Why Do Physicians Volunteer at Student-Run Free Clinics? A Look into What Drives or Hinders Their Participation

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Introduction
Student-run free clinics (SRFCs) are an excellent way for medical students to practice history taking and physical exams while delivering quality health care to uninsured members of their community, thus providing outstanding value to all involved. 1[8] A fundamental aspect of SRFCs is the presence of physician preceptors.Medical faculty must supervise students to ensure quality care and model intangibles such interprofessional behavior and professionalism.A 2008 survey found that 38.8% of physicians had volunteered in some capacity within the prior year, a statistic that is higher than that of the general public. 9However, physician volunteerism appears to be declining more recently, posing a major challenge to organizations that rely on physicians to either provide free care or supervise those who do. 10 A 2015 American Academy of Family Physicians study found that the average family practice physician works nearly 50 hours per week, which could be a contributing factor to the decrease in physician volunteering. 11Additionally, some studies indicate that the prevalence of physician burnout could be as high as 80%, another potential impediment to physician volunteerism. 12A major challenge to SRFCs is finding and retaining physician preceptors.
The physician volunteers provide invaluable educational benefits to medical students, however, there are other benefits to consider.Physician volunteerism may encourage trainees to make volunteering a part of their future career, creating a ripple effect of increasing volunteerism. 13There are also many benefits to physicians themselves.Volunteerism may help protect against the development of burnout 14 and there may also be positive physical impacts like improved cardiovascular health 15 and cognition. 16he SHARING (Student Health Alliance Reaching Indigent Needy Groups) Clinic is a SRFC at the University of Nebraska Medical Center (UNMC) in Omaha, Nebraska.A major challenge for the SHARING Clinic is finding and retaining physician preceptors from the pool of faculty.From July 2018 to June 2019, five physicians have contributed over 70% of the volunteering hours at the SHARING primary care clinic.This dependance may feel burdensome to these volunteers and poses a threat to the clinic's sustainability.It is for these reasons that this study was conceptualized.It is important to examine motivations and barriers to physician participation to increase retention and expand the volunteer pool.Physician volunteerism at SRFCs is still poorly characterized and deserves more study.

Methods
An anonymous online survey was sent out to faculty institutional email addresses once during the fall of 2020 (Online Appendix).The survey, via Microsoft Forms (2020, Microsoft, Albuquerque, NM), was sent to all physician faculty in the Family Medicine, Internal Medicine, including all Internal Medicine sub-divisions, and Emergency Medicine departments.These were selected because physicians from only these departments provide supervision at the SHARING Clinic.The survey was not sent to any of the non-physician preceptors, such as medical laboratory science or pharmacy.The branching survey consisted of a minimum of seven questions for those who had never heard of the SHARING Clinic and a maximum of fifteen questions for those who had previously heard of SHARING.The survey included free form questions like, "Regarding the answer to the previous question about your satisfaction with volunteering, why were you satisfied or dissatisfied?"and close-ended questions like, "In your experience, have the students seemed sufficiently trained and prepared to volunteer at the SHARING Clinic?Yes or No," as well as five-point Likert scale questions like, "Please indicate your level of agreement with the following statement: Volunteering my time at SHARING improved my mentor relationship with students.Strongly agree, agree, neutral, disagree, strongly disagree."Microsoft Forms was used to construct, distribute, and analyze the survey and its results.The survey was deemed exempt by the UNMC Institutional Review Board.Results were compiled and frequencies, response rates, and free responses were analyzed.Themes were identified and reported.

