Sandwiches, 6 Feet Apart: Reflections on Community (and Medical School) During COVID-19

• community
• COVID-19
• medical humanities
• homelessness
• medical education
• racism

In the last few months of our medical education, we, as clinical medical students, have come to perfect the peanut butter and jelly sandwich. There is a science to making sandwiches, swiftly (and without too much mess), for inclusion in brown bag meals to be distributed to people experiencing homelessness.

These last few months, we have also played (and lost) a lot of Monopoly, listened to a fair amount of amateur rap, debated UFOs, tried to relearn 12th-grade math, and baked more cookies than there are skeletal muscles in the human body. We have heard a lot of stories, through face masks at a distance of 6 feet. And, perhaps most surprising, we have grown tremendously as human-minded future physicians; student doctors whose identities had to change in order to meet this present moment.

At the start of the COVID-19 pandemic, our clinical rotations were abruptly put on hold as mandated by the American Association of Medical Colleges.¹ This hit us particularly hard, both as clinical clerkship students, and as members of a student organization, Wolverine Street Medicine, that provides clinical care in nontraditional settings to people experiencing homelessness. Fellowship in this organization, which provides street-based medical care to community members in Ann Arbor and Detroit, had been sustaining us throughout our education. The hospital and the streets, our places of learning and becoming, were now closed to us. As a result, we felt, all the more acutely, that ever-present tension of being a medical student—occasionally useful but not quite essential enough to keep around.

Of course, there were important, practical reasons to dismiss us. In a public health emergency, the patients and their providers, who must have access to limited personal protective equipment (PPE) supplies, come first. Athough we understood that we could add public health value at a distance in the clinical space, we still worried about our Wolverine Street Medicine patients: our neighbors on the street left behind by this pandemic.

We spoke to our partners still providing care on the street, now without us, and to the director of The Shelter Association of Washtenaw County (SAWC). They explained that COVID-19 had amplified preexisting systemic structures that perpetuate housing insecurity. SAWC saw an influx of families experiencing homelessness, owing to a combination of factors including lost jobs and lack of employment opportunities in a pandemic economy. There was not enough space in the existing shelters to socially distance nor sufficient shelter employees to accommodate increased need. The typical patchwork of meal programs, emergency shelter support, and social service support had abruptly halted.

Their words were clear: in the absence of our rudimentary clinical skills, they needed community volunteers; people willing to sit in church basements converted into temporary shelters and provide company to the men housed there. They needed community volunteers, not medical volunteers: individuals who could wipe down surfaces, make dinner, remind everyone to put on their masks and encourage frequent handwashing. To make snack packs and coordinate donations. To help their clients, our former patients, fill out unemployment forms and apply for stimulus checks. We were needed to help make these men feel seen and heard.

So, we took off our short white coats and put away our stethoscopes. This was hard. We have learned to wrap our identity around these objects. We put on gloves and face masks. We made sandwiches. We put clementines into paper bags. We wiped door handles and folding chairs with bleach. We went into churches, now serving as emergency shelters, and played Scrabble.

At first, this did not feel like it added tangible benefit. We are medical students! This is a pandemic! Surely, we could be doing something more important? Something more helpful!

But we kept going back. Over time, occupying this community space began speaking to us in a way that months of clinical education had not. Slowly, we stepped out of the medical student role. That inner voice that called for us to “sleep less, study more!” quieted. True, we could no longer provide medical care, but we now had a chance to listen to the voice that had first called us toward a medical education; the human one. We are not practicing medicine but trying very hard to practice some version of humanity. Pre–COVID-19, we learned physical exam skills, wound and foot care, and how to take a history of present illness from these neighbors on the streets, as part of our nascent medical education. Now, we re-learned the importance of connection as the foundation to persevering through hard times.

