Megan Rich, MD MEd
Program Director, The Christ Hospital/ University of Cincinnati Family Medicine Residency
Learning objectives
- Describe the ethical issues encountered in free care settings (e.g. student-run free clinics, community based free clinics)
- Discuss the challenges associated with service and learning in an under resourced environment.
- Discuss how the four ethical principles of autonomy, beneficence, non-maleficence, and justice apply to the free clinic setting.
- Describe the role free clinics play in caring for those un/underinsured
Please respond to one of the quotes from below, providing your perspective and an example as a student of how this viewpoint applies to your experience.
· “To be clear, patients do not choose SRFCs for the opportunity to educate students, they end up at the clinic for lack of other options.”
· “Charity care, certainly in its current configuration, represents a failure of imagination. While some good may come of these well-intentioned stop-gap measures, they are ultimately not good enough.”
“Charity care, certainly in its current configuration, represents a failure of imagination. While some good may come of these well-intentioned stop-gap measures, they are ultimately not good enough.”
While I agree that charity care is ultimately not good enough, I disagree that they represent a failure of imagination. I think charity care or student-run free clinics come from the hard work and creativity of medical students, residents, physicians, and other stakeholders who recognize gaps in the healthcare system and act within their means to make a positive difference. Do I think we need a better solution? Yes. But I know there have been a lot of people much smarter and much more creative than myself (and most likely the authors [boom roasted]) that have come before me to try to address or fix the healthcare system in the U.S. and have been unsuccessful. So, while it’s good we are acknowledging a lot of work needs to be done, I don’t think it’s fair to say the main issue is a lack of imagination. Imagination is part of the equation, but systemic barriers and entrenched inequalities are larger factors. I am biased of course because I am very passionate, like Dr. Rich and Kiesler, about SRFCs and think they have a lot of benefits connecting patients to care who otherwise would not be.
Alec, I could not agree with you more. Charity care ultimately exists because our system as a whole is not good enough. I completely agree that findings ways to fill the gaps even if imperfect takes a significant amount of imagination, considering that our system as it stands is unable to do so.
I strongly agree with you Alec. I think that charity care does represent a failure, but not of imagination. I agree with you that if anything, charity care is rather an example of how imagination and creativity may be used to address a failure of the healthcare system. While the dependence on charity care is not a great option, it nonetheless represents the passion and hard work of caring individuals who are using their creativity and resources to help make a difference.
“Charity care, certainly in its current configuration, represents a failure of imagination. While some good may come of these well-intentioned stop-gap measures, they are ultimately not good enough.”
I believe that there is some degree of validity in this stance. SRFCs are not a “solution” to health disparities by any means, and they do not absolve our larger medical system from working towards racial justice on a systemic and structural level. I don’t think these clinics were designed to be “enough,” I believe for someone with no established provider and acute concerns, these clinics help meet a need in a way that is safe, accessible, and dignified (when done appropriately, i.e., adequate supervision and standardized protocols). I strongly believe that all patients deserve to have an established provider, and SRFCs can serve as that bridge to connect patients to more robust resources for their medical and social needs. If viewed as a launching pad rather than a final destination for patients, we as the medical field are challenged to “imagine” beyond this space while simultaneously working ensure those who serve in the clinic are provided with our best efforts.
“To be clear, patients do not choose SRFCs for the opportunity to educate students, they end up at the clinic for lack of other options.” / “Charity care, certainly in its current configuration, represents a failure of imagination. While some good may come of these well-intentioned stop-gap measures, they are ultimately not good enough.”
When reflecting on these statements, the first thing that came to mind is a passage we read by the author Atul Gawande during our M1/M2 years. I cannot remember the title of the passage or the book it came from, but to summarize, the passage discussed the medical training system and its impacts on patient care. He tells the story of a loved one of his (I believe it was his child) who was in the hospital and required a procedure to be done. A resident came to talk with the family and do the procedure, but they refused because they did not want a new resident in training to be the one to do the procedure. They requested an attending to do it instead, because they did not trust someone who is still in training to do the procedure. He reflected on how he does not regret this, but at the same time recognized the dissonance in this decision. He was a resident at one point, as are all people who go through medical school and become physicians, but did not want a resident to help, because he thought it would lead to inferior care. People who do not go through medical training however, generally aren’t aware of what being a resident means and the fact that residents are still in training and may not be as experienced in procedures as a person might expect. The ethics of all of this becomes murky- should people have the right to refuse residents/medical students being involved in their care when their involvement may lead to inferior care, but their involvement in medical care is vital to their learning and the continuation of medical education?
