Home > Medical School, Medical/Health Commentary > Whither the student-staffed clinic?

Whither the student-staffed clinic?

When recently discussing medical school extracurriculars with my parents I mentioned the student-run, student-staffed clinic that operates evenings and weekends for the benefit of the uninsured population living in the neighbourhoods surrounding SUMS.

Their response:  “what do you mean, a student-run clinic?  The patients see the students instead of real doctors?”

After I explained what I knew about the structure (i.e. the existence of attending-level oversight and guidance), we tried to figure out why they were so perplexed by this concept.  We figured out that it was a question of not understanding why someone would choose to go to a clinic run by medical students instead of actual doctors.

The concept seemed strange to me at first, to be honest.  Medical training requires a balance between ensuring trainees gain sufficient experience caring for patients with increasing degrees of independence, on the one hand, and respecting patients’ rights to receive quality care from qualified providers when they seek care, and not having their health unnecessarily sacrificed on the altar of medical education.  This tradeoff is apparent in discussions of resident supervision and work hour restrictions and the teaching of procedural skills, but it seemed to be epitomized in the question of whether medical schools should allow pre-clinical students to assume such a significant role in patient care.

Remember, though… we live in Canada.  Virtually everyone can see a physician at no cost [insert obvious caveat about availability and wait times here]… there are no large numbers of uninsured patients who would benefit from free care at a student-run clinic, at least not to my knowledge.

From what I’ve been able to figure out, those few Canadian medical schools that do have student-run free clinics tend not to reach out to the “uninsured,” per se (given that there aren’t that many), but rather to those at the true fringes of society… typically the homeless.  American medical student-run clinics (anecdotally, looking around and asking among my friends tells me that there are many, many of these) seem to focus on the uninsured more generally.  There are enough uninsured patients out there to keep these clinics busy, and to allow medical students to gain direct clinical experience early on in their training.  A handful of the medical schools from which I received acceptances consider their student-run clinics to be major features, from a recruitment point of view.

This all raises the question of what will happen in 2014.  Barring any major legislative or regulatory changes, the entirety of the PPACA will enter into force that year, including the individual mandate and Medicaid expansions.  Most of the current uninsured will have private insurance or Medicaid.  So what will become of these student clinics?

If these newly insured patients refuse to continue settling for medical student-provided care, instead opting to use their new coverage to access actual physician care, then these clinics will have to change to stay relevant.  This could mean refocusing to serve those populations who will still be left without access to care (the homeless, similarly marginalized groups, etc.), or transitioning away from clinical care and towards the sort of health promotion and education activities that are already performed by non-physicians.

Of course, this assumes that the PPACA-insured will have meaningful access to care as a result, particularly primary care.  I can’t say I’m too optimistic on this front.  If access to primary care doesn’t improve — this is especially plausible for those whose will be covered by Medicaid expansion — then these patients will have insurance coverage, but no easy access to primary care.  It’s conceivable that some of those who are currently served by student-run clinics might find it expeditious to keep using them.  In this scenario, the role of these clinics would be reduced in scale, but not in scope.

If this second scenario does unfold, it will probably open yet another front in the debate over what qualifications should be required of those seeking to care for patients.

Either way, it’ll be interesting to see what happens.

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