A free smoking intervention clinic initiated by medical students

How Are We Doing? A Scoping Review of Published Patient-Centered Outcomes Research in United States Student-Run Free Clinics

Phenomenon: Student-run free clinics (SRFCs) serve an integral role in most United States (US) medical schools and contribute substantially to literature on the quality of care to uninsured persons. There has been substantial growth over the past decade of scholarly work produced by SRFCs as they have increased in size and number. Research on patient care outcomes informs better care structures for patients, however there is no current synthesis of patient care outcomes research among SRFCs. This article provides an overview of SRFC research on patient outcomes to understand current research domains and to identify gaps in the literature. Approach: We completed a scoping review by searching Scopus, PubMed, and Journal of Student Run Clinics in June 2021. All peer-reviewed, English-language articles focused on patient-centered outcomes at SRFCs in the US were included. Two independent reviewers performed title, abstract, and full-text screening of relevant works, and eight reviewers conducted data extraction. Descriptive data analysis was performed along with relevant content analysis of patient-centered outcomes. Findings: The search strategy identified 784 studies, of which 87 met inclusion criteria. Most studies were published within the last six years (81.6%), located in California, New York, or Florida (43.7%), and intervention based (33.3%). Many studies (46.0%) had a specific disease of focus of which diabetes was the most researched(19.5%). Patient-centered studies were the leading focus of the study aims (40.2%), where key findings demonstrated primarily improved outcomes in clinic metrics post-intervention (36.8%) or equivalent/better clinical performance than national metrics (20.7%). Insights: This review brings to light gaps in the literature reporting research in SRFCs and can be applied to other low-resource settings. Future efforts to expand SRFC outcomes research should focus on community relationship building, understanding institutional support, and ensuring education on best practices for research within SRFCs. Doing so informs patient care improvement as SRFCs continue to operate as safety net clinics for marginalized populations.

Patient Outcomes from Student-Run Health Services: An Integrative Review

Background

Student-run clinics (SRCs) offer an innovative approach to expand healthcare access and equity and increase clinical placement opportunities for students. However, research on the health benefits and/or outcomes of such clinics is currently fragmented.

Methods

An integrative review was conducted to capture and synthesize findings across a range of study types involving varied student disciplines, student delivered intervention types, and health conditions addressed or care areas of focus. Only published and peer reviewed studies were included. Studies needed to report outcomes in a defined study group measured over time, or report SRC data with explicit comparisons to non-SRC settings. Data were analyzed using inductive content analysis to identify major themes and natural clustering of health outcomes measured.

Results

Fifty-one articles were selected for review based on the eligibility criteria. Studies were predominantly from the United States, and most (n = 34, 67%) adopted a case review methodology for measuring outcomes. Health outcomes were evaluated in relation to a range of health conditions that, for the purposes of this review, were considered to naturally cluster into eight categories: diabetes, hypertension, functional health/quality of life, depression, hospital utilization, substance use, weight, health screening/vaccinations, and others.

Conclusion

This integrative review sought to evaluate the health outcomes accrued by patients in student-run health clinics. Taken as a whole, the literature suggests positive health outcomes resulting from student-run clinics across a range of health conditions. Greater confidence in care-related findings would be achieved from future research utilizing more robust and prospective study designs.

Experiences of the homeless accessing an inner-city pharmacy and medical student-run clinic in Johannesburg

Background

Mental and physical health problems are both contributory factors and drivers of homelessness. Adding to this, the homeless encounter numerous barriers when accessing healthcare services.

Aim

The aim was to determine the experiences of the homeless when accessing healthcare services and the reason why they visit Trinity Health Services (THS).

Setting

Trinity Health Services, a student-run clinic (SRC) based at an inner-city church in Johannesburg, South Africa, provides free acute healthcare services to the homeless.

Methods

This qualitative study comprised three focus group discussions (FGDs) with the homeless who access services provided by the church. Those who had previously visited THS on at least one occasion were invited to participate in FGDs. The FGDs were audio-taped and transcribed verbatim. The data were analysed thematically using Tesch’s eight steps.

Results

Three themes were identified. The first theme, homelessness affecting health, explains how limited access to food, ablution facilities and shelter negatively impact their well-being. This led to the second theme, health needs, where tuberculosis, influenza, sexually transmitted diseases and dental infections were identified as ailments occurring frequently. The need for healthcare services was explicit, yet participants were reluctant when accessing healthcare services as they faced stigma and discrimination. The third theme, THS in addressing health needs, denotes the value of THS in the community it serves where they were treated with compassion and empathy.

Conclusion

The needs of this homeless community as well as the role played by THS were clearly identified. However, THS provides limited services, and integration with existing healthcare services is essential.

