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Squatter Sam and Professionalism

David C. Dale, MD
[+] Article, Author, and Disclosure Information

From University of Washington, Seattle, Washington.

Potential Financial Conflicts of Interest: None disclosed.

Corresponding Author: David C. Dale, MD, Department of Medicine, University of Washington, Box 356422, 1959 NE Pacific Street, Seattle, WA 98195.

Ann Intern Med. 2007;146(3):226. doi:10.7326/0003-4819-146-3-200702060-00013
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“Squatter Sam” (1) is a story worth reading and sharing. It is a physician's story, a story about the kind of patient we all remember well. In a few words this vignette goes deeply into the physician–patient experience. It speaks to critical professional qualities of caring, bonding, doing what's right, and reflecting on what we have done.

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Preventing Deaths among Homeless Patients
Posted on February 21, 2007
David Buchanan
Stroger Hospital of Cook County / Rush University
Conflict of Interest: None Declared

To the Editor: David Grauman(1) and David Dale(2) should be applauded for calling attention to the professional issues involved in the care of homeless and marginally housed patients. As a physician who has been caring for homeless patients on the streets and in shelters for the past 10 years, I found a different aspect of this story to also be educational. Over the years, I have cared for numerous patients who have been murdered, died from exposure, and overdosed from drugs and alcohol. In the vignette, "Squatter Sam", the patient dies due to a "terrible old wood stove" which causes a fatal fire. I have cared for relatively few homeless patients who have died from cancer or heart disease. Research on large cohorts of homeless patients has confirmed my experience that homeless patients die from causes which differ from that of the general population.(3) Despite this, our usual approach to improving the health of homeless patients is to perform screening mammograms, Pap smears, and lipid tests as we do for our middle class patients.

This knowledge should be utilized to improve the approach that health providers and health system take toward decreasing mortality in this population. The most effective approach to reducing homeless patients' health disparities is likely to be meeting their basic needs and providing safe housing options. If the patient in this vignette had lived in an ordinary apartment with a traditional heating system, this death would have likely been avoided. Appropriate housing has also been shown to significantly reduce the need for costly hospitalizations. (4) Excessive spending on traditional medical care while not meeting patients' basic needs is an inefficient approach to improving the health of homeless patients in America.

David Buchanan, MD

Head, Section of Social Medicine John Stroger Hospital of Cook County / Rush University Assistant Professor, Rush University Chicago, IL


1. Grauman DS. Squatter Sam. Ann Intern Med. 2007; 146:227-8.

2. Dale DC. Squatter Sam and Professionalism. Ann Intern Med. 2007;146:226.

3. Hwang SW, Orav EJ, O'Connell JJ, Lebow JM, Brennan TA. Causes of death in homeless adults in Boston. Ann Intern Med. 1997;126:625-8.

4. Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: A cohort study. Am J Public Health. 2006; 96:1278- 81.

Conflict of Interest:

None declared

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