Mass General's quarterly vascular surgery clinic, run in partnership with Boston Health Care for the Homeless, is built around a single idea: for patients who won't walk through the door of a conventional hospital, you bring the care to them — before it's too late.
Carlton Haynes had one demand before agreeing to surgery. He wanted a smoke.
Anahita Dua, the vascular surgeon looking at his imaging, told him the open wound on his shin was spreading. Without intervention, he would lose his leg. Haynes understood. OK, he said. But first he wanted a cigarette.
So Sujin Lee, a vascular surgery resident, wheeled Haynes, 56, four floors down in a wheelchair and out of the hospital's no-smoking perimeter into the rain, where he dug a Winston from his pack and asked if anyone had a lighter. Nobody did. They went back inside empty-handed. Haynes went to the operating room.
That sequence — the negotiation, the rolled wheelchair, the missing lighter — is what it looks like when a hospital builds a clinic specifically for people a standard emergency department will see too late. The quarterly vascular surgery clinic at Mass General, run in partnership with Boston Health Care for the Homeless Program (BHCHP), is designed to catch patients before infection, poor circulation, and delayed care combine into an amputation. It is, by the clinic's own assessment, the only one of its kind in the country.
"Because there's lack of flow to the foot, for example, they'll get a black toe and they'll go to the ER," Dua said. "In the American health care system, the model unfortunately is such that there's a lot of firefighting, but in general, we're not huge on prevention. So these patients will turn up, and of course they'll have had no care anywhere previously and certainly no records."
The clinic traces its structure to a gap Dua identified between primary care for unhoused patients and emergency intervention. BHCHP's primary care clinicians can identify vascular problems early. But sending a patient with a growing aneurysm to the ER, she said, is a message that person is unlikely to receive. "This person's not going to go to ER, so they die," she said. "That's where this idea was born that we would create a clinic where we could do the next step."
Every three months, approximately 30 patients referred by BHCHP primary care clinics arrive at Mass General for a single visit that would otherwise require multiple appointments on separate days: wound care, imaging, vascular evaluations, and compression sock fittings. The hospital sends shuttle vans or arranges Uber rides. Volunteers guide patients through up to five steps in one afternoon. Staff — doctors, nurse practitioners, nurses, ultrasound technicians, and trainees — volunteer their time.
David Munson, a primary care physician at Mass General and medical director of BHCHP, estimates that 125 to 150 people have received care since the clinic opened in 2023. "A lot of that is done upstream," he said, "where people have done work to either engage people on the street or engage people in shelters or in our respite program, and they have a relationship with a provider."
For Haynes, the immediate problem was a wound exposing bone on his right shin. Dua planned to remove damaged tissue and apply a fish-skin graft — a product called Kerecis, made from Icelandic cod, which promotes healing and is considered superior to tilapia skin for this purpose. When she first proposed the procedure, Haynes declined. Not if he couldn't smoke while admitted. Dua's response was pragmatic: "The minute you make it an us-and-them thing, the patient will immediately reject you. This one cigarette allows him to get the care he needs now."
Mark Picard, 53, came to the clinic with a wound on his lower left leg that had resisted healing for eight years, dating to a bike pedal injury. He also needed his toenails clipped — pain in his hip made that impossible — and was awaiting a hip replacement that an infected leg wound would delay. "I've been a drug addict for 30 years, too, so I used to think that that was the reason," he said. "I've gotten some time under my belt and finally, you know, after a lot of years of hard work, I'm trying." He arrived via the BHCHP van with six other patients.
Francia Echevarria, 67, originally from the Dominican Republic, came for her second visit with leg pain from peripheral artery disease that made basic movement difficult. She is the primary caretaker for two autistic grandchildren, ages 11 and 8. "I used to be afraid of doctors, but when I come here, I feel so confident that I have no fear," she said through a hospital interpreter. "Not anymore. Here, people are treated wonderfully."
Kenneth Bolster, 63, was referred for follow-up on blocked carotid arteries after a decade that included a leg amputation from a tree fall, a quadruple heart bypass, brain damage from an assault that ended his 35-year career as a tattoo artist, and a prognosis he'd be dead within a year. That was six years ago. "They said I'd be dead in a year and that was six years ago, so I'm not going anywhere," he said.
The clinical logic for the clinic is grounded in the epidemiology of peripheral artery disease. PAD, which narrows arteries and reduces blood flow to the limbs, affects at least 12 million Americans, according to federal research published in the Annals of Vascular Surgery. The lifetime prevalence is estimated at 30% for Black adults and 22% for Hispanic adults, compared to 19% for non-Hispanic white adults. Black Americans are three times as likely as other Americans to undergo limb amputation. Among people with diabetes — a population with sharply elevated PAD risk — the crude incidence of lower-extremity amputation in 2018 was 6.1 per 1,000 adults with diabetes, a rate that researchers expect to rise as both diabetes and PAD prevalence increase.
The Amputation Reduction and Compassion Act, first introduced in 2020 and reintroduced in 2021, was designed to address these disparities through provider education, routine PAD screening for at-risk populations at no out-of-pocket cost, and restrictions on amputation performed without prior vascular assessment. The bill notes that amputation risk for Black Americans with diabetes is up to four times the national average. Dua supports the intent but is not optimistic about its passage.
The structural failure the clinic is built to address is well-documented: disadvantaged groups face higher rates of PAD at presentation, longer delays before diagnosis, and limited access to the specialist care that can prevent progression to chronic limb-threatening ischemia. Up to 29% of individuals with chronic limb-threatening ischemia will undergo major amputation or die within one year of diagnosis. "Racial, socioeconomic, and insurance coverage disparities in lower extremity amputation reveal systematic failures in the diagnosis and management of lower extremity vascular disease in the US," according to the federal research on the ARC Act.
The MGH clinic does not resolve those systemic failures. It works around them. The care model — volunteer staff, quarterly cadence, transportation coordination, one-visit-multiple-specialists — is labor-intensive and not easily scaled. What it offers is a specific, traceable response to a specific gap: people who need vascular surgery but who will not, or cannot, navigate a conventional referral pathway until the situation becomes an emergency.
After the last patient was seen, Dua went to the operating room to perform Haynes's procedure. Lee had begun prep. The clinic's staff gathered for a debrief and a meal ordered by a second-year medical student who had spent the morning coordinating Ubers and takeout. The patient charts would be updated. The next session was three months away.
For Picard, the near-term goal was simpler: heal enough to get the hip replaced, then get back to the things he used to do. "I love golf," he said. "I've got nieces and nephews that are golfing. I can't wait to be able to play with them."