S5E13: The Inadequacies of Student-Run Clinics

Harjit: They're not as fufu fafa?

Hạ: I don't know. I like the fufu fafa because sometimes I'll play Kpop.

Harjit: I mean, we're so sophisticated. I drink tea with my pinky up.

Hạ: No, I know what you mean when you say that. I just play Kpop and it makes everything more hilarious in the background.

Harjit: I love it. We are academics.

Hạ: It's the discordance of the fufu fafa. For context, my goal is to include Kpop in every single starting part. And eventually, Chloe will include it in the edits.

Harjit: Hopefully.

Hạ: Hopefully. But anyway, hello, dear listeners. This is Ha in the virtual studio. Woo-woo.

Harjit: Woo-woo.

Hạ: Thanks, Harjit. And I am here with Harjit and a very special guest who you might have actually heard from before if you've been a long-time listener. So I'm here with my classmate, Siale, and she was here on Season 3 during Harjit's identity episode, "Confidence from Community," which I encourage y'all to listen if you haven't checked out that episode yet. But I'm so excited to have both of them today as a part of this conversation.

Harjit: I'm so excited again to be with Siale. I feel like I just love her so much and I was like, "If she's going to be on this episode, I'm going to be on this episode."

Siale: I'm excited. These are two of my favorite people to talk with. People who just get me.

Hạ: Siale, you're making me emotional before the episode even starts. This is going to . . . Calm myself down. Okay.

Harjit: You guys are cutie bears.

Hạ: Cutie bears? I'm a cutie sloth, Harjit. But the topic that I want to talk about today is something that I've been thinking about for maybe quite over a year now. And the topic is student-run clinics.

I've been thinking about it a lot because a huge proportion of medicine really asks us to frame our identities and our passions based on our pursuits. For instance, earlier this season, we had talked in an episode about the research and publication craze. And similarly, I feel that oftentimes our community work inadvertently ends up being a means for us to market ourselves without really investigating the problems in our system and providing a solid solution for those issues.

And all of this context is to say that I really think about this framework quite a bit when I think about student-run clinics, in particular because when I participated in a student-run clinic as an undergrad in the greater Boston area, that was what solidified my interest in underserved urban health. And then about a year ago, I joined a couple of my peers to help start a student-run clinic at the medical school.

So to say it simply, in the aspect of student-run clinics and its complicity in perpetuating some problems, I'm an accomplice in it. And I've always seen this podcast as a means of having collective growth and for reflection, which is why I'm really excited to have a conversation about this today with you all to hear what are your initial thoughts when you think about student-run clinics.

Siale: There will be a lot of thoughts, but I just want to share one of my experiences during our first year of medical school when I was working at a student-run clinic.

Well, like most student-run clinics, they serve the uninsured, underserved populations, which is primarily BIPOC community members, at least here in Utah. It's interesting because most of the student-run clinics, you'll notice that the attendings are old white guys.

And so I remember I participated regularly, probably monthly during first-year. During one of the times I participated, I remember I walked in, it was before class one day, and it was me and then three other white students. And then the attending was like an older white male. I introduced myself and, of course, he was fixated on my name and how to pronounce it and where it came from.

And then it led to this conversation. For whatever reason, he started asking me about what my parents did for a living and just kind of some interesting personal questions. And I told him, I was like, "Oh, my dad is a contractor. He does landscaping and concrete." And he's like, "It's very impressive that you're here in medical school." It felt weird.

And then I later asked some of my classmates that were there with me. They were like, "Yeah, we didn't get any of that when we got here," because their names are very American.

And then later on that exact same day, there was a community member that was elderly. And they had their . . . I don't know if it was grandson/granddaughter who came to translate for them because English was their second language. And we were sitting in the little work area, but in that setting, the patients walk right by the work area so everyone can hear what you're saying. And he was like, "Man, this community, they're so lazy to learn English."

Harjit: Oh my God.

Siale: "They've been here for how long, and they still choose not to learn English."

Harjit: Oh my God.

Siale: Yeah. And so, obviously, did not sit well with me, but I already kind of felt . . . Reflecting back, I feel bad that I wasn't as . . . I don't know. Responsive? But I think I was feeling weird because of being singled out that I was the only BIPOC student.

But luckily, my classmates that were with me were like, "No, maybe it's just really important for them to keep their indigenous language. And I respect that, and the language they speak is much harder than the language we speak," and stuff.