Evaluation of multidisciplinary and pharmacy-only student-run clinics on student's perceptions of interprofessional roles

BACKGROUND AND PURPOSE

To determine how participation in multidisciplinary training workshops and student-run clinics impacts students' perceptions of the role of other health professions. Student perceptions from pharmacy-only versus multidisciplinary smoking cessation clinics were also compared.

EDUCATION ACTIVITY AND SETTING

Students from pharmacy, osteopathic medicine, physician assistant, and clinical psychology programs participated in two multidisciplinary smoking cessation training sessions, then provided smoking cessation services to the underserved population in either a multidisciplinary or pharmacy-only student-run smoking cessation clinic. Students completed a survey regarding the roles of other healthcare professionals prior to the workshops, after the workshops, and after the smoking cessation clinic.

FINDINGS

Fifty-six students attended both smoking cessation training sessions and showed statistically significant increases in familiarity and confidence related to smoking cessation after the training workshops. Forty-two students participated in the ten smoking cessations clinics, which included six multidisciplinary clinics and four pharmacy-only clinics. A statistically significant improvement was seen between the pre-workshop survey and post-clinic survey regarding the students' perception of the roles of other healthcare providers in a smoking cessation clinic. Students who participated within the multidisciplinary smoking cessation clinics experienced a significantly greater impact on their perceptions of other healthcare providers than students who participated in the pharmacy-only clinics.

SUMMARY

Student participation in a student-run free clinic is an effective method to increase role awareness of other health professional students in an underserved setting.

A health sciences student-run smoking cessation clinic experience within a homeless population

OBJECTIVE

The primary objective is to describe a professional and graduate student-run approach to smoking cessation education combined with motivational interviewing and pharmacotherapy in regard to the frequency of follow-up with a smoking cessation quitline program in the homeless population. The secondary objective is to assess participants' self-reported level of confidence, knowledge, and willingness to quit before and after participation in the student-run smoking cessation clinic.

SETTING

Homeless shelter in Phoenix, Arizona.

PRACTICE DESCRIPTION

A previously established professional and graduate student-led clinic focused on providing a wide variety of free health services to homeless populations at a homeless shelter. One service not offered was smoking cessation support; thus, a student-run smoking cessation clinic was established.

PRACTICE INNOVATION

Patients were provided smoking cessation education, motivational interviewing, and pharmacotherapy by health sciences professional and graduate students. Patients were then given a 2-week supply of nicotine replacement therapy and referred to the state's smoking cessation quitline. The impact of multiple concomitant smoking cessation strategies provided by students within a homeless population has not been studied previously.

EVALUATION

A 10-day post-referral status update on the success of contact with patients was provided to study investigators from the smoking cessation quitline. Surveys were also used to assess the patient's self-reported level of perceived benefit with the student-run smoking cessation clinic.

RESULTS

Of the 139 unique patients, 19 (13.7%) successfully contacted the smoking cessation quitline. Patients reported high baseline confidence, knowledge, and willingness related to quit attempts; they reported a small improvement in reported values after participation in the student-run clinics.

CONCLUSION

In the homeless population, smoking cessation education, motivational interviewing, and pharmacotherapy had a low follow-up frequency with a smoking cessation quitline, but slightly increased the patient's confidence, knowledge, and willingness to quit.

Learning in student-run clinics: a systematic review

CONTEXT

Student-run clinics (SRCs) have existed for many years and may provide the most realistic setting for context-based learning and legitimate early clinical experiences with responsibility for patient care. We reviewed the literature on student outcomes of participation in SRCs.

METHODS

A systematic literature review was performed using the PubMed, EMBASE, PsycINFO and ERIC databases. Included articles were reviewed for conclusions and outcomes; study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

A total of 42 articles met the inclusion criteria and were included in the quantitative synthesis. The effects of participation on students' attitudes were mainly positive: students valued the SRC experience. Data on the effects of SRC participation on students' skills and knowledge were based mainly on expert opinions and student surveys. Students reported improved skills and indicated that they had acquired knowledge they were unlikely to have gained elsewhere in the curriculum. The quality of specific aspects of care delivered by students was comparable with that of regular care.

CONCLUSIONS

The suggestion that students should be trained as medical professionals with responsibility for patient care early in the curriculum is attractive. In an SRC this responsibility is central. Students valued the early training opportunity in SRCs and liked participating. However, little is known about the effect of SRC participation on students' skills and knowledge. The quality of care provided by students seemed adequate. Further research is needed to assess the effect of SRC participation on students' skills, knowledge and behaviour.

Medical students as teachers at CoSMO, Columbia University's student-run clinic: a pilot study and literature review

BACKGROUND

Although medical students are expected to teach as soon as they begin residency, medical schools have just recently begun adding teacher training to their curricula. Student-run clinics (SRCs) may provide opportunities in clinical teaching before residency.

AIM

The aim of this pilot study was to examine students' experiences in clinical teaching at Columbia Student Medical Outreach (CoSMO), Columbia University's SRC, during the 2009-2010 school year.

