When you find something inconvenient, change it!

I met with Marek Havrda immediately after he received from the hands of dean of the First Faculty of Medicine and a representative of student associations a check for over 58,000 CZK, which students – with the faculty’s support – managed to raise thanks to several benefit events. The money was raised to support the Medics in the Streets association. From Marek’s reactions, I felt the experiences of a student who, during the demanding studies to become a physician, also works at another three healthcare and/or social care clinics. He believes in active approach to studies and his motto is ‘When you find something inconvenient, change it’.

What are you going to use the money raised from students of the First Faculty for?

Mainly nursing and caregiving supplies. Vast majority of money is going to go towards that. The purchased material should cover our functioning for three months. That is great help. A smaller part will go towards support of operation of the association or organisation of training. We are trying to focus now a bit more on our members and organise seminars for them. Thanks to great support by various entities, we are in a situation where we can buy our members at workshops for instance a cup of coffee and in that way express our thanks for the time they give our homeless clients for free and in their free time.

You are part of the management, but what is the structure of the Medics in the Street association?

Until this summer, we were a civil initiative. Then we became registered as an association with a three-member board that represents it. The board consists of Karolína Jelínková from the Third Faculty of Medicine of the Charles University, Jan Pokorný from the Faculty of Medicine of the Masaryk University in Brno, and me. In Prague and in Brno, we also have eight-member leading teams in which all members have an equal say and decide together. These two teams provide supervision to dozens of students who are members of the association. The students always work at the infirmary as a team of one ‘experienced’ person and one ‘newbie’. Many of our members are from the First Faculty of Medicine of the Charles University and this year, too, our recruitment campaign was extremely successful. We were joined by many friends and colleagues from the faculty.

What does the management actually decide on?

We meet once a week for one hour. Our primary task is to make sure that the infirmaries work well: they must be well-stocked, opened during the declared times, and we want to make sure that the terms of operation do not change. We are also checking whether we have enough students and from a long-term view, keep track of whether we are succeeding in meeting our vision.

Do you also follow the development of your clients’ health status?

Naturally, we do discuss some concrete cases, especially clients we have been taking care of in the long term, people for whom we have been trying to find accommodation, a spot in an asylum house. Sometimes we share our care with some other organisation, such as the Salvation Army, and that requires some cooperation.

Who do you turn to when client’s health problems are complicated?

The Naděje [Hope] charitable organisation, next to the Main Train Station, has a GP office. If a client suffers for instance from high blood pressure, we send him there, to that doctor’s office. For daily consultations, however, we usually just call doctors who support us or friends who had already finished their studies. This year, we have a great advantage in that the first generation of Medics in the Streets had graduated; they are now doctors, and work in hospitals. In Brno, we have a supporter in a young surgeon: we are now planning to go to visit him and ask him to provide us with some training. In Prague, our graduates are mainly in internal medicine.

This seems to show that already during studies, you acquire a range of professional experience. Do you think you learn some things earlier in the streets than you would at the faculty?

The experience from the infirmaries is invaluable. One can encounter all sorts of things there. At the same time, though, we put a lot of stress on not experimenting, which is why we always have one person with some experience and one who is new. Our standard is help with changing dressings, but if we suspect something more serious, we consult it with a doctor and depending on his or her recommendation recommend the client to either to go a GP or we call an ambulance ourselves. Such experiences are thus closely linked to what we are learning in school. I can easily remember, for instance, seeing in the infirmary a medical problem that is the subject of a lecture, and I concur with graduates who say they learned a lot in school but at internships, they learned the most. For me personally, going to a day-long practical training is like an equivalent of several days spent pouring over books. Being in the infirmary is a great benefit for our studies.

But perhaps this is not an experience for everyone. It must be quite demanding to come into contact with people from the streets...

Many situations are psychologically quite demanding. Although we often stress that once a sufficient level of communication is established, collaboration with clients works, it would be unfair to claim that it always does. For difficult situations and dealing with such experiences, we have now in the leading team a system of supervision, which is what I think every healthcare team should have in future. We are trying to create a safe environment also during training, when we speak about this subject and motivate medics to talk about such experiences or concerns themselves.

Does the curriculum of the First Faculty of Medicine include any hint of ‘street medicine’?

