AAMC Reporter: July 2009

In Rough Times, Student Clinics Do Their Part

—Madeleine Evans, special to the Reporter

When a middle-aged man recently walked into the University of California UC-Riverside's student health clinic, medical student Duc Do had no idea what lay in store for him. The uninsured man, a stroke survivor, would become a regular over the next several months, as Do and the rest of the clinic staff helped the man gradually gain control of his alcoholism, quit smoking, and rein in his hypertension. They also had a chance to educate him on the dangers of unprotected sex.

"We helped him knock off one bad habit at a time," Do said. "Now, he comes in for follow-ups every week, he has regular physicals, he quit drinking, and he committed at New Year's to stop smoking."

Nationwide, hundreds of medical students are having similar experiences as volunteers in student clinics— student groups that, under faculty supervision, provide acute and chronic care to needy and underinsured populations. Many clinics also have agreements with specialists to provide free or discounted services.

The first student clinic opened 40 years ago at the University of North Carolina at Chapel Hill (UNC). Today, there are 111 clinics associated with 49 medical schools, according to a 2007 study published in the Journal of General Internal Medicine. And that number may be on the rise. In mid-June, Howard University Hospital in Washington, D.C., announced that a new student clinic would offer free medical treatment to lowincome uninsured patients. Together, they average 36,000 patient encounters annually, and most provide medical, pharmaceutical, and social services. Some even provide dental care. Traditionally, student clinic volunteers were interested in primary care. However, today, many clinics confirm that would-be specialists are volunteering in higher numbers.

These clinics are also treating patients in higher numbers, as the struggling economy takes its toll on an ever-larger segment of the population. As more people lose health insurance, student clinics are doing their part to pick up the slack. For example, the UC-Riverside clinic has doubled its activity from 2008 to 2009, treating a projected 600 patients this year. Vanderbilt University School of Medicine added additional clinic hours as increased interest pushed the clinic to capacity—roughly 1,400 patients per year. Most clinics report serving mainly black or Latino patients. However, the UNC clinic has seen a rise in all patients recently, according to clinic co-director Brian Zeithaml, although exact figures were unavailable.

As the popularity of these clinics grows, so does their efficacy as a teaching tool. On March 27, the University of Nebraska Medical Center (UNMC) held the first student-organized conference on student clinics. Representatives from the allied health schools of 30 universities attended to discuss issues facing these clinics, including continuity of care, incorporating nursing students into the provider team, pharmaceutical costs, and the best strategies for launching a clinic.

"Our goal was to help every school incorporate a student clinic into their programs because we've seen the impact our clinic has made in the Omaha area," said Natalie Stavas, co-president of UNMC's student clinic. "This was a multidisciplinary conference—we wanted to include everyone so we could share best practices and increase the dialogue about the role of student clinics."

Overall, student clinics represent a tiny, but growing, percentage of the estimated 1 billion ambulatory interactions that occur in the United States each year. But they can provide a substantial piece of a community's health care safety net, said Judith Long, M.D., University of Pennsylvania assistant professor of medicine and co-author of the Journal of General Internal Medicine study of student clinics. No one expects these clinics to solve all the country's health care problems, Long said, but nevertheless they are adept at catching those who fall through the cracks of mainstream health care.

"These clinics have special characteristics—shorter wait times, longer hours—and often have greater flexibility to provide a wider range of services than other medical clinics, including social work or pharmaceutical assistance," she said. "But we can't hope that student clinics will step in and fill the voids. They can really only identify the holes."

They also enhance medical education, experts said. Since medical students spend the bulk of their first two years of medical school in the classroom, student clinics provide the only opportunity during that time to see how diseases present in real patients, said Richard Usatine, M.D., faculty advisor at the University of Texas Health Sciences Center in San Antonio and a professor in the school's department of community and family medicine. Usatine spoke about the best methods for creating a student clinic at the UNMC conference. Volunteer time in the clinic helps students remember why they decided to become doctors and allows them to help patients who can't find care elsewhere, he said.

"These students have specifically decided they want to give back to the community and not wait until they finish their medical degree," said Usatine. "They take the time and make the effort to establish these clinics and go above and beyond to provide the best care for the patients."

Additionally, said Audrey Paulman, M.D., UNMC clinical associate professor and faculty advisor to the student clinic conference, student volunteers learn about the business of running a clinic.

"Students learn how to keep a clinic running, be it maintaining adequate pharmacy supplies or organizing volunteer schedules," Paulman said. "These are the students that graduate and are uniquely qualified to work in a community-based health care setting."

But establishing a student clinic requires more than students, said Ellen Beck, M.D., clinical professor of family medicine and founding director of the Free Clinic Project at the University of California, San Diego. Students and faculty must address legal and safety issues, and the faculty must directly supervise all clinical services, she said.

Often, patients need services the student clinic cannot easily provide, such as specialty procedures and surgeries. Free clinic projects must negotiate with other medical professionals to secure donated and low-cost services so they can offer the best care possible. Fundraising is also a challenge, Beck said.

"Student clinics are faced with finding enough money to keep the doors open and the quality of care high," she said. "It's important for the associated medical school to support the program and provide core infrastructure funding. Then, larger private foundations will take an interest in providing funding, too. It all leads to offering better care for clinic patrons."

Nationwide, faculty advisors and students involved with these clinics agree that volunteering early in medical school is a valuable opportunity to put classroom work into action. They recommend all students consider the option. However, they stop short of suggesting it be a required portion of the curriculum.

According to Alon Peltz, a volunteer at the Vanderbilt clinic known as Shade Tree, making clinic participation mandatory could unwittingly create complications in patient care delivery.

"We welcome and encourage students to consider volunteering, but we have to balance that with maintaining continuity of care for the patient," Peltz said. "They already see many student volunteers simply because students' schedules sometimes preclude them from being there each time a patient comes in."

Many medical schools offer electives for students seeking long-term involvement with a clinic's patients population, but Beck cautions against making volunteerism part of the core curriculum. It is important, she said, that each student take the initiative to provide clinic care. If programs want to offer this experience as a core curriculum element, they must ensure the student experiences continuity of care, learns an empowerment model, and experiences a sense of shared ownership in the clinic, she said.

Although student clinics are not ideal for all students, Beck said, many consider it vital and meaningful—a place where they learn to practice primary care and learn the skills and limitations of underserved medicine and how to address the needs of the underserved.

"Many students arrive in medical school with so much compassion, and often it gets lost. Data show there is a rise of cynicism and arrogance as they go through their education," she said. "But programs like student clinics help them keep the dream of why they decided to become a doctor alive and can give them the basic skills to live that dream."