Reynolds, Herbert Y. MD
Physicians have always been confronted with sick people who need health care but who are in financial need or not otherwise included in the medical delivery system. Moreover, illness often creates economic hardship for people. Different approaches to this dilemma have been tried. Medical practitioners have cared for needy patients in their communities, squeezing them into busy office practices or working in municipal or county health clinics. As a youth, I can remember the holiday gifts, a quart of shucked oysters or special food plate, brought to my practitioner father at our home by a grateful patient.1 In addition, health care for the indigent has been provided in hospitals affiliated with medical teaching institutions where students and physicians in training (residents) provide care under faculty supervision. In exchange for medical care, patients participate in educational activities and/or undergo procedures performed by learners. There is a considerable legacy of teaching and training in many hospitals that collaborated with academic medical centers. Hospitals and their associated academic partners long subsidized the cost of uncompensated health care. But, in 1965, as part of welfare reform legislation and through the recognition that many people in the United States could not afford the rising costs of health care, the Medicare and Medicaid health insurance programs were created.2(pp52-56) These programs had an immediate beneficial effect,3(pp231-236) and yet, the problem of providing health care for indigent citizens persists. Medicaid, which is linked with state governments for its payment budgets, covers many groups; however, certain Medicaid requirements, such as whether the patient is a U.S. citizen or is a lawfully admitted immigrant, mean that not all of the country’s population is covered.4
Although free clinics have long existed for dispensing health care at homeless shelters, soup kitchens, and emergency disaster sites, an alternative way of dealing with health care for the needy emerged in the modern free health clinic movement in the late 1960s. The new concept of an urban free clinic was a response to multiple societal needs of people with new and evolving health issues that the established health system did not readily address. Perhaps the first such urban clinic dates to 1967, when Dr. David E. Smith founded the Haight-Ashbury Free Clinic in San Francisco.2(pp28-30) Since then, a free clinic movement has evolved that offers various kinds of services and features various organizational structures but that remains adaptable to meet the demands and needs of individual communities. At present, there are approximately 1,200 free health clinics in the United States. The National Association of Free Clinics defines free clinics as “private, nonprofit, community-based organizations that provide medical, dental, pharmaceutical, and/or mental health services at little or no cost to low-income, uninsured, and underinsured people.”5 These clinics accomplish these goals through the use of volunteer health professionals and community volunteers and in partnership with other health providers.
It has been my privilege to be involved with three free health clinics as a volunteer caregiver. Each clinic was established to provide free medical care where it was needed, but each also affected medical training and practice. This unexpected outcome gives another incentive for many participants to work enthusiastically in these clinics. It is this unanticipated dimension that is highlighted in the three examples below.
Bradley Bache Memorial Clinic
Conception and organization
In the late 1960s and 1970s, a social revolution was occurring: Lifestyles were being liberalized, behavioral conformity was diminishing, and moral issues were being reassessed. This revolution happened in the context of reaction to the unpopular Vietnam War (1965-1975) and in a culture of illicit drug use, expanded mobility and uprootedness, availability of oral contraceptives, and less parental control over teenage children. The young people of Bethesda, Maryland, were not untouched by these social circumstances. Two factors came together in 1970 to create the Bradley Bache Memorial Clinic, which would meet in the undercroft of St. John’s Church, Norwood Parish, Bethesda, for the next decade.6 (The clinic was named for Bradley Bache, a hotline worker who was killed in a motor vehicle accident in 1970.) The first factor was that Montgomery County, Maryland, decided that, to help alienated teenagers, a house for runaways and a free medical clinic were needed. The second factor was that, in the spring of 1970, the rector of St. John’s appointed a parish taskforce to explore ways that the church building could be made more useful to Bethesda and the adjacent community of Chevy Chase, Maryland. On March 8, 1971, the Bache Memorial Free Clinic opened in the basement of St. John’s, under the auspices of a nonprofit organization and operating without cost to the church. Two examination rooms, a waiting area, a counseling room, and a pharmacy-laboratory space were outfitted. About 10 volunteers staffed the clinic from the community, and at least two physicians from the nearby National Naval Medical Center and the National Institutes of Health would be there three nights a week to see patients between 7:00 and 10:00 pm. Financial support was difficult to attract and depended largely on private donations. Pharmaceuticals were supplied by industry representatives or donated from physician offices; the appropriate supply was adequate, and patients could leave with their medicines in hand.