Results
In total, 348 physicians were sent the survey, and 49 responded for an overall response rate of 13.5%.Of the respondents, nine (19%) were Family Medicine physicians, seven (14%) were from the Emergency Medicine Department and eight (16%) were from General Internal Medicine.The remainder were from divisions of Internal Medicine.The years since residency graduation can be seen in Figure 1.Overall, 35 (71%) of physicians responding to the survey report that they volunteer at least one time per year in some capacity at any organization (Figure 2).Of the respondents, 41 (87%) heard of the SHARING Clinic before, with 16 (39%) reported volunteering at least one time at SHARING in the past.Detailed volunteer frequencies are shown in Figure 3.
The main motivations selected from the provided list were, "I enjoy being a mentor to health professions students," by 14 (29%) respondents and, "I feel it is important to help those in need,"   This chart depicts the number of times respondents volunteered at the SHARING Clinic.Forty-one individuals responded to this question, with the majority (n=25, 61%) had never volunteered at SHARING Clinic, and sixteen (39%) had volunteered.SHARING: Student Health Alliance Reaching Indigent Needy Group.I believe that the students learned something from me while volunteering.
I learned something from the students or practiced skills that I had not used in a while.
Volunteering my time at SHARING was a valuable use of my free time.
I was satisfied with my experience when I volunteered.
Strongly disagree Disagree Neutral Agree Strongly agree by 12 (24%) respondents.All responses to motivations and barriers to participation are reported in Table 1.
When asked about student volunteer preparedness, of the 16 physicians who have volunteered at SHARING, eight (50%) said students were well prepared, eight (50%) said students were somewhat prepared and none said that students were not adequately prepared.In response to whether student preparedness affects faculty's desire to volunteer at SHARING, one (12.5%)responded that it negatively impacts their desire to volunteer and six (75%) responded that it does not affect their decision to volunteer.One person (12.5%) selected "Other" and wrote, "Because I don't regularly volunteer it just makes it more time consuming for me to troubleshoot things if students are also less prepared." Most respondents who had volunteered at SHARING Clinic were satisfied with their experience and felt that they improved their student mentor relationships (Figure 4).Ten free form responses to the question, "Why were you satisfied or dissatisfied with your experience volunteering at the SHARING Clinic?" encompassed themes of satisfaction with service to the community (n=3) and mentoring students (n=4) and themes of dissatisfaction with inefficiency (n=1) and the multidisciplinary workflow of the clinic (n=2).
Forty-seven respondents answered a multi-select question regarding what could entice faculty to volunteer more.Of the options provided within a list, 21 (45%) physicians selected increased flexibility in scheduling, 20 (43%) "Other," 14 (30%) the ability to volunteer from home via telemedicine, 11 (23%) Relative Value Units (RVUs) as compensation, and three (6%) recommended more knowledgeable/prepared students and less patient load.Zero physicians responded that awards/recognition would entice them to volunteer more.
Additional comments were requested via a free-form question.Select responses included the following: • "I volunteered with SHARING clinic when I was a medical student.I remember that the clinic went late into the evening and that is a barrier to me at this stage in my life."• "This is a great idea but the times to volunteer that I've seen in the past are at night.I already work approximately 50 hours a week and then taking another night to be away from my family is unrealistic." • "…the workflow is always a little confusing: how do students close the notes?How do we assign ourselves patients?Are there certain ways to order things with this being a volunteer clinic?Are there things we can or can't offer/refer to?"

