HL20: Jim Withers, MD—Bringing Tender Care to the Mean Streets

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Jim Withers, MD.

This profile was published in the December, 2012 issue of HealthLeaders magazine.

 "The idea of going to where people were always stuck with me: Joining patients in their reality and respecting their reality."

The value of the house call and taking the care to the patient's environment was a lesson learned early in life for Operation Safety Net founder and medical director Jim Withers, MD.

As a youth, Withers accompanied his father, a physician, and his mother, a nurse, when they travelled to Nicaragua, Guatemala, and St. Lucia on healthcare missions.

"I had the benefit of growing up with medical parents and making house calls as a kid," says Withers, an internist who teaches medicine at The Mercy Hospital of Pittsburgh. "The idea of going to where people were always stuck with me: Joining patients in their reality and respecting their reality. As I was trained it became more and more obvious to me that knowing the patients' reality was central to all you were going to build subsequently in terms of a medical interaction."

Twenty years ago Withers was looking for an avenue to teach his medical students "the way into someone else's reality." He had tried medical volunteer work overseas for resident students, which was rewarding but difficult to coordinate.

"I thought: 'I need a classroom that is conveniently located, that has people who are living in a different world, who are in need, and who are hopefully really stubborn people who will force me to bend my skills to their world and not the other way around,' " he recalls. "It occurred to me that street people were good candidates."

In May 1992, Withers teamed up with outreach worker Mike Sallows, a one-time denizen of the streets, to take healthcare delivery to the curbsides, back alleys, and bridge bottoms where many homeless people live. "Without a handbook on how to do this I used to dress up like a homeless person and go out with Mike at night. He allowed me to visit the camps and abandoned buildings, which just opened a whole world for me," Withers says. 

"Mike chastened me that I better not look like a doctor. I just wanted to start fresh. I didn't want to come in with my own answers or presumptions. For me it was my own personal frame of reference that I really wanted to start with a clean slate," Withers recalls of his first days practicing "street medicine."

"It didn't take long before I realized I had a moral obligation to respond to unmet medical needs—and they were profound. So I began to put things into a backpack. It made sense to have some antibiotics and bandages and some referral information, and I could see how cost-effective it was to not have these folks cycle through the emergency room over and over."

In his two decades of outreach Withers has learned that reasons for homelessness are as varied as the homeless people themselves. "Each individual is different. You just don't know until you ask someone," he says. "There are certainly things that are common in the street population: Mental health problems that are untreated; addictions that get you on the street and that people pick up when they find themselves in that situation. There is a lot of history of abuse and particularly child abuse in their past."

Withers says many homeless people have undergone severe psychological trauma from life on the street and the issues that brought them there.

"They feel like they are an outsider and they adapt in a really deep way to not being part of us," he says. "It is an endlessly fascinating spectrum of the human condition, but there are people who are thwarted by survival instincts that kicked in when they were younger—someone was molesting them or hurting them when they were younger. They stood up to it and the pattern becomes one of defiance. You tend to use the tools you have in your toolbox. I do think that there is a survival mode, that a lot of people have gotten to where they just focus on what is in front of them."

In the 20 years since Withers and Sallows teamed up, Operation Safety Net has grown to include 20 employees and more than 100 volunteers, including physicians and nurses, all of whom have served thousands of homeless patients on the streets and in clinics.

The mission has expanded, too. "A lot of things have grown off of the initial house call vision of taking medical care under a bridge," Withers says. "We have housed more than 800 individuals in apartments over the past eight years. We have a severe weather center that we run and a lot of volunteers help serve food and other activities. Plus we have people who donate material goods."

There is even talk about building a curriculum around street medicine for medical students. "They are beginning to understand how popular it is and all the incredible intrinsic lessons it teaches for patient-centered care and meeting people where they are," Withers says. "An organization like ours creates a fabric within the street communities that lets people attach themselves and say, 'When I am ready, there is an option. There is someone who is not going to judge and dismiss me because I was having a bad day. They actually are accepting my reality, and who I am is okay.' "