By the clinic’s first anniversary, it had treated 2,815 patients and provided care or medically related counseling for patients with the following problems: venereal diseases, approximately 18% of patients; hepatitis, 1%; birth control devices and information, 30%; and common illnesses, such as respiratory and gastrointestinal infection, anxiety, and minor musculoskeletal complaints, 45%.7 When the clinic closed in April 1981, it had had about 62,000 patient visits and treated about 20,000 cases of venereal disease and 40,000 cases of other infections.8 The combined population of Bethesda and Chevy Chase Village in 1970 was about 32,000; by 1980, it had increased to about 38,000.9 It was said that the clinic contributed to preventing many unwanted pregnancies through its counseling. The problem of obtaining medical malpractice insurance coverage for physician volunteers contributed to the closing of the clinic in 1981. Insurance was not an issue for those of us volunteers who worked at the nearby National Naval Medical Center or who were members of the U.S. Public Health Service at the National Institutes of Health, but the difficulty of obtaining coverage precluded recruitment of volunteers from the community, and it is still a barrier issue for volunteer physicians.10
Impact and contribution
The clinic staff indicated that it “learned from helping.” It was also said that the attitudes evidenced by caring for these patients and their problems were adopted by local hospitals and area medical schools.8 Thus, the Bache Clinic gave free and humane care to an important and vulnerable segment of the public, and that approach may have prompted other parts of the health care establishment to provide the same kind of care to previously shunned teenagers and college students.
I provided regular medical care at the Bache Clinic from 1972 to mid-1976. As one of the medical volunteers, I remember the frustration, the near-exasperation that some college-aged patients felt in searching for sympathetic health care providers from whom they could get help and answers about medical issues. This help was not available from the traditional sources because of the reluctance of some young people to ask their parents. These problems also were not necessarily handled by school- or college-based health facilities, and the young people’s peers themselves did not know what advice to give. Our encounters with so many young people with varied infectious diseases, some unexpectedly chronic, sparked an underlying interest in medical research that we did not truly realize until later. Had we witnessed, unbeknownst to us, an initial phase of an epidemic that would be recognized in 1981? Later, when our research and patient care were directed to HIV/AIDS,11 we asked ourselves if this infection had first appeared to us among the patients in the Bache Clinic.
Bethesda Mission Medical Clinic and Lion Care Clinic
Conception and organization
Like many U.S. cities, Pennsylvania’s capital city, Harrisburg, has homeless residents who need services and amenities that are provided by its citizens in soup kitchens and at community shelters, including the Bethesda Mission men’s shelter and the women’s and children’s shelter. In 1991, then-medical student Edward Bollard, who later became a member of the faculty and is now the director of the Internal Medical Residency Teaching Program, Department of Medicine, Pennsylvania State College of Medicine, Milton S. Hershey Medical Center, and Dr. Andrew Sumner, then a chief medical resident in the department, created the Bethesda Mission Medical Clinic.12 The clinic was designed to provide homeless persons with free medical care, given by medical residents in the internal medicine training program and by third-year medicine clerks on their medicine rotation. Supervision was provided by the faculty of the Department of Medicine. This once-weekly evening clinic evaluates and treats about 25 patients, usually middle-aged but often older. The Bethesda Mission is located in a sparsely populated downtown area of Harrisburg. The experience of parking one’s car in the lot across the street, looking around, and hurriedly crossing the street produces some personal anxiety, until one has climbed the steep steps to the porch and reached the front door of the mission, when someone in the group of standees says, “Welcome, Doc, and don’t worry, we’ll watch over your car.” This bit of “give back” by the mission residents makes one feel appreciated.
In the five examination rooms, patients are evaluated by a third-year medical student or a medical resident, who then presents each case to a faculty volunteer; that volunteer will see the patient with the student or resident and will help develop a plan for further evaluation and/or therapy. Nearby city hospitals provide basic radiologic tests for patients. These hospitals also analyze laboratory specimens for free and handle emergency problems. Pharmaceutical sources provide free samples of medications, and the good supply enables patients to have most medications in hand when they leave the clinic. Depending on the staffing situation, faculty might also see patients themselves.