We have connected with our neighbors in ways simple and mundane. In meeting people whose lives are so different from our own, we have found it amazing how easily they welcomed us into their community. They wanted to sit and tell us jokes from their childhood, share their poetry. To cook with us and send home leftovers. To teach, play, and be with us. How quickly these men invited us into their lives. How openly they shared.

As with any congregate living situation, this experience has not been without its challenges. We de-escalated arguments, were the listening ears of frustrations about other shelter-mates, and were privy to the never-ending saga of complaints about the state of the bathroom. The laughter, anger, tears; this humanity transformed us. It helped us cope with a pandemic and reminded us of our value. Not as students marked by some notation of “Pass, High Pass, or Honors,” but as fellow human beings.

This experience reminded us that to work in health care, we are stepping into an inherently fragile space; one where illness, hardship, and death are daily realities. Our neighbors, experiencing homelessness, know this fragility intimately. They are constantly walking a line between being ok, and not. Many sources—from the hidden curriculum of medical education to news media articles—seem to place the onus of poverty and homelessness on the individual and their behaviors. With this lens, it becomes too easy to negate the systemic factors that intertwine to perpetuate housing instability and appease our own deep-seated discomfort. This pandemic underscores the struggle of our neighbors experiencing homelessness, but this injustice has been present far before, and unless we are moved to act, will persist well beyond.

Often, as medical students, we are pushed to understand a person’s experience based on a few key facts. As medical students, we learn illness scripts by homogenizing patient populations. It is convenient to label a person as “homeless,” and let that be their identity, reducing their personhood to the key thing that they lack. But to memorize an illness script or to generalize all patients with complex social needs as members of a “vulnerable population,” is not to be a doctor. To be a physician, to fully occupy that role of scientist and artist, caregiver and human, we must transcend what we think illness should look like, to see the person within the experience.

When we develop relationships with people and begin to care for them as brothers and sisters, work becomes meaningful and personal. In shedding our white coats, we found it easier to connect. We were not “student doctors,” seeing “patients.” We stopped play-acting a role of separation; the healthy from the sick, the “haves” from the “have nots.”

We were just being ourselves. And now, it is more true than ever before; we are not advocating for a nameless group of men experiencing homelessness. We are supporting new friends during a hard time. They would do the same for us.

We, the writers of this piece, have found it easy, given our class, race, and socioeconomic reality, to surrender completely to a medical education system that can sometimes enable ignorance of the hardships and realities outside an academic ivory tower. Our position of privilege also leads us to undervalue those activities like wiping down tables and preparing meals that, ultimately, provided such incredible value to our neighbors.

By virtue of nothing more than luck and circumstance, we have been privileged with a life that allows us to step in and out of spaces such as temporary shelters, community kitchens, and street dwellings, without consequence. It would be inappropriate to pretend that an experience, such as this one we shared with members of our community, is all that is needed to dismantle the racialized systems preventing families, particularly families of color, from home ownership and realization of their renter’s rights.² It would be wrong to surmise that, if only all medical students spent time in such settings, that we could unwind the burden of racial and socioeconomic societal ill. We do not argue that experiences like the one we shared solve the problem, but we do posit that they are part of the solution.

If we are to be physicians who seek to change the systemic injustices of homelessness and poverty, we must ground our understanding of being a care provider in our human identities. We had to take off our white coats, for a time. We ask you to do the same. Seek out an opportunity to meet and serve your patients, your neighbors, whether they be well-served or underserved, housed or experiencing homelessness, in a place that is not the clinic or the wards. We believe we’ve come to understand something important about community, identity, and becoming. One day, we will be doctors. And we hope that we remember this: sometimes, the most and best we can do for one another, is just, simply, to be a person. Someone present; trying to help.

Until that day, however, we will be making sandwiches. Let us know if you need any tips for a perfect PB&J.

• Received for publication June 7, 2020.
• Revision received October 27, 2020.
• Accepted for publication November 11, 2020.

• © 2021 Annals of Family Medicine, Inc.