And so I was really grateful for allies that day, but it made it so clear to me about what the problem is with student-run clinics. There are a lot of problems that I'm sure we'll get into, but that was a prime example. We're here serving people, but we're saying horrible things about them and judging them and pushing people to be westernized and colonized and we think we're so much better than them.

We're not making it a safe space for BIPOC people in general. And that's a problem with our healthcare system. No one wants to go somewhere where they don't feel safe, and BIPOC students don't want to be in places where they don't feel safe either.

So when I think of student-run clinics, I always reflect back on that experience because I think it's shaped a lot of how I view those clinics and how we address serving underserved communities.

Hạ: Yeah, Siale, I've definitely heard very similar stories and every time I hear them, it always continues to . . . I wouldn't say it surprises me, but it continues to disappoint me.

And it touches upon something that I really think about, which is that there's a savior complex and it becomes a lot stronger when we deal with people who come from underserved or uninsured or communities of color.

Harjit: Yeah. I really want to thank Siale for sharing her experience. I think I've probably been to a couple of the different student-run clinics, and a common recurrent theme that I found was we are serving these communities that have low resources, but are we giving them the proper or equal or equitable care that they deserve?

When you both bring up the savior complex, it reminds me a lot of global health work. But I did a global health trip to India and I saw how much of that savior complex came out.

I remember very consciously thinking that I don't want to do this work in India. I want to do it in my communities. But then when you come here, the avenues that these exist in, it's the same issue. That savior complex is so prevalent.

I too remember that people volunteer their time to work at these clinics. And you would think that they want to do this for providing good care in a sense, but it's very interesting to hear that it's these complaints or talking about patients . . . which I have an issue with in regular hospitals, is the way we talk about our patients and not honoring and respecting them as individuals and them as people. But it's very much like, "Let's go to this resource-poor place. Let's 'practice.'" Why are students there? It's to practice medicine. At what cost and at whose cost?

Siale: That's why it's hard, because as a student it's like yeah, I want to learn and stuff, but they frame it like we can run an hour behind and we don't honor the patient's times. And that just feels so wrong to me, especially because often these community members work jobs. They can't afford to take off an hour or two hours extra of their time, often living paycheck to paycheck. But then also feeling like, "Well, I am a medical student and I want to learn," and it just feels wrong in a lot of ways.

And like you said, there are just such limited avenues, especially for us who come from communities like this. We want to give back and we recognize, "Well, I don't necessarily need to do a global health trip," but then all the avenues we have here are just so . . .

It's like the idea is not bad, but the system that we have to do it within is just so corrupt and just filled with so many problematic things that it makes me as a BIPOC feel trapped and not sure what role I do and don't want to play in the system.

Hạ: And I also think a lot about how as a third-year medical student, I am learning off of patients, but it's a very different perspective learning as a third-year medical student versus learning in a student-run clinic.

I think one of the key distinguishing factors in that is that student-run clinics are medical apartheid. I know that throwing out that word seems very harsh and might hold a lot of heaviness to it, but to me, I see that student-run clinics are a way for medical students without as much foresight as they might be able to get in an actual clinic setting to use people of color, particularly those from the Black, Latinx, and indigenous communities and the poor community to train themselves and to get some skills.

And another thing I always really think about is that it was different for our year because of COVID. We got limited in what we could do with student-run clinics. But sometimes when I would hear some people talk a about it, they would say, "Yeah, this was the experience in the first and second years for me to get better as a clinician." And I understand the desire to be able to see patients and to kind of remind about why you're in medicine. I understand for a lot of people the intent might be good, but considering the way that it's built as a system, the impact becomes so much more problematic.

The one thing I like to add about it is the reason why it's partly medical apartheid is I feel that those patients who come into student-run clinics don't have a choice in choosing to allow if a student is involved or not.

Versus as a third-year, I can go in and say, "Hey, I'm a medical student working with Dr. So-and-so," and the person can say, "Hey, I don't want a medical student in this room." Or they can say, "I don't want to tell you about this. I'll tell you this much information, but I'd rather have the attending in here to tell you everything." But for a lot of these people who come in here, they don't have that choice. This is the best care that they can get.

And the reason why I started thinking about this topic and really investigating why student-run clinics are so problematic is partly during the first two years, I felt a bit weird about it. But then also partly when I was trying to set up student-run clinic, we were getting all of our patients as insured patients through a regular standing clinic.

