Growth of free clinics driven by students

At University of Texas Southwestern (UTSW) Medical Center in Dallas, medical students are so eager to participate in free clinics that slots for each month's volunteer shifts at one clinic fill up almost immediately, according to James Wagner, MD, MSc, FACP, associate dean for student affairs and professor of internal medicine.

Dr. Wagner became involved with UTSW's Monday Clinic in 2006, when a group of medical students approached him looking for a faculty sponsor. He agreed and helped them to partner with North Dallas Shared Ministries, a charitable group with which he was already involved.

Today, the clinic opens every Monday from 5 p.m. to 9 p.m. at the North Dallas Shared Ministries' facility, which also offers services such as a food bank and a clothing repository. Most volunteers at the Monday Clinic are medical students, but there also are some undergraduates, nursing students, and graduate students in various disciplines. They are now involving dental students, Dr. Wagner said.

Building on the success of the Monday Clinic, and a desire for more service opportunities, UTSW students have created other clinics with other community partners, Dr. Wagner said. And the trend of community clinics nationwide is growing.

Benefit to students

The number of medical schools with student-run free clinics has more than doubled in the past decade, and more than half of all medical students are involved with such clinics, reported a study published in the Dec. 10, 2014, JAMA. According to several experts, much of that growth is motivated by students who want experience with patients earlier in their training and have a desire to help people in need.

A commentary in that same JAMA issue drew a correlation between the rise in students seeking clinical experience outside their formal training and the fact that today's residency programs are more focused on urgent management decisions instead of the “smaller tasks that might be secondarily entrusted to a medical student.” The commentary authors continued, “The student becomes more of a bystander, contributing less to patient care.”

In contrast, those students who approached Dr. Wagner knew, or learned quickly, that being involved with a free clinic early in medical training helps them in many ways because it contributes greatly to their clinical skills, he said.

He said the Monday Clinic's patient mix is typical of what most primary care practices see, from colds and runny noses to cardiac disease and poorly controlled diabetes, along with a few more uncommon diseases, such as leishmaniasis and advanced syphilis. Psychiatric problems, from anxiety and depression to psychosis, are seen as well.

“You never know what's going to walk in the door,” Dr. Wagner said. “It's always a challenging, problem-solving activity.”

From students to leaders

Like many other free clinics, the Monday Clinic pairs first- or second-year students with more experienced students to perform tasks such as taking a history and performing a physical exam. They review their findings and present them to an attending physician on site, such as Dr. Wagner. The students, along with the attending physician, then go back in to see the patient. The physician confirms or refutes the students' findings, and they all discuss treatment plans with the patient.

“It is a great way for younger students to refine their skills and for upper-level students to polish those skills through teaching and serving as an interim mentor before the faculty member comes in,” he said.

It also teaches students about being involved in the community and helping underserved patients, he added. “They are exposed to a population that really is disenfranchised from our current system.”

At most clinics, students select managers who oversee operations. The managers coordinate students and physicians, organize shifts, sometimes schedule patients, catalog medications, and manage supplies. ACP Member Alyssa Cook, MD, of MedStar Franklin Square Medical Center in Baltimore, was involved in free clinics in medical school and as a supervisor during residency and fellowship. It was very helpful in her education, she said, because “It's a great way to start seeing patients early on.”

Lucy Guerra, MD, MPH, FACP, is a faculty mentor for the student-run Bridge Healthcare Clinic at the University of South Florida (USF) in Tampa. She has been involved with free clinics for many years, initially by working at a clinic in Miami while getting her masters of public health before she started medical school.

The Bridge Healthcare Clinic was started in 2007 by a group of USF students. Their clients are from the underserved community near the school and include immigrants as well as homeless people. Dr. Guerra said many don't have health insurance, often because they work in low-wage jobs that don't offer benefits or have health plans with very high copays.

