Hannah Korah (HK): In a time when we began medical school online during the peak of the COVID-19 pandemic, most of our preclinical medical education was lecture-based. This meant my experiences at the free health clinics affiliated with our institution were more valuable than ever in introducing me to patient care. As the state of Arizona is home to significantly large border and Native American populations, these clinics serve as the only point of health care contact for many underserved and marginalized communities. This made my experiences not only valuable for personal and professional growth but also served to deepen my understanding of health care disparities that exist in the United States.
Prem Thirunagari (PT): The Commitment to Underserved People (CUP) program provides services from a variety of specialty-specific free health clinics to address the diverse needs of the Tucson community. In witnessing the logistical challenges and social dynamics of a health care team providing for the underserved, my perspective of patient care was broadened. While I initially anticipated that the greatest difficulties in running a free health clinic would stem from my lack of medical education, I quickly realized that, in some regards, the organization, documentation and planning required to provide for patients were even more challenging. From my participation in CUP, I was able to improve not only my clinical acumen and knowledge base but also my abilities to manage busy patient workloads and streamline the health care process.
HK and PT: Here, we share our reflections on select encounters over the past few years that taught us unique and valuable lessons through the various medical student-run and physician-supervised CUP clinics at the University of Arizona College of Medicine-Tucson.
TotShots provides a variety of care for pediatric patients, including well-child visits, vaccinations and sports physicals for those who are uninsured or require free health services for financial reasons.
PT: My initial involvement in the CUP clinics was through the TotShots pediatric clinic. I took on the role of vaccine coordinator, which involved ensuring that the vaccines in the clinic were still viable, that each patient received the correct set of vaccines with proper documentation and that the patients we saw were registered into the health department system to extend their care beyond our visit. Through this role, I acquired a greater understanding of the work that occurs behind the scenes in health care. For example, in order to administer a polio vaccine to a patient, the patient coordinator would call or be called by the patient’s parent/guardian, set up an appointment and communicate the location and directions to our clinic on the day of appointment. The vaccine coordinators would then have to confirm the type of vaccine in the health department system. In addition, the lab coordinators would train the rotating clinical team, comprised of new members weekly, to provide the vaccines in a systematic and safe manner. Being a part of this well-oiled system taught me the importance of communication in health care in executing tasks in a timely and effective manner. TotShots showed me that not all problems in medicine are directly health or patient related. One of the most unexpected challenges that we faced at TotShots was our vaccine refrigerator malfunctioning. To address this issue, I dedicated a day to calling various home improvement stores and driving throughout Tucson in search of a new refrigerator. From this experience, I learned that running a clinic requires responsibilities beyond core patient duties, which added a novel dimension to my understanding of health care.
Shubitz CUP Clinic is a family medicine clinic that provides free primary health care services, including but not limited to routine screenings, chronic illness management, health education, vaccinations, lab work, referrals and much more.
HK: One of my first meaningful encounters in a CUP clinic was during a visit with “Ana,” a five-year-old girl with a rash on her hands and forearms. Upon meeting her, I first thought she was shy and that I was doing a subpar job at holding a kid-friendly conversation. I tried to engage her with many different conversational topics, including TV shows, favorite colors and friends at school. In response to each of these attempts, she would simply nod, smile and squirm uncomfortably. I soon discovered English was not her first language, and that neither of her parents spoke English fluently. After recruiting a volunteer Spanish-speaking interpreter, I saw the instant relaxation wash over the family’s faces upon being able to communicate their health concerns in their native language. Even a task as straightforward as filling out a form became instantaneously simplified with the help of a translator. Not only did this type of inclusive care allow for the patient and her family to be more comfortable, but we as a clinic were able to provide more quality care by fully addressing all their concerns.
I was shocked after learning more about Ana’s case. From our team’s evaluation, I soon discovered her rash was likely a minor allergic reaction to a new hand-soap. My shock set in when I was told that Ana and her family had driven over four hours from Yuma, Arizona to address their medical concern. This was an absolutely eye-opening experience for me, making me more aware of the inequality in access to care that exists amongst my neighbors within Arizona and the lengths of inconvenience some go through for basic health care.
