Tosi A and Van De Graaf M. Bilingual free clinics: a win-win for students and patients or an ethical quandary? HPHR. 2021;48.
There are 152 Student-Run Free Clinics (SRFCs) in the United States today, most of which are operated by medical students (Society of SRFCs, 2021). As the number of SRFCs has grown to encompass immigrant Hispanic patients, so have the ethical implications of providing bilingual care for this vulnerable population. Nonetheless, advocates argue that SRFCs provide a “win-win” situation in which students gain clinical skills and a better understanding of Social Determinants of Health (SDOH). At the same time, patients receive medical care that would otherwise be unavailable. In this piece we discuss benefits and challenges facing SRFCs that serve the Hispanic community. We then offer recommendations that strive to better address the healthcare inequities illustrated.
Core to the ethos of a Student Run Free Clinic (SRFC) is the emphasis placed on student autonomy and real-life experience with health inequities. Advocates argue that students learn valuable lessons volunteering in a SRFC that extend far beyond how to conduct a standard patient visit or present to an attending physician. They witness firsthand how poverty, lack of insurance coverage, language barriers, discrimination, unstable housing, and other SDOH play out in the real world (Xu, 2013). For example, one study examining County Health Rankings showed that socioeconomic factors made a 47% contribution to health outcomes whereas actual clinical care was attributed to just 16% of the health outcome (Hood et al., 2016). Advocates surmise that early exposure to SDOH encourages trainees to be more attentive to these factors in their future patients as well as to advocate for better health equity (Xu, 2013).
Though students benefit greatly from volunteering in SRFCs, the more important service is to the patients. Serving immigrant pediatric patients is the focus of the SRFC at our medical school, and we strive to provide an essential service to patients who have no other options for affordable, quality care. Children in low-income families are often assumed to have health insurance through government programs. Unfortunately, immigrant children only qualify for such insurance coverage in six states (National Immigration Law Center, 2021). In our region, a 2019 census survey found that approximately 3000 Hispanic children were uninsured (US Census Bureau, 2019). The families seeking care with us do not receive insurance through their employers and cannot afford to pay for private insurance or out of pocket. Therefore, we serve pediatric patients who would seek medical care in the Emergency Department or not at all.
Critics of SRFCs, however, will argue that SRFCs provide substandard care, especially with regard to addressing language barriers. For example, one study showed that as many as 31% of patients seeking care in SRFCs are uninsured Hispanic residents and are often served by student interpreters who lack formal training, introducing further ethical concerns (Diaz et al., 2016). The National Board of Certification for Medical Interpreters (NBCMI) offers professional credentialing in the field of medical interpreting with emphasis placed on ethics, standards of practice, role boundaries, and medical terminology (National Board of Certification for Medical Interpreters, 2016). Unlike professional interpreters working in the hospital setting, student interpreters often do not undergo rigorous training and certification, and SRFCs may lack a standard by which to certify their volunteers. This can result in negative effects on patient care. A drastic example of this is the landmark case of 18 year-old Willie Ramirez, a Spanish-speaking patient who became paralyzed following an interpretation error that resulted in incomplete medical care (Foden-Vencil, 2014). Mistranslations are often more subtle than this but can, nonetheless, impact patient care. One study of informal interpreters working in an outpatient pediatric setting found that a substantial 66.1% of spoken exchanges were mistranslated (Laws et al., 2004). In addition, word count was inversely related to error rate, meaning that the longer a patient’s visit, the more they were subjected to poor interpretation. This can have real consequences for patients, especially for those with complex problems or those without consistent access to healthcare which is common among recently immigrated patient populations. Furthermore, as clinicians in training, students are unlikely to act as neutral interpreters during a patient visit and may end up advocating for or counseling the patient, a phenomenon known as “role exchange” (Monroe & Shirazian, 2004; Yang & Gray, 2008). This blurring of lines creates confusion for the patient and forces the student to straddle responsibilities of learner, clinician, and interpreter which has been shown to lead to more errors (Robinowitz et al., 2014).
The need for a free clinic is inherently tied to disparities and inequities in healthcare. In our case, the need for a pediatric free clinic arose due to the fact that there are Hispanic children in our community who do not have equal access to health insurance due to restrictions that prevent them from participating in Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Affordable Care Act (ACA) Marketplace (Robinowitz et al., 2014). Many aspects of the SRFC experience for these patients can be improved. Within our institution, mastery of an online medical interpretation course as well as an oral evaluation are required before director approval to interpret in our clinic. Strong emphasis placed on community outreach through health fairs, cultural events, and weekly tutoring sessions with bilingual community members has allowed our program to cultivate both linguistically and culturally competent student providers.
