QMed Cares

​By: Valera Castanov, Adam Gabara, Minnie Fu, Meds 2022

Problem: Healthcare Growth Despite the Ongoing Healthcare Cuts
Solution: QMedCare - a Student Run Clinic

Student-Run Clinics
Although Canadian healthcare is regarded as universal, major barriers to healthcare access exist for many Canadians. These barriers are a result of social, economical, and political disparities that consequently lead to increased hospital readmissions, higher rates of infectious and chronic disease, and ultimately, lower life expectancy (Pan-Canadian Health Inequalities Reporting Initiative, 2018). These challenges are exacerbated for those who do not have healthcare cards, guaranteed access to meals or shelters, or those who struggle to navigate the Canadian healthcare system. These include new immigrants, refugees, and those who struggle with home insecurity or substance use disorders. 
Recent cuts to healthcare such as the elimination of more than 800 full-time healthcare positions, cuts to 6 overdose prevention sites, and future plans to cut up to half a billion dollars in OHIP services, just to name a few, have dug deep into many medical services leading to ongoing shortages of staff, equipment, and space. Unfortunately, it is those that are most vulnerable with the least options that have the greatest to lose. As students and future Canadian healthcare leaders, we see an opportunity to use our time and energy to do something to help bridge this gap and address these unmet healthcare needs through the development of a student run clinic (SRC) here in Kingston.

SRCs are a model of healthcare delivery that places students in a leadership position to organize and facilitate care under the supervision of licensed healthcare professionals. With  at least one hundred operating in the USA, these free clinics hold an important role in providing primary care services to the poor and uninsured while offering medical students an educational opportunity to practice both their empathy and clinical skills. Starting in 1989 with a group of first year medical students at UC Berkeley-UCSF Joint Medical Program who provided free blood draws and screenings at a local homeless drop-in center, this model arrived in Canada in 2000 when students from the University of British Columbia picked it up. Known as the Community Health Initiative by University Students (CHIUS), their clinic currently hosts an interdisciplinary student and resident-led team that partners with both the Vancouver Native Health Clinic and Three Bridge Clinic. 
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With now more than 8 SRCs around the country, some of these clinics have expanded beyond medical services provided by medical students to become hotspots for interprofessional partnership. In Toronto, Ontario, The Interprofessional Medical and Allied Groups for Improving Neighbourhood Environment (IMAGINE) clinic has medical students interacting with pharmacy and nursing students to provide comprehensive care. Moreover, some of them have become community centers where patients can access social work, tax filing services, and in Saskatoon, Saskatchewan, at the Student Wellness Initiative Toward Community Health (SWITCH), even pick up a hot meal for the day.

Benefits of Student Run Clinics to the Community, Students and the System:
With having an SRC, adding in interprofessional care that these vulnerable populations are unable to afford or access in the community, is both holistic and cost-effective. It provides patients the ability to engage in more holistic care of their own health, allowing them to take ownership instead of being subjugated to their circumstances. It allows them to not only have access to medications, but they will be able to obtain care for physical pain or conditions, social/mental/occupational issues, and potentially be able to achieve goals and have access to opportunities that they would not have been able to before. SRC’s have been shown to increase patient compliance, patient satisfaction, and have fewer return visits, which marry the two ideas of patient-centered care and ideal outcomes for patients (Charon, 2001; Gross et al., 1998; Cepeda, et al., 2008; Arntfield et al., 2013)

Students will also benefit in that they will have the opportunity to interact with vulnerable populations almost exclusively in the SRC. They will better understand this population, be able to form connections with them, refine their skills taught in practical classes, and be able to carry forward this experience to their future practice with a more empathetic approach. Furthermore, current healthcare professionals lack a strong sense of what their other colleagues scope of practice is, which potentially can lead to confusion and lack of proper referrals (Curren et al., 2008). As such, students from the various fields will be able to witness and discuss cases with each other, fostering positive attitudes to colleagues from these fields that will hopefully carry forward into their careers. Coincidentally, student-run clinics also improve interest in primary care for medical students, where interdisciplinary care of patients is essentially required (Shabbir & Santos., 2015).

