Jennifer Tan, MD: Homelessness & Dermatology: Promoting Better Wellness Through Skin Care

The number of people in the state of Massachusetts experiencing homelessness has more than doubled since 1990 to over 20,000 in the most recent count. These numbers will likely continue to grow as the effects of the opioid crisis, increasingly high rents, and limited housing stock combine into a perfect storm of challenges. Facts like these have driven dermatologist Dr. Jennifer Tan to take action. 

From the very beginning of her medical studies she knew she wanted community work to be a part of her career. As a student she planned on becoming a primary care physician, but along the way she fell in love with dermatology and learned that there is actually a great need for subspecialty care in vulnerable populations like those experiencing homelessness. As a resident she began volunteering with Boston Healthcare for the Homeless, then returned to Mass General three years ago on a joint appointment that allows her to spend half of her time building a dermatology program for homeless patients.

This program encompasses not just medical care but also creates space for patients to engage in self-care as well, which helps to encourage them to take better care of themselves overall. So welcome, Jen.

A:  Thank you so much for having me.

Q: I know in your work at Mass General you spend part of your time here at the hospital, but you also spend a lot of time working with people who are experiencing homelessness here in Boston. How did you get involved in that work?

A:  Well, I would have to say it’s a combination of my upbringing and a unique set of life experiences. I grew up in a suburb of New Jersey and was raised by my parents who both came from fairly poor backgrounds. My dad is from Singapore and he is one of 10 children and he grew up in a time before Singapore was the developed metropolis that it is now, and my mom is from Brooklyn, she was raised in a family with very limited means as well. My father came here to the United States at age 21 with pretty much no family in search of a better opportunity, and both my parents frequently reminded me and my sister growing up how lucky we were to have a roof over our head and food to eat, and they asked us basically two things when we were growing up: to always be kind and to try to take care of those less fortunate than ourselves.

And so I became aware of the issues surrounding homelessness when I was an undergrad student at Rutgers University in New Brunswick, New Jersey. I was volunteering at a soup kitchen called Elijah’s Promise Soup Kitchen and my role there was to serve food as well as to clean up after dinner was served, and during that time would listen to the stories of some of the clients who were served at Elijah’s Promise. And they would often tell me about their struggles with being homeless. And there was actually a young man who was about my father’s age when he came here, he was actually an immigrant from Mexico, and he told me his story about coming to the United States with little or no financial resources, no family, in search for better opportunity, and it really resonated with my father’s story.

And during that time I remember, I remember he told me about trying to find a job, working hard, experiencing prejudice and also finding it hard to find a community where he belonged. And I think that I realized at that time that that person could have very easily have been my father and felt from that point forward that it was very important to me to take care of people who were largely ignored by society.

So, fast forward four years to medical school and I found myself again at Elijah’s Promise Soup Kitchen, but this time in a different role. I was a medical student and volunteering to take vital signs, and during that time learned about some of the medical barriers that people experiencing homelessness were encountering. And I had the opportunity to spend two years working with the community service organization that was part of our medical school called HIPHOP, the “Homeless and Indigent Population Health Outreach Program,” and that is based in New Brunswick, and it fosters relationships between medical students and the community.

And this experience really burst open any preconceived notions that I had about the state of homelessness and poverty in America. So, during my time as a medical student, I organized with a number of my friends and colleagues in medical school, a new student-run clinic called the Promise Clinic which still exists today in New Brunswick, it actually just celebrated its 10 year anniversary, and our goal was to really pair a homeless individual with a team of first through fourth year medical students, so a medical student would actually follow a person, a patient experiencing homelessness over a longitudinal four year experience, where they would serve as an advocate for patients and also learn about longitudinal care and the complexities being a patient who was experiencing homelessness in New Brunswick.

in my time at the Promise Clinic I recognized that there were many barriers to specialty care. As you can imagine, skin disease is kind of ubiquitous, the skin is the largest organ in the body and when there is something wrong it makes itself known. And it’s no different for patients experiencing homelessness. And I think even if you have insurance and you’re well-connected in the healthcare system it’s sometimes hard to get an appointment with a dermatologist, so if you are underinsured you can imagine that it’s nearly impossible in some states. And so encountering and understanding the complexities of accessing specialty care in the homeless population that’s how I first got interested. 

 Q:  I wanted to back up a little bit. Something you said jumped out at me. You talked about when you first got involved at the shelter and doing this work and meeting the people and it upended your notions of homelessness. Can you talk a little bit more about what that was like and what you learned?