Hey Grace!! That last sentence is a great question that I will not claim to know the ultimate answer to. But I will say I have had similar thoughts as Gawande. While I have never been put in a position like his, I’ve thought I would potentially advocate for a family member or friend in this way if I deemed it necessary. However, when people ask me as a medical student to not be involved in their care, I typically am not that upset. I understand. After all, we know very little. However, we’ll see how my opinion changes throughout residency, especially if I encounter a similar scenario as a resident.
Grace, I’ve been grappling with the same question you bring up here. Fun fact – I’ve spent most of 4th year growing a human baby and I hear that it will eventually have to come out. When considering my delivery, I’ve thought about what level of learner I’d like involved in that process. No med students, not because of their training, but because that’s a little too intimate to share with my classmates. But interns? There’s something not very comforting about having someone who is only a year ahead of me in training be a big portion of my care. But the ability to consider including learners is a privilege. My level of health literacy is a form of privilege. And this gives me more options and confidence and possibly, better outcomes, than folks who are not aware or able to make those choices. And it robs trainees of a vital opportunity to learn. Does that align with the principles we have been taught? It puts patient autonomy ahead of the others, to be sure. Either way, medical educators and trainees and even patients have been struggling with this since medical training began. I doubt we can solve it, but there is value in at least addressing it.
“Charity care, certainly in its current configuration, represents a failure of imagination. While some good may come of these well-intentioned stop-gap measures, they are ultimately not good enough.”
I have a bit of a complicated relationship with the student run free clinic model. While I think they are a great opportunity for medical students and residents to learn more about the challenges that patients from underserved communities face, and I think there are likely some critical diagnoses and triaging that have happened in SRFCs, the time that I have spent in these clinics has shown me that patient encounters are cumbersome as early leaners spearhead providing care. Furthermore, the clinics that I have spent time in seem to provide limited treatment options for patients and a list of PCP offices that may be able to provide more care. In other words, from my (albeit limited) time in SRFCs, it almost seems like patients are volunteering their time to educate medical students, with some medical advice provided at the end as thanks from the care team. Suffice to say, patients are probably not receiving the kind of care they anticipated through the student run free clinic.
That’s not to say I haven’t seen a free clinic model work well; I spent time shadowing at the Good Samaritan Free Health Clinic where uninsured patients received high quality care for acute issues, followed up with PCPs, had referrals to specialists, and were able to access medications through a pharmacy. Visits did not take an hour (unlike what I experienced at SRFCs) and in-person interpreters were available to facilitate care and communication. And as a student, I was able to garner just as much (if not more) about social determinants of health through my time at the Good Sam clinic as I was at SRFCs. Obviously, there are many limitations to increasing patient access to these free clinics – especially funding to build more clinics and providers who want to provide care to this patient population – but I believe the care patients received at the Good Sam clinic was much more impactful than what I have seen at SRFCs. There have to be better options to integrate the effective free clinic model run and staffed by physicians with the education opportunities that medical students desire; this is where I see the “failure of imagination” the quote mentions. As someone interested in working in underserved communities in my career, and as someone with an interest in medical education, I hope to find a way to bridge this gap.
Hi Caroline!
I considered a similar problem in my response- reflecting on the passage we had to read from Atul Gawande earlier in our medical school career. In that passage he reflected on how dependent residents are on patients to learn and grow as physicians, and how many patients likely do not realize, as he himself declined to have his child treated by residents as opposed to attending physicians. I think this concern gets amplified when SDoH get added in, as patients at SRFC are treated by medical students (with supervision from physicians)- but I think the point still stands that those who do not have the knowledge or power to decide who they receive their care from may receive lesser care as a result, which is ethically concerning, but at the same time learners are dependent on patients to grow as physicians. Therefore I’m not sure what the correct answer is, or if there even is one, but it is something that we need to think about irregardless.
“To be clear, patients do not choose SRFCs for the opportunity to educate students, they end up at the clinic for lack of other options.” I highlighted a quote very similar to this one while I was reading, so I am happy to have the chance to discuss it.
