What Drives Faculty to Volunteer at a Student-Run Clinic for the Underserved?

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Introduction
Despite the advent of the Affordable Care Act, the United States (US) is still home to approximately 30 million uninsured people. 1 Through student-run clinics (SRC), allied health students and faculty in medical schools across the country provide much needed care to persons who remain without health insurance.SRCs thus are potent contributors to a still necessary safety net.In a 2007 survey, 52% of responding medical schools had at least one student-run clinic managing acute illness and chronic conditions. 2 These clinics have been shown to improve students' expertise in working with the underserved and may increase interest in primary care. 3Working in a SRC also improves student attitudes toward inter-professional teamwork, 4 and provides unique opportunities to learn systems-based practice through experience that students report are valuable and unparalleled additions to their education. 5,6[9][10] Though the vast majority of patient care, staffing, and administrative organization at SRCs is performed by medical students, all clinics must have at least one supervising faculty physician. 11Volunteer physicians fulfill vital roles in the SRC by overseeing clinical care and also providing ethical and professional guidance required to protect vulnerable patients from substandard care. 12Students who recruit physician volunteers aim to attract faculty with a deep commitment to service, strong clinical experience, and the ability to focus on teaching while working in a busy clinic.Because physician volunteers precept in SRCs during off-hours, clinics strive for a large network of reliable physicians to ensure adequate staffing and prevent clinic closings.Thus, physician recruitment and retention are key considerations for all SRCs.
The East Harlem Health Outreach Partnership (EHHOP) is a student-run, attending-supervised free clinic sponsored by the Icahn School of Medicine at Mount Sinai that provides comprehensive primary care to uninsured residents of East Harlem. 7,8The clinic operates every Saturday and is staffed by medical students, two attending physician volunteers, a paid social worker and a nutritionist.Two additional faculty physicians and a nurse practitioner oversee student-directorship and daily medical care.The clinic provides prescription medications, medical supplies and laboratory tests at no out-of-pocket cost.EHHOP also operates several specialty clinics which provide services in gynecology, mental health, cardiology, and ophthalmology.Additional specialty care is available at low-cost through specialists in the Mount Sinai Health System; patients pay for services on a sliding scale income assessment.A few services such as screening colonoscopies, radiography, rheumatology, and dermatology consultations are provided at no cost.
EHHOP has a roster of more than 150 physicians, with 35 different physicians volunteering at least once between April 2014 and March 2015.Physicians receive information about volunteering from the student Physician Recruitment Chair.Each clinic date requires two board-certified physicians; one physician must be employed as an attending and the second may be a fellow or chief resident.The clinic continues to face significant challenges securing volunteer physicians on many dates throughout the year; recruitment can often be last-minute, desperate, and tenuous.
In this study we analyze the responses of faculty to a post-clinic survey assessing positive and negative experiences while volunteering at the clinic.The purpose of the study is to identify specific targets on which to base interventions enhancing physician recruitment.While a number of studies have focused on the appeal of SRCs to medical students, [3][4][5][6] to our knowledge no study has examined the physician experience at SRCs and the factors that contribute to continued physician volunteerism.The survey results should help SRCs across the country attract and retain qualified and passionate physician volunteers to ensure that these extensions of the nation's safety net remain open.

Methods
The EHHOP Physician Recruitment Survey was administered between January 2012 and March 2015 for internal Quality Improvement purposes.The study was determined to be exempt from internal ethics review based on guidelines provided by the Mount Sinai Medical Center Internal Review Board.Surveys were administered electronically (Google Forms) and sent by email to physicians in the week after they volunteered in clinic.To simplify study design and safeguard privacy, no personally identifying information was collected and the survey was not mandatory.An inherent limitation of this study design is that demographic information about the respondents (age, sex, medical specialty, etc.) cannot be determined nor can the possibility of multiple responses from the same individual be excluded.
The present survey evolved from a previous, pilot study administered by the EHHOP Quality Improvement Council, a student-led team tasked with improving clinic efficiency and effectiveness.The initial survey was sent to all active volunteer physicians (those on the physician recruitment mailing list) at a single point in time rather than longitudinally after clinic visits.This survey asked physicians to rank possible "incentives" such as "teaching dollars" (money disbursed by the institution to departments in exchange for teaching activity by faculty), CME credits, and babysitting.This preliminary study was based on the assumption that incentives are an important factor in physician recruitment.In part to test this assumption, the present study was designed to gain a more accurate and complete understanding of physician attitudes toward volunteering in the clinic.
The present survey consisted of ten questionstwo yes/no and eight free text (Table 1).None of the questions were mandatory meaning that physicians could select which specific questions they wanted to answer.The free text answers were analyzed individually and then categorized into key themes for the sake of simplicity.The categorization was performed by student researchers based on the presence of similar words and ideas, such as "working with and teaching students" or "babysitting services."In order to be listed as a key theme, a threshold value of 3 survey respondents needed to provide the same response.Responses listed fewer times than this are included in the "other" categorization.The purpose of this threshold is to improve readability of the data tabulation.