A:  You know, I think that there are a lot of stigmas around homelessness, and many times I think a lot of folks have a misconception that most homeless individuals are either struggling with a psychiatric illness or a substance abuse disorder. And while that is true for a portion of folks who are experiencing homelessness, there are many faces to homelessness. There are a number, especially in Massachusetts, of homeless men, women, and children. There is a working poor population, also the immigrant population, elderly population. And sometimes folks become homeless because they no longer can afford to live in a city where housing prices are escalating on a daily basis, such as Boston. Or maybe somebody in the family loses their job and they have many children or somebody is diagnosed with a medical illness and can’t pay their medical bills, and therefore they lose their housing.

What I’ve learned through the years of working with patients experiencing homelessness is that almost any of us could become homeless at any given time under the wrong circumstances.  

Q:  I was surprised in reading up that the city of Boston actually keeps fairly close tabs on the population and who is in it and how many and where they are. I don’t know that I would have expected that.

A:  Yes, the numbers are staggering. The state of homelessness can affect somewhere between 2 and 3.5 million Americans on an annual basis, and on a given night in 2018 when the U.S. Department of Housing had looked at the number of individuals experiencing homelessness on a given night across America it was over 500,000 and that’s about 1/3 of individuals sleeping on the streets and another 2/3s that are in either shelters or safe havens or medical respite centers. I believe that this is a public health crisis.

Q:  I know you have spent a lot of your work here has been building this program within Boston Healthcare for the Homeless. Can you talk a little bit about what that program is as a whole and then what you’re doing within it?

A: I would have to credit Dr. Ernesto Gonzales with really creating this program, and he is a full Professor of Dermatology at Mass General and I was lucky enough to be assigned to his clinic when I was a first year resident. After clinic one day we were talking about career paths and he mentioned to me how he had grown up in Puerto Rico in poverty, his mother was actually homeless, and as a result had become involved with Boston Healthcare for the Homeless Program which was created by our friend and close mentor, Dr. Jim O’Connell, who is also on faculty here at Mass General.

And Jim created Boston Healthcare for the Homeless Program in 1985, but it wasn’t until 1998 that Ernesto started to volunteer his services there. And during the first 10 years or so of his time at Healthcare for the Homeless he was informally volunteering where he would go into the medical respite center, which is actually an inpatient medical center where patients who are too ill to live on the streets are actually able to stay for a period of up to three months. 

So, we were just chatting about this volunteer opportunity and I asked him if I might be able to attend with him, and it seemed almost like the stars were aligning. This was an interest that I had had throughout medical school and then had the opportunity to work with him to actually deliver dermatologic care. What really excited me was that I didn’t think anybody in dermatology was doing, had really found a way to unite this kind of community service with their profession.

So, we attended rounds together, and what I realized was that there was a tremendous need for a more formalized consultative service and to be available on a more official, formalized basis for our primary care colleagues of homeless medicine. So, during my time as a resident here I worked closely with Ernesto and Jim as well as Dr. Jessie Gaeta at Boston Healthcare for the Homeless Program and Adam Lipworth, who is a dermatologist at the Lahey Clinic, to formalize a clinic and integrate it into the Harvard Dermatology Resident Program curriculum.

And in this program we started very small, just with a monthly clinic initially where Ernesto, myself, and a group of residents would go to Boston Healthcare for the Homeless Program and see both outpatients and inpatients. This program started in 2009, and for the first five years we slowly expanded from a monthly clinic to a bimonthly clinic. And during that time Dr. Molly Cavanaugh who is a faculty member at Brigham as well as Adam also joined in. And this became a team of dermatologists who were really seeking to increase access to dermatologic care for homeless men and women.

So in our first few years we had bimonthly clinics and I actually moved out of Boston for a few years, and just three years ago was recruited back for this joint position between Mass General and Boston Healthcare for the Homeless Program where we were able to significantly increase the number of services that we’re able to offer.

So now we have weekly dermatology clinic, and we have also been able to establish monthly pediatric services. We have a program where we see homeless youth at Bridge Over Troubled Waters as well as a shelter that is located in Dorchester as well. So, we have expanded significantly, because now we’re not only providing weekly services at Healthcare for the Homeless but we’re providing monthly services for families experiencing homelessness, and as needed we also sometimes provide street care for patients and have developed a tele-dermatology program over the past year.

Q:  I’m curious, with all this expansion it sounds incredible and you’re doing a ton of work, but is it enough? 

A:  I don’t think we have met the need. I think that with each step forward where we have created a new program I learn of another barrier to care. It seems as if with each step forward there is, it reveals how much more work needs to be done. Right now I am very fortunate to have part of my time protected to be able to do this work, but I do think that I could probably spend all of my time doing this sort of work and to some degree I do think that moving forward to really deliver the best possible care to this population we have to be available almost all the time.

