Redeeming Value

Another patient walks through the door of the LIFE Clinic in west Louisville, and Kristi McCauley is there to greet her with a smile.

The patient, a homeless drug user who's just started putting her life back together, returns the warm gesture as she settles into a chair and rolls up a sleeve so her blood pressure can be taken.

McCauley asks the patient, now a regular visitor, if she's changed her hairstyle, and the two chat excitedly about the new 'do as McCauley scribbles notes in a chart.

The scene is a familiar one to staff members of the LIFE Clinic, a free outpatient medical facility housed at a homeless shelter called The Healing Place.

The shelter, funded by the Jefferson County Medical Society and private donations, is dedicated to serving women with a history of substance abuse by providing housing, medical services and comprehensive counseling.

"A lot of these women just need someone to talk to," McCauley says of the patients. "They want to tell you what's going on in their lives because they're very excited about where they're headed. They feel like they have a new lease on life, and it's great to be a part of that.

"I'm a firm believer in starting over," she adds. "It's nice to get involved with people who are trying to turn their lives around. I make a real effort to develop a relationship with the patients -- to show them I care. I think they're more likely to follow your medical advice if they trust you and like you."

McCauley's philosophy would make her an ideal physician at the LIFE Clinic, except that she's not yet a practicing health care professional. Rather, McCauley is a second-year medical student at UofL with an itch to treat patients and an equally strong desire to make the world a better place.

She and a handful of other second-year students volunteer to run LIFE -- short for Louisville Inner-city Family care Experience -- for about three hours each Tuesday night as part of a community service elective for which they earn course credit.

McCauley is one of three student directors who manage the clinic for an academic year, overseeing patient scheduling, clinical procedures and policy matters.

Student directors, who are selected by a UofL committee, also assist with patient care. Most assessments, however, are provided by the three or four medical students who volunteer to rotate through the clinic every three months.

To ensure quality care, all of the students' activities are supervised -- either by a community physician who volunteers at the clinic or by Shari Brindley, a nurse practitioner who is director of health care services at The Healing Place.

Just like the patients, Brindley is thankful for the help.

"The students are an indispensable part of our program, and not just because they provide their time," Brindley says. "They also have a fresh perspective and a lot of enthusiasm. They've come into medicine because they want to help people, and our clients really need someone to care about them."

The LIFE clinic is one of three such operations in Louisville, all staffed by UofL medical students who receive course credit. The other clinics -- GLOH and HOPE -- function in much the same manner as LIFE, except that their operations fall directly under the control of the Department of Family and Community Medicine at UofL.

Students at the HOPE Clinic are supervised by area physicians who volunteer their time, while GLOH students are supervised by an upper-division family practice resident from UofL and an attending physician who is a university faculty member.

Like LIFE, HOPE and GLOH treat underserved patient populations.

The HOPE Clinic -- short for Health Outreach and Pediatric Education -- is located in the East Broadway branch of the Family Health Center, a local non-profit organization, and serves women and children from homeless shelters and halfway houses in central Louisville.

GLOH -- the Greater Louisville Organization for Health -- is located in the Iroquois branch of the Family Health Center and treats a large number of low-income patients, including recent immigrants from Asia, Latin America and Eastern Europe.

On a typical night each clinic will treat about a dozen patients, usually free of charge, but GLOH collects a $10 fee from those who can afford it. The money is used to buy supplies that supplement drug inventories donated by pharmaceutical companies, says Donna Roberts, M.D., GLOH's course director and an associate professor of family and community medicine at UofL.

The students do everything necessary to run the clinics, from greeting patients and taking medical histories to recording vitals signs, running lab tests and performing physical exams.

Once each exam is complete, the student will present his or her findings to a physician, who then checks the student's work and conducts another physical exam. Together, they formulate an appropriate course of treatment.