When I decided to change careers and go to medical school, I remember struggling to find clinical experiences that didn’t make me the provider of sub-standard care. I eventually took a position as a pharmacy tech in a free clinic, where I was keenly aware of how little I knew about the medications I was dispensing. Luckily, I was also closely supervised, and not allowed to actually counsel patients on their meds.
I carried that same concern when I came to medical school and I deliberately did not volunteer for SRFC or MedVoUC. From what I understood, the care provided there was quite limited (especially in the covid-era) when the patients had such robust needs. It would rely heavily on being able to refer patients elsewhere. But even with referrals, there are major barriers to care – another trip or time off of work, the other resources are also limited and overburdened, etc. The same goes for pop up events like blood pressure screenings. What is the value if we do not have a way to connect folks to consistent, good quality care and the medications that go along with it? We ask the uninsured to settle for much less than we would routinely provide to people who are insured.
Perhaps FQHCs with sliding scale payment options are the better solution. When I worked in marketing, I wrote the website for Illinois coalition of FQHC’s. A big part of our messaging was that FQHCs offer quality care for everyone. They take insurance and they are subsidized by the federal government to be able to offer sliding scale to uninsured patients. If they treat a mix of insured and uninsured, then they will likely offer all patients a high standard of care. Plus, the income from private insurance will help cover costs for those who cannot pay. It seems like a win-win IF you can convince privately insured patients to get their care there.
I like the perspective you have from your previous marketing experience! It’s super important that people from different backgrounds and with different skillsets are involved in a solution, so it provides adequate care but is also sustainable from a business point of view. I agree- referrals are not the answer and were not a satisfying resolution to visits at the Student Run Free Clinic. If care is not given equitably, then we are going against our oath.
Hi Taylor! I think you make a lot of really good points and bring up a lot of thoughts that I haven’t thought of myself before. I think you make a good point about FQHCs and sliding scales possibly being a way to fix care gaps currently solved by SRFCs. I agree that one of the barriers that prevents a model like this from closing the gaps is limited patients with private insurance choose this option to receive their care.
One question that I do have (and I don’t know the answer) in the world we currently how easy is it to access information about these clinics, the services they provide, and about how much people will be expected to pay. Does lack of transparency about this also drive people away from getting care?
“To be clear, patients do not choose SRFCs for the opportunity to educate students, they end up at the clinic for lack of other options.”
I don’t think it necessarily is a failure of imagination, as I think some amount of (quality) care is better than no care at all. And medical students (if properly supervised) are able to provide some levels of care to patients. I would agree that this measure is not good enough and signifies a problem with the larger system. From my limited experience with SRFC, many visits ended with referrals to further levels of care (like the PCP or hospital), but it was known that most of these patients didn’t have the resources or time to get themselves to these facilities. We were sometimes able to give patients a few doses of a medication they needed, with the knowledge that they likely weren’t going to be able to get any more of it in the near future. The work felt very futile, and I didn’t participate in these opportunities very often. It definitely is a very slippery slope in trying to balance medical student education and opportunities to learn in general, as we don’t want to take advantage of patients’ need for care.
I think, as Dr. Rich says in the video, a solution might be to have clinics associated with a hospital system so that way there is a better chance care can be coordinated and that the hospital can provide further resources and more in depth care. Maybe we expand the Public Service Loan Forgiveness so if people do x amount of shifts in a free clinic they can also have some amount of loans forgiven. Maybe we go straight to the crux of the problem and go right for fixing the healthcare system at large. I don’t really have a great answer to be honest, but I think it’s important that when we get situated in our roles, we try to find a solution that works for our communities.
“Charity care, certainly in its current configuration, represents a failure of imagination. While some good may come of these well-intentioned stop-gap measures, they are ultimately not good enough.”
The word charity by itself skews one into thinking that giving material objects and one off services is enough to fix anyone’s problems. It essentially absolves those who are “more generous” with their time and money from committing to real actionable changes. Something that I have been working on for a long time is the way I navigate spaces as someone with a lot of privilege and power and interact with communities as an outsider. I very much believe any intervention needs to garner buy in from the population it is supporting to be both successful AND sustainable. In that way, I agree that SRFCs are not created as a foundation for communities to rely on, but rather as bandaids for the larger social disparities that exist.