It would be an unusual day where I didn’t receive either a text message or an email from one of my primary care colleagues at Boston Healthcare for the Homeless Program because they are at a remote shelter or clinic beyond the Boston area with a patient who has terrible skin disease that has been unmanaged for a long time and they need almost immediate feedback about how to triage this patient.

 Q:  Are there additional challenges-- I think when people think about being homeless obviously the lack of housing is a very acute problem, but are there other challenges that exacerbate that primary problem?

A:  Absolutely. Patients who are experiencing homelessness face unique obstacles to care. So, the daily struggle for shelter and food competes with healthcare priorities, so not only preventative care but also specialty care as well. And this leads homeless individuals to utilize emergency and inpatient services at a rate of five times more frequently than the general population actually.

Some barriers to care, if you think about it, there are communication barriers, so patients may or may not speak English, they have no permanent address, they may lack a telephone. 

There are also living and transportation barriers, so if you can imagine living in a shelter system, you may or may not have access to a locker to store your belongings, meaning that you have to carry everything on you. Transportation tends to be, if available, sometimes unreliable.

And other obstacles include social barriers like basically fear of social stigmatization, the daily need for finding shelter and food and personal and family stress as a result of being homeless can be incredibly difficult. 

Similar to the days of home visits where a physician would bring their services to a patient who had trouble coming into a main hospital site, I think patients who are experiencing homelessness, especially those who are carrying nearly everything they own on them, have a hard time making it over to the dermatology clinic at the main hospital and sitting in the waiting room and feeling comfortable. So, delivering care in a medical center where patients are comfortable has been really important, and that kind of flips the current model of specialty care delivery on its head.

Q:  This brings me back to something else I wanted to ask you about. You mentioned teaching students to care for this population, how have you gone about teaching students to feel comfortable and to provide care in a setting that is a little bit different?

A:  That’s a great question. I would say that I learned from my mentor, Ernesto Gonzales, and observing him interact with patients experiencing homelessness. You know, in addition to asking them about their skin problems and how their skin disease was affecting their health, he is so good at establishing rapport with patients and demonstrating empathy. And he would ask patients a little bit about themselves, where they come from, what makes them tick, their struggles in life, where they are staying, as well as their simple things like their hobbies. 

And I think that in establishing that sort of rapport with patients it reveals a common humanity amongst all of us and it really is a great way to not only create a patient/physician relationship that a patient can trust and feel comfortable with, but also just seeing that underneath everything we’re essentially all the same.

Residents will see me asking patients a lot about their life and how they’re doing, and the conversation may lead away from dermatology from time to time, but I actually think that that is a very important piece of building trust with this population and for residents to see to learn how to deliver empathetic care, which is a hard thing in medicine to teach but incredibly important. 

Q: Can you talk a little bit more about why there is this particular need for dermatologic care in this population? I think sometimes people think of the dermatologist as maybe not as essential as maybe your PCP or some other doctor.

A:  I probably have two responses to that question. The first is to just address the misconception about dermatology which I think that there is some perception that dermatologists focus mostly on either cosmetic concerns or acne, and while both of those issues in dermatology are important, I think that what we do is much broader than that. Many of us treat patients for medical dermatology conditions, so that includes common inflammatory conditions, such as psoriasis and eczema and acne and dandruff. We also treat skin cancer and we do skin checks for patients who have a lot of moles or a history of skin cancer. There is a subset of my colleagues here at Mass General who actually focus on, their expertise is in inpatient dermatology.

There are also dermatologists who focus only on surgically treating skin cancers, and there are some dermatologists who do something called dermatopathology which is actually a subset of dermatology that includes examining the skin under the microscope. And then finally there is a subset of pediatric dermatology. So, I think that the breadth of what we do is a lot more expansive than what most folks think of when you hear the word dermatology.

And the skin is the largest organ in the body, and I think it, all of us have suffered with a skin condition from at one point of time, and as you can imagine patients who are living in shelters, in close quarters or they’re living on the streets with significant exposure to the elements, or they just haven’t had access to medical care for so long, skin disease can be quite widespread at the time of diagnosis and infectious disease and infestations, locally communicable disease is also very commonplace.

Burns as a result of trauma is also common, and skin disease that would not normally be infected, such as psoriasis or eczema, has gone untreated for so long that it might involve such a significant part of the body that it can become secondarily infected. So there is a great need for dermatology.

Q:  So, things that ordinarily might be a small problem balloon into a bigger problem when untreated.

