Clinical and Health Affairs
HOPE Clinic
A Place to Care
By Ruth Westra, D.O., M.P.H., Steve Skube, and Melissa Zant
■ The University of Minnesota Medical School and College of Pharmacy in Duluth worked with a local drop-in center in 2008 to start a free clinic. The HOPE (Health of People Everywhere) Clinic is a student-run, faculty-organized effort that offers students an opportunity to develop their clinical skills and learn how to work in interprofessional teams while providing needed care to people who are underserved or uninsured. This article describes how this initiative came about and the impact it is having on medical students.
The second-year medical and pharmacy students tap gently on the door to the men’s dormitory. “Come in,” they are told. The floor is covered with mattresses and bedding; a faculty physician and pharmacist sit in the room’s few chairs. The students present their first case of the day. They describe a 44-year-old male who sustained a laceration to his left forearm four days ago during an altercation. He does not have insurance, so he stitched the wound with dental floss. The students describe a two-inch area on the patient’s left forearm that is red and swollen. The faculty and students then return to the exam room to evaluate the patient and discuss further care options with him.
A Real Learning Experience
One patient at the HOPE Clinic, who seemed to have vague symptoms of an upper respiratory infection, proved to be a real learning experience. The first team of students to meet her assessed her symptoms and then counseled her about over-thecounter medications that might alleviate them. Although the patient told us that she did not like doctors, she seemed at ease during the time she spent with us. She returned week after week for a month or so, arriving with vague complaints and clearly enjoying the opportunity to have three open-minded students listen to her story and answer her medical questions.
As we slowly pieced together her story, we gained her trust and were able to convince her that she should have a primary care provider address her chronic health problems. We set up a referral, and hoped she would go to her appointment. To our delight, she returned to our clinic a week later with stories of how great her provider was and cards for her follow-up appointments.
The students at the HOPE Clinic performed a great service for this patient, but the patient also taught us a great deal. We helped her establish a relationship with a clinic where she can get the care she needs to enjoy better health. She made a lasting impression on us. We now know that it is possible to break down the barriers that separate patients and providers. We appreciate the difficulties of people who are underserved. We know that people are more alike than different when it comes to their need for health care. Most importantly, we learned that listening and having an open mind may greatly affect the life of a patient. – Melissa Zant
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This is a typical afternoon at the HOPE (Health of People Everywhere) Clinic, a student-run free clinic at the Churches United in Ministry (CHUM) Drop-in Center in Duluth. The center serves more than 7,000 people a year who are homeless or who have low incomes and are in need of shelter and support services.
The Founding of HOPE
The HOPE Clinic, which opened in October 2008, is a joint effort of the University of Minnesota Medical School and College of Pharmacy in Duluth. Its mission is twofold: to provide basic medical care and referrals for underserved and uninsured people in the Duluth area and to provide a learning opportunity for first- and second-year medical and pharmacy students. The medical students who serve the clinic are enrolled in the Rural Academy of Leadership, a two-year elective course offered through the department of family medicine and community health. In order to receive credit, they must serve the clinic at least three times a year for each of the two years. The pharmacy students are enrolled in the College of Pharmacy’s early pharmaceutical experience course. When working in the clinic, they are supervised by faculty from the two schools as well as adjunct faculty from the community.
The clinic, which operates every Tuesday afternoon, grew out of efforts of medical students who had volunteered at CHUM, taking blood pressure readings and talking with people about their health. The students often met people who had great need but few resources. In 2006, student leaders decided they wanted to do more to help this population. After conducting a needs assessment and looking at possible locations for a free clinic, they realized the drop-in center would be a great site and approached the leaders of CHUM, who agreed to provide space free of charge. In addition, the students sought donations to purchase basic medical equipment and supplies such as bandages, over-the-counter medications, office supplies, educational materials, and bus passes for patients. They have received financial support from a number of organizations including Maurices, a national clothing retailer; the Rural Health Resource Center; the University of Minnesota Medical School Student Council; the Women in Medicine student organization; and Pasek Pharmacy, which donates prescription medications. The clinic is run by an executive board composed of students and faculty advisers Ruth Westra, D.O., M.P.H., from the medical school and Tim Stratton, Pharm.D., B.C.P.S., F.A.Ph.A., from the college of pharmacy.