Integrative Medicine CUP Clinic (IMCUP) is an outpatient clinic supervised by integrative medicine-trained physicians and fellows. IMCUP provides a variety of evidence-based integrative medicine services, including acupuncture, nutritional wellness education and stress-reduction technique counseling.
HK: My next memorable patient experience was at IMCUP. I was tasked with the challenge of caring for a patient with a complaint of chronic pain named “Mike.” After spending almost six hours with him, I realized that with the resources we had available to us at the free clinic, we could realistically only address three of Mike’s 20 health concerns. I was heartbroken to share this news with him and could not imagine his frustration after spending so much time at the clinic and so many years in pain. Moreover, being uninsured, living alone and lacking a steady income were the least of his concerns since his overwhelming pain was degrading his sleep hygiene, appetite and mobility. We offered and explained the benefits of supplementary over-the-counter treatments such as anti-inflammatory turmeric and fish-oil and educated him on the importance of a healthy diet and balanced sleep habits for better pain management. We also helped him set up an appointment with our free Shubitz Family Medicine CUP Clinic, which is equipped with more resources to provide care for some of his other health concerns. My time with Mike especially taught me the importance of holistic care.
Health for the Homeless (H4H) is a twice weekly free health clinic in downtown Tucson, Arizona that provides many different services to individuals experiencing homelessness. These services include preparing food, organizing clothing drives, hosting discussions on wellness and providing medical care in the clinic. Medical students volunteer at this clinic through the CUP program, allowing the opportunity to further understand the unique needs of this patient population.
PT: One of my most meaningful CUP program experiences was volunteering for the Health for the Homeless Program. During this time, I learned how to perform wound care and manage patients with the limited resources we had available. For instance, as the clinic was unable to afford an X-ray machine, one of the medics shared their solution for evaluating bone fractures using just a tuning fork and a stethoscope. These details and unique styles of management are those I look to incorporate into my clinical knowledge and utilize when necessary. As the recruited physicians working in the program were volunteering their time on the weekends, I learned that the doctors through our CUP program are some of only a few who regularly serve the homeless in Tucson. This realization added a new perspective to my understanding of care for this vulnerable population; if not for the collaboration of a dedicated group of health care professionals, the quality of care these patients receive would be end-stage at best, likely non-existent for most. Not only did this increase my motivation to become a physician, but it also demonstrated the importance of collaboration in the medical setting and the significance of team-based care.
HK: One of my favorite clinics is the H4H Clinic where we provide care for the homeless population of Tucson. The staff is comprised of a diverse group of professionals, including, but not limited to, a respiratory therapist, a reverend trained in the medical field, osteopathic medical students and more. I was able to learn specific skills in medicine that are used in budget-conscious situations. For example, the respiratory therapist taught us how to provide distinct percussion-massages that help clear the airway, as used in cystic fibrosis patients, in lieu of the standard $2000+ chest physiotherapy vest. On another occasion, an osteopathic student shared with us the use of peppermint oil in pain and stress management. We also learned to use a black-light to find foot-fungus, a useful tool especially among the homeless population where many individuals lack shoes and other foot protection. Donations of items as simple as socks or baseball caps from the Tucson community were immensely appreciated in preventing such cases of foot fungus and melanomas in a population exposed to the harsh Arizona sun. I recall coming across the puncture wound of a patient who had stepped on a nail recently after walking barefoot. As H4H was the only consistent care he had ever had, I was grateful that we were able to keep a medical record of matters like his most recent tetanus shot to provide accurate and longitudinal care for him and many others.
Overall, the free health clinics in the CUP program taught us how to provide timely, more effective care in resource-limited settings. We developed a greater appreciation for the collaborative roles of the various health care professionals and learned to think outside the box to create innovative solutions for holistic patient care. Providing health care for the underserved gave us a deeper understanding of the inequalities that still need to be bridged in health care, the insight into burdens beyond the surface of a medical complaint and appreciation for the extent of the impact we can have on our communities as health care providers now and in the future.