The Robert R. Frank Student-Run Free Clinic: Cultivating Clinical Skills at Wayne State University School of Medicine
At Wayne State University School of Medicine (WSU SOM), the Robert R. Frank Student-Run Free Clinic (SRFC) serves as a valuable platform for preclinical students to acquire clinical experience. Student-Run Free Clinics (SRFCs) are service-learning, student-driven outreach projects across various disciplines, all aimed at enhancing community health and well-being. Understanding the impact of such clinics on medical student development is crucial, especially considering the increasing number of SRFCs nationwide.
The Robert R. Frank Student-Run Free Clinic
Wayne State University School of Medicine (WSU SOM) in Detroit, Michigan, established the Robert R. Frank Student-Run Free Clinic in 2010. This clinic offers primary care services to the uninsured and underserved populations. Medical students at all levels of training administer the clinic, with supervision from attending physicians. The roles of students are diverse, encompassing primary care, social work, patient education, laboratory services, front desk management, and pharmacy operations.
Volunteer recruitment for the SRFC at WSU SOM commences at the beginning of each school year during the medical school’s organization fair. Students receive information about all volunteer opportunities and student organizations. Within the clinic, a primary care team consists of an upperclassman (Year 3 or 4) paired with an underclassman (Year 1 or 2). This team is responsible for interviewing patients and conducting physical examinations. Subsequently, the team presents the patient to the attending physician for discussion, after which the team, along with the attending physician, concludes the visit with the patient. For further management, patients can access in-house laboratory, pharmacy, social work services, or patient education, all managed by student volunteers. Each volunteer documents patient encounters in the clinic’s electronic medical records.
Study Design and Methods
A study was conducted to determine if volunteering at a SRFC in the preclinical years of medical school training impacts clinical skill development. The study aimed to specifically measure three related but distinct aspects of clinical skills: self-confidence, self-reflection, and professionalism using validated instruments. The study was approved by the Institutional Review Board (IRB) at WSU.
Four anonymous surveys were distributed to all Year 1 students enrolled in WSU SOM at the beginning (August 2011) and end (April 2012) of the school year: the Experience Questionnaire, Confidence Survey, Groningen Reflection Ability Scale (GRAS), and Pharmacy Professionalism Instrument (PPI). The Experience Questionnaire collected demographic information, baseline clinical experience prior to medical school, and clinical experience at the end of Year 1, including SRFC volunteerism. The Confidence Survey assessed clinical confidence on a 5-point Likert scale, with 20 items related to skills tested on the Year 1 OSCE and 4 specific to SRFC skills. The GRAS, validated on first-year medical students, measured self-reflection ability using 23 items on a 5-point Likert scale. The PPI, a 32-item self-assessment tool, evaluated professionalism.
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Clinical skills were also measured at the end of Year 1 using the OSCE, based on the SEGUE framework. Each student completed a simulated patient encounter with a standardized patient.
Responses from all surveys were analyzed quantitatively using IBM SPSS Statistics 19. Results of the Experience Questionnaire were used to divide subjects into two groups by SRFC volunteerism (volunteered at least once during Year 1 or did not volunteer at all during Year 1). For the Confidence Survey, GRAS, and PPI, total scores were calculated in each subject. Then mean and standard error of total scores within each group were calculated. A multivariate analysis of variance (MANOVA) was conducted to compare mean scores in self-confidence, ability to self-reflect, and professionalism (dependent variables) based on group (SRFC volunteer vs. non-volunteer) and time (beginning vs. end-of-year). Year 1 OSCE scores were also analyzed quantitatively. Mean score and standard error were calculated for each group (SRFC volunteer vs. non-volunteer). An independent-samples t-test was used to compare mean scores between groups. The frequency of students establishing each of the 3 levels of rapport was identified, and those frequencies were compared between the two groups using a Fischer’s exact test.
Survey Response Rates and Demographics
At the beginning of Year 1, 206 out of 302 first-year medical students (68.2%) responded to the surveys. The respondents included 94 (45.4%) male and 112 (54.6%) female students, with an average age of 23.6 years. At this time, no Year 1 students had volunteered at SRFC.
