PE R S PE C T IV E
isn’t provided, such as clothing Unsheltered people have long
assistance and medically tailored
meals. These models are being
implemented by street teams such
as the Healthcare in Action group,
which delivers comprehensive pri-
mary care services to unsheltered
patients in California in partner-
ship with third-party payers.4 Per-
person health care spending is
substantially higher among un-
sheltered adults than among shel-
tered adults,5 and payment multi-
pliers that go beyond standard
risk adjustment may be needed
to ensure adequate per-member
per-month payments under global
payment models. Payers should
also account for the fact that
street medicine generally involves
the provision of care using proac-
tive and deliberate outreach to an
entire patient panel, which is dis-
tinct from traditional models of
care in which many attributed pa-
tients aren’t seen regularly.
The Maternal Crossroad
The Maternal Crossroad
Larissa H. Mattei, M.D.​​
I come from a long line of im-
patient women. Even through
the haze of dementia, my grand-
mother remained alert and ori-
ented to the list of tasks left to
do around the house. Her daugh-
ter, my mother, was similarly af-
f licted with an intolerance for
idle time. On post-op day 3 after
her debulking surgery, she sum-
moned her nurse into the room
because her IV was “basically
falling out.” (It wasn’t. She had
pulled all the tape off.) Besides,
she was “going home tomorrow
n engl j med 390;23
The New England Journal of Medicine
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No other uses without permission. Copyright © 2024 Massachusetts Medical Society. All rights reserved.
Sustaining and Scaling Up Street Medicine
(D.G.M.) — all in Boston; and the Depart-
been relegated to the margins of
society and excluded from the
health care sector. Street medi-
cine serves as a critical bridge to
this population. The implemen-
tation of place-of-service code 27
not only affirms that street med-
icine is an integral part of the
health care system but could
pave the way for delivering com-
prehensive and patient-centered
care to all unsheltered people.
Such advances in health care de-
livery, though indispensable, will
need to be paired with compre-
hensive social, economic, and en-
vironmental policies to achieve
the ultimate goal of preventing
and ending homelessness.
Disclosure forms provided by the authors
are available at NEJM.org.
From Harvard Medical School (M.L., S.S.),
the Department of Medicine, Massachu-
setts General Hospital (D.G.M.), and Bos-
ton Health Care for the Homeless Program
anyway.” (She wasn’t. She had an
ileus.) After eventually bringing
my mother home, and after she
pointed out the plants that need-
ed watering, I sat in front of a
computer for my next fellowship
interview.
“Why gynecologic oncology?”
“What do you think you’ll
struggle with most in fellowship?”
“Tell me about your most mem-
orable patient.”
Two weeks earlier, on the first
day of my final year of residency,
my parents called from the emer-
nejm.org June 20, 2024
ment of Family Medicine and USC Street
Medicine, Keck School of Medicine, Univer-
sity of Southern California, Los Angeles
(B.J.F.).
This article was published on June 15, 2024,
at NEJM.org.
1. Roncarati JS, Baggett TP, O’Connell JJ, et
al. Mortality among unsheltered homeless
adults in Boston, Massachusetts, 2000-2009.
JAMA Intern Med 2018;​178:​1242-8.
2. Richards J, Kuhn R. Unsheltered home-
lessness and health: a literature review. AJPM
Focus 2022;​2:​100043.
3. Feldman BJ, Feldman CT, Kogan AC, Salu-
ja S, Cousineau M. The California street medi-
cine landscape survey and report. March 2023
(https://www​.­chcf​.­org/​­w p​-­content/​­uploads/​
­2023/​­03/​­CAStreetMedLandscapeSurveyReport​
.­pdf).
4. Lynch KA, Harris T, Jain SH, Hochman
M. The case for mobile “street medicine” for
patients experiencing homelessness. J Gen
Intern Med 2022;​37:​3999-4001.
5. Koh KA, Roncarati JS, Racine MW,
O’Connell JJ, Gaeta JM. Unsheltered vs. shel-
tered adults experiencing homelessness:
health care spending and utilization. J Gen
Intern Med 2022;​37:​2100-2.
DOI: 10.1056/NEJMp2314560
Copyright © 2024 Massachusetts Medical Society.
Sustaining and Scaling Up Street Medicine
gency department to read me my
mother’s CT report. Peritoneal
carcinomatosis. A large pelvic
mass. My pulse roared in my ears
as I felt the air being sucked from
my lungs. My mother, stoic as
ever, asked, “What do you think
it is?”
I hung up the phone and im-
mediately vomited. The next morn-
ing, with the Covid-19 pandemic
still in full swing, my husband
drove the car as I cried across six
states and 14 hours of highway
traffic to be with my mom during
2139
PERS PE C T IV E
her surgery and recovery. My he-
reditary impatience was, in a way,
responsible for much of my suc-
cess as a resident, but now it par-
alyzed me. A heavy, aching dread
bloomed in the pit of my stom-
ach. How terrible and breathtak-
ing to see the end from the be-
ginning.
I feel as if I have since come as
close as one can to experiencing
ovarian cancer without actually
having it myself. I am intimately
familiar with the simultaneous
urgency and inertia that fuel every
moment after someone receives a
cancer diagnosis.
My first week of fellowship, I
entered an exam room to find my
patient in tears, tightly clutching
her notebook as she awaited her