METHODS

A mixed-methods approach was used. Data included closed and open-ended surveys (n = 34), combined interviews with preclinical and clinical student pairs (n = 5), individual interviews (n = 10), and focus groups (n = 3). The transcripts were analyzed using the principles of grounded theory.

RESULTS

Many students had their first clinical teaching experience while volunteering at CoSMO. Clinical students' ability to teach affected the quality of the learning experience for their preclinical peers. Preclinical students who asked questions and engaged in patient care challenged their clinical peers to balance teaching with patient care. Clinical students began to see themselves as teachers while volunteering at CoSMO.

CONCLUSION

The practical experiences in clinical teaching that students have at SRCs can supplement classroom-based trainings. Medical schools might revisit their SRCs as places for exposure to clinical teaching.

Evaluation of a student-run smoking cessation clinic for a medically underserved population

Background

Smoking is common among medically underserved populations. Accessible resources to encourage and support smoking cessation among these patients are limited. Volunteer medical student-run free smoking cessation clinics may provide an effective option to help these individuals achieve smoking abstinence. In order to demonstrate the feasibility and cost-effectiveness of a student-run clinic, we analyzed a case series of patients receiving care in a medical student-run Smoking Cessation Clinic (SCC) at the Rochester, Minnesota Salvation Army Good Samaritan Health Clinic (GSHC).

Findings

Between January 2005 and March 2009, 282 cigarette smokers seeking care at the SCC were analyzed. Student providers at the SCC conducted 1652 weekly individual counseling sessions averaging 18 minutes per encounter. Patients were offered a choice of pharmacotherapies including nicotine replacement therapy (NRT), bupropion, and varenicline for up to 12 weeks. Smoking abstinence was confirmed with exhaled carbon monoxide (CO). Thirty-two patients completed the entire 12-week program (11.3%). At last contact, 94 patients (33.3%) abstained from smoking for ≥ 7 days and 39 patients (13.8%) were continuously abstinent for ≥ 4 weeks. The 7-day point prevalence abstinence rates at last contact were 58.6% for varenicline, 41.2% for bupropion, 33.9% for NRT, and 23.5% for bupropion and NRT. Analyzing missing patients as smoking, the 7-day point prevalence abstinence rates were 7.1%, 8.9%, and 8.2%, at 1 month, 2 months, and 3 months after program enrollment, respectively. No serious adverse drug reactions were recorded.

Conclusions

Our medical student-run smoking cessation clinic provided an effective and safe experience for medically underserved patients who might not otherwise have access to conventional smoking cessation programs because of high cost, lack of insurance, or other disparities. Similar medical student initiatives focusing on healthy lifestyles may be feasible and beneficial for individuals with limited access to healthcare resources.

Students learn systems-based care and facilitate system change as stakeholders in a free clinic experience

Systems-based practice (SBP) is rarely taught or evaluated during medical school, yet is one of the required competencies once students enter residency. We believe Texas A&M College of Medicine students learn about systems issues informally, as they care for patients at a free clinic in Temple, TX. The mandatory free clinic rotation is part of the Internal Medicine clerkship and does not include formal instruction in SBP. During 2008-2009, a sample of students (n = 31) on the IMED clerkship's free clinic rotation participated in a program evaluation/study regarding their experiences. Focus groups (M = 5 students/group) were held at the end of each outpatient rotation. Students were asked: "Are you aware of any system issues which can affect either the delivery of or access to care at the free clinic?" Data saturation was reached after six focus groups, when investigators noted a repetition of responses. Based upon investigator consensus opinion, data collection was discontinued. Based upon a content analysis, six themes were identified: access to specialists, including OB-GYN, was limited; cost containment; lack of resources affects delivery of care; delays in care due to lack of insurance; understanding of larger healthcare system and free clinic role; and delays in tests due to language barriers. Medical students were able to learn about SBP issues during free clinic rotations. Students experienced how SBP issues affected the health care of uninsured individuals. We believe these findings may be transferable to medical schools with mandatory free clinic rotations.

Smoking cessation in a homeless population: there is a will, but is there a way?

This cross-sectional study sought to determine the prevalence of smoking, readiness to quit, and preferences for smoking cessation treatments among a sample of 236 homeless adults attending 9 sites serving homeless persons (mean age 41.8 years; 73% male). Two thirds (69%) were current smokers, of whom 37% reported readiness to quit smoking within the next 6 months. In bivariate analyses, persons were significantly (P <.05) more likely to be ready to quit if they had tried to quit in the past and if they had social support to quit smoking. Nicotine replacement was the most commonly preferred assistance method (44%), and self-efficacy to quit (10-point scale) was significantly greater if assistance was available (7.3 vs 4.9; P <.001). The findings suggest an urgent need to develop and implement smoking cessation programs for homeless persons.