In health care, as in all professions, there are many ways to learn. Students in medicine, nursing, pharmacy, physical therapy and other areas spend plenty of time burying their heads in books, scribbling lecture notes and asking questions of their instructors well before they put their acquired skills to the test with a patient encounter or a clinical test.
Rarer is the opportunity to take on the challenges of delivering health care in a bustling clinic while juggling schedules, triaging patients and collaborating with colleagues in different professions. Rarer still is the chance to serve patients with the greatest need for medical care and assistance overcoming barriers to meeting that need: the uninsured.
But that’s exactly what happens each Tuesday night in a brick storefront facility in downtown Aurora. There, dozens of students from the University of Colorado health sciences schools volunteer their time for the DAWN (Dedicated to Aurora’s Wellness and Needs) Clinic. Opened two years ago with support from the health sciences schools and UCHealth University of Colorado Hospital, the clinic has expanded its capacity while continuing to see patients with diabetes, hypertension, acid reflux, chronic pain and a wide variety of other issues, many of them on a regular basis.
Both the university and UCH remain committed to supporting and contributing to the clinic’s fundraising efforts. Preceptors from the university – licensed health professionals with faculty or clinical appointments – offer guidance to the students with patient care, and the hospital provides additional clinical support. Jeff Thompson, vice president of government and corporate affairs for UCHealth, serves on the clinic’s executive steering committee.
“We have a close relationship and partnership with the DAWN Clinic,” said Keith Peterson, director of Community Benefit for UCHealth. The clinic’s work helps the hospital to build stronger ties to the community, Peterson noted. In addition, the students provide basic services that help prevent unnecessary emergency department visits and hospitalizations. The clinic also serves as a referral source for the hospital for patients who lack insurance coverage.
Student volunteers form the backbone of the clinic, as was evident on a recent Tuesday afternoon. They began gathering at the Dayton Street Opportunity Center, a facility that offers a variety of resources for Aurora residents, well before patients arrived for appointments that begin at 5:30 p.m. It’s an unassuming setting that includes six exam rooms, up from the three available two years ago. An open seating area serves as the waiting room near tables where students handle triage and take patients’ vital signs.
The clinic schedules in advance repeat and follow-up patients. The routine includes check-in at a table set up near the door, triage, an examination and basic medical care. A care coordinator meets with them to identify other needs that can affect their health – food, housing, transportation, and so on – and point them to available resources.
Before any of this happens, planning for the evening begins. In a conference room behind the seating and triage areas, clinic directors, managers and preceptors go over summaries of the scheduled patients to prepare for their visits and identify resources they might need.
Go with the flow
But as in any clinic, the nights rarely if ever go exactly as planned, noted Miles Viseur, a second-year med school student. Viseur began working in the DAWN Clinic as an interpreter; he’s now a student director, working with the clinic’s teams to meet their needs and keep patient flow moving as smoothly as possible.
“There are still a fair amount of no-shows,” Viseur said. “We balance that with walk-ins; we may see three to eight a night.”
The no-shows and walk-ins are wild cards that make for unpredictability and can increase patient wait times, Viseur said. The clinic’s additional capacity has increased the challenge. In 2015, the students typically saw eight or nine patients a night, he said. With the additional exam rooms, the number is 18 to 22.
That makes for an operational challenge, but large numbers of volunteers have stepped forward for training that includes learning to use an electronic health record, preparing for a patient encounter and learning to discreetly solicit health information from patients in interviews. Viseur estimated that two-thirds of his class of 184 signed up to volunteer in the clinic. Aster Degu, a second-year physical therapy student, said about half of her class 68 are “very involved.” (Physical therapy students see patients in the DAWN Clinic on Wednesday nights.)
Ready for action
Shortly before the clinic begins business, the back area hums with activity as volunteers arrive and await their assignments. It’s a mix of planning, socializing and networking that reflects another important feature of the DAWN Clinic. Medical, nursing, pharmacy, and public health students not only freely mingle, they learn to work together to meet patients’ needs.
“Interprofessional care is one of the things that sets DAWN apart,” Viseur said. “I’ve learned from other students. Med school is almost all lectures, so it’s nice to be able to see how different skills are applied to real patients.”
This night’s real patients are waiting, so student director Rachel Ancar, a med student working on her PhD, calls for the volunteers’ attention. Second-year med student Rachel Pauley heads to the triage tables, her assignment for the night.
Ancar briefly explains how to set up a patient encounter and reminds the volunteers to assess each patient’s risk. She also outlines for the preceptor physicians the process for recording and prescribing medications in the DAWN clinic’s electronic system. A volunteer then describes the challenges of meeting the medical and social needs of a patient with COPD. A colleague listening says the case is a reminder that patients’ problems often persist and may even worsen despite their providers’ best efforts to develop a care plan.