At the Third Faculty of Medicine, there is an optional subject ‘Healthcare for Homeless Persons’, which is open also to students from other faculties. At the beginning of the winter term, we are always trying to draw attention to the fact that this is open also to medics from the First Faculty.

Is there something you are missing in the curriculum, something you view from the perspective of street medicine as important?

Not only for our members but for any healthcare professional, it would be beneficial to acquire at the faculty some education in crisis intervention or communication with problematic clients.

Every healthcare professional at times finds him or herself in such situations and if they want to really help the patient, not just send him or her to another hospital department, they must address the communication barrier. It need not be just a homeless person or a person in a difficult social situation: it can be any demanding client. Although I am already in the fifth year, I had so far no opportunity to train the ways of dealing with such situations. It was included in neither the psychology nor the psychotherapy course, where there should be some space for training problematic situations.

It would probably include judgemental communication: what actually in practice constitutes it?

In non-judgemental communication, I accept clients are they are. I react to each one’s current situation and focus on the problem that is supposed to be addressed. Let me give you an example: I work also in Sananim, an outreach centre that helps people with additions. I had in my care a client in whom I suspected an acute blockage of artery of the left leg. This is an emergency: one can lose the leg because it dies off. In a worse case, the patient gets lung embolism, and that is life-threatening. At the same time, I knew that earlier when we called an ambulance for this client on account of a different problem, he ran away. This time, before calling an ambulance, I tried communication intervention. I explained to him that it is a life-threatening situation and that I am on his side. It took me 15 minutes before he understood the situation and I won his trust. The result of such communication is that the client will not run away from life-saving care and sometimes even shows interest in getting further help. That is frequently a problem of these people, that they are not interested in treatment. If that is so, why should a healthcare worker become involved?

What kind of diagnoses do you most frequently deal with among homeless people?

It is mainly various skin infections and defects, often chronic skin infections. Wide-spread are also psychiatric problems, whereby this is a group where psychiatry is addressed very little and there are very few psychiatrists who deal with the psychological health of homeless persons.

Given the range of health problems in homeless persons, it is clear that students can find here an interesting training opportunity, regardless of whether they want to later focus on internal medicine, addictology, dermatology and sexually transmitted diseases, psychiatry, or emergency medicine.

Sure. I believe that students should not be passive, that they should take an active approach to their studies. I sometimes hear from my classmates that it is the faculty’s fault that there is too little practical training or that something is not perfect. Naturally, there is a lot of space for improvement. But when we are unhappy about something, let us stop complaining and let us try to make it better. If someone has a feeling that there is too little practical training, it is so easy to just cross the street at the General University Hospital, go to the SPIN, and ask whether one could take some duties over the weekend. Or when in year five, your practical training ends not at noon but already at ten, one can go for the two remaining hours to another doctor’s office. I believe that by organising activities of Medics in the Streets, we are creating another opportunity for getting in touch with practical medicine.

Did your work change due to the Covid-19 epidemic?

In addition to work for Medics in the Streets becoming more intensive, I was also more busy at the central intake of internal medicine departments of University Hospital Královské Vinohrady. My father works there, and I often used to go see him when he was on duty. That is how I got to know that place. It shortened the process of training so from my perspective, the help was efficient. This is why I chose this place. During the first wave of Covid-19, I was also member of the organisation team of volunteers from the ranks of students of the First Faculty of Medicine.

During the epidemic, the Prague townhall provided accommodation to some homeless people in various accommodation services, such as dorms and hostels. Do you see your clients there as well? Does the fact that they have a roof over their heads make a difference to their health?

From the health perspective, the effect was vast. In the spring, we visited hostels and tent camps three times a week and treated chronic wounds of always the same people. At the beginning of the epidemic, we would start at 8 am and end at 6 pm and there were many demands on our help. By the end of June, we only had at each place just one or two clients who needed care. During those several months, their chronic skin problems became resolved. We keep working in these accommodation facilities but also returned to our infirmaries and the field. We also work in an establishment set up by the townhall for Covid patients who have no one to take care of them.

Right now, one cannot tell what the situation of people who got this accommodation will be after the end of the epidemic, but it is certainly a change to use this situation to further develop projects such as Housing First, which tries to teach selected clients to live in a house while providing assistance and help them become gradually more independent.