An already clogged and overworked healthcare system benefits from the SRC model as well, as this holistic approach could keep patients out of emergency departments and avoid preventable hospital admissions (Thakkar et al., 2019, Kramer et al., 2015; Stuhlmiller and Tolchard, 2015; Arenas et al., 2017; Trumbo et al., 2018). Especially with having the multidisciplinary function, SRC’s  will improve the quality of care and allow the clinic to tackle multiple issues at once. The SRC at theUniversity of New England in Australia,for example, has managed to save the health system an estimated $430,000 in their first year of operation (Stuhlmiller and Tolchard, 2015). Another SRC situated in Philadelphia managed to save an estimated $850,000 with an operating budget of only $50,000 (Arenas et. al., 2017). 

With strong evidence for the benefits of SRC’s, , the primary focus moving forward , is to assess the need and feasibility for this multidisciplinary approach in Kingston, Ontario., to ensure that patients indeed desire and will utilize these services for maximum benefit.

Updates regarding the first Student Run Clinic in Kingston:
Despite the proven benefits of opening a SRC to the community, students and the system, our team was faced with numerous challenges when pioneering the first SRC in Kingston.

Firstly, finding the support of faculty and staff was challenging in the beginning phases of this initiative. As any novel idea, which is filled with uncertainty and more questions than answers, there was initial hesitation to support our proposal. However, throughout the past 6 months and many meetings, we were able to finally secure the support of the Office of Undergraduate Medical Education, and Inter-professional offices of Nursing, Occupational Therapy and Physical Therapy at Queen’s University. Following a landmark meeting in October of 2019, the leadership of these programs agreed on the value of opening such a clinic in Kingston. However, it was also agreed that numerous challenges have to be overcome first before QMedCare - Student Run Clinic can be launched. 

One of the challenges outlined was defining the scope of responsibility of medical and allied health students. It was discussed at the meeting with faculty leaders that medical students would have the same scope of responsibility as during regular curricular observerships, with the duty of care ultimately on the supervising physician. This is the same structure of operations of other Canadian and American SRCs, and it makes sense. Pre-clerkship students lack the necessary knowledge and training and should be supervised at all times. The case is similar for interprofessional students, where a licensed allied health professional will have to supervise students and the duty of care will be ultimately on him/her. 
Another challenge discussed was establishing the continuity of the QMedCare SRC, not just at the intra-departmental level, but also at the inter-departmental. In medicine, QMedCare was recently approved by the Aesculapian Society as an official student interest group, which provides us with logistical support and financial backing of a larger organization necessary for the clinic to begin and continue its operations.  Our team will soon begin the recruitment and training of next year’s executive council to further establish continuity. Recruiting students from the next cohort is essential, as they will be able to learn from the current council this year, and take over the leadership during the 2020/2021 school year. In terms of continuity in inter-professional departments, we were able to recruit two representatives from the schools of nursing, occupational therapy, and physiotherapy and we will be discussing with them how they see establishing continuity of operations in their departments. 

Our team was very fortunate to find great support in our initiative from other Canadian SRCs. We had in-depth conversations with the IMAGINE clinic in Toronto and SWITCH clinic in Saskatchewan, who guided us throughout the start-up process, answered our questions and shared their experiences with us. Recently, we have joined the Canadian Student Run Clinic Association (SRCA), which governs and provides logistical support to SRCs. QMedCare will be sending its delegates to the SRCA Summit in Toronto on November 30th, 2019. 