A:  Absolutely. And we have seen that in particular for skin cancers. It’s been an observation amongst other cancers in the body that they often are diagnosed at a later stage for as a result of lack of access to care in patients experiencing homelessness, and it seems like from an observation at Boston Healthcare for the Homeless Program that that may be the same. We have seen some very advanced stages of melanoma, as well as the more common types of skin cancers, which includes basal and squamous cell skin cancer. Usually basal cell skin cancer is a type of cancer that can be locally aggressive but very infrequently would metastasize or result in death, and we have actually had several cases over the past 30 years at Healthcare for the Homeless of patients who have died from their basal cell skin cancer, which is quite unusual.

 Q:  You mentioned earlier the SPA Program. Can you talk a little bit about what that program is and what it does?

A:  The SPA Program is something that we are very excited about. It’s a unique women’s wellness program that we call the Skin Empowerment for All Program, and this was created by Dr. Diana Bartenstein, who is a current first year Harvard dermatology resident when she was a medical student.  

On Saturdays Boston Healthcare for the Homeless Program will open up the lobby space to allow women to spend time together and also have access to primary care services, sometimes we’ll actually have skin cancer screenings during that time.  

And what SPA days does is it’s a monthly program where medical students are able to provide a relaxing dermatologic treatment in self-care to women experiencing homelessness, and each element of self-care is actually paired with an educational workshop. So, some of our treatments include facial masks, hand and foot massages, cleansing foot soaks, and the educational topic that is paired focuses either on skin cancer prevention, photo protection, dry skin care, foot care while living in the shelters, and it uniquely partners this element of self-care with patient education.

And what we have found over the past two years of this program is that it not only boosts self-confidence in women who are participating, but it also reduces immediate stress levels, which can be very powerful in this population. Women experiencing homelessness are frequently burdened by a history of either sexual or physical assault, and being homeless is associated with more than triple the likelihood of sexual assault for women. So it can be really difficult to build trust in the healthcare system with women experiencing homelessness and what we found over time is that while participating in one of the SPA day sessions, while either getting their face mask or their hand massage women will often open up about some of the difficulties and struggles in their daily life.

And it’s interesting, since the start of SPA days I have noticed that the number of women who are coming in to see me in dermatology has increased substantially, and we think that it’s the rapport that our medical students are really developing with these women. It’s been a surprising point of medical engagement with the population that while they’re having a few minutes to just reflect on their life and some of the things that are bothering them they start to open up about their skin problems and then they are willing to come in to dermatology. It’s been a very powerful program.

Q:  It’s so interesting. I think people would be surprised to hear that something as simple as a face mask could have such a big impact.

A:  Absolutely. And I think that when you’re considering basic necessities like shelter and food and primary care services, self-care often goes by the wayside. And I think that we have all experienced that during stressful times in life just taking a step back and doing something kind for yourself actually can have a tremendous impact in emotional and physical wellbeing. And I think that that is exemplified through the SPA days program.  

Q:  For me it reflects back to one of the first things you said about when someone is experiencing homelessness it doesn’t take away the rest of their humanity. 

A:  And I also think that it’s allowed our medical students to really create some special relationships with some of these women. There are some women who repeatedly come back on a monthly basis for their SPA day service. And if there is a way that dermatology can help, that offering a piece of self-care or offering access to skin care could help these women engage in, seek treatment for other disorders I think that is incredibly powerful.

And actually it makes, it reminds me of one of my patients who we’ll call her Karen. So, this is a patient who I met at Boston Healthcare for the Homeless Program, and when Karen was admitted to the inpatient medical respite center, and she was struggling with both opiate and alcohol addiction at the time when we met. She also had psoriasis, and it was covering, psoriasis is an inflammatory condition, and it at the time was covering more than 75% of her body, and her skin was infected, that’s how she ended up in the inpatient medical respite center.

And it was interesting when I first met Karen she told me that she had difficulty finding a dermatologist who would manage her disease because of her opiate and alcohol addiction. So, she needed a systemic medication, she needed either an oral or an injectable medication that have certainly have side effects, and she was having trouble finding a specialist who really understood the complexities of her addiction to manage her skin disease at the same time.

Karen told me that her skin disease was so bad that it was, it was feeding into her opiate addiction, because she was having incredible skin pain and at the same time leading to depression and anxiety, because she felt very embarrassed by her psoriasis. And so over time I built rapport with her, seeing her on a weekly basis while she was at our medical respite center, and we started her on a systemic therapy with very close monitoring. She actually used starting systemic medications for psoriasis as a reason to cut down on her alcohol use, and when she was able to cut down on the use of alcohol she was so proud of herself that then she sought treatment for her addiction. 