Patients present with a mixture of acute and chronic illnesses that reflect common medical problems, such as hypertension, diabetes mellitus (perhaps with complications), respiratory diseases, various infections, worry and anxiety, or evident discouragement or depression. Some patients have particular problems that are work related, such as low-back pain. I remember in particular a few patients with finger and hand skin infections that were related to meat and poultry food processing and other patients in landscaping jobs who had contact irritation of skin that had been exposed to chemicals and pesticides. Several years into the clinic’s operation, the clinic gained the capacity to treat obstetric-gynecological problems and to see children, in special sessions. Volunteer residents and faculty from the Department of Pediatrics later served at the clinic. A skin clinic staffed by residents and faculty from the Department of Dermatology was also begun.
In 2000, the Bethesda Mission clinic effort expanded to support Lion Care (“Care” comes from “Compassionate health care, Advocacy, Renewal, and Education”) as a medical student clinic, started by Vivek Bansal, Sonia Badreshia, and Tim Weaver.13 The intention was to introduce preclinical medical students to the medical and social issues facing the homeless and underserved community and “to keep humanism in medicine.”13 At this clinic, students obtain patient histories and background material under staff supervision, which facilitates patient evaluations by the medical residents. The Lion Care Clinic, now in its eighth year, began as an extracurricular activity for students, offering a weekly clinic; three subspecialty clinics were subsequently added. In addition to patient visits, the clinic gives educational sessions for patients, is used for student research projects, and is part of an international program in India.14
Impact and contribution
I participated in the Bethesda Mission clinic from 1992 until 2002, supervising residents and often providing medical care as needed; I was also involved with the Lion Care Clinic from its early days until 2002. The Bethesda Mission continues, after 17 years of volunteer efforts, to provide free health care to an underprivileged community. Both clinics responded to another problem that emerged during the 1990s in medical education and training—namely, where could patient-interviewing and physical examination skills optimally be taught? Previously, this instruction for second-year students used in-hospital patients. As academic health centers adjusted to the era of cost-containment and managed care and began to receive payments governed by Diagnosis-Related Group strictures, the pressure was considerable to shorten the length of hospital stays.3(pp349-369) The dynamics of patient hospitalization changed. Only sicker patients were admitted, tightly focused problems were addressed, and rapid turnover of patients was stressed, all of which made it more difficult to find suitable patients with whom beginning students could interact. (The same problem pertains for student clerks on hospital rotations.) Moreover, outpatient clinics had to accommodate more patients with shorter visits and turn over clinic rooms more quickly. This setting was not the ideal venue in which to teach interviewing and physical diagnosis. As a substitute, there has been an increased use of simulation laboratories and simulated patients using actors/actresses to portray illnesses. These are wonderful new dimensions for teaching and for clinical training,15 but a discussion of them is outside the scope of this paper. The experience of working in simulation, however, is different from dealing with sick patients, and simulated patients usually do not have many important physical findings.
The free medical clinic provides a more low-key and personal atmosphere in which beginning students can interact with patients. It seems to be a more optimal environment for students to learn basics that need to be performed efficiently but not rushed. Patients are grateful to be receiving health care attention and are not as anxious and fractious as when they are made to feel like “just a number” and are hurried through a clinic visit. The milieu of the clinic is more patient-friendly and less tense, and learning seems to be more optimal. Recently, several medical students have used the Lion Care program as a resource for designing their medical student research project. In addition, faculty in the Division of Infectious Diseases have done clinical HIV/AIDS research at the Bethesda Mission.
Mercy Health Clinic
Conception and organization
The Mercy Health Clinic (Mercy Clinic), located in Gaithersburg, Maryland, was established in October 2000 to serve uninsured, low-income adult residents of Montgomery County. [For more information, go to the clinic’s Web site at: (http://www.mercyhealthclinic.org).] The Mercy Clinic is in a network of 10 health clinics16 extending primary care and some subspecialty services to approximately 80,000 uninsured persons living in Montgomery County, which has nearly one million residents. Recently, I reported on volunteering in this clinic and interacting with the other volunteer staff, who provide excellent care for indigent residents of our county.17
In June 2007, the clinic relocated into larger quarters, so that patient care could be expanded. Since that time, patient visits have increased 24% over the total in 2006, to 5,427 physician visits.18 The clinic’s 150-person volunteer staff includes 30 primary care physicians, 1 nurse practitioner, 2 physician assistants, 40 nurses, 3 pharmacists, and Spanish-language interpreters, registrars, and administrative assistants. The demographics of the patients served remain approximately as described elsewhere.17 The ethnic and racial distribution of patients remains about 70% Latino, about 12% African American, 11% Asian, and 7% Caucasian; 72% of the patients are female. Although the average age of the patients is 50 years, the age distribution has shifted in the past two years, with the number of patients in the 50- to 64-year-old range increasing from 27%17 to 36% (as tabulated from the author’s own medical notes from 2006 to 2008). The most common diagnoses remain chronic diseases.17 Many patients need referrals for dental care, eye examinations, mammograms, and colonoscopies, and those referrals are made to colleagues in the area who provide volunteer referral care. Increasingly, the Mercy Clinic is adding specialty clinics; these clinics are staffed by 21 volunteer specialists in obstetrics-gynecology, orthopedics, dermatology, endocrinology-diabetes, urology, and rheumatology.18 A Lifestyle Clinic teaches groups of patients about proper diet and exercise.18 These demographic and diagnostic details emphasize that the Mercy Clinic is serving a diverse group of needy patients and is attempting to provide comprehensive care for them.
