American College of Physicians: Internal Medicine — Doctors for Adults ®

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Why you should consider doing community service

Free clinics offer residents a first-hand look at 'real' medicine

From the November 1996 ACP Observer, copyright 1996 by the American College of Physicians.

By Christine Wiebe

From Los Angeles to Baltimore, a growing number of residents have discovered a way to expand their clinical skills and recapture some of the idealism that first drew them to medicine, one that has proven so successful that medical educators are looking for ways to get more housestaff interested.

These residents have latched onto the notion of community service and are volunteering their time and expertise in community clinics to help the nation's underserved. By making community service a part of their already overscheduled lives, they say they are reaping the benefits of helping others.

"Leaving the hospital at 6 and then going to the free clinic can be exhausting," said Susan H. Thompson, ACP Associate and chief resident in internal medicine at Georgetown University Hospital, "but once you get there the patients are so appreciative that it's very gratifying." Dr. Thompson, who is a member of ACP's Council of Associates, has worked as a volunteer throughout medical training, from starting a free clinic as a medical student in Chicago to working at a similar clinic in Washington, D.C.

She said that volunteering her time and effort has provided more than personal satisfaction. "It's more like real medicine than what we see in tertiary care academic medical centers," Dr. Thompson explained. That is part of the reason she thinks more students and residents should get involved. "I think it's essential in training," she said.

Internal medicine's leaders agree. The Residency Review Committee's special requirements state that residents should be encouraged to participate in community service and that training programs should create an environment that supports such activities. And to further encourage resident involvement in community service, ACP's Council of Associates recently launched its Community Service Initiative. The Council is conducting a survey to identify residents who provide community services and has created a recognition program to honor housestaff involved in community service. The first residents will be honored at Annual Session in Philadelphia in March.

For now, however, the move to community service is still a small one. A recent American Board of Internal Medicine (ABIM) survey, for example, found that only 35% of training programs comply with the RRC's community service requirement, according to Linda Blank, the ABIM's vice president for clinical competence and communications. While some leaders were satisfied with that level of involvement, Ms. Blank said that others are pushing for stronger requirements. "I think there's an opportunity to raise that bar a little bit," she said.

Should it be required?

Ms. Blank noted that the RRC may strengthen its language to get even more residents involved in community service, but it raises a thorny question about whether housestaff should be required to do what has traditionally been volunteer work. Residents currently involved in community service include both those who volunteer their time and those who are required to do rotations at urban clinics, according to responses to the ABIM survey.

"I think it should be encouraged but not required, because that takes away from the whole idea of community service," explained Richard E. Scranton, ACP Associate, a third-year resident at Naval Hospital in Portsmouth, Va., and a member of ACP's Council of Associates. He chooses to do non-medical volunteer work like building homes for the poor, primarily through his church, and insists that the spirit of volunteerism is an essential component of community service.

At the same time, however, Dr. Scranton acknowledges that requiring rotations in community clinics for the poor might make residents more likely to volunteer on their own time. Practicing physicians are expected to contribute to the community, he argues, and such assignments would help housestaff get involved. Furthermore, such experiences would bolster efforts to produce more "complete" physicians, said Dr. Scranton.

Residency leaders at Union Memorial Hospital in Baltimore have opted for the mandatory approach and send housestaff to work at Shepherd's Clinic, which provides care for the working poor. The clinic is run by retired volunteer physicians and has only one part-time employee. "Our residents really provide a lot of the manpower," said Robert P. Ferguson, FACP, Union Memorial's program director for internal medicine.

While Dr. Ferguson admits that the third-year residents who do a one-month mandatory rotation at the clinic cannot be called volunteers, he said that they get the same benefits as volunteers and still fill a real community need. "I think it's been good for both," he said. "It gives our residents some good community primary care experience." The older physician volunteers also serve as good role models for the residents, he said.

Arvinder Bains, MD, who recently finished a rotation at Shepherd's Clinic, said she found the work challenging and fulfilling. "You have to depend more on your clinical skills," she said, because expensive diagnostic tests and medications are not readily available. Patients were very thankful, she explained, and she said the experience will make her more likely to do volunteer work in the future.

The voluntary path

But some programs have found it difficult to incorporate such experiences into formal training and have instead made volunteer opportunities readily available. Ed Eckenfels, MD, tried to integrate community service into the curriculum at Rush Medical School, where he serves as associate chair of the department of preventive medicine. But he encountered so much "red tape" that the Rush Community Service Initiatives Program has remained voluntary. Even so, he said it has attracted about 60% of the medical school's students, as well as residents and attending physicians.

The program got its start several years ago when a group of medical students that included Dr. Thompson set up their own free clinic in Chicago. Today, it allows students to volunteer at 12 different projects that range from infant to elderly care.

The fact that students receive no credit or compensation is significant, Dr. Eckenfels said, "because this is an act of commitment on their part; this is why they want to be doctors in the first place."

That's what inspired Scott Metzger, MD, to volunteer his time to work on a suicide hotline throughout medical school. "I had some calls where I really felt like I made a difference by the end," Dr. Metzger said. "It was a really powerful thing to know that you could help someone go from despair to knowing that things aren't as bad as they thought." Even now, as a fellow in pain management at Johns Hopkins University in Baltimore, Dr. Metzger continues to work in the community tutoring special-needs children. "There's so much reward from getting involved that I've always felt good about it," he said.

And the satisfaction of helping others may be one of the most potent benefits of getting involved in community service, according to Mohan Nadkarni, ACP Member, clinical assistant professor of internal medicine at the University of Virginia. As a resident, Dr. Nadkarni helped start a free clinic in Charlottesville; he still works there as a volunteer. "Spending just an hour per week can really open your eyes to what service is about," Dr. Nadkarni said. "Often that can replenish some of the initial motivations for going into medicine in the first place."

Christine Wiebe, of Providence, Utah, writes frequently on issues related to medical residency.

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