Learning to Return

When I spoke with Dr. Jim O’Connell, founder of Boston Health Care for the Homeless Program, I expected to learn about street medicine. I expected to hear about shelters, outreach vans, respite care, and the challenge of caring for people whose lives do not fit neatly into the structure of the healthcare system.
I did learn about all of that.
But what stayed with me most was something simpler and deeper: the importance of returning.

Again and again, Dr. O’Connell returned to the idea that care for people experiencing homelessness cannot be built around the expectation that patients will enter the system on the system’s terms. Medicine often assumes structure. It assumes that a patient can make an appointment, remember the date, find transportation, sit in a waiting room, and return for follow-up. But for someone surviving outside, in a shelter, or in deep social and economic instability, that structure may not exist. “If you say, ‘Come see me next Wednesday at three o’clock,’ they’re never going to be there,” he told me.
That sentence captures so much of what traditional medicine can miss. It is not that patients do not need care. It is not that they are uninterested in care. It is that the architecture of care often assumes a life very different from the one they are living.

Dr. O’Connell’s career began with learning that lesson firsthand. When Boston Health Care for the Homeless Program was being built, its early model was shaped by people who understood the needs of the homeless community from the inside. They insisted that the program could not simply exist outside the hospital. It had to remain connected to the hospital system because when people became seriously ill, they needed someone who knew them to follow their care.

That insistence became one of the program’s greatest strengths.
The model that emerged was not just street medicine. It was continuity. Shelter clinics were connected to hospital-based clinics at Boston City Hospital, now Boston Medical Center, and Massachusetts General Hospital. Care was meant to move with the patient from street to shelter to hospital and back again. Physicians and nurses became the continuity in a life where almost everything else might be unstable.

The same community wisdom led to the creation of respite care. The question was simple: where does someone go when the hospital is ready to discharge them, but they are still too sick to return to the street or a shelter? The answer became medical respite, a space between hospitalization and homelessness, between acute illness and survival outside.

This was not an abstract systems design problem. It was a human one.
Dr. O’Connell described learning during the first winter that there was a small group of people the shelter clinics were not reaching: those staying outside. Boston, unlike places such as Los Angeles, shelters the vast majority of its homeless population on a given night. But the people who remain outside often do so for complex reasons. Some cannot tolerate a crowded shelter. Some hear voices and find those voices harder to distinguish in a 500-bed room. Some are carrying psychiatric illness, substance use, trauma, medical illness, or all of these at once.

Many of the deaths that winter occurred among those staying outside. That realization led the team to obtain a van and begin going out to people directly.
Street medicine grew from that need.
What moved me was that Dr. O’Connell did not describe this work with romantic language. He described it as necessary, complicated, humbling, and often learned through failure. He said he knew nothing about homelessness when he began. He had never been in a shelter. The learning curve, especially in the first ten years, was steep.

The program began amid outbreaks of multidrug-resistant tuberculosis and the early devastation of the AIDS epidemic. Medicine outside the walls of the hospital became far more complicated than anyone might have imagined. The patients needed excellent care, specialty care, imaging, oncology, cardiology, infectious disease, psychiatry, addiction medicine, and primary care. They did not need a lesser version of medicine because they were homeless. They needed the best medicine, delivered differently.

That distinction matters.
Dr. O’Connell was clear that the goal was not simply to do good work. It was to pursue excellence. Caring for people experiencing homelessness should not be treated as charity on the margins of medicine. It should be part of the mainstream of academic and clinical care. This is one of the reasons he values the program’s connection to Harvard Medical School, Boston Medical Center, and Mass General. For him, teaching students about homelessness is not about adding a charitable experience to medical education. It is about asking whether the healthcare system can provide excellent care to those who need it most.

As someone preparing to enter medicine, I found that deeply important.
A lot of young people enter medicine wanting to help. But Dr. O’Connell’s work suggests that wanting to help is only the beginning. The harder question is whether we are willing to adapt the system, not just the patient. Are we willing to meet people where they are? Are we willing to learn why someone cannot come in, rather than simply labeling them as noncompliant? Are we willing to build care around the whole picture of a person’s life?

That question connects directly to why I created Prose for Patients.
As an EMT, I often met people in moments of crisis. The ambulance encounter is brief, intense, and incomplete. Patients enter your life mid-story. You learn their medications, symptoms, vital signs, and immediate needs. Sometimes you also learn something more human: what they are afraid of, who they want called, what they have survived, what they need someone to hear before the hospital doors open.

