Backpack medicine

Vital Signs » Winter 2015
Sara Doorley, M.D. (’05), with a patient

Sara Doorley, M.D.,’05, brings health care to the homeless

When Sara Doorley, M.D., first entered the medical profession, she believed her job was to make people better. But after working with the homeless population for several years, her perspective has changed.

“The most important aspect of my job isn’t finding the cure but creating a dignified, compassionate space where individuals can receive support and be cared for in times of both sickness and health,” said Doorley, medical director of the Valley Homeless Healthcare Program in San Jose, California. “At times, a compassionate touch or a dignified encounter can be more healing than the provision of a medicine.”

The Valley Homeless Healthcare Program is a patient-centered medical home environment that provides primary care services in multiple freestanding clinics, medical mobile clinics, and mobile dental vans.

San Jose is located in Santa Clara County, California, which has more than 6,500 homeless people, according to the a 2015 Santa Clara County Homeless Census. 

“In order to meet the needs of our county’s homeless population, we have designed our program as a network of fixed clinic sites, mobile clinics, and street medicine teams that are able to provide health care services to this vulnerable patient population living in an expansive area,” Doorley said. “Sometimes a visit can be a quick medication refill but other visits involve really complex medical problems and care coordination.”

Doorley and her medical staff have designed their delivery system to best meet the needs of their patients. They work in teams that include primary care providers, behavioral health specialists, and social workers. It also requires working in a location that is most accessible to the patients in need, whether it be a clinic on wheels, a typical primary care clinic, or an encampment that requires hiking down with a backpack full of medications. 

“You never quite know what the day will entail or what crisis might occur,” she said. “Doing this work requires the ability to be flexible and to be able to work in an uncontrolled environment with a certain level of inherent chaos.”

The Valley Homeless Healthcare Program, which was established in 2004, serves about 7,000 homeless individuals on an annual basis. More than 70 percent of Santa Clara County’s homeless population is unsheltered. Of these individuals, 30 percent sleep on the streets, 23 percent sleep in cars, vans, or RVs, 14 percent sleep in encampments, and 4 percent sleep in abandoned buildings, said Doorley who joined the program in 2009 and became the medical director in 2012.

Mobility is key

“One of the first lessons we learned is the importance and necessity of going to the people,” Doorley said. “If you’re going to work in the realm of poverty medicine and/or with vulnerable patients, you will quickly learn that there are many barriers to health care. We found that we could decrease this barrier by being as mobile as possible.”  

The program’s backpack team includes a nurse practitioner, physician, registered nurse, community outreach worker, and
psychologist. Through both a mobile medical unit and an outreach team, the program is able to provide vaccinations, rapid HIV testing, hepatitis C testing, primary care, mental health treatment, and social work services to patients who are unable to access medical and mental health care.

Backpack medicine allows the program to treat the most marginalized patients who have the greatest needs. In addition, backpack medicine enables medical providers to diagnose and treat medical and psychiatric conditions at an earlier stage. This helps to prevent more severe medical complications like AIDS, and also avoids unnecessary health care costs in medical and psychiatric emergency room visits in the future.

The program’s mobile medical unit is a large RV-like facility that has been redesigned as a clinic. The interior of the mobile medical unit includes two rooms with a central waiting area. A nurse uses one room for the initial intake and assessment, and the medical provider uses the other room to see patients. The central room is the space where patients register and wait to be seen.

Comprehensive care for migrant farm workers

The program also treats migrant farm workers. Similar to the homeless patient, the average life expectancy of the farm worker is 49 years.

“Agriculture is the second most dangerous job in the United States,” Doorley said. “Migrant farm workers are at risk for work related injuries such as chemical burns, pesticide poisoning, and musculoskeletal problems. In addition, migrant farm workers have a higher rate of chronic diseases such as hypertension and diabetes.

Once a week, Doorley’s team pulls the mobile medical unit into the middle of a farm worker camp. They start the migrant farm worker clinic at 5 p.m. and end around 9:30 p.m. to accommodate the schedule of the migrant farm workers.

“We address the health needs of this population through a team-based approach relying on the services of an outreach worker, a psychologist, a nurse, and a primary care physician,” she said. “At this site, we really focus on preventative health interventions, health education, and health empowerment.”

Each year, the program has a large flu vaccine campaign, provides treatment for latent tuberculosis infection from the mobile clinic, and offers pap smears and colon cancer screenings. The health care providers spend a great deal of time addressing social isolation, depression, and healthy living.

“It’s the small encounters on a day-to-day basis that are the most rewarding,” she said. “Being able to walk beside these individuals at times of great vulnerability is a gift.”

