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Chapter 17 Balancing Service and Education: Ethical Management of Student-Run Clinics David Buchanan Renee Witlen In a cramped hallway of a cash-strapped student-run clinic at a homeless shelter, six medical students interview patients with minimal provisions for privacy. Senior students tutor first-year students on how to present to the faculty preceptor and write a progress note. The volunteer faculty member supervises the care of 20 patients during the three-hour session. The patients feel comforted by the students’ enthusiastic and attentive care. This evening, there are 5 patients with severe persistent asthma, all treated with only short-acting beta-agonists. (Short-acting beta-agonists without concurrent inhaled steroids have been linked with increased mortality.) Three have been treated previously in the clinic. After teaching the students about the assessment and treatment of asthma, the preceptor gives each patient another beta-agonist inhaler (no other inhalers are available) and tells them they can obtain better medicines free of charge at the public hospital one mile away. Student-run free medical clinics have been established in homeless shelters and other locations by students of many United States medical schools. Often, these clinics begin as small student-initiated grassroots efforts. Some have grown into extensive enterprises that provide clinical services for low-income patients and educational opportunities for students. As these clinics grow in size and number, it is important to evaluate their clinical and educational impact and to reflect on the relationships that support their operation. The central groups involved in student-run clinics (SRCs) are patients, students , faculty or community preceptors, and medical school administrators. We will examine student-run clinics from each of these perspectives, emphasizing the essential role of faculty and administration support for their clinical and educational activities. David Buchanan, MD, MS, is chief clinical officer at Erie Family Health Center and an associate professor at Northwestern University. Renee Witlen, MD, is a clinical fellow in psychiatry at Cambridge Health Alliance. 182 Buchanan and Witlen The Patients Patients who seek care from SRCs typically lack insurance or face other barriers to accessing more traditional points of entry to the health care system. Student-run clinics providing quality medical services confer advantages to patients, including the physical benefits of health care and the psychological benefits of having time and attention spent on their needs. However, depending on the resources available , patients may receive diagnostic evaluations or treatments that would be considered unacceptable within the traditional medical system, as in the vignette above., Appropriate medications and supplies may be unavailable. Because clinics are often set up in facilities not designed for patient care (e.g., homeless shelters, churches), a clinic’s limited space and its arrangement may deprive patients of privacy as they discuss intimate health situations. In the worst case, SRCs with limited resources could unintentionally divert patients from more established and better supported safety net institutions. Although the quality of care provided in SRCs has been questioned in at least one instance, we were not able to identify any published health outcomes of patients served by an SRC. Clinic patients and community members can play an important advisory role in SRCs. By engaging community-based advisers, students can help ensure that the clinic addresses the community’s most urgent health needs. The Students Although students establish clinics for the benefit of indigent patients, students also benefit professionally from gaining clinical experience with diverse patients and personally by experiencing feelings of self-worth and personal satisfaction. First-and second-year students particularly benefit from hands-on clinical experience during a time when their training is largely classroom based. Two published descriptions of student-run clinic programs have documented a preponderance of preclinical students among their volunteers., Another noted that, “Many medical students have their earliest clinical experiences at student-run clinics” (p. 430). At our institution, two preclinical students are scheduled for each student who is in the third or fourth year; even this ratio can be difficult to achieve at times due to the enthusiasm of the preclinical students. While this imbalance likely results from the time pressures faced by students in their clinical years, it also may reflect the relative importance of the educational benefits that first-and second-year students receive. In addition to the educational benefits of providing direct patient care, students volunteering in SRCs can also benefit from the opportunity to improve their crosscultural communication skills through interactions with patients from socioeconomic , racial, and ethnic backgrounds different from their own...

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