Letting Medical Students Run the Clinic

By Jennifer Xu
(Matt Rourke/AP)

Every Saturday from 1:30 p.m. to 5:30 p.m., the abandoned Pinckney Community Public Library in the rural town of Pinckney, Michigan flickers to life. Two caravans bearing young professionals in white coats roll up to the parking lot. Once inside, they loop stethoscopes around their necks, shuffle color-coded forms around the front desk, and smooth out paper bed covers on mattresses. One of them swings a sign stamped with the words “Clinic Open” toward the front door.

In the cramped back room, a senior medical student is giving a crash course to a second-year on the essentials of heart pharmacology. “What do statins do?” the senior student asks, pointing to a small square of text on a patient’s intake form. The younger student pauses, sifting mentally through facts learned by rote memorization from textbooks and lectures. “They lower cholesterol,” she says, hesitating. “I think I remember that from cardiology.”

This is the University of Michigan Student-Run Free Clinic, a satellite medical operation that provides primary and preventive health services to uninsured patients in a low-income area of southeast Michigan. A student-run clinic is similar to a standard clinic in that it provides basic tests like urinalysis, bloodwork, and mammography free of charge, except it is almost completely staffed, operated, and led by medical students.

“I think this is where they teach medical students to be late,” Ron, a grizzled convenience store clerk, cheerfully jokes to me in the waiting room. He spent months on the waiting list of another free clinic before the staffers there referred him to an alternative, student-run option. This is his second visit to the University of Michigan clinic, and so far he has no complaints about the quality of care he’s been receiving.

While interviewing for medical schools last fall, I observed a strange phenomenon: every institution I encountered would underscore its student-run free clinic as a major highlight of the medical education they could offer. First- and second-year students would speak rapturously about the experience they gained from clinic. Working there, they said, reminded them of why they wanted to become doctors in the first place.

“I feel like medical school can be really about yourself—how much I can learn, how much I can do,” says Chelsea Reighard, one of the student directors at the University of Michigan Student-Run Free Health Clinic. “I really wanted to serve people and work with them to improve their health.”

The “student-run” modifier is not overstated. With the exceptions of official diagnoses and prescription signing, medical students are responsible for everything that goes on in clinic. They schedule patient appointments, take comprehensive health histories, and conduct physical examinations. Though M.D.-bearing physicians lurk in the background overseeing clinical decisions and assuaging liability concerns, the initiative remains a primarily autonomous affair.

Free clinics are by no means a novelty on the medical landscape, tracing their roots to the Haight-Ashbury Free Clinic movement of the 1960s. But historically, many of them have depended on religious institutions for funding and support. Then, in 1989, a group of first-year medical students in the UC Berkeley-UCSF Joint Medical Program began providing free blood draws and screenings to the uninsured individuals who frequented a homeless drop-in center, and the free clinic model seriously began considering medical students as potential staffers.

Today, the majority of all U.S. medical schools have at least one student-run free clinic under their auspices. Some, such as the University of California, San Diego School of Medicine, have up to four.

The proliferation of these clinics can partially be attributed to a growing desire among the medical community to provide care to those who lack health insurance. Though the Patient Protection and Affordable Care Act is projected to extend healthcare coverage to 32 million more U.S. residents starting January 1 of next year, this still leaves about 30 million individuals uninsured and unable to pay for health services. What has increasingly begun to emerge is a healthcare “safety net,” a complex web of hospitals and community health centers that provide low-cost medical services to individuals regardless of their ability to pay.

Lauren Wozniak, another student director at the Michigan clinic, recalls an experience she had while teaching at a low-income middle school. A student approached Wozniak’s desk after class and asked Wozniak to look at her tooth. Before Wozniak could respond, the student pried back her jaw to reveal a large crevice in the back of her mouth. Her tooth had completely rotted away.The student had apparently never been to the dentist in her life.

Proponents see the student-run free clinic as playing a small but vital role in the healthcare safety net. The clinic can help uninsured patients, many of whom suffer from complicated chronic diseases, secure care they otherwise would not be able to afford. And because a medical school affiliation gives student-run clinics a steady source of funding and supplies student volunteers eager to work, the student-run model may be more sustainable than its nonprofit counterpart.

“I don’t know where I’d be without this place,” Ron says to me before he is whisked away for his appointment. He’s waited close to an hour for these doctors-to-be to see him, but feels it’s a small price to pay for the time and attention he’ll be receiving for his healthcare needs.

Lately, “health disparities” have become the in-word among the medical community, defined as gaps in quality of healthcare among racial, ethnic, or socioeconomic groups. Though measurements like infant mortality and lifespan have improved across the nation as a whole, the medical community has increasingly begun to identify minority groups that bear a disproportionately greater burden of preventable disease, death, and disabilities compared to the rest of the population.

African Americans, for example, have an elevated likelihood of developing diabetes or hypertension that cannot be exclusively explained by their genetic makeup. Health experts believe that the reasons for these health differences lie within the medical system itself, whether it’s because factors in these patients’ lives prevent them from getting regular medical attention or because physicians are not asking the right questions during visits. People interested in eliminating health disparities do not just focus on diagnosing diseases and prescribing medications, opting to take more creative approaches to healthcare. For instance, the Mobile Clinic Project at UCLA is funding bus ticket vouchers to make sure patients do not miss appointments, while the Joy Southfield Clinic in Detroit is sponsoring community gardens to promote healthy eating habits.

