-competencies-curriculum/, https://nhchc.org/clinical-practice/homeless-services/core-competencies-curriculum/

5. Caring with Compassion | ACP Online. Published December 12, 2022. Accessed July 19, 2023. https://www.acponline.org/cme-moc/online-learning-center/caring-with-compassion

6. Ayu AP, el-Guebaly N, Schellekens A, et al. Core addiction medicine competencies for doctors: an international consultation on training. Subst Abus. 2017;38(4):483-487. doi:10.1080/08897077.2017.1355868.

7. Muzyk A, Smothers ZPW, Akrobetu D, et al. Substance Use Disorder Education in Medical Schools: A Scoping Review. Academic Medicine. 2019;94(11):1825. doi:10.1097/ACM.0000000000002883

8. Recommendations for Curricular Elements in Substance Use Disorders Training. Published March 24, 2023. Accessed June 15, 2023. https://www.samhsa.gov/medications-substance-use-disorders/provider-support-services/recommendations-curricular-elements-substance-use-disorders-training