But then the call ends.
I started Prose for Patients because I wanted to create a space where stories did not have to be compressed into chief complaints. I wanted patients, caregivers, healthcare workers, and others to have the chance to speak in fuller sentences about illness, identity, memory, caregiving, grief, and survival. After those conversations, I write narratives and poems that are returned to the participants. They can revise them, keep them private, share them, or choose to publish them. The story belongs to them.
In my conversation with Dr. O’Connell, I shared that I hoped to keep following up with some of the people I interview. Not to extract more from them, but because the relationship matters. I told him about wanting to check in months later, to see how someone is doing, to learn how their story changes as illness, treatment, or life continues.
His response helped clarify something essential.

He told me that all stories are valuable, but there is something especially powerful about stories that unfold over time. A story told after one afternoon with someone can be meaningful. But a story told after years of knowing them carries a different kind of truth. It includes change, contradiction, outcome, growth, disappointment, and surprise. It teaches patience.
That idea stayed with me because it challenged one of the quiet risks of narrative medicine: the temptation to turn a single encounter into a complete story. A one-time interview can capture something real. But people are not static. Illness changes. Relationships change. Meaning changes. What someone says the week they are diagnosed may be very different from what they say a year later. The story written in crisis may not be the story written after adaptation. The person who seemed hopeless one day may reveal an extraordinary capacity for humor, tenderness, or endurance over time.

Dr. O’Connell learned this through decades of continuity. He spoke about writing Stories from the Shadows, a collection of short pieces about people he had known through his work. Some stories began from brief notes written years earlier. But by the time he returned to them, he sometimes knew the person decades later. The story he could tell after forty years was not the same story he would have told after the first encounter.

That is a profound lesson for anyone who wants to write about medicine.
The first version of a story is not always the whole story.
For me, as an aspiring physician and writer, this is both exciting and humbling. I am drawn to stories because they reveal what clinical language can miss. But Dr. O’Connell reminded me that storytelling carries responsibility. Stories can illuminate, but they can also mislead if they are treated as universal. A single story of one person overcoming homelessness, illness, or trauma can inspire, but it can also obscure the millions who face similar circumstances without the same outcome. Stories are powerful, but they must be held carefully.

They need context, humility, time.
That is especially true when writing about people who have been marginalized. People experiencing homelessness have often been studied, photographed, pitied, judged, or used as symbols. The task is not simply to tell their stories more beautifully. The task is to ask what gives us the right to tell them at all, and under what conditions storytelling becomes an act of witness rather than extraction.

Dr. O’Connell’s answer, through his career, seems to be relationship.
You show up. You keep showing up. You build trust slowly. You let people move at their own pace. You offer the best care you can without forcing the encounter to happen according to your expectations. You understand that care is not only an intervention, but a commitment.

This has implications far beyond homelessness.
Rare disease patients, chronically ill patients, elderly patients, disabled patients, psychiatric patients, patients with addiction, immigrant patients, and many others often encounter systems that were not built around their realities. Medicine asks them to fit into forms, schedules, rooms, and categories. When they cannot, the failure is often assigned to them.
But Dr. O’Connell’s work suggests another way to see it.
Maybe the system should be the one adapting.
Maybe the question should not be, “Why didn’t this patient come back?” but “What would it have taken for care to reach them?”
Maybe continuity is not a luxury. Maybe it is the foundation.
Near the end of our conversation, I asked how I could become more involved with the work of Boston Health Care for the Homeless Program as someone who is not yet a medical student, but is an EMT and deeply interested in street medicine. Dr. O’Connell was honest. Space is limited. The work is complicated. Many sites are already crowded with students and volunteers. But he was also encouraging. He offered to help connect me with people who might know where volunteer opportunities exist.

That generosity meant a lot to me. But even more than the possible opportunity, I left with a clearer sense of what I hope to carry into medicine.

I do not want to be a physician who only enters a room with answers.
I want to become the kind of physician who learns how to return.
To the patient, story, community.

To the parts of medicine that are easiest to overlook.
Dr. O’Connell’s career shows that medicine can be practiced as accompaniment. It can be shelter clinics and hospital wards, respite beds and outreach vans, tuberculosis treatment and cancer care, a conversation on the street and a relationship that lasts decades. It can be the pursuit of excellence for people who have too often been offered only fragments.

And for those of us trying to write from within medicine, his work offers another lesson: stories are not separate from care. They are one way of remembering what care is for.

At Prose for Patients, I often say that every patient has a story worth telling. After speaking with Dr. O’Connell, I would add something else.
Every patient has a story worth returning to.
Because the first encounter is rarely the whole truth.
Because people change.
Because illness unfolds.
Because trust takes time.
Because sometimes the most important thing medicine can do is not only arrive, but come back.