Learning the Value of Teamwork
We were just a few months into our first year as medical students, and it was my first time volunteering at the HOPE Clinic. I had learned most of the physical exam skills and barely knew how to write a patient note when the clinic coordinator turned to me and a classmate and said, “One of the secondyear students just called in sick. You two can handle seeing patients, right?” As the coordinator turned away, we stammered, “Uhh…” But we couldn’t let the team down. We rifled through the patient’s paperwork, discussed how we would take the patient history, and quickly reviewed our exam skills before walking into the exam room.
We worked through a focused history and physical exam together. What one of us may have missed, the other one remembered. We agreed that the patient had an upper respiratory infection. The next task was presenting the case to the physician preceptor.
We must have looked anxious because our preceptor immediately told us to calm down and take our time. We presented our case, and after she spoke with our patient, she agreed with our diagnosis. We were thrilled to “crack our first case.”
Our preceptor then showed us some physical exam techniques that would have been helpful for our particular patient, taught us the meaning of thenforeign words such as “erythematous” and “rhinovirus,” and discussed the importance of learning how to properly write a patient note. – Steve Skube
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An affiliation agreement between the university and CHUM was approved in 2008. Since then, the clinic has provided care for more than 250 patients with concerns ranging from sore throats to diabetes. Two clinical teams staff each session. Each team consists of a student pharmacist, a medical student clinician, and a medical or pharmacy student who serves as a patient advocate. After doing an initial examination and taking the patient’s health history, the team gives an oral presentation to the faculty supervisors, and together they develop a care plan for the patient. The patient is then seen by the entire team, and they discuss appropriate treatment options. If patients do not have a primary care provider, the students connect them with one through the Health Care Access Office at the Lake Superior Community Health Center or the Duluth Family Practice Center.
Preparing Students for the Experience
Students at the University of Minnesota Medical School, Duluth, learn physical exam and history-taking skills early in their first year. Those who are involved in the HOPE Clinic participate in an orientation session to prepare them for the unique challenges that come with working at a free clinic.
The orientation begins with the basics. First-year students take a field trip to the HOPE Clinic to become familiar with the CHUM Center and the clinic examination rooms. During that visit, second-year students perform a mock patient encounter to show the first-year students how the clinic operates. Finally, the students serve a meal to clients. Listening to their future patients’ stories helps them understand that each person faces unique challenges and gives them an up-close view of the concerns of the homeless and uninsured as a population.
Students then attend three workshops where they learn how to take a patient’s vital signs, do laboratory testing, give oral presentations, and provide referral information. Medical and pharmacy faculty provide ongoing instruction and advice during the afternoon clinics.
Assessing the Impact on Students
The 60 medical students who work at the HOPE Clinic gain valuable experience that prepares them for their clinical years. One thing they learn is the value of team work. The teams of three students work together to complete the initial patient history, applying what they have learned in the classroom. Because the medical and pharmacy students bring different perspectives, they see how they can obtain more information from the patient together than if they were working alone.
After each session at the clinic, students complete a survey about their experience. They also are required to write a reflection on what they saw and learned (see “A Real Learning Experience” and “Learning the Value of Teamwork”). In surveys, students noted that they gained confidence in their ability to perform examinations and that their history-taking skills improved. They also reported having better relationships with pharmacy students and said that they were more comfortable working with patients who are underserved and uninsured.
Conclusion
In the HOPE Clinic, the University of Minnesota Medical School and College of Pharmacy in Duluth and CHUM have created a unique partnership that not only benefits underserved and uninsured people in the area but also allows medical and pharmacy students to gain clinical experience early in their academic career. In addition, serving in the clinic helps medical and pharmacy students understand the complexity of caring for patients and allows them to experience being part of an interprofessional health care team. MM
Ruth Westra is chair of the department of family medicine and community health at the University of Minnesota Medical School Duluth. Steve Skube and Melissa Zant are third-year medical students. They were co-directors of the HOPE Clinic during the 2010-11 academic year.