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An Even Exchange

OFFERING CARE AT NO CHARGE, STUDENT-RUN FREE CLINICS PROVIDE SOME OF THE BEST TRAINING GROUND FOR FUTURE PHYSICIANS.

The New Physician September 2000
It’s a fair trade, the relationships between caregivers and patients at student-run free clinics. The patients need free medical care, and the physicians-in-training require inspiring and challenging learning environments.


Practicing physicians who spent time at a free clinic while still medical students say the experience was the highlight of their training. It made them better physicians and savvy clinic managers. And when managed-care cost-containment pressures and productivity mandates get them down, these physicians recall their time at the clinic—a time purely dedicated to healing and helping. The medicine practiced at free clinics is the liberating kind. It’s what made these physicians join the medical profession, and it’s why many medical students continue to operate free clinics all over the United States.


Sharewood Project in Boston is one of a handful of student-run free clinics conceived and operated by first- and second-year medical students. Like most student-run free clinics, Sharewood would not exist if it weren’t for the vision and drive of a few students and physicians. Take for example, Sharewood’s Dr. Brian Lisse, an emergency medicine physician and professor at Tufts University School of Medicine. He believes one measure of a civilized nation is accessible—affordable health care for all. Lisse grew up listening to his grandfather’s stories about being a country doctor during the depression, when corn, chickens and a spray of lilacs in May were payment enough for services rendered.


The doctoring genes must run in the family because three of Lisse’s brothers grew up to be doctors, too. “A couple of my brothers wanted to make a lot of money,” Lisse says. “But I was the one who was always going to save the world.” And he began to save part of it in February 1997, when the Sharewood Project first opened its doors.


His involvement with the project began the year before, when several first- and second-year Tufts medical students asked Lisse to be their physician sponsor. Finding a great physician sponsor is important for medical students wanting to operate a free clinic. Luckily for the students and the clinic, Lisse turned out to be just that. “He overcame the school’s trepidation, handled the politics and encouraged physicians to volunteer at the clinic,” says Caroline Williams, a fourth-year Tufts medical student. “He’s a lovely man who’s committed to what he believes.”


And Lisse believes the free clinic experience to be important in preparing students for what lies ahead. It also keeps medical students excited about the field during those first two grinding years of textbook monotony. “Talk to any first- or second-year,” he says. “They all ask, ‘When do we get to see patients?’ They’re sick of memorizing stuff and cramming for exams. It’s not too early for them to learn about differential diagnosis and taking [histories and physicals]. And at the clinic, they’re exposed to people who have very different life views and backgrounds than their own. When former students come back to volunteer at the clinic, they tell us the experience made them better doctors and made [their] third and fourth years easier.”


Since Sharewood opened in the Church of All Nations in Boston’s Chinatown more than three years ago, students have diagnosed and treated 800 patients. Every Tuesday evening, 10 to 15 medical students see patients, mostly low-income ethnic Chinese, on a walk-in basis. Volunteer translators bridge communication gaps, while two students take down a patient’s medical history, ask her questions about her chief complaint and perform a brief physical. Next, they step outside the exam room and confer with one of the volunteer attending physicians on duty. Then students watch the attending perform a more in-depth history and physical. All three discuss and develop a treatment plan.


“This is why I went to medical school,” says Erica Frank, a fourth-year Tufts medical student. “It confirms for me that I’ve made the right choice to devote my life to medicine. In an era of managed care, when patient time is cut to a minimum, I’ve had the experience of spending an entire evening with a patient—seeing him through an EKG and supporting him emotionally through an emergency room visit.”


Sharewood patients receive free care and prescription drugs. Those who need follow-up care are referred to nearby community health clinics that run on a sliding-fee basis. “We operate more like an urgent care clinic,” Lisse says. “We don’t have a good primary care model in place because of the limited number of hours we are open each week.” Some patients do get referred to Tufts’ alumni, who’ve agreed to see Sharewood patients in their offices at no cost. Such referrals are done only for individuals who do not qualify for hospital payment programs geared to low-income patients.


As for malpractice insurance, Tufts covers the medical students. This is made possible since Tufts’ medical school dean has declared the students to be faculty while they’re working at the clinic. Volunteer physicians get their Sharewood malpractice insurance paid through their employers. For retired volunteers, the Massachusetts Medical Society picks up the tab.


The clinic is officially a nonprofit organization under the Tufts umbrella, but it is entirely separate from the medical school. A student board of directors operates Sharewood, handling scheduling, raising money and paying bills.


The clinic is fortunate to receive monetary gifts, medical supplies and services. Sharewood receives grants and donations from the Tufts University School of Medicine, the American Medical Student Association, the American Medical Women’s Association and the Massachusetts Medical Society. So far, they’ve managed to stay clear of corporate cash grants—avoiding strings. Pharmaceutical representatives provide free medication. The New England Medical Center donates equipment and offers free X-rays. Quest, a Boston-area lab, provides lab services at no cost. And each year, the students hold an auction of donated items. In 1999, they raised $7,500; 1998, $10,000. This year, students hosted an online auction that raised $6,000.


None of this happened overnight. “At first I was surprised [at] how much time and effort it took—lots of meetings, phone calls and e-mail,” Lisse says. “But in retrospect, it was far easier to bring Sharewood to life than anyone would imagine.”


But as with most projects, politics tend to complicate matters, sometimes threatening to crush plans altogether. Luckily for the students, Lisse was there to help them navigate the choppy political waters. “The politics can be dicey,” he says. “For this reason, plans to start free clinics have been turned down by a lot of organizations. At least one highly placed [Tufts] faculty member told me he expected the students to give up. He was surprised they stuck it out.”


One of the biggest political obstacles to opening the clinic was convincing the community health center in Chinatown that Sharewood would not be a threat. “They were afraid we would compete against them for money and patients,” Lisse says. He defused antagonism by promising that Sharewood would bow out of any sponsorships or grants that might fund the other clinic. As for taking away patients, Sharewood actually brings patients to the community clinic by sending them there for follow-ups. “They’re the ones with the good primary care model,” Lisse says.


Now in its fourth year of operation, Sharewood is stable, and students still run the show, although Lisse remains actively involved. He routinely attends board meetings where he encourages consensus-building, resolves personality conflicts and helps steer a straight course for the clinic’s future. He volunteers at Sharewood, serving as medical director and providing quality assurance chart review.


When one class hands over responsibility to the next, Lisse is there to assure new recruits that their predecessors were just as scared and uncertain as they are. He still runs interference for the clinic in the political arena—one of the most difficult areas for students to manage, Lisse says. And he’ll always be searching for physician volunteers and talking up the clinic when he hobnobs with Tufts alumni and other colleagues who can help the clinic succeed.


Perhaps most important to the clinic—Lisse keeps himself “on call” for any medical student who needs him. “He encourages us to go as far as we’re able to,” Williams says. “He cares about how we’re surviving and reminds us the quality of care we provide is not measured by how well we do on a microbiology test.”


Even though it’s not required, nearly every first-year Tufts medical student signs up for a rotation at Sharewood. Medical students from Boston University and Harvard now volunteer at the clinic as well. Lisse hopes that Sharewood will soon be able to expand its hours. There are enough students for each school to run the clinic on a particular night, but finding enough volunteer physicians to cover expanded hours is a problem.


As students graduate, Lisse says he hopes they will be free clinic Johnny Appleseeds—dispersing across the country and establishing Sharewoods in other towns.


“Starting Sharewood was simply the right thing to do,” he says. “Health care should be available and affordable to everyone. That’s a message we need to give students.”
New Physician contributing editor Howard Bell is a medical writer living in Onalaska, Wisconsin.