Impact and contribution
For eight years, the Mercy Clinic has provided the indigent population of Montgomery County, Maryland, with good patient care. It can refer many patients with special needs to physicians in the community who give volunteer service, which enables the comprehensive care of patients. I have provided regular general medical care as a volunteer since 2003. Caring for patients with a spectrum of chronic illnesses is not simple, but most of the problems encountered are familiar to experienced health care providers. Because one is not grappling with unexpected illnesses, there is confidence in deciding treatment, which may free up some time with the patient to delve into other health concerns not usually or easily broached in a rushed office practice setting. This extended conversation permits a broader, more in-depth assessment of the patient, which gives the physician greater satisfaction. Moreover, the clinic provides a supportive milieu for us senior (many, retired) health care givers. One can enjoy the comradeship of colleagues in a less competitive medical practice arena. In contrast to the medical students and residents who are volunteering in the Bethesda Mission Clinic, we senior physicians are not building clinical skills at this point but, rather, preserving skills, which is a satisfying benefit (both to us and to our patients) late in a career. We feel that we are still helpful and essential and staying mentally active and involved in medicine. Keeping skills current is an educational endeavor.
Summary and Perspective
My impression, which is based on serving in these three free medical clinics, is that each clinic was created in response to special health care needs that developed unexpectedly in U.S. society. Free clinics could address patients’ concerns quickly, whereas the established health care system was slower to perceive these concerns and provide ready solutions. First, during the turbulent and changing social environment of the late 1960s, young people, teenagers, and college students could not get the help they wanted from the usual sources. They often felt ostracized and excluded from the health care they needed. They appreciated a free clinic, such as the Bache Memorial Clinic, that was sympathetic to their needs and that would treat them. This clinic’s lifespan was a decade, and its usefulness was then spent; its care of young people was subsumed by other medical entities, especially as the HIV/AIDS epidemic grew. The lack of malpractice coverage for community voluntary practitioners was a factor that might have been solved in time. For example, the government of Montgomery County now provides this insurance for volunteer physicians at the Mercy Clinic. Since 1992, Virginia has provided liability protection for health care professionals who volunteer to serve patients in free clinics.19 This is a strategy that all states were urged to adopt20; a few have done so. In 2004, the Health Resources and Services Administration of the U.S. Department of Health and Human Services provided, through the Federal Tort Claims Act, malpractice assistance for clinics that apply for the coverage, to protect volunteer providers.21 But this program’s total resources were decreased substantially in fiscal year 2008.21 Finally, I suggest a possible legacy for the Bache Clinic. Is it likely that, in the future, another groundswell clinic movement responding to new public health concerns will be part of an unsuspected clinical illness such as AIDS? I suggest that it is both possible and likely.
Second, substantial changes in the delivery of health care, emanating from the managed-care era of the 1990s, have made the traditional use of hospitalized patients for the training of students and, in some respects, residents, less convenient. This change has stimulated other approaches, especially the simulation laboratory method. This alternative for learning and training is quite successful,15 but it differs from the use of actual patients. Caring for patients at a free clinic has been a good learning experience for students at the Lion Care and Bethesda Mission clinics because it provides actual exposure to sick people and inserts realism into dealing with their health needs. For discussion, free clinics that pertain to learners should be separated into those geared for preclinical medical students and those for students on clinical clerkships and physician residents.
