Verified by 
When I volunteered this Fall to start seeing patients at a nearby free clinic, I had little idea what I was signing up for. The term "free clinic" conjured up memories of me as a medical student in East Baltimore tending to patients at a local homeless shelter with severe frostbite or at a student-run clinic rummaging through a storage room for anti-hypertensive medications. I expected the clinic to be little more than an overrun warehouse, for supplies and medications to be scattered and few, and for the care we provided to be more about putting out fires than delivering high-quality primary care.
But the place I have come to cherish working at is none of these things. Our clinic has a dedicated space and by appearances looks no different than any other primary health center. Patients call for appointments and when they arrive are triaged by a nurse who takes their vitals and escorts them to an exam room. Our onsite supply room is well stocked with medications freely donated by major pharmaceutical companies. And we provide comprehensive primary care complete with routine lab tests for cholesterol and diabetes, age-appropriate vaccinations, and referrals for mammograms and colon cancer screening. In short, to the untrained eye, our clinic is less a free clinic than it is simply a community-based primary care center that happens to be free.
However, as I have spent more time taking care of patients at this clinic, I have come to appreciate subtle yet important differences between the care I provide at the free clinic and my regular, hospital-based clinic. Most unexpectedly, these observations suggest that being free is more than just happenstance - it fundamentally changes the way I deliver health care in my community-based clinic and in ways that are largely for the better.
Perhaps the greatest difference is in dispensing medications. At our free clinic routine medications are provided to patients free-of-charge. For most patients, I write out a prescription, which is then filled by clinic staff and made ready for pickup in 1 to 3 days. For medications that patients need right away or for patients who can't easily return to pickup their medications, I dispense the medications myself from our stock room (picture me counting out pills into empty containers and then labeling them with the medication's name and adminstration instructions). Though I can only prescribe medications on our clinic formulary, I take comfort in knowing that my patients have their medications in hand. In my hospital-based clinic, I can write for any prescription I want but I'm never sure whether the prescription gets filled. Sometimes I write a prescription for one type of cholesterol-lowering agent only to find out a month later my patient had to pay hundreds of dollars for it, or more commonly because of the price didn't fill it at all.
Less obviously, handing patients their medications has changed the dialogue I have with patients. It's less transactional and more didactic -- often as I hand patients their pill containers I find myself telling them about the importance of taking their medication regularly, warning them about what side effects to look out for, and instructing them on how and when to take the medication. Between free access to medications and better counseling I can't but wonder if their medication adherence is better. At the same time, the medications themselves become a check on the patient following up. We rarely give out more than 3 months of medication at a time. When their pill bottles start running out, patients know it's time to come back to clinic, which keeps me seeing them at more regular intervals and decreases the chances of someone slipping through the cracks.
Another important difference is in our charting. In my hospital-based clinic, medical documentation occupies at least one-third of my time. In American health care, medical records serve three roles - medical, billing, and legal. As a result we spend hours filling out billing sheets and dictating complete physical exams and review of systems, often with little direct benefit to patients. Charts become unmanageably large, with low signal-to-noise ratios and "meaning-less use" health information -- while I may be able to easily find a patient's insurance information, I have to wade through reams of paper to find out when their last mammogram was. At the free clinic, I document only what matters. The chart is meant to support high-quality patient care -- any information that detracts from this goal is left out.
Finally, the services we provide are also different. The free clinic as a whole does what makes sense for patient care and not the bottom line. The clinic is a run by a non-profit entity whose mission it is "to deliver comprehensive, patient-centered health care at no cost to low-income, uninsured individuals".[1] Clearly the clinic is constrained by its finite resources. But within those bounds, they offer services that they believe in. At my hospital-based clinic we offer services based on reimbursement and margins. It's no surprise then that my uninsured patients at my free clinic have access to weight loss programs and nutrition counselors while my insured patients at my hospital-based clinic do not.
Overall, at my free clinic, service is divorced from financial concerns. Money is not a factor for patients who don't have to worry about paying for medications or appointments, or getting a huge bill in the mail. And it's not a factor for me in the way I choose which services to provide or how I document their medical record. Instead the patient just focuses on doing what makes sense for her, and I do what makes sense for the patient. If it's ordering an expensive lab test, so be it. If it's telling them they are fine and don't need to see me again for another year, then that's fine too.
Clearly in the free clinic there are some drawbacks. Patients have longer wait times for referrals, for example. Like the rest of us, specialists offer their time on a voluntary basis and routine referrals for dental care or GI specialists may take a few months. But these delays, while inconvenient, have not negatively impacted patient outcomes in my brief time working at the free clinic.
Overall the differences between my hospital-based clinic and free clinic parallel the differences between the American fee-for-service health care system and a single payor health system like Canada's. In the American system the care we provide patients is largely dictated by rules of reimbursement. Patients receive services that are paid for by insurance companies, not necessarily those that are best for their health. They often have copays for doctor visits and medications, which decreases treatment adherence and can worsen health outcomes, particularly in low-income populations. Those with expansive health insurance plans often get "more" health care (though not necessarily better care) than those with less or no insurance. In the Canadian system, patients are offered services that are made available by the government based on national guidelines and individual patient-doctor decision-making. Services including medications are free, and everyone receives the same care regardless of socioeconomic status.
At the risk of being political, which system do I prefer? For me the litmus test comes down to two questions: which clinic do I prefer working in and which clinic would I prefer to be a patient? On both accounts I'll take the free clinic down the street.
- Shantanu Nundy, M.D.
Copyright Shantanu Nundy, M.D.
If you enjoyed this post, please visit Dr. Nundy's web site BeyondApples or read his book, Stay Healthy At Every Age.