I have never worked at an SFRC so I cannot speak about it directly. I recognize that medical students and residents need spaces to learn but I would agree with Dr. Sural Shah in the AMA Ethics article that allowing trainees to provide substandard care may also normalize these clinics. At UC, we have at least 3 student clinics alone. While the clinics themselves may provide some necessary care, if you were to ask more communities that were more wealthy, they would probably go to an urgent care or an ED before going to an SRFC, let alone a provider clinic. Good intentions are not enough, but it becomes hard to outweigh the pros and cons when the alternative is no care at all. Medical students can focus on learning medicine during their rotations, and incorporate service learning to another aspect of healthcare – nutrition, exercise, lifestyle etc.
Regardless, we need to change the way we look at supporting our more marginalized communities. I have definitely heard this discourse a lot in a global setting when the health disparities and cultural differences are so blatant that medical voluntourism becomes evident. However, I appreciated the comparison to the domestic setting as well. Rather than a white savior mentality, we need to switch to community based approach. Similar to community based participatory research, efforts to make change and support communities should start with participation or at least input from the communities it affects.The challenge is how to provide healthcare within a system that is so expensive and regulated by insurance. I think thats why community health centers and FQHC that provide holistic and wrap around resources are so critical. It’s why we need community to healthcare pipelines to create representation in healthcare fields. Why we should look to utilize medical students to support intake and other tasks in volunteer positions but have patients seen by trained providers who access to more resources and treatments. It will certainly required imagination.
“To be clear, patients do not choose SRFCs for the opportunity to educate students, they end up at the clinic for lack of other options”
I agree with this statement but to a certain extent. Yes, for some patients (particularly with an acute care complaint) SRFCs can serve as a quick, free, and accessible option that these individuals can utilize to get the care they need. SRFCs do serve as organizations that fill the care gaps that exist in our society and for the most part, this is what drives people to use SRFCs and not the prospect of educating medical students.
However, in Dr. Faustino’s paper, they argue that there are a number of services which also draw patients to SRFCs including access to preventative care and subspecialty referral. In terms of preventative care, the largest benefit is that individuals can easily access health screenings (glucose/blood pressure) and vaccines. This can allow any patient (including those who even possibly have otherwise good access to primary care) to continue to monitor their health status outside of the doctor’s office. It can also help people learn more about their health status and help determine if they should follow up with their primary care provider. These SFRCs typically take place in community spaces, so people can get access to these preventative services while going about their normal, everyday activities and without having to go out their way.
Similarly, individuals who are seen by the SRFCs can also get access to information and referrals to primary care and specialty doctors who can see them at little or no cost. This information is not always readily available on the internet or at an average primary care office so is certainly a positive reason which may drive an individual to utilize an SRFC.
Overall, my personal experience in SFRCs has been a net positive for me and I hope for the patients we serve as well. Yes, I agree that there are a lot of people who come see us because they have no other option. However, I do think that there are a lot of people who come to our SRFCs because they simply want their blood pressure or blood glucose checked. Additionally, we are able to identify, refer people, and give information about free/low cost primary care/specialty care which the person may otherwise may not have access to.
These are great points, Amanda. Depending on how well the clinic runs, accessibility and overall convenience is a huge pull for patients. And the educational resources being more robust than community practices is not something I considered, this can absolutely serve to improve health literacy and informed decision-making for patients.
