Care for the Underserved, Interprofessional Learning Focus of Student-run Clinic

For more than two months, medical and nursing students from Case Western Reserve University, or CWRU, in Cleveland have been training together as they provide primary care at a student-run clinic for the city's underserved. Supervised primarily by family physicians, the interprofessional teams participating in this pilot manage all aspects of patient care, from preliminary intake and assessment of vitals to clinical evaluation and plan of care.

The CWRU Student-run Free Clinic, which is scheduled to open officially in October, is one component of an interprofessional learning initiative aimed at bringing together students from the CWRU School of Medicine and Frances Payne Bolton School of Nursing to learn to work as health care partners for patients. These future physicians and nurses have the opportunity to collaborate not only in clinical care but also in the daily management and administration of a community clinic.

Organized as part of a vision to increase access to care for the underserved in Cleveland, the clinic represents a collaboration with The Free Medical Clinic of Greater Cleveland, which has a nearly 40-year history of serving as a critical health safety net for patients in Cleveland. The clinic is designed to be self-sustaining, and participating students raise money themselves for operating expenses.

"There's a lot of energy among the students," said George Kikano, M.D., chairman of the family medicine department. "The idea is that the medical and nursing students learn together."

Tammy Wang, a third-year medical student and one of the four founders of the clinic, told AAFP News Now that the clinic's founders -- two medical students and two nursing students -- received encouragement from both the medical school and the nursing school. Working together for more than a year, the student founders set up the clinic's organizational structure.

For patient care, a medical student and a nursing student are paired as a team. The team performs patient histories and physical exams, presents findings to attending preceptors, usually family physicians, and discusses appropriate plans of care, including medications and connections to community resources.

The collaboration continues outside of the clinic sessions, with medical and nursing students working together to plan all logistics for the clinic. The clinic's board of directors, in fact, is made up of seven medical students and four nursing students.

It is anticipated that both CWRU medical and nursing students will acquire team-building skills as they voluntarily participate in the student-run free clinic, according to Wanda Cruz-Knight, M.D., who is an assistant professor in the medical school's family medicine department, director of the school's predoctoral program and faculty adviser to students in the clinic.

And, she added, the fact that the clinic is being managed by the medical and nursing students allows them to incorporate aspects of business, office practice and clinical models they've identified as being effective.

"Working with nursing students has absolutely been a valuable experience," Wang said. "Though we have differences in our training, our skills can still complement one another to provide more comprehensive patient care.

"Working together at this point in our education builds mutual respect and effective communication skills for two disciplines that traditionally may have held some biases toward one another," Wang added.

Nicholas Kucher, a first-year medical student, leader of the campus family medicine interest group and volunteer coordinator of the clinic, agreed. "We're all learning as we go, but working with each other is key, because there is so much to coordinate and new issues are popping up," said.

"The key point that we want participants to take away is that medicine is no longer centered around someone with an M.D. It is centered around the patient, and different perspectives and training, such as with nurse practitioners, are important in providing the best possible treatment," Kucher added.

Alyssa Wagner, a first-year nursing student and a clinic director, told AAFP News Now that nursing students also gain special knowledge from the collaboration.

"The nursing students get to learn more about differential diagnoses, we both (medical and nursing students) get to work on our assessment skills, and the medical students get to participate in patient education. We get to use the strengths from each of our fields to provide the best care we can for our patients," she said.

After each of the clinic sessions during the recently completed pilot, the medical and nursing students met to discuss what went well, what didn't and what could be improved. They're using the results of this exercise to design a patient satisfaction and well-being survey that will set measures for future quality assessment and improvement activities.

CWRU's collaborative learning initiative offers a real-world model of recommendations in the Joint Principles for the Medical Education of Physicians as Preparation for Practice in the Patient-Centered Medical Home (12-page PDF; About PDFs) issued by the AAFP and other primary care groups last December.

Promulgated as a guide to the education of physicians in the context of a reformed health care environment that will rely heavily on primary care, the principles say, for example, that medical students should learn to work effectively with others as a member or leader of a health care team. Students also should be able to articulate the roles, functions and working relationships of all members of the team and apply knowledge of leadership development, quality improvement, change management and conflict management.

AAFP Vice President for Education Perry Pugno, M.D., M.P.H., who helped develop the joint principles, praised the CWRU initiative as embodying many of the concepts on which those principles were founded.

"This program is a prime example of what we hoped to accomplish in the creation of the new joint principles -- namely, an immersion experience for health professions students in actually delivering patient care in a highly functional interdisciplinary setting," Pugno told AAFP News Now. "This isn't just book learning; it's pragmatic hands-on learning."

And the learning continues.

Wang said the students presently are analyzing data from the four pilot clinic sessions, which provided care to more than 50 patients, and considering strategies to improve clinical care. Possible future directions include the incorporation of additional professional schools to provide patients with even more resources, she said.