At the end of Year 1, 80 students (26.5%) completed the surveys, including 49 (61%) males and 31 (39%) females with an average age of 25.3 years. Of these 80 respondents, 49 (61.3%) had not volunteered at SRFC during Year 1, while 31 (38.7%) had volunteered at least once.
Impact on Clinical Skill Development
The analysis of the Confidence Survey was broken down into total score and score of the questions that pertains to SRFC. For the overall score of the Confidence Survey, statistically significant differences were found based on time (beginning vs. end-of-year; p < 0.001), but not based on group (SRFC volunteer vs. non-volunteer; p = 0.544). When looking only at the items on the Confidence Survey that pertain to the SRFC, there was no statistical difference between time (beginning vs. end of the year; p = 0.064), but the difference between groups (SRFC volunteer vs. non-volunteer) was statistically significant (p = 0.032). This indicated that those who volunteered at the SRFC scored higher at both the beginning and end of the year compared to non-volunteers. For the GRAS, comparisons in time (beginning vs. end of the year; p = 0.534) and between groups (SRFC volunteers vs. non-volunteers; p = 0.749) were not statistically significant.
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All 302 first year medical students participated in the Year 1 OSCE, 275 (91%) of which did not volunteer at SRFC and 27 (9%) of which volunteered at SRFC at least once. The average OSCE score of non-volunteers was was 92.6% while that of SRFC volunteers was 92.7% (p = 0.888). The number of subjects establishing a rapport level of 0 was 2; both subjects were non-volunteers (0.7%). The number of subjects establishing rapport level 1 was 41 (15%) within non-volunteers and 2 (7.4%) in SRFC volunteers. The rest of the subjects, 232 (84.4%) of the non-volunteers and 25 (92.6%) of the SRFC volunteers, established rapport level 2.
Benefits of Early Clinical Exposure
The transition from preclinical to clinical years of medical school can be a stressful period. Students are expected to quickly adapt to the hospital environment while applying their basic science knowledge to patient care. Early clinical exposure during preclinical years can be advantageous in building self-confidence for the clinical years.
Furthermore, clinical exposure enhances the ability to self-reflect, which is crucial for identifying areas for improvement, integrating new knowledge, and establishing a professional identity. Professionalism, often considered an elusive concept, can be shaped through exposure to clinical settings, allowing students to develop their own understanding. These skills are essential for becoming a competent physician.
Discussion of Findings
This study examined self-confidence, self-reflection, and professionalism at the beginning and end of Year 1 in SRFC volunteers and non-volunteers. Statistically significant differences were observed only in the Confidence Survey, indicating an overall improvement in clinical confidence during Year 1. When focusing on clinical skills specifically practiced at SRFC, volunteers demonstrated greater self-confidence than non-volunteers at both time points.
The analysis of other surveys and Year 1 OSCE scores did not reveal any statistically significant findings. This may suggest that individuals with a strong sense of self-reflection and professionalism are more inclined to pursue a career in medicine. The high performance on OSCE scores, regardless of SRFC volunteerism, indicates a generally high level of clinical competence among students.
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Limitations
The study encountered several limitations. The sample sizes varied between the two survey time points and the OSCE, with significantly lower participation at the end of the school year. Furthermore, there was a disproportionate representation of SRFC volunteers in the end-of-year surveys, suggesting a higher motivation among volunteers to participate.
The PPI used was validated only for pharmacy students, as no specific surveys exist for medical students. Although the tenets of professionalism in the PPI were applicable to medical students, future studies should employ scales specifically validated for this population.
The high performance of WSU SOM students on the Year 1 OSCE made it challenging to draw meaningful conclusions from the analysis of OSCE scores. Differences might have been more evident if the patient encounter was modeled after the SRFC setting. The subjective scoring system for rapport building on the OSCE also posed a limitation.
Lastly, various confounding variables, such as prior clinical experience or volunteering at other clinics, could have influenced the study outcomes.
tags: #wasu #medical #school #student #run #clinic
