By Timothy Judson, MD MPH
Former clinical co-director of the Weill Cornell Community Clinic and current UCSF medicine resident
It was spring of 2015 and I was in Munich, Germany for an international health policy rotation. In a mater of weeks, I would graduate and complete four years of intensively accruing medical knowledge.
I stood with medical students from Ludwig Maximilian University as our six-member team rounded on patients on the cardiac inpatient floor. The German medical jargon was partially decipherable thanks to common acronyms, and I understood that we were discussing the plan for a 66-year-old male after a percutaneous coronary intervention. What surprised me was the brevity of the discussion and the limited number of participants. The senior physician calmly dictated the plan to the junior physician, who nodded and wrote it down. The medical students stood quietly and like a row of ducks, followed the physicians into the room to see the patient.
To many readers, this may seem like standard practice. But for a student nearing matriculation from a medical college that prides itself on student engagement in the intellectual practice of medicine, it was startling. During my rotations at Weill Cornell, we presented patients to our team, designed treatment plans, and conducted a team discussion about nearly every patient. The German academic system has a different culture, where medical students learn by watching, with only limited participation.
Perhaps the most dramatic difference between my education and that of my brilliant and motivated peers in Germany was that I had the opportunity to take my learning one step further. Not only did I get to take the first crack at constructing care plans in the hospital, I got to take ownership of patient care in the ambulatory setting.
When I first volunteered as a senior clinician at the Weill Cornell Community Clinic, I was struck by the freedom I had to conduct patient care from history to physical to treatment plan. Under careful supervision, I put in orders for labs, wrote prescriptions, and followed up with patients over the phone. While still in medical school, I got to practice “being a doctor” while a seasoned physician monitored my progress and made corrections when appropriate.
This type of opportunity does not exist in Germany for two reasons. First, physicians are not accustomed to offering this degree of oversight to medical students due to the educational culture discussed above. Second, and most importantly, universal health insurance coverage and the nearly ubiquitous practice of patients regularly seeing their primary care physician makes the existence of student-run free clinics unnecessary.
Student-run free clinics fill a niche of caring for a population of uninsured and impoverished patients who otherwise would have nowhere else to turn for primary care. Many of these patients in the United States rely on Emergency Departments as their only source of access to care.
In theory, the Patient Protection and Affordable Care Act (ACA, also known as Obamacare) should lessen the need for such clinics by mandating insurance coverage for all Americans. However, a large number of these patients still exist. Undocumented immigrants are not eligible for insurance subsidies, and frequently have no health insurance. Many low-income U.S. citizens, despite subsidies, are unable to afford health insurance and opt to instead pay a fine and take their chances being uninsured.
Recent estimates suggest that less than 12 percent of Americans remain uninsured, from over 16 percent prior to the ACA implementation. Despite the improvement, the uninsured population remains substantial. Therefore, for the foreseeable future student-run free clinics like the WCCC will continue to represent both the best and the worst of the U.S. health system. They offer an incredible educational opportunity that other medical learners, including my German counterparts, must do without. However, they are also a constant reminder of the failure of the U.S. healthcare system to do what European countries consider standard – provide universal access to health care.
