As a first year medical student, there are notoriously few ways for you to have meaningful interactions with patients. And for good reason. Your medical knowledge is scant, your clinical skills unpracticed. Every time you walk into a room, it still feels a bit like the first time and the poor patient — who is the one there for a legitimate medical reason — is subjected to your fumbling with the blood pressure cuff, your forgotten questions that must be picked up by the resident or attending later, and who knows how many other unknown ills that come from an incomplete history and physical.*
Nevertheless, students — even first-year students — are closely involved with one of the only sources of primary care for the uninsured: free clinics. Free clinics account for 3.5 million medicine and dental visits a year seeing nearly 2 million patients. They provide care for the patients that would typically go to emergency rooms for their primary care, and they provide critical training for medical students to practice their skills at taking a history and physical and refresh their enthusiasm for medicine in the midst of basic science classes. Despite the fact that students are in charge of care, the few studies have been done have found that free clinics do reinforce clinical guidelines of quality care.
As a first (now second-ish?) year medical student, I can say that the free clinic has definitely allowed me to appreciate how much can be done with a full history and physical. Even more so, it has reinforced how important it is to patients that they have someone to take a moment and listen to their problems, even if we can find no immediate solutions to all of them. It has also allowed me to appreciate how little just providing charity care can do in underserved medicine because these patients need so, so much more than simply free medical care.
Take last weekend for example: I was working at a busy free clinic, fumbling through my questions, doing the best I could to come up with a treatment and plan for the patients with the attending physician. My first patient was (I thought) fairly straightforward — a new diagnosis of diabetes. I was happy to be able to give this straightforward diagnosis and plan to my attending, thinking that he would have a set idea of what he needed to tell her and advise her in terms of self-management and treatment.
Instead, he turned to me and asked: “do you know what the procedure is here?” The procedure for what, I wondered. Normally, it turns out, he would refer to a dietitian and/or health educator who would explain all of the necessary lifestyle changes for living with diabetes. On his own, especially within the context of a twenty minute visit, he was not at all clear on how to coach her through what she needed to know to care for her diabetes. Even as a Medicaid patient, there was a whole system of diabetes education that we could have connected her with within the community health clinic network. However, since she was uninsured, the best we could do was try the group education classes currently being piloted at the free clinic where I was and hope that that would be enough.
My next patient was proclaimed “difficult” by my coordinator because she was tired, grumpy and needed a service that the clinic could not provide: assistance with her application for disability. It was explained to me that the clinic was unable to provide patients with a designated primary care physician. So, they were basically telling her she needed to go somewhere else for her primary care, even though she was clearly here because she could not afford it.
As someone who has worked in case management before, it never fails to astound me how little community clinics (especially the free, under-resourced ones) know about the resources in their community. They did not know which primary care clinic to refer her to, and I had to draw on my recalled information from working in a completely different neighborhood in the city as a case manager as to what number would be appropriate to call to get her general legal assistance with her disability benefits application. Even then, when I went to speak to her, she had already gotten so much conflicting and confusing information that I’m not sure any of the advice that I gave about her social issues or the attending gave about her health issues stuck at all.
I suppose part of the point of working in free clinics is to emphasize the point we learn in classes on the social context of medicine: that there are glaring gaps in the medical care available in the United States, that the care provided to the uninsured is almost criminal in its patchiness and insufficiency. In addition, my work at free clinics has also highlighted the glaring gaps in my medical education. As we joked in between patients about how little we remembered about microbiology and pathology, my patient cases brought home just how much we still needed to learn about caring for patients in resource-constrained environments — and how much we simply would not learn in our medical education, even if we would continue to care for such patients given the setting where our hospital is based.
After days like this, I sometimes wonder whether I’ve made the wrong career choice after all. At least if I went to the School of Social Services across the street, I would be among those who recognized the psychosocial concerns of health care, even if I would have no idea what to do with a social work degree. But then I remember that while I am here, doing community health within the context of an academic medical center, I can effect change — I can inform myself, my classmates, and the clinics where we work of resources within the community, and we all can do what we can to communicate with patients about what is possible within the fragments of our safety net system.
- Lest you not think that history and physicals are important because we allow first year medical students to do them, they are actually very important. In fact, evidence shows that 76% of diagnoses can be made from a careful history alone!
Image credit: Google Street View of the clinic