Survey Completion
Forty five surveys were completed between January 2012 and March 2015.Of these respondents, 6 of the 45 were first time volunteers.All 45 respondents indicated that they would volunteer at EHHOP again in the future.
The response rate for each individual question varied.The most answered questions were "what did you enjoy about volunteering at EHHOP" with a response rate of 100% and "are you satisfied with the caliber and quality of our student clinicians" with a response rate of 96%.Questions "Further comments or advice?" and "Is there anything that could have made your experience better?" had the lowest response rates of 18% and 51% respectively.Response rates for all questions are in Table 2.

Survey Responses
Results of the physician-focused questions are listed in Table 3.The top reason given for why physicians enjoyed volunteering at EHHOP was working with and teaching students (N=40).The other two significant reasons were working with underserved patients in the community (N=19) and the well-managed and efficiently-run clinic (N=9).There were a few different suggestions on specific Free text survey responses organized by key themes and listed in descending order of frequency.
incentives that could be implemented to encourage additional volunteering including babysitting services, time off/credit, and credit for promotions.The most popular suggestion for improving clinic flow was to have increased focus on time management and communication with preceptors (N=5).
The results of the student-focused questions can be found in Table 4. Overall respondent satisfaction with the quality of students who volunteer at EHHOP was high, with 43 respondents stating that they were satisfied with the caliber and quality of the student clinicians.First/second year students were asked to participate more (N=3) while third/fourth year students were encouraged to focus on details of outpatient management and patient education (N=6), as well as improving case presentations (N=2).