And at the same time her skin cleared. She is doing very well now. She is now in housing. She has a boyfriend. Her skin remains clear. She has been treated for her alcohol and her opiate addiction, and she says that actually treating her skin disease was one of the things that really got her life back on track. 

And I think that there have been multiple similar examples, maybe not to that extreme, but similar examples of how offering dermatologic care and being accessible and available to patients can help in other aspects of their health.

 Q:  What about too when you have met a patient and you have diagnosed some issue and it might need medication or treatments that require some routine or some regularity that might be difficult to maintain? How do you deal with that challenge or that barrier to care?

A: That can be a very difficult barrier to care, especially because a lot of first line treatment options for skin disorders include creams, and patients who are experiencing homelessness and living on the streets or in shelters don’t have anywhere to store these medications. And so even getting patients involved in a regular routine to take care of their skin while they are experiencing homelessness can be a barrier. And this doesn’t apply just to topical medications but also systemic pills, keeping medications safe is a challenge for almost all of our patients who are experiencing homelessness. 

Additionally another barrier to the management of skin disease in this population includes lack of access to over the counter medications. So, a lot of our common skin conditions, including acne or dandruff or even eczema, frequently require the use of over the counter products and because these are typically not covered by insurance this can be a very large barrier for our patients.

 Q:  So when doing this work, I’m wondering about you personally, what it is like to do this work day in and day out. How do you stay motivated and how do you stay hopeful in the face of all of those challenges that I imagine you encounter every day?

A:  I feel very privileged to do this work, and I feel that I am a small piece of the team at Boston Healthcare for the Homeless Program. But I think I am driven by the fact that I have been really blessed with so much in my life, from access to education to growing up with, in a loving and supportive environment. I think it’s our responsibility to take care of the poorest and most vulnerable members of society, and I think that I have learned a tremendous amount from my patients and their struggles, I think that what keeps me motivated is that you see, you see patients get better and you see patients who are experiencing homelessness get into housing.

 [13:33:32]

And some of them will work at soup kitchens or Boston Healthcare for the Homeless Program, and it’s incredibly rewarding to see, to see patients do that well. It’s part of my goal on faculty here at Mass General to expose our residents to some of the social problems that exist in our patients, and I think that if I can inspire a small amount of our trainees to consider this population in the future or even to take a small piece of empathy or an understanding of our common humanity with them in the future then I have done my job.

Q:  I think living in a place like Boston where we see the homeless population around the city every day, they’re very visible often, and I think there is probably a lot of people who think about it and maybe want to help but aren’t sure what to do or how to get involved. If someone came to you and said, “How can I help?” what advice would you give?

A: I think that starting small by volunteering in a soup kitchen or in a local shelter and hearing the personal stories of people experiencing homelessness is a good starting point. 

For folks who are interested in the interface between medicine and homelessness, I would reading Dr. Jim O’Connell’s book, Stories From the Shadows, where he really recounts his career experience.

There are also resources available through Boston Healthcare for the Homeless Program and on the national level there are resources available through the National Healthcare for the Homeless Coalition. 

And I think just educating yourself about, about the social issues is a good way to start.

 Q:  Thank you so much. This has been a wonderful learning opportunity.

A:  Thank you so much for having me. It’s a real honor to be here.

Q:  Before you go I have my final five questions. If you weren’t a doctor what would you be?

A:  I’d be a social worker.

Q:  What advice would you give your younger self?

A:  In medicine and in a rigorous academic environment such as here at Harvard Medical School, you can easily lose track of the road for the end goal, and I would tell myself to not forget that the path is always just as important as that end goal and the people who are on that path with you, especially the ones you love and the ones that love you can get overlooked sometimes when you are in such an intense environment. And I would just remind myself on a daily basis that at the end of the day that is probably what matters most.

Q:  What was your first job?

A:  My first job was working as a face painter in New Jersey for children’s birthday parties. I was very good at the shamrock.

Q:  What do you consider your superpower to be?

A:  Well, I think for my age I can run pretty fast. If I could have any superpower it would be to heal anybody or to be a better healer. I think I have the ability to empathize well with patients.

Q:  What are you curious about right now?

A:  I would say I’m very interested by social psychology, and I spend a lot of my time reading about, reading or listening to podcasts about what makes people tick and why people behave the way they do. And I think that that’s probably, outside of my profession, what piques my curiosity the most. 

Q:  Thank you, Jen, so much for being here. It’s been such a pleasure talking with you.

A:  Thank you for having me, Amy. I really enjoyed this experience.