And one of our discussions was, "Why is it that the other student-run clinics didn't have as much issues getting patients agreeing to be a part of it as much as our clinic was because we had insured patients?" And the resounding answer was the patients at the other student-run clinics had no choice.

Harjit: I think what you said, Ha, is very powerful and it is heavy because nobody wants to hear that, right? No one wants to believe that they're a part of . . . That's how I see it too. I see it as medical apartheid. Can I say that right now? Yes, I can, because that's exactly how I see it, right?

Coming from a community of color, working in the system as a medical student and now as a resident, I can fully say that. So I just want to back you up and say yeah, that's how I feel as well.

And I think it's very much for the benefit of the student, right? We're not looking at the benefit of these patients. We're looking at the benefit of these students. Why are they there? Why are they not properly trained to be there? But they're there doing what even a third-year medical student cannot do in the hospital.

I think this is where we look at things, and I guess this is the first time I'm actually thinking about it because . . . You just said this, and it's literally buzzer after buzzer of epiphanies of how we still continue to profit off of BIPOC people, off of people that are poor, off of people that are uninsured. This is the profit that we get. And in the end, our ego is inflated in us saying, "Oh, we're helping people."

It's "in" these days to help BIPOC people. It's "in" these days to help underserved, underrepresented people. People love that, especially talking about it on residency interviews, talking about it on residency applications. People who end up becoming leaders in these groups, this is what I'm saying. It's very important that we look at our own intent.

With that said, I do want to say I do feel like students can actually have that power of being critical. Siale, when you say, "I want to do this and I feel bad," you shouldn't feel bad because you're being critical. But is every single person who's participating in these student-run clinics critical? I don't think so.

Ha, I actually didn't think about all this until you mentioned that. And I think that's what's so powerful about the statement you made. Maybe it is heavy, but it's the truth. And sometimes the truth isn't the best thing to hear, but it's what is true.

Siale: The other day I saw another post on the class Facebook page about another program that they're doing for underserved community members. I feel like I can say this because I am LDS and I am a return missionary. But when I see who posts it and I see this pattern of the same people going there, these return missionaries that speak Spanish. And I feel like I can say this. I served a mission.

I think we forget that just because we served a mission, we don't truly understand. And we just continue this white savior complex that we started on our missions and we just carry it with us through the medical field.

That's a big problem about it. And then it leads to us appearing like we're doing so much for these communities. Like you said, it's "in" and it's this fad and people get all sorts of awards. They even have the Gold Honor Humanism Society or whatever.

How much of that is just filled with people who started this complex when they decided to serve, whether it was a church mission or they went on a humanitarian experience, and then it's like, "I'm just going to carry this with me through medical school and just feel like I'm always saving people"?

Hạ: I think a lot about whenever you bring up arguments about student-run clinics are problematic, what a lot of people like to do is cite the research because there's a lot of research out there showing, "Look at this student-run clinic. It's been able to help with improving health literacy. It's been able to help with better diabetes control."

And if anyone ever wants data about it, I . . . In my investigation of student-run clinics, I did a deep dive into all the data that exists. But the problem is, again, it's just for show.

And the thing that you really have to think about is that yeah, there's data that these student-run clinics might be helping the few people that run into it, but at the end of the day, it's just a band-aid solution. It's really not looking into the deep-rooted structural changes that need to occur for us to have health equity.

And it's not even investigating how actually student-run clinics are just an extension of a problem that has been going on in our medical education system for quite some time.

I think about it a lot because there was an episode on a podcast by Dr. Tiako, who's now an IM resident at Brigham and Women's Hospital. It's called "Flip the Script," his podcast, which I also highly recommend. But in that podcast, he interviewed a Yale physician about the "Flexner Report" and how it brought a huge shift in medical education.

And a lot of people know about it as just eliminating black medical schools, but what it also did was it created this change with how medical schools were run. Basically, what they talked about is that these academic medical centers had this conflict where they had to train clinicians while also providing quality care to paying patients.

So what they ended up doing, a lot of them, is that they moved their location to more low-income populations. It was their way of allowing us to be able to learn from patients without really giving the patients that choice.

It's been perpetuating, and I think one of the first steps to thinking about equity and more inclusive care and being anti-racist is to really understand the history and see what we're perpetuating.

This is something that the medical system has always cared about and has always done, and it's absolutely heartbreaking, but we have to realize that we're complicit in it. I am complicit in it because I participated in these clinics and I started one. And it breaks my heart, but we have to start there and then we have to go, "Well, where do we go from here?"