results. “You people can’t under-
stand what this feels like!” she
told me. “It’s like someone is
holding a gun to my head every
time I come here.” My phone vi-
brated in my pocket — I had been
waiting for my mom to text me
her latest CA-125. My face burned
and a familiar tightness began to
build in my chest. A gun to my
head, indeed. The voices in the
room grew muffled, and for a
brief moment it seemed as though
I sat beside myself watching some-
one else do the counseling.
I have sometimes struggled
with the best way to guide pa-
tients through their surveillance
visits. Where does careful reas-
surance end and false promising
begin? What is the right balance
of pragmatism and optimism? I
strive to be an impartial shep-
herd through my patients’ cancer
treatments, but found these lines
more blurred than usual with
my own family. When my mother
asked me about her rising CA-125,
I kept my answers vague. Maybe
2140
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some inflammation, a recent in-
fection — a lot of things could
cause a false elevation. My true
suspicions were later confirmed
— a recurrence — and I felt guilty
for having given her the hope of
something benign.
While still in the midst of her
treatment, my mother came to
stay with me after my daughter
was born. Even on her bad days,
she cooked for me or folded laun-
dry, and we fell into the roles I
had known my entire life. Moth-
er and daughter, now grand-
mother and new mother. As she
drove me home from a postpar-
tum appointment she remarked,
“I thought this would finally be
my time to really do something.
And then I got f–ing cancer.”
With striking unanimity, my pa-
tients likewise comment on the
unfairness of their diagnosis.
Most are in their 50s or 60s, their
children grown and partners re-
tired. So many have arrived at
this phase of life with a sense of
relief that it was “finally their
time” to focus on themselves.
My patients are mothers, sisters,
aunties, matriarchs — the sup-
port structure for their families
and communities. These women
have given and supported and
stepped aside, at times graciously
and at times grudgingly, so that
their loved ones could thrive.
With the start of my clinical
years of fellowship, I found my-
self at a similar and, at times, suf-
focating crossroads, where physi-
cian, mother, daughter, and wife
converge. My mother’s health de-
clined, my hours grew longer,
and I often pleaded with my hus-
band to keep our daughter awake
long enough for me to see her. As
I drove home, I would call my
mom to ask about her chemother-
n engl j med 390;23 nejm.org June 20, 2024
The New England Journal of Medicine
The Maternal Crossroad
apy schedule or what to do about
my baby’s rash. We would later
discuss what “platinum-resistant”
means and whether to get a PEG
tube, and I fumbled through the
counseling that had come so easily
with one of my patients moments
before.
Often still, I arrive home to
an overtired toddler who seldom
sleeps through the night. I breast-
fed my baby until her second
birthday. Some part of me imag-
ined it would compensate for
missed bedtimes and routines
that were no longer mine. When
she wakes late at night, my howl-
ing baby squirms in my arms be-
cause the wrong parent has come
to soothe her, and I wonder once
again if the choices I’ve made are
worth the struggle. I sometimes
think of my mother in these mo-
ments. In the weeks before she
died, my sister and I tried to think
of all the questions we would
one day wish we’d asked her. My
sister asked what it was about
motherhood that she had least
expected. When I rock my baby
to sleep at night, I recall my
mother’s initial look of surprise
and her eventual frank response.
“I wish someone had told me you
can’t have it all.”
My daughter can recognize my
mother in pictures, but in the
time since I first drafted this es-
say, I know she has already for-
gotten the woman I admired most
in this world. It’s estimated that
in 2022, approximately 12,800
women died of ovarian cancer.
Among them was my mother.
Gone with these 12,800 women
are decades of family secrets,
home remedies for everything
from colds to menstrual cramps
to broken hearts, and the rich-
ness of someone else’s experience
PE R S PE C T IV E The Maternal Crossroad

that we cling to when we don’t am also a new mother, and now nally seen for their vibrancy in-
know what to do next. a daughter who lost her own stead of their sacrifices.
There are as many opportuni- mother just as my life was get- Disclosure forms provided by the author
ties for victory as there are for ting started. When I stand at this are available at NEJM.org.

tragedy in my field. It is a duality
I made peace with long before
applying to fellowship, never
knowing how soon it would be-
come my own reality. As a gyne-
cologic oncologist, I am equal
parts surgeon and clinician, but I
intersection, willing these many
parts of myself to combine, I
think of how my mother and
women like her must have navi-
gated a similar path before me.
I imagine them standing with
their faces turned to the sun, fi-
From the Karmanos Cancer Institute,
Wayne State University, Detroit.
This article was published on June 15, 2024,
at NEJM.org.
DOI: 10.1056/NEJMp2400914
Copyright © 2024 Massachusetts Medical Society.
The Maternal Crossroad

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