A large part of the explosion of the student-run free clinic is attributable to this push to address health disparities. The thinking goes that if students are exposed to health disparities early in their training, they will be motivated to tackle those disparities on a deeper level in the future.

A key feature of sustaining student interest in health disparities is letting them take charge of their own initiatives, says Dr. Brent Williams, associate professor of internal medicine at the University of Michigan Medical School. To Williams, true commitment to these issues can only be achieved if students take ownership of their projects, learning not just by observing, but by doing. As a result, the young volunteers in a student-run free clinic are allotted much more freedom than if they had been working at a standard, physician-operated clinic.

“Our job is to help eliminate barriers and let the students manage and really own it,” says Williams, who also serves as an advisory board member of the University of Michigan Medical School Student-Run Free Clinic. “If you sit around at the advisory meetings, you’ll see the dynamic constantly, as to what can we do to be sure that the students maintain genuine ownership, accountability, responsibility of the operations.”

Shannon Cramm, another student director at the Michigan clinic, agrees with the medical school’s philosophy toward maintaining student ownership. “If you just get told to do something, it becomes something you have to do,” she says. “But when we’re in charge of the clinic as a leadership group, it means that I will put in the extra hours because this is my big idea and I am excited about helping our patients in this way.”

Yet the “student-led, student run” philosophy has drawn ire from some individuals who are invested long-term in alleviating health disparities. The idea that students, not M.D.-holding physicians, are chiefly responsible for a patient’s healthcare might compromise the care the patient ultimately receives, says Dr. David Buchanan, chief clinical officer of Erie Family Health Center and associate professor at Northwestern University’s Feinberg School of Medicine.

Most students who volunteer at the clinic are in their first and second years of medical school, a time traditionally dominated by booklearning, with very little patient contact. The majority of their clinical experience thus far has consisted of practicing on “standardized patients”—a cast of actors pretending to suffer from a repertoire of minor medical maladies for their benefit. For many of these volunteers, the student-run clinic marks the first time they ever conduct a physical examination on a real patient.

A patient seen by a medical student might receive care that is less efficient and less informed than if he had been seen by a medically licensed professional. And though these volunteers are prohibited from writing prescriptions and are strictly overseen by an older third or fourth year medical student and a presiding physician, Buchanan worries that the autonomy associated with student-run clinics promotes the harmful stereotype that poorer individuals ought to receive lower quality healthcare than those who have health insurance. Patients who can afford to pay for healthcare can refuse care they see as inadequate. But those who receive free care from student-run clinics don’t have as much flexibility.

“I think there’s a sort of natural, easy path to say, here are some folks who just don’t have any other options, and no one’s taking care of them, so the students should sort of fill this void and do their best to help these people,” Buchanan says. “But I don’t think that’s the approach we should take as a society. I don’t think it’s a good bargain for the patients.”

Proponents of the student-run free clinic argue that patient care and student education can coexist, perhaps even augment one another. They dismiss the argument that student-run clinics provide care that is sub-par. Studies have been published comparing patient outcomes at student-run free clinics with those at staffed, insurance-accepting facilities, many of which have revealed no significant gap in quality. Advocates see the student-run clinic as a win-win situation: individuals without regular healthcare receive much-needed attention, and medical students get the opportunity to flex their clinical muscles and gain firsthand exposure to health disparities.

But to Dr. Renee Witlen, an adult psychiatry resident at the Cambridge Health Alliance near Boston, there is no guarantee that student volunteers will leave the clinic with such lessons intact. Medical students come to the clinic motivated by a number of things, including the opportunity to see interesting pathologies, to practice their physical examination skills, or to network with older students and physicians. To Witlen, students cannot be expected to emerge from the experience fully formed and empathic to a homeless individual’s social situation just because they spent a few hours volunteering at the clinic. In fact, she worries the experience might even reinforce negative beliefs, namely that it is permissible for students to learn by practicing on the impoverished.

“I think there were plenty of people in medical school, where, while they weren't grossly dehumanizing toward the poor, they had different priorities,” Witlen says.

Williams, the Michigan clinic advisory board member, admits that he initially had reservations about student-run clinics but has now been converted into a “total cheerleader, bleachers-sitting advocate.”

“If your comparator is an ideal situation, no, I don’t think from a clinical point of view that a student-run free clinic is as good as a … ” Williams says, trailing off. “As an ideal,” he clarifies.

But Williams believes that not doing something because of the theoretical risks of a project is both ineffective and paralyzing. As long as volunteers have enough oversight to learn from their mistakes and adjust, he sees no reason why the student-run free clinic shouldn't continue to flourish. “Compared to the realistic alternative, which is nothing, the community is a ton better off,” he says. “This is a great example of not making the perfect the enemy of the good.” 

This article available online at:

http://www.theatlantic.com/health/archive/2013/11/letting-medical-students-run-the-clinic/281241/