As discussed in the articles above, free clinics are often established in low-income communities that are home to minorities and immigrant populations. Although they provide essential primary care to many people, the development of these clinic reflects a failure of the medical system. Those who are ineligible for public insurance or have financial or social barriers to care often access care at these clinics. Many hospital systems or private clinics in the U.S. are difficult to navigate. It is also common for people in minority and low-income groups to avoid these routes of care due to fear of being burdened by medical debt, hesitancy caused by distrust of medical professionals, and, even, fear of their safety in this country due to immigration policies. Consequently, free clinics have been a last resort for many patients. However, it is still important to question the quality of care patients are provided at free clinic settings. Free clinics are often run my medical and pharmacy students overseen by attending physicians and experienced pharmacists during after-hours or the weekends. While there is supervision, trainees often have more autonomy than they would in traditional settings. Additionally, limited point of care testing is available in these settings to inform diagnoses and treatments (i.e. blood glucose testing, urinalysis kits). Advanced laboratory services and imaging modalities needed to inform the treatment for chronic diseases are often not available. Thus, while free clinics serve as an initial point-of-contact to the medical systems for many patients, they should not be the last. Referral systems should be in place between free clinics and safety net hospitals or clinics with more advanced services and in-house physicians should be establishes, but this is not always the case. For instance, a person experiencing homelessness may present with signs of diabetes and an elevated A1c and initiated on metformin, but may be completely lost to follow up after leaving the shelter and losing access to the free clinic. Community engagement and partnerships between hospitals and free clinics can help streamline care to underserved patients and improve outcomes in these populations. As stated in the article by Vinarcsik and Wilson, “Charity care, certainly in its current configuration, represents a failure of imagination. While some good may come of these well-intentioned stop-gap
measures, they are ultimately not good enough.” Most free clinics cannot serve as primary care clinics to patients because they are not able to provide the standard of care that patients deserve.
“To be clear, patients do not choose SRFCs for the opportunity to educate students, they end up at the clinic for lack of other options.”
As someone who has been heavily involved in the SRFC for the last few years, I completely agree with this statement. With that being said, I disagree with the light in which this article is painting SRFCs. SRFCs are typically seeing uninsured patients who cannot otherwise access healthcare, or who otherwise have not found the community resources that can offer them healthcare. I think it’s clear to all of us that our healthcare system is far from perfect. In fact, it is quite broken leaving many patients without a method of accessing care, or at least accessing it affordably. We’ve all seen patients fall through the cracks, and ultimately it is due to the manner in which our current healthcare system is structured. Yes, SRFCs inherently exist because our healthcare system is broken. No, SRFCs will not be able to provide the comprehensive care that a more affluent or privileged patient may get with private insurance. But does that mean we just throw our hands up and say “I guess there’s nothing we can do”?. The second quote states, “Charity care, certainly in its current configuration, represents a failure of imagination. While some good may come of these well-intentioned stop-gap measures, they are ultimately not good enough.” I would argue that it takes immense imagination to find ways to offer healthcare access to communities that are under resourced. Yes, these systems are far from perfect, including our own SRFC here at UCCOM. However, every project has to start somewhere, and it is not going to be perfect from the start. Our SRFC relies heavily on connecting patients with a nearby FQHC so that they can get long term primary care, and further referrals as needed. However, without the SRFC, many of these patients may have never gotten to that FQHC. As I said, SRFCs exist because our system is broken, and undoubtedly we must look upstream to determine why our healthcare system as it stands is failing so many patients across the country. The manner in which this article is written makes it seem like there is a definitive “ideal” answer to how to fix our healthcare system however they offer no solutions. While they make valid points regarding balancing student education with ensuring patients do not receive substandard care, I disagree with the sentiment that these clinics are functionally useless.
“To be clear, patients do not choose SRFCs for the opportunity to educate students, they end up at the clinic for lack of other options.”
I think that this viewpoint significantly undermines the role that students have in our healthcare system, particularly given that the care provided in numerous academic settings includes students. This statement suggests that the care received at SRFC is subpar because of the student-run component. However, while medical students, and even residents, are still learners, they help provide a significant amount of care while simultaneously learning.
During medical school, I have certainly come across patients that erroneously assume that the oldest members of a department are the most experienced and talented. However, particularly in surgery, this can be a very incorrect statement as very often those that are currently performing the most of that specific procedure are the ones best suited. This very often may be a resident. My experience as a medical student on my medicine AI really helped me appreciate the amount of work that medical students put into the healthcare system, even when we aren’t full physicians and are still learning.
In the setting of a SRFC, medical students may certainly be contributing a significant amount of the work, however the final decisions of care are still guided by the preceptor and the care that patients receive are fully vetted by a physician. To suggest that SRFCs cannot provide quality care throws into question the structure of academic medicine facilities as a whole.
I think it true that the medical decisioning making in SRFC may not be compromised because of supervision from attending, but I do think the quality of care may be. SRFCs often dont have the same resources as other clinics in the community. For instance, diagnostic testing and imaging is limited, and so I do not think they should be a standard for patients.