A Transient Doctor for the Homeless

Dr. Chris Searles holds office hours all over town. He’s both a family physician and psychiatrist, and he travels in mobile clinics to places where the homeless gather, whether they’re in North Park, Pacific Beach or Chula Vista. In the winter, he treats people at San Diego’s cold-weather homeless shelter.

Searles is director of clinical outreach at St. Vincent de Paul Village and an associate professor at University of California, San Diego. His job is to gain the trust of homeless people who are often ravaged by physical illness and suffer from crippling mental problems. He might never see them again, or he may serve their needs for years to come.

In an interview, we talked with the Chula Vista High and UCSD graduate about the unique medical needs of the homeless, how he measures success and how he draws fulfillment from his work.

The mobile clinic is on the road six days a week. What is its value?

The purpose is partly to help people and partly to build trust.

There are people who’ve seen our clinic multiple times. Sometimes it takes seven or eight times before they’re ready to make an appointment. We see the people who are willing to make contact with us, those willing to see a doctor. For every one I see, I know there are countless others who don’t have it together enough or trust enough to come in or don’t identify that they have a problem.

Just yesterday, I had a patient I saw in Ocean Beach who literally slept in the parking lot that we rolled our clinic into. It was a great day for a guy who’s homeless to have a clinic roll into his parking lot. He was struggling with addiction, but I was seeing him for his skin infection. It was pretty clear that he had MRSA (a contagious bacterial infection).

Did you treat the alcoholism?

He had a skin condition that didn’t care how much he drank last night. Maybe the alcoholism is for a different day.

Do you see some people again and again?

I’ll go to a place like Pacific Beach, where I used to be a lifeguard for the city of San Diego. There are people I used to wake up in the morning in fire pits and tell them to move on, when I was in my early 20s. They’re my patients now.

How are they still around after about two decades on the street?

There’s a lot of resilience. There are a lot of homeless people who have been homeless for a long time. They survive, they’re survivors.

It’s much more difficult to survive on the street than anywhere else. It’s amazing.

What sorts of physical problems do you see that you wouldn’t see in a typical practice?

We see a lot of people with skin infections. We see people who make their living from canning (gathering cans for recycling) in dumpsters get impetigo (a skin infection that cause blisters), different types of skin infections and a lot of respiratory problems. In the winter, they’re outside, it’s cold, it’s wet. You get a lot of complicated respiratory problems that aren’t just one thing.

You see a lot of sprains and strains, joint injuries. They fall down embankments by the freeway. They’re walking at night, they tend to want to be on unlit streets because they’re harder to find that way.

What sorts of mental problems do homeless people have?

It’s really hard to know if someone has schizophrenia or is high on meth. There are people who are clean and sober who still clearly have symptoms of mental illness, but the majority of homeless people don’t have a strict mental illness aside from an addiction problem.

About a third of those folks identify themselves as having a mental illness, and a little more than half say they have a problem with addiction like drugs or alcohol. Overall, 60 percent will have one or the other or both.

What do you see in terms of mental illness in the homeless that isn’t as common elsewhere in society?

It’s not that the diagnosis changes, but the level of severity is striking. We see people who’ve lived with untreated schizophrenia or bipolar disorder for years, and sometimes the very thing they need to be treated for is pushing them away from the clinic. A paranoid schizophrenic who doesn’t trust easily is not going to want to go to a doctor.

In a physician’s office, you might see schizophrenia when a family comes in and is concerned about their 19 year old. I usually see the 19 year old when they’re a 49 year old and the family has given up.

What about medication as a treatment?

When it comes to pills, they’re either really old and have a lot of side effects, or they’re new and cost $10 a pill. You’re asking someone who has no income to pay $300 a month, and often they’re on three. It’s difficult.

When you see a homeless person talking to themselves, is that typically a sign of schizophrenia?

That’s one of those symptoms that could have overlap with a lot of different things. It could be schizophrenia, it could be drugs. Often they’re responding to something inside themselves, and there are a lot of different things that do that.

The reality is that schizophrenia is prevalent among homeless, and it’s difficult to treat. If they’re having paranoia as part of their symptoms, they don’t believe you, they don’t trust you, they think you’re out to get them.

How often are you able to help people get back on track?

A lot of people get better, but there’s a huge distance to travel from being on the street and having mental illness that you haven’t treated for years and the kind of life that people would define as a turnaround, a success.

I’d say success is getting you off the street into stable housing and getting you treatment and skills to get and keep a job. How often does that happen? Not very often.

To do all of those things takes a huge amount of resources. There’s this idea if you just give them housing that that will be the thing. But you know intuitively if you give someone who has untreated mental or physical problems, there’s a high chance that they’ll lose the house.

On the other side, the risk of falling through is very high when you try to treat people who live on the street and don’t have a home. They lose their medications or they get jumped. Treating their problem when they don’t have a stable place to live is very difficult.

So how come you’re not a doctor in some quiet place and playing golf every Wednesday? That might be pretty cushy.

I’m a family physician and a psychiatrist, and working with underserved patients is the place to use those skills. When you’re able to use both skills when you’re got 20 minutes and one shot at somebody, that’s a fulfilling way to practice.

Interview conducted and edited by Randy Dotinga, who you can contact directly at randydotinga@gmail.com. Follow him on Twitter: twitter.com/rdotinga.