The clinic has more than 100 volunteers, including medical students, pharmacy students, physical therapy students, social work students, and faculty and staff member supervisors. Most services are offered at no charge. Some lab services are available for free as well, and there are some discounts available for prescriptions. The clinic is able to offer referrals, when needed, to USF physician groups, which provide a certain number of visits per year.

Dr. Guerra said her years working in free clinics, as a student and as a mentor, have affected her career deeply. “I have seen many patients in the ER who really just needed access to primary care for conditions such as diabetes or hypertension or treatment for an infection,” she said. “We help keep these patients out of the ER.”

Recognizing that, she said, area hospitals have supported the clinic. For example, Florida Hospital has given $1.2 million in goods and services in recent years. The Bridge Healthcare Clinic's funding comes primarily through the USF Foundation, to which many people make donations specifically to fund the clinic. In addition, local churches and other groups provide support.

The patient experience

As is typical, all prospective patients at Bridge Healthcare Clinic are screened for eligibility by a social work team. Once patients are accepted, a typical visit can last up to 2 hours, although that often includes time spent learning about social services such as food stamps or how to get a high school equivalency degree.

Patti Pagels, MPAS, PA-C, an assistant professor at UTSW, said the patients appreciate having a medical professional who spends more time with them than a typical physician can; 30 to 60 minute visits are not uncommon. “They feel very grateful to be listened to so thoroughly,” she said.

However, it can be a challenge to not keep the patient too long.

“It's important to strike a balance [between providing care and teaching]. For example, students take longer to take histories and conduct a physical exam. Their supervisors want to respect the patients' time while still teaching the students,” Dr. Cook said.

She believes most students do a very good job serving the patients while obtaining important skills for themselves.

“I interview medical students applying for our residency, and I am happy to see how many have experience with free clinics,” she said. “It really speaks to their dedication because this is not something that is required but that they have sought out.”

Creating access for patients

Dr. Cook said a challenge that students face is finding sources of information that their patients can understand. “[Patients] typically don't have a lot of resources and often don't have a lot of education about health conditions,” she said. Some lack Internet access or basic English literacy.

The students also have to work to help their patients get additional resources, such as help paying for medications or seeing a specialist. Most clinics have some community resources available, but as they are typically limited, the students and their supervisors are challenged to only order tests or make referrals when they are truly needed.

“Learning to use resources wisely is good practice for anyone,” Dr. Cook said. “It really pushes the physicians and students to think about what they can manage on their own. Those skills translate into any patient population.”

Dr. Guerra said she and many others involved in student-run free clinics thought that patient demand might decrease as access to health insurance increased through the Affordable Care Act. However, that has not proven to be the case.

“We don't know why,” she said. “Maybe people don't know how to access care through the new law. Or it doesn't cover all of their expenses.”

Current demand at the Bridge Healthcare Clinic is already so high that there is about a 3-month waiting list for new patients to be seen. The clinic is open 1 night per week but is adding a second day, thanks to assistance from a local hospice in providing clinic space, Dr. Guerra said.

Dr. Wagner at UTSW also sees a constant need for services. He said 1 in 4 Dallas County residents does not have adequate insurance.

Other rewards

Few free clinics offer academic credit for volunteering. For first- and second-year medical students at UTSW, participation is purely voluntary. However, the institution recently decided to allow upper-level medical students who commit a substantial amount of time to the clinic and who do a special project such as a quality improvement review to apply for credit.

“A lot of effort is required to meet these requirements,” Dr. Wagner said.

Still, as much as students love working in these clinics, their faculty mentors say they get a lot out of it themselves.

“I love teaching and giving back to the community. Often we are the only source of help for some people,” Dr. Wagner said. “It's rewarding to work in the context of this group of people who are so giving and devoted to helping people in need.”

Dr. Guerra agreed. “I love it. I get more out of it than the patients or the students,” she said. “It's a great opportunity for physicians to give back to the community and for students to learn.”