Discussion
In this study we showed that several key factors are crucial to securing ongoing physician support of an SRC.Many clinics struggle to obtain sufficient faculty staffing 13 and with doctors taking on larger patient loads with increasing financial constraints it can be difficult to find the necessary number of volunteers. 14,15Our study looked to identify additional motivators for volunteerism.Though students are heavily involved in both operations and clinical care, SRCs simply cannot operate without attending physicians.Therefore, all SRCs must focus on the sustainability of their physician volunteer pools; aspects highlighted in this study could steer interventions that improve recruitment of new volunteers and retain existing contributors.The survey results show three major reasons why physicians volunteer at SRCs.Firstly, they enjoy working with the medical students, secondly, they want to volunteer in underserved communities, and lastly, they enjoy volunteering in a well-run clinic.These results provide key insight into what it takes to maintain robust physician engagement at an SRC.
All 45 respondents indicated that they would be interested in volunteering at EHHOP again.This implies that regardless of other reservations the physicians may report in their survey responses, physician volunteers truly do value the opportunity to participate in an SRC.Nearly all physicians (N=40) reported that the ability to work with and teach medical students is one of best parts about volunteering at EHHOP.Additionally, 43 responses from physicians expressed strong confidence in the caliber and quality of student clinicians.This suggests that physician recruitment and the quality of student volunteers go hand-inhand.While anyone can volunteer at EHHOP, the work is rigorous and not part of the required curriculum which may attract more motivated and capable students who are able to handle the extra work.There are also specific programs based at the clinic in which students interested in primary care undergo an extensive application process and once accepted are required to volunteer at EHHOP a certain number of times per semester.This merit based selection process likely contributes to the strong group of students noted by the responding physicians.
In addition to the opportunity to work with medical students, the physician volunteers also reported that the opportunity to treat an underserved patient population is a major incentive for clinic volunteering.This answer was provided by 19, or 42% of the respondents, and was the second most popular answer.At the same time, a number of physicians expressed interest in further incentives including babysitter services, additional time off, and credit towards promotions.There are some examples of SRCs that offer additional physician incentives, and even clinics that provide care to insured populations where physicians receive financial reimbursement. 16However, financial constraints make it difficult for most clinics to offer any substantial incentives even those such as babysitting.It therefore may be higher yield for clinics to focus on the first two items -ensuring high quality student volunteers and providing access to an underserved patient population -rather than focusing on other incentives which may be difficult to implement and finance.
A well-managed and efficiently-run clinic was the 3rd point physicians provided for enjoying their volunteer experience.This was given by 9 (20%) of the respondents.As covered above, physicians appear to volunteer in order to focus on student education and patient care.As such, the luxury of not having to worry about clinic flow and administrative duties must certainly be appealing.Yet, there were still a number of suggestions given as to how clinic flow could be improved.Physicians wanted student leadership to better communicate with the preceptors, and to focus more on time management of patient encounters.Additional and more focused training has been added addressing communication to ensure that preceptors and students are on the same page.Additionally, all students come into clinic an hour before it begins in order to learn about a common topic in primary care, but also to review policies, procedures, and clinic workflow to help ensure the clinic runs on time.On a related note, a number of physicians noted that there tended to be a buildup of patients waiting to be seen at certain times, and that it may be helpful to stagger appointments, schedule fewer patients, or have additional preceptors.Our clinic has already begun to incorporate some of these suggestions, specifically focusing on scheduling patients appropriately to eliminate any bottlenecks.Improvement in this area will be tracked to ensure that the changes are having their desired impact.Continuing to incorporate physician suggestions on clinic flow will be of great importance going forward, as the survey results seem to indicate that a smooth running clinic is one of the main features that keeps the physicians coming back to volunteer.This study has several major limitations.First, the number of responses obtained for the study was limited (N=45).As we continue to administer the survey at EHHOP we hope to boost the number of respondents.Second, given the anonymous nature of the survey we are unable to determine if duplicate surveys were submitted.Although this is a serious limitation, the survey was administered over multiple years, during which a wide array of physicians volunteered.Additionally, the nonmandatory, anonymous survey design is vulnerable to sampling bias: the attending physicians who respond may be biased toward those most enthusiastic about the clinic.However, in a resource-limited context where the emphasis is on patient care, simple online surveys are a valuable data collection tool.Finally, this study is limited to a single SRC from a single institution; future studies on physician incentives should look at responses across multiple sites to improve generali-zability.Similarly, we only surveyed physicians who were already volunteering at EHHOP.
The EHHOP Physician Recruitment Survey has proven a valuable tool in providing insight into the factors that make physician volunteerism at SRCs attractive and encouraging beyond traditional work incentives.All of the physicians who completed the survey indicated they would volunteer again given the opportunities to teach passionate students, provide care to an underserved community, and work in a well-managed and efficientlyrun clinic.Physicians also had suggestions related to outside incentives such as increased time off and babysitting, but these may be quite difficult for some clinics to implement.The survey results suggest that even without outside incentives physicians can be enticed to volunteer if the clinic experience itself is optimized.
Over the past two years, EHHOP has succeeded in cultivating support from a large group of volunteer physicians with zero clinic cancellations related to staffing issues.This is in stark contrast to our past experience in which clinic cancellations due to physician non-presence numbered 2-5 per year.The increase in physician attendance is due to the work of a number of student physician recruitment chairs who have improved outreach and clinic awareness thereby increasing the number of physicians willing to volunteer.Additionally, recruitment chairs have helped implement changes to clinic flow which has made the volunteer experience smoother and helped improve physician retention.EHHOP has created a robust student recruitment arm to ensure that skilled and motivated students routinely staff the clinic, and the student leadership works to disseminate the message to faculty about the efforts of students in providing the highest quality care and compassion to the most vulnerable in the community.Continued faculty retention and growth requires SRCs to build infrastructure, augment funding, and improve clinic flow to provide care to patients in a time-efficient and organized manner with high quality care and advocacy as central efforts.If the experience is valuable, worthwhile, efficient and well publicized, SRCs should be successful in establishing a strong network of physician volunteers who can also act as ambassadors to recruit additional faculty.

Table 1 .
Physician Survey Questions

Table 2 .
Survey Completion

Table 3 .
Physician Clinic Experience Free text survey responses organized by key themes and listed in descending order of frequency.To be considered a key theme, at least three survey respondents must have listed a given response.Responses listed fewer than three times are classified under "other."

Table 4 .
Student Assessment