And I personally think where we should go from here is that we should advocate and we should actually fight to have these structural changes. I want to envision a world where we don't need student-run clinics anymore to give care to all of those populations.

Harjit: Oh, yeah, definitely, Ha. I think that's such an important point.

One thing I really try to hone into my patients is that of agency. I think agency is really important. And I think we take that away from our patients that go to these student-run clinics. And that's why I think they're the most harmful and they're actually not helpful, is because we don't give agency to our patients.

I tell my patients when I'm at the psychiatric hospital, "You should know what medication you're on. You should ask your provider how that medication works. You should ask why you're getting that medication." It's about empowering patients to make a choice. Even if it's against my choice, it's their choice.

I think that's what's so harmful, because student-run clinics take away the agency from patients or it doesn't teach students to give the agency to patients, right? That is where our education can change.

I have so many patients who are like, "Yeah, I don't know why I'm on this medication. I don't know how this medication works." And I'm like, "Do you know what disorder you have?" And they're like, "I don't know." Then I have to draw a whole picture and be like, "This is what you have, and this is why we're using this medication because this is the neurotransmitter it's working on."

And you would say, "Interesting, Harjit. Why are you teaching this patient who has no education?" Just like Siale, this doctor assumed that this patient didn't learn English, it's these assumptions that really harm relationships with patients.

This doctor assumed that this patient didn't want to learn English. They probably assumed that they're dumb. And this is where have to be better. Our patient can have a fifth-grade education and still understand how things work. They function in this world. We need to respect our patients and we also need to respect and empower their agency.

I think that what ends up happening is we also teach our medical students not to have agency and fall in these traps. Let's just go in these circles and go in these circles. But we also need to remember, Siale and Ha, since you guys are still in medical school, we have agency. So our participation in student-run clinics, although harmful, we also have the choice to change things, like you said, Ha, which is advocating. And I'm so happy you said that.

Siale: Yeah, I think it's interesting, like Harjit said, when we take away their agency, are we really helping them? I feel like I can honestly say I did not help my patients. I just went in and I was like, "Here's your medication." Yeah, it's helpful because I gave someone who has diabetes Metformin, but we're not even getting down to it.

And when we don't educate people and we don't give them agency, then . . . I don't know. That's the whole problem with the healthcare system. But it just feels even worse when you're doing it to communities that are already suffering so much, who have big health disparities. An attending walks in there for like one minute and is like, "All right. Here's your prescription," and walks out, doesn't even listen to them.

That's why it just feels like hard to say, "Yeah, I really helped someone," because I don't . . . I feel like I can't genuinely say I did help someone or I made someone's healthcare better because I don't think just handing someone a prescription really makes their life or health that much better.

But like you all said, I guess moving forward is calling it out. And sadly, I reported this incident to several people and finally, one of the admin was upset about it, but they didn't do anything about it. And so I think that's where I get discouraged too. I have agency and I feel like I want to make a change, but sometimes I feel so tired all the time that it falls on me.

And that's what's hard. It's setting this boundary for myself, but also feeling like, "This is going to feel really yucky if I don't say anything and if I don't do anything." But then being disappointed when admin or clinic directors don't respond because they're a part of this large problematic system and they just see it as a means to show that the school is doing something when they're not really.

Hạ: And I think that's often where the big double whammy comes in for me with this issue and why it breaks my heart so much. As you've both said, student-run clinics take away agency, but we use them to promote our ego and to promote our image, when in reality it really doesn't go deep into the patient and provider interface and how meaningful and impactful that can be when done well.

There was one time I was in this team of students at a student-run clinic. It was pharmacy, PT, nutrition, and me, and we had to go to break bad news to a patient and our attending wasn't in there. It was just us.

Harjit: Oh my gosh. So the attending wasn't there? It was just a bunch of students.

Hạ: It was a bunch of students and I was busy typing a note, so I didn't even catch it until the very end, but the news got broken terribly to this patient and the patient ran out of the door crying. And at the end of it, everyone just shrugged and said, "What else could we do?" as if this is a situation that these patients brought on themselves, that it's something unavoidable because they come from an under-resourced environment.

And to that point, I sit there and I go, "Then what is the point of this clinic if we're not able to really impact these patients, if at the end of the day it looks like we're just checking boxes to feel good about ourselves?"

