One crisp Sunday morning in October, I arrive at the community free clinic to find four student volunteers — two of whom are in their third month of medical school like I am — and one attending physician. As usual, we are overbooked. There is no time to discuss any of the patients that would be seen that day in advance, so I immediately head to an exam room to see my first patient with another newly minted medical student. Having not yet learned the basic physical exam skills, I google “how to listen to lung sounds” on my way to the room.
The free clinic is located in a community primarily composed of immigrants who are largely uninsured or underinsured. Our patient does not speak English, so I try my best to conduct the visit in Hindi, my second language. The patient has a number of common risk factors for heart disease and communicates that she is having some discomfort in her chest, so I need to rule out the possibility of a heart attack. When I begin asking questions for nonclassical heart attack symptoms, I realize I do not know the word for “heartburn.” I settle for motioning towards my stomach and asking, “Any pain?” I hope she understands because we don’t have an interpreter on hand. “Free” means just me.
Another patient I see has uncontrolled diabetes. He needs to have his A1C measured, but the phlebotomist is not in today, and there is no one available to draw blood. He also needs insulin, which he cannot afford, but insulin is not one of the seven medications the clinic has stocked for distribution. I leave him with an unsatisfying “Please come back when the phlebotomist is in.” I am not sure how strongly I should insist that he return. Once we get his A1C checked, which I fully expect to be elevated, we will have nothing to offer him. “Free” means a diagnosis but not treatment.
One of the first things you learn as a medical student is the four universally accepted principles of health care ethics. Of them, the one that applies to more than just the individual patient is justice, tasking health care workers with the fair and equitable distribution of resources. While my classroom experience taught me to strive for justice, my clinical experience has already demonstrated that justice is aspirational at best.
Downtown, the General Internal Medicine Clinic at the academic medical center affiliated with my school practices the medicine you see on television. There are groups of health care providers huddled around monitors having spirited conversations about patients, making long lists of differential diagnoses, ordering various tests to narrow their thinking and referring patients out to specialists to ensure nothing is overlooked in the patient’s care.
Here, clinic starts with the full team reviewing the patients on the schedule. Each patient is first seen by a medical assistant who records their heart rate, temperature, blood pressure and reason for visit. I then go in with an MS3 to examine the patient, doing as much as I am comfortable with before they take over. We step out and finalize our assessment and plan to present to the attending physician. She comes in, examines the patient herself, and reviews the findings and recommended course of action with them. If indicated, lab work can easily be completed across the hall on their way out. Unbeknownst to the patient, by the time they leave, their care has been discussed multiple times.
Clearly, the care delivery model is very different at the free clinic where I volunteer. Free clinics supported by volunteers and donations — distinct from Federally Qualified Health Centers funded by the government — help fill the health care gap that the uninsured experience. An analysis of patients at Grace Medical Home in Orlando, Florida showed that 58.5% of patients come to their clinic because they can’t afford insurance premiums. Before finding the clinic, 80% were unsure how to access medical care or where to go for help.
Student-driven clinics allow for low operating costs and are a popular model for free clinics. More than 75% of medical schools have associated free clinics, with ~60% of medical students at these schools volunteering there at some point in their training. These clinics do provide significant benefits to patients. The United Community Clinic, a student-run clinic with an annual budget of less than $50,000, estimated that their preventative services avoided future morbidity and mortality that would have cost $850,000.
While free clinics have a significant impact on a population that critically lacks access to health care, they are by no means enough. Our health care system strives to be just but offers some patients care from world-renowned physicians and facilities while others spend most of their visit with first-year medical students who cannot always speak their language, fully assess them or help them get the medications they need.
Until our health care system evolves to provide universal coverage, justice will always be aspirational. I cannot offer a path to get there or a solution that will lead to equitable distribution of medical resources. I can only remember the patients from the free clinic who allowed me to practice exam techniques for the first time and patiently waited as I fumbled through visits in their native language.
The small piece of their interaction with the health care system that I can influence is the quality of care they receive at free clinics. As an attending, I hope to continue volunteering, providing expert care to patients and more robust support to learners. Free clinics mold many medical students during their training years, largely because of the increased responsibility they are able to take at an earlier stage. If we, as attendings, share a small amount of our time with free clinics, we will not only give back to the patients who contributed so much to our success but also make our piece of the health care system a little more just.
Image credit: Charles Camsell Hospital (CC BY-SA 2.0) by Kurayba