“Everything can change,” he said.
That’s especially true among the patients that DAWN serves, said volunteer Belinda Enriquez, who earned her master’s degree in toxicology last December and is now on a pre-med track. They are, by definition, underserved. They lack not only medical and behavioral health care but in many cases basic necessities like food, clothes, housing and physical security.
“We have to be aware of the social determinants of health,” said Enriquez, who worked in a free clinic as an undergraduate at the University of California San Diego before joining the DAWN Clinic as an interpreter. “It’s important for us to be culturally competent and conscious of the disparities in the community.”
Help close to home
The clinic’s work falls close to home for Degu, the physical therapy student, who graduated from nearby Aurora Central High School and has volunteered at DAWN for a year. Her parents are refugees from Ethiopia.
“I could relate to the patients,” she said. During a Wednesday night clinic session, she typically spends an hour with each patient. “There is less awareness [among them] of physical therapy,” she said. “I’m passionate about it. I’m able to help get them active and healthy and back to work and the activities of daily living.”
A key clinic aim is to establish the trust with patients that will encourage them to return regularly to the clinic and learn to manage their own care. That heightens the importance of tightening the clinic’s workflows and minimizing wait times. As Enriquez put it, “Many of our patients believe this is the only place they can stop for care. We feel the responsibility to them.”
In the clinic on this night is a man who offers a vivid example of how important the clinic can be to its patients and the community. A year and a half ago, Pancho Bustamante, 45, was close to death. He suffered from severe liver disease, the result of heavy drinking over a period of years. Describing his then-bloated condition, he extends his arms over his stomach as a pregnant woman would.
Bustamante’s body had few reserves, said Brett Friedman, a DAWN volunteer and student with the Colorado School of Public Health. “He was emaciated, skin and bones,” said Friedman, who was part of the care team, including DAWN Clinic medical director Joseph Johnson, MD, who helped Bustamante get on a road they hoped would lead to recovery.
A pair of hospitalizations at UCH left Bustamante with a stark choice. An ultrasound revealed the severe damage to his liver. “The doctor gave me two choices,” he said in Spanish as Friedman and volunteer Diana Merjil interpreted. “I could die or live life.”
In an exam room, Bustamante speaks with second-year med student Hieu Duong while nursing student Monica Mana documents the encounter on a laptop. Duong asks about his medications and pain in his abdomen. He says he still feels a little bit of discomfort, but he pulls up his shirt to show that his stomach is mostly flat. He’s alert and articulate. For a time, he said, he couldn’t lift much weight and detailed cars to earn some money to pay for his medications. Now, however, he can lift more and has gotten regular maintenance work, he added.
“I’m getting stronger, gaining muscle,” Bustamante tells Duong as she examines him.
Friedman notes that the DAWN Clinic helped to stabilize Bustamante’s life by assisting him with getting food and medications. Establishing trust with him was just as crucial, Friedman added. “We showed him we cared, that we could help with more than just giving him a pill.”
But to recover, Bustamante had to take responsibility for his own health. He said he stopped drinking well over a year ago, drawing a smile and two thumbs up from Duong.
Friedman and Johnson “gave me energy to live,” Bustamante said. “I realized the seriousness. I chose for my family to watch out for myself. You have to fight for your life. Nothing is free.” Several times during the conversation he credits God for his retreat from death.
After Duong and Mana finish, care coordinator Beatrice Guillermo comes in the room and converses with Bustamante in Spanish about additional help the clinic might provide. She can refer him to the School of Dental Medicine on the University of Colorado Anschutz Medical Campus, which provides services to underserved patients at discounted rates – and sometimes for free.
“Whatever they tell me, I follow,” Bustamante says before the clinic’s medical team comes in for a final consult. “They pay attention to you if you need something.”
Not many patients have as dramatic a story as Bustamante’s. But without regular care, many are at risk for sliding into serious illness, particularly those with chronic conditions like diabetes and hypertension.
“We help these patients get primary care when they have nowhere else to go,” Johnson said. “That helps to keep them out of the emergency department.”
The clinic has broader goals, Johnson added. It already provides specialty services, including ophthalmology, pulmonology, dermatology and psychology, the third Tuesday of every month. In the coming year, Johnson said he wants to build relationships between the clinic and discharge planning teams at UCH.
Whatever the challenges, the responsibility for meeting them largely will fall with the student volunteers. “That’s why we are here,” Viseur said.
“We all have a common motive,” he said. “A lot of us should be studying right now, but we have an additional desire to be here.”