Unfortunately, even the most innovative solutions to improve care provided within bilingual SRFCs cannot overcome glaring inequities within our healthcare system. Those of us working in medicine have a responsibility to address the wide-reaching policies that have created and perpetuated healthcare disparities. Currently, six states (CA, IL, MA, NY, OR, and WA) and Washington DC use state-only funds to provide health insurance coverage to income-eligible children regardless of immigration status (National Immigration Law Center, 2021). In June 2019, California approved an expansion to cover undocumented young adults through the age of twenty-five (Allyn, 2019). In Virginia’s 2021 legislative session, a budget amendment was approved that requires the Department of Medical Assistance Services to establish a workgroup on strategies to provide healthcare services to undocumented immigrant children (TrackBill, 2021). By pairing free clinic services with long-term goals to change healthcare policy, we care for children today while working towards providing equitable care for all children.
Allyn, Bobby. (2019, July 10). California is 1st State to Offer Health Benefits to Adult Undocumented Immigrants. National Public Radio. https://www.npr.org/2019/07/10/740147546/california-first-state-to-offer-health-benefits-to-adult-undocumented-immigrants
Diaz, J. E., Ekasumara, N., Menon, N. R., Homan, E., Rajarajan, P., Zamudio, A. R., Kim, A. J., Gruener, J., Poliandro, E., Thomas, D. C., Meah, Y. S., & Soriano, R. P. (2016). Interpreter training for medical students: Pilot implementation and assessment in a student-run clinic. BMC Medical Education, 16(1), 1-7.
Foden-Vencil, K. (2014, October 27). In The Hospital, A Bad Translation Can Destroy A Life. NPR. https://www.npr.org/sections/health-shots/2014/10/27/358055673/in-the-hospital-a-bad-translation-can-destroy-a-life.
Hood, C. M., Gennuso, K. P., Swain, G. R., & Catlin, B. B. (2016). County health rankings: Relationships between determinant factors and health outcomes. American Journal of Preventive Medicine, 50(2), 129-135.
Laws, M. B., Heckscher, R., Mayo, S. J., Li, W., & Wilson, I. B. (2004). A new method for evaluating the quality of medical interpretation. Medical Care, 71-80.
Monroe, A. D., & Shirazian, T. (2004). Challenging linguistic barriers to health care: Students as medical interpreters. Academic Medicine, 79(2), 118-122.
National Immigration Law Center. (2021, January). Medical assistant programs for immigrants in various states. https://www.nilc.org/wp-content/uploads/2015/11/med-services-for-imms-in-states.pdf
Program Overview. THE NATIONAL BOARD OF CERTIFICATION FOR MEDICAL INTERPRETERS. (2016). https://www.certifiedmedicalinterpreters.org.
Robinowitz, R., Arguello, R., & Artiga, S. (2014, March 26). Children’s health coverage: Medicaid, CHIP and the ACA. Kaiser Family Foundation. https://www.kff.org/health-reform/issue-brief/childrens-health-coverage-medicaid-chip-and-the-aca/
Society of Student Run Free Clinics. (n.d.). Retrieved June 25, 2021, from https://www.studentrunfreeclinics.org/
TrackBill (2021). Virginia HB1800. Retrieved May 27, 2021, from https://trackbill.com/bill/virginia-house-bill-1800-budget-bill/2024258
U.S. Census Bureau. (2019, July 1). Quickfacts Virginia. https://www.census.gov/quickfacts/VA
Xu, J. (2013, November 12). Letting medical students run the clinic. The Atlantic. https://www.theatlantic.com/health/archive/2013/11/letting-medical-students-run-the-clinic/281241
Yang, C. F., & Gray, B. (2008). Bilingual medical students as interpreters–What are the benefits and risks? The New Zealand Medical Journal (Online), 121(1282), 15-27.
Amanda Tosi, MS is a fourth-year medical student at Eastern Virginia Medical School in Norfolk, Virginia and will be pursuing residency training in internal medicine. Her research interests include the intersection of medicine and global health, immigrant Hispanic health, and medical education.
Matt Van De Graaf, MS is a fourth year medical student at Eastern Virginia Medical School and will be pursuing residency training in pediatrics. He’s particularly interested in primary care pediatrics, health policy, and health equity.