Free health care clinics run by medical students have developed, if not flourished, during the past decade, as students have been motivated to interact early on with patients and to affect their health care. Results of a survey of U.S. allopathic medical colleges (N = 124), conducted in 2005, showed that, among the 94 responding colleges, 52% had at least one student-run clinic.22 It is of interest that most of the teaching at these clinics was given by other students. Among things that preclinical students learned were performing a physical examination (47% of responses) and taking a patient history (34% responses); however, learning to present a patient to a physician was the skill most often cited (81% of responses)! I have had informal discussions with medical school faculty involved in educational programs, acquaintances of mine at 14 medical schools, about additional issues surrounding student participation in free clinics. These conversations have confirmed that many medical schools have relationships with community-located free clinics and that preclinical students are encouraged to volunteer and participate at these clinics. The learning sessions are not, however, part of the medical school curriculum, and a specific assessment of student attendance or proficiency of skills is not always required. Although students’ activities are supervised, the attendings may not be faculty members. Some of these issues will undoubtedly change soon, because of the recent requirement from the Liaison Committee on Medical Education, which provides accreditation standards for medical educational programs in the United States and Canada. A new Standard of Service Learning, I S-14-A, which became effective July 2008, states that medical schools should make available service-learning activities for medical students and encourage participation.23 Service learning is defined as “a structured learning experience that combines community service with preparation and reflection.”
Free clinics that attract medical and specialty resident volunteers—and, often, medical students in their clinical years—exist at many medical centers. They usually are community clinics, and faculty attendings may supervise housestaff work. The precise number of these arrangements is not known. This volunteering effort is encouraged, but certain issues are not addressed or are variable in practice. In some programs, first-year residents serve in free clinics as part of an ambulatory intern rotation. Other important issues are that clinic volunteering must not occur during busy clinical rotations, to avoid upsetting the hourly workweek limits imposed on residents; the precise nature of malpractice coverage is sometimes vague; and feedback or evaluations are not necessarily received or required.
Third, access to health care for uninsured people, which is not just emergency care service, remains an important societal issue in the United States24 that affects almost 50 million persons, or about 16% of the current population. Another 20 million in the United States are underinsured. Maintaining free clinics requires a combination of municipal or government financial support and/or private philanthropy and personal donations. An economic downturn, as is now occurring, affects tax revenues and charitable giving, which may have an impact on the continued support and, perhaps, the viability of free health clinics. Yet the need for free health care seems more critical than ever, and dependence on it seems to be increasing. At the Mercy Clinic, the patient clientele is becoming older. More new patients coming to the clinic report that they have recently lost their medical insurance because of a job change or that they are suffering financial troubles. A last resort for them is to shift to the free clinic system. But providing health care to indigent people is a daunting effort25 that relies greatly on volunteer services to sustain the operation. Older and often retired health care providers are essential, but recruiting more of them to expand volunteer services is problematic.16 At the same time, among the quarter- million U.S. physicians aged 55 years or older, there may be a sizeable reservoir of those who are interested in volunteering to practice in free medical clinics. In a North Carolina survey of 869 responding physicians (29.5% indicated family medicine and general practice specialties), about 38% indicated a high level of interest in volunteering when in retirement.10
The present overload of people in our society without predictable health care access is a national emergency of sorts. Free clinics will be part of the future remedy.2(p171) Having willing and experienced, perhaps retired, volunteer care providers is an important ingredient needed to meet the clinical demand. The prior clinical experience of these generalist and specialty physicians meshes with the common patient illnesses encountered, as illustrated at the Mercy Clinic. Equally important, the volunteer receives great personal enjoyment and reinforcement for his or her efforts. That there is such a need for the older generation in a professional capacity is an unexpected pleasure.
The author appreciates the materials and review of the manuscript provided by Richard G. Hewlett, archivist of St. John’s Church, Bethesda, Maryland; Debra Stevens, Dr. Edward R. Bollard, and Dr. Richard J. Simons, Department of Medicine, Pennsylvania State College of Medicine, Hershey, Pennsylvania; Dr. James A. Ronan, Jr., and Dr. Amra McClanen, the Mercy Health Clinic, Gaithersburg, Maryland; and Anne L. Reynolds. In addition, the author has appreciated helpful discussions with many medical colleagues and special suggestions made by Dr. Julie S. Darnell, the University of Illinois, Chicago, Illinois; Brenda Flinchum, the Bradley Free Clinic, Roanoke, Virginia; and Mark R. Cruise, Free Clinic Solutions, Richmond, Virginia.