Medical students who work at the Stout Street Clinic in Denver, Colorado, often come away from their experience surprised at how dramatically they have been affected. One student who recently worked at the clinic for a 6-week rotation, noted afterwards that among her many reasons for coming to Stout Street were to see interesting pathology and learn more academic medicine—both of which she did. Her surprise came when she also learned a lot about life. Students are often changed in unexpected, profound, and lasting ways after experiencing first-hand health care delivery to the poor, underserved, and marginalized.
The Stout Street Clinic (SSC) of the Colorado Coalition for the Homeless (CCH) has been operating in Denver for 20 years. I was drawn to working there in 1994 because it was a clinic that did more than treat homeless clients with GABHS (group A beta-hemolytic streptococcal) pharyngitis with penicillin; the staff actually delved into the deeper dilemmas affecting their clients and tried to solve them. Common problems of clinic visitors include domestic violence, mental health issues, substance use, and lack of access to jobs, housing, and health care. The clinic itself and CCH provide an array of resources that includes medical and mental health services, substance use treatment, community outreach, and housing for homeless clients. In 2004, 8877 individuals were served at SSC, and there were 29 497 client encounters.
For the last 14 years the medical students at the University of Colorado Health Sciences Center have operated a Saturday clinic at SSC as part of an elective medical course. The student-run clinic is open 24 Saturdays per year and is supervised by an on-site, volunteer, attending physician. The clinic provides weekend services for working and nonworking homeless clients.
SSC is run by first- and second-year medical students, with the participation of third- and fourth-year students. Every year approximately 40 students participate in 4 teams of 10. Each team is in charge of the clinic 6 times per year. A 6- to 8-person medical student steering committee oversees recruitment of students for the operation of the clinic. In September, the steering committee, in conjunction with SSC provider staff, holds an orientation evening at the clinic. During the orientation, all new students get acquainted with the training areas, including front desk, SOAP (subjective, objective, assessment, plan) chart notes, laboratory, and treatment room. This whirlwind orientation of mostly "shell-shocked" first-year students gives them a taste of what to expect when they are thrown into the clinic setting a few weeks later.
Fortunately, there are experienced second-year students at the clinic each Saturday, and a comprehensive orientation manual serves as a guide for specifics that may have been covered during orientation but not remembered. Furthermore, one of the clinic health care professionals is on-call for the harder questions. These range from the mundane, such as where to find a cab voucher for a homeless family who needs a ride to a distant motel, to the critical, such as how to arrange a mental health hold for a severely depressed, psychotic client.
Students gain experience in various areas of clinic operations by working at the front desk and in the lab or treatment room and by seeing patients. Patients appreciate the extra attention of multiple physicians-in-training all coming together with the attending physician to deliver personalized care.
Students who work at SSC almost always have a paradigm-shattering experience about who the homeless are and how they got there. The stereotypic image of skid-row alcoholics just doesn't fit the children, the woman fleeing domestic violence, the client with severe depression and limited or no access to mental health care, or the client with a methamphetamine addiction, a shooter's abscess, and no treatment program that will admit him. When a student does meet a person who seems to fit into society's caricature of the homeless and comes to know him or her and how he or she became homeless, the student is changed. Serving in the Saturday clinic teaches many students that even chronically homeless men and women with alcohol dependence are no different—underneath their layers of indescribably hard knocks, too much alcohol, and too little love—than you, me, and the rest of humanity.
Students also come face-to-face with the deleterious impact that our inadequate health care system has on people without health insurance or without access to health care, a perspective they may not gain through traditional medical education. They see, directly, the reality of the recent Institute of Medicine report that at least 18 000 people die per year because of their lack of health care . When medical students learn that more than 700 000 Coloradans lack health care, they understand that this statistic metes out personally negative consequences for people with whom they have met and for whom they have cared. Students also see first-hand the many factors that can cause homelessness and affect health negatively, such as lack of affordable housing, jobs that do not provide a living wage, domestic violence, and other social circumstances.
Many times I have heard from former medical students that their Stout Street Clinic experience inspired them to work with indigent populations full-time, to volunteer regularly in a clinic, or to treat patients regardless of their financial status. The experience frequently does much more than just motivate medical students to deliver charity care—it inspires them to work for justice in the health care system and instills within them the notion that those who are homeless and disenfranchised have as much right to high quality, compassionate, and comprehensive health care as anyone else.
One memory in particular remains fresh for me, even though it is from 8 years ago. I was calling a local emergency room, spinning my usual tale of advocacy for a homeless gentleman without insurance or a payer source. "Lowell" had severe lower extremity stasis dermatitis with a secondary infection, and discharging him to the streets would not allow him to get better. The emergency room doctor interrupted early on and said, "Oh, don't worry—I worked at Stout Street Clinic as a medical student. We'll definitely admit him and I'll make sure the inpatient team is aware of Lowell's circumstances." Clearly, medical students' perspectives and horizons are widened in life-changing and career-changing ways, when they have the benefit of working in a clinic that serves disadvantaged populations.
Institute of Medicine. Coverage Matters. Insurance and Health Care.Washington, DC: National Academy Press; 2001.