Discussion
Physician volunteerism is important to the SHARING Clinics and other SRFCs.Without physicians, the clinics cannot run nor serve those who rely on these safety-net healthcare centers.Moreover, the opportunity for students to learn from attending physicians in an environment that is separate from graded work cannot be overstated.our knowledge, no other paper has looked at or reported physician statements regarding their reasons to volunteer or not at an SRFC.
Our results indicate that physicians would like to volunteer but simply do not have time due to family and work obligations.Seven (44%) of the 16 respondents who volunteer at SHARING Clinic do so on average once per year or less, meaning they have volunteered at least once in the past but not necessarily annually.Most physicians who had volunteered at SHARING enjoyed their experience, believed students learned something from them, and found the experience to be valuable.Because physicians struggle with scheduling time for volunteering due to outside commitments, one solution based on the results of our survey is to increase the offerings of clinic times to include daytime, evening, and weekend hours, rather than only four evenings per month as currently offered.During the height of the coronavirus disease 2019 (COVID-19) pandemic, SHAR-ING Clinic moved their operations to a telehealth modality.We recommend that SRFCs consider the addition of telehealth technology for at least one clinic night per month.As modeled in a 2021 publication, SRFC telehealth options provide underserved populations better access to healthcare due to the flexibility of this service, while maintaining proficient medical management. 17This may also address physician barriers, specifically family obligations, by allowing them to participate from home.Considering 11 (23%) survey respondents agreed that RVUs would entice them to volunteer more, offering RVUs for their work could increase participation.The implementation of RVUs for physician preceptors was a Quality Improvement project that was explored at UNMC but was ultimately found not to be feasible.The small number of patients seen each clinic night and low work RVUs generated per visit (estimated to be less than 0.5) would be a negligible benefit to our physician preceptors' total annual expected work RVUs.In addition, the cost of tracking these work RVUs without charging the patient with UNMC's current billing system could be significant.Further study is needed to search for solutions to these issues.
Interestingly, our survey results show that awards and recognition might not be an ideal target to increase volunteerism as no physician made that selection.On the other hand, 14 (88%) physicians responded that their principal motivation for volunteering was acting as a mentor to health professions students.A novel solution that SRFCs could employ is to create a direct mentorship program whereby students and physicians agree to volunteer together in a longitudinal fashion.This would create a sense of shared success when the student improves their skills and confidence with the support of their preceptor.A potential pitfall to such a mentorship program is that fewer students would have the opportunity to participate.In addition, it would require an even greater commitment from an already small faculty volunteer pool.
Our results suggest that SHARING Clinic and other SRFCs could potentially increase volunteerism by having a robust student training program and better instruction for physicians with regards to procedures, rules, and best practices.Some of the free-form comments indicated that some faculty volunteers felt uncomfortable volunteering because they lacked instruction and guidance.This would be a significant area for further quality improvement studies to assess the impact on clinic efficiency, workflow, and student and preceptor feelings of overall satisfaction with their volunteer experience.This is especially important since student leadership teams at SRFCs may have frequent turnover.
One of the main limitations of this study was the low response rate of 13.5%, which could be due to the one-time distribution of the survey.The response rate was also likely impacted by the COVID-19 pandemic and the temporary suspension of the SHARING clinics.Though we anticipated the possibility of a low response rate, we felt it was important to not further increase the email burden on these physicians with multiple emails.In future survey studies, however, we recommend that researchers send out the original survey followed by two reminder emails.We also recommend that department chairs be recruited to send and encourage the response of at least one of the emails.Another limitation was that we were unable to perform satisfactory statistical tests with our data due to the low response rate.Despite these limitations, the data we collected has provided valuable insight into motivations and barriers to physician volunteerism that we have been able to use to provide recommendations for further increasing volunteer participation and retention.
Physician volunteerism at SRFCs is an important area of research that should be further explored.Although it is too early to assess the full impact that the COVID-19 pandemic will have on the health and finances of Americans, it is safe to say that unemployment has increased and with that, private health insurance coverage has likely decreased. 18Safety-net healthcare may play an increasing role in the American health care system over the coming years and thus, stability and sustainability of these organizations is paramount.To that end, the current study was borne out to explore motivations and barriers to physician volunteering at SRFCs and elucidate strategies to increase physician retention.

Figure 1 .
Figure 1.Reported years since graduating residency for all respondents

Figure 2 .
Figure 2. Physicians reporting the number of times they volunteer anywhere in any capacity per year by department

Figure 3 .
Figure 3. Physician volunteerism at the SHARING Clinic and how often those who volunteer report volunteering at the SHARING Clinic per year.

Figure 4 .
Figure 4. Five-point Likert scale questions and proportions of responses

Table 1 .
Motivations and barriers reported This chart shows the motivations and barriers that physician reported impacting their choice to volunteer or not.Respondents could select more than one response.SHARING: Student Health Alliance Reaching Indigent Needy Group