Furthermore, we are very thankful to Dr. Meredith MacKenzie, Carol Lynch (NP), and the Street Health Centre (SHC, 115 Barack Street) who generously offered us training, supervision and clinic space. Without their ongoing support our initiative would not be possible. They have offered to host our clinic at SHC, under their supervision, every Tuesday from 5-9pm. We are so thankful for their generosity. 
As our team grew and became increasingly inter-professional, Valera - the founder and executive director of QMedCare, decided to rename the SRC to be more inclusive of our inter-professional colleagues. As this initiative was pioneered by Queen’s Medicine students, QMedCare was a great initial name of the initiative. However, as our team welcomed inter-professional members, it was an executive decision to rename the SRC for every team member to feel welcome and included. The new name of the clinic has not been decided yet, as we want to make it a collaborative decision with the input of all inter-professional members - which will likely occur at an upcoming meeting in November. 
Overall, our team was able to achieve great progress in a very short span of time and we are very proud of the work that we have done and continue to do. From securing faculty approval and support, supervision, clinic space and inter-professional collaboration, we came a long way from just “Valera’s dream”.

Conclusion
Regardless of the challenges, as future healthcare leaders we are obliged to do what is best for our community, patients, and colleagues, and therefore, we will work hard and do what is in our capacity to establish the first SRC in Kingston. Having talked to many other Canadian SRCs, every clinic had challenges when they first started. In many cases, it took years for their respective clinics to open. After all, Rome was not built in a day. 

We have heard from our colleagues that medical students at the Schulich School of Medicine at Western University have also recently brought the proposal of opening a SRC to help their community. This is very inspiring to see, as in the background of ongoing cuts to healthcare, medical students across Canada are striving to open pro-bono health-clinics to help the underserved and marginalized populations.  

Let’s contribute to healthcare growth together. Let's open the first student run clinic in Kingston! ​

References:
Pan-Canadian Health Inequalities Reporting Initiative. “Key Health Inequalities in Canada: A National Portrait – Executive Summary”. Public Health Agency of Canada. 2018 May 28.
Charon R. “Narrative medicine: a model for empathy, reflection, profession, and trust”. Jama. 2001 Oct 17;286(15):1897-902. 
Gross D, Zyzanski SB, Cebul R, Stange K. (1998). “Patient satisfaction with time spent with their physician”. J Fam Pract. 1998;47(2), 133 
Cepeda M, Chapman R., Miranda N, Sanchez R., Rodriguez C, Restrepo A, ... Carr DB. “Emotional disclosure through patient narrative may improve pain and well-being: results of a randomized controlled trial in patients with cancer pain”. J. Pain Symptom Manage. 2008; 35(6), 623-631. 
Arntfield SL, Slesar K, Dickson J, Charon R. “Narrative medicine as a means of training medical students toward residency competencies”. Patient education and counseling. 2013 Jun 30;91(3):280-6. 
Curran, V. R., Sharpe, D., Forristall, J., & Flynn, K. (2008). “Attitudes of health sciences students towards interprofessional teamwork and education”. Learning in Health and Social Care, 7(3), 146-156.
Shabbir SH, Santos MT. “The role of prehealth student volunteers at a student-run free clinic in New York, United States”. Journal of educational evaluation for health professions. 2015;12.
Thakkar A , Chandrashekar P, Wang W, Blanchfield BB. “Impact of a Student-Run Clinic on Emergency Department Utilization”. Fam Med. 2019;51(5):420-423. https://doi.org/10.22454/FamMed.2019.477798.
Kramer, Nick, Jaden Harris, and Roger Zoorob. “The Impact of a Student-Run Free Clinic on Reducing Excess Emergency Department Visits”. Journal of Student-Run Clinics 1.1 (2015). 
Stuhlmiller, Cynthia M., and Barry Tolchard. “Developing a student-led health and wellbeing clinic in an underserved community: collaborative learning, health outcomes and cost savings.” BMC nursing 14.1 (2015): 32. 
Arenas, Daniel J, et al. "A Monte Carlo simulation approach for estimating the health and economic impact of interventions provided at a student-run clinic." PloS one 12.12 (2017): e0189718. 
Trumbo, Silas P., et al. "The Effect of a Student-Run Free Clinic on Hospital Utilization." Journal of 
health care for the poor and underserved 29.2 (2018): 701-710.