This hands-on approach is, not surprisingly, an excellent form of instruction, says Mark Pfeifer, M.D., vice dean for clinical affairs in the School of Medicine and the LIFE Clinic's faculty liaison.

"After I do my own exam of the patient, students sometimes say, 'I wish I'd asked that question I heard you ask.' There is no better learning moment than that," Pfeifer says. "It's the best experiential learning."

Students do get a similar experience at the School of Medicine by "treating" standardized patients -- actors who are trained to present with various medical conditions and respond appropriately based on the care they receive. But, in the words of Roberts, "nothing beats real life" for a realistic clinical experience.

"I'm very much a proponent of standardized patient programs, but interviewing a standardized patient is not the same as interviewing the real thing -- the person for whom you have to seek out the answers," Roberts says.

"The students are getting that real-life experience, and they're getting to practice their physical exam skills in a setting where they don't feel they're being graded for every decision."

Toni Parsons, a medical student who just completed a three-month rotation at the LIFE Clinic, agrees.

"With standardized patients, we usually have a specific goal for each session," Parsons explains. "An instructor may tell us, 'You're going to take vitals and do a cardiac exam.' But in the clinic, we had to come up with our own course of action based on each new patient.

"The clinic also wasn't a threatening environment because we knew a doctor was coming in right after us," Parsons adds. "So if there was something we forgot or overlooked, we knew it would still be addressed by the attending physician."

The student experience is further enriched because educational opportunities go beyond simple medical assessments or treatment options, says Stephen Wheeler, M.D., course director for the HOPE Clinic and an associate professor of family and community medicine at UofL.

They also, by necessity, touch on social issues unique to these underserved patient populations.

"It's an eye-opener for many of the students to see that Louisville has a pretty good system to support people in need, but it's still a basic system," Wheeler says. "There are things you expect of patients that are very difficult for some of these folks to do because they may be staying in a shelter.

"For example, they may not have access to a private refrigerator to refrigerate medications. They may not have access to a bathtub to do something simple like bathe. They sleep in rooms with lots of other people, so the kind of privacy that changing bandages might necessitate is difficult. Some of the simple medications that we think nothing of using, like antihistamines, are potentially dangerous for people who are trying to throw off addictions.

"So we have to adjust what we recommend, and that really does broaden the students' perspectives as they're thinking about these folks and their problems."

With so many complex factors to consider, Wheeler says the three clinics provide an unsurpassed learning opportunity. In fact, Roberts says that students who volunteer to staff them demonstrate "a much higher level of maturity" when it comes time for school-mandated clinical rotations in the students' third year.

But the clinics also provide something else: a chance for students to serve their community while they learn their profession.

"The real-world application of facts and skills they're learning in medical school, in this type of setting, is a very appealing combination," Wheeler says.

So appealing, in fact, that one student-run clinic hasn't been enough.

Roberts notes that the HOPE and LIFE clinics are relatively recent complements to the 1970s-era GLOH, having been established in 1991 and 1998, respectively, to meet student demand for more community service opportunities.

"I think it's interesting that two other clinics grew out of GLOH at a time when we think people are pulling away from community service activities," she says. "But our students keep pushing into them. That's a wonderful thing."

McCauley says it's important for doctors to give back to their communities because it demonstrates character and leadership. She also says medical students need to set the standard for service now, while they're still learning the profession of healing.

"It's easy to get buried in academic work because the first two years of medical school are so rigorous," McCauley says. "But I firmly believe that the way you begin to practice medicine now is the way you will continue to practice for the rest of your life. At times, you may feel like you don't have time to do it. But your life is only going to get busier and busier. If you don't find the time to do these things now, when will you?"

Despite the sacrifice, students say the spiritual rewards of working at the clinics far surpass the costs.

"Something like this is redeeming," McCauley says. "To finally utilize what you've learned in class reminds you of why you went to medical school in the first place -- to help people in a compassionate and empathetic way.

"That's why I wanted to work at the clinic, and that's why I want to be a doctor."