All of this is to say that it frustrates me and I also feel like I'm one cog in a system that all I can do is just speak about it, tell people about it, think about it, but I don't know sometimes that I can create change.

At the same time, I also sometimes feel that when I center myself in community and thinking about ways that I can have impact in a more community one-on-one basis, I feel a bit of healing.

It's not as big enough to create the change that I would like to see, but I believe that if I can just start a small ripple effect, if I can talk with one person and educate them about this issue with student-run clinics and have them also bring it up to the next person, or if I can have one impact on a patient and tell them, "This is what you need to," like what Harjit does with her patients, and help them tell other patients to do the same, I feel like maybe we can cause change. At the end of the day, I feel change starts with the community and with the collective.

Harjit: When you, Ha, and, Siale, you also said, "Sometimes I feel like it's just one of me speaking," the truth is that you're speaking because you're standing in your power and your agency, which shows that this is a possibility to other people and even your patients.

Empowered people empower others. I know there's some type of quote like that. But what I'm trying to say is when you start acting in power, realize that you also have the agency. And I think that that's what's important.

And if you can do anything . . . As someone from a student-run clinic, I'm going to give free advice for everybody. Just talk to your patient and say, "Do you know why you're taking these medications? Let me tell you." I literally tell my patients, "Why are you not asking your doctors this question? Go talk to them."

If they talk about weight loss, why are they telling you to lose weight? These are the questions you have to work with your patients to ask because they feel ashamed. They feel guilt for doing X, Y, Z. They're sad and then they fall in the same pattern.

Obviously, if you are going to not give them the power to make those choices themselves, they're not going to feel empowered. So I think that's what students can do.

That's my free advice. Empower your patients. Tell them to ask questions. Tell them to ask questions to your doctors.

Siale: And I love that because . . . Well, at least in my community, we are very much like, "You don't question authority. You don't question if your doctor tells you something. You don't question your mom or your dad or whatever." So I think giving patients, especially from these communities, permission to question and to give them the skills so that they know how to question.

With my community, I think I get it when I see health disparities because I feel like it's one thing if people know and they say no, but when they don't know anything, that's what makes it so hard.

Harjit: Exactly.

Siale: In the end, if you want to choose to eat that way and have diabetes, as long as you know that, then I feel okay with that because that's your definition of health. But if you don't know that, if no one gives you the power or the skills to ask questions or really understand what's going on, that's where I feel a lot of guilt or responsibility to help people understand how they can better their health and stuff.

And so I love that, giving patients permission and power to question, especially when that's something that may be against their own cultural upbringing.

Harjit: And I also will say the three of us on this podcast identify as people of color. We also need to remember our power. I know that we all struggle with confidence, but this is what I'm talking about. How can we transfer that power to our patients if we don't believe in ourselves?

And this is where I think it's about the collective. It's about the community. It doesn't matter if I'm a doctor and my mom sells ice cream. We're together. We're part of the same community. And that's why it's so powerful.

I think that's one thing education and critical thinking gives us, is understanding the power of how important our lives are here, how much our education matters, and also that we are doing a great job. And that's the power that we then can transfer to our patients.

I know that feels like a side note, but everything is connected, y'all.

Hạ: I really do think one of the big themes in our podcast is the power of the collective and the power of our own voices.

I think that those thoughts are such beautiful ways for us to wrap up this episode, to reaffirm everything that Harjit and Siale have so wonderfully said. We touch upon very tricky concepts, such as student-run clinics, that extend quite deep into the historical darkness of medicine. I know that sounds pretty dramatic, but I'm pretty dramatic. But at the end of the day, I feel a lot of healing just from being continually reminded about our own personal ability to effect change.

I hope that this conversation has helped our listeners to think about the ways that they can effect change in different ways, be it at student-run clinics or in any other means in which they feel the medical system or any other system in their lives is profiting off of others.

Thank you so much for listening to us. Always a reminder that you can listen to us on Spotify, Apple Music, wherever you get your podcasts. Feel free to follow us on Instagram. Like all of our posts. Comment about how glorious we look.

Harjit: We are so glorious.

Hạ: We always need that confidence boost. I know, I'm a glorious baby sloth.

Harjit: You are the cutest baby sloth.

Hạ: Thank you. And I will give Siale the honor of signing us off.

Siale: Bye. Thanks for listening.

Harjit: That was so cute.

Siale: I didn't know what the heck to say.

Harjit: It was beautiful.

Hạ: It was good.