Homelessness is unacceptable

VS-Winter2015-Backpack-p52.pngHowever, despite the rewards, there are some frustrations. One of the hardest things about Doorley’s job is the frequency with which they lose patients. For every age group, homeless people are three times more likely to die than the general population, she said. Homeless people have an average age of death of 47. “Homeless individuals suffer the same illnesses experienced by people with homes, but they experience them at a rate that is three to six times higher,” she said. “I’m always aware of the incredible vulnerability of these patients, the possible limited amount
of time I might have with them, the potential pending tragedy.”

Doorley believes that homelessness is unacceptable and that every person has a right to adequate food, housing, clothing, and health care. “My frustration stems from our system’s inability to better take care of our most vulnerable,” she said. “Each of us at the homeless program dreams of the day when we no longer have any work because individuals in our society are sheltered and safe.”

She and her team also are a housing-first program. They acknowledge their ineffectiveness in healing while individuals are unsheltered. “Our team and community focus on helping patients not only transition into housing but maintain housing,” Doorley said. “Seeing a patient for the first time after they have received housing is an incredibly joyful and rewarding moment.”

Doorley has always been drawn to opportunities that have allowed her to work with populations with the greatest need. Through her medical school education, international volunteer experiences, and residency training in the South Bronx in New York, she acquired a certain comfort level and skill set that enabled her to transition into a position working with the homeless.

Growing up in Ohio

When she was in elementary school in Fairborn, Ohio, she decided to become a physician. Her parents, Bill and Jane Doorley, emphasized the importance of choosing a profession that embodied both personal meaning and service to others. Her father is a retired teacher, and her mother is a retired professor of nursing at Wright State.

She chose to attend the Boonshoft School of Medicine partly because of Gary LeRoy, M.D., associate dean for student affairs and admissions. She was impressed with his commitment to service and the community. She also liked the medical school’s mentorship of students and support of student initiatives.

Cofounder of Global Health Initiative

As a first-year medical student, she cofounded the Global Health Initiative (GHI) with Allen Chudzinski, M.D. (’04), in 2000. Ryan Buchholz, M.D. (’04), also was instrumental in the development of the organization.

Because of an undergraduate experience that had a profound impact on her, she wanted to create a similar opportunity for medical students. When Doorley was a junior at the University of Notre Dame, she spent the summer working with a team of Arab-Israeli health care workers in Palestine. The experience was life changing.

“It was the first time that I fully understood the impact that war, poverty, violence, and resource distribution can have on health,” she said. “If medical students can have this transformative experience early on in their career, they will then go on to be more compassionate physicians with increased awareness of cultural competence, resource utilization, and health care disparities.”

GHI seeks to enhance the education of medical students by facilitating their exposure to both the medical issues facing people in other countries and medical issues of immigrants in the United States. Since 2007, GHI has helped send students to more than 14 countries for international medical service trips.

During her fourth year of medical school, Doorley took a sabbatical working with Doctors for Global Health in El Salvador. At that time, it was uncommon for medical students to take a year off for a global health commitment.

“The School of Medicine supported me doing that work and again created the space for me to take that year,” she said. “The fact that this is now common practice at Boonshoft is incredible and really speaks to the School of Medicine’s incredible growth, flexibility, and cutting-edge practices.”

She completed her internal medicine residency training in the Social Medicine Residency Program of the Albert Einstein College of Medicine/Montefiore Medical Center in the Bronx, New York. During this time, she also served as the South Bronx health promoter project coordinator and resident leader with an emphasis on improving health care access for the immigrant population of the South Bronx through a model of community health empowerment.

Doctors for Global Health

With Doctors for Global Health, she served as an international medical volunteer in Santa Marta, El Salvador, a couple of times. She also went to Uganda in 2008 to serve as a medical volunteer. She served on the Doctors for Global Health Board of Directors from 2005-2008 and 2011-2014. Since 2009, she also has volunteered with Health Rights International, providing medical affidavits for individuals seeking asylum within the United States.

In Santa Clara County, Doorley feels called to promote human dignity, relieve suffering and provide hope so people can achieve their full potential and improve their quality of life. She is honored to work with the homeless patients in whom she has witnessed strength and beauty in the face of great adversity.

“Not a day goes by that I don’t feel incredible gratitude for the opportunity to work at the Valley Homeless Healthcare Program,” said Doorley, who has a toddler with her husband, Orion Weihe, a mechanical engineer and inventor. “I have the dream job. Every day, I get to wake up and go to work with an incredibly compassionate, committed team of individuals who are all working to achieve the same goal.”

—Heather Maurer

Last edited on 10/17/2016.