The disparity in HBV prevalence between APIs and the general population, coupled with San Francisco’s demographics, presented an opportunity for students to create a preclinical curriculum that simultaneously: (1) provided a needed service to the surrounding community and (2) educated health professional students about engaging in community advocacy and addressing health disparities.
There is a growing emphasis in health professional schools to incorporate community-based and patient care experiences early into the preclinical curriculum20,21
. Creating a structured, service-learning elective allowed our students to work with an underserved community soon after entering graduate school. Health professional students often come from backgrounds where volunteerism is valued and expected, especially in settings of helping vulnerable persons, and many students are eager for direct patient contact early in their health professional programs22
. In a survey of 49 medical schools with one or more student-run clinics, the most commonly cited reasons for student volunteerism included opportunities to serve the poor, interact with patients, and learn clinical skills23
. Our curriculum also allowed students to gain an early understanding of clinic operations and to take an active role in a larger citywide public health intervention addressing a health disparity.
Our outreach efforts, using language-concordant methods, successfully reached our target population, as the majority of our patients were API immigrants with limited English proficiency and low socioeconomic status. Given these language and financial barriers, such patients often suffer from poor access to care and subsequent poor health outcomes24–27
. In fact, limited English proficiency has been suggested as the largest barrier to successful management of chronic HBV infection—a potentially treatable condition—ultimately putting patients at risk for complications of liver disease and furthermore posing a potential public health hazard for disease transmission24,28,29
Community-based outreach efforts and screenings have been shown to be effective strategies to promote HBV knowledge and awareness among API populations15,30,31
. Our 90% completion rate for the three-shot HBV vaccination series was higher than reported in the literature32,33
. This success may be attributed to intensive patient education during initial screening encounters and return visits, follow-up phone calls to patients who missed return visits, as well as culturally appropriate and language-concordant patient materials and telephone scripts, which have been shown to improve vaccine compliance rates34–36
. A major challenge experienced by other community HBV screening programs has been ensuring follow-up care, particularly surveillance for disease progression and initiation of antiviral treatments for HBV-infected individuals37
. We addressed this issue largely through our partnership with the community-based Chinatown Public Health Center, where we provided HBV-infected individuals with initial follow-up and referrals to specialty clinics.
The majority of students were of API descent, mirroring the ethnic makeup of the patients. This inherent interest of API students to learn about and address disparities within their own ethnic community is important, as race-concordance between patients and providers has been shown to improve health care outcomes38–41
. This may partially explain the high proportion of student participants from the pharmacy school, which has a high enrollment of API students. Pharmacy students were likely also drawn to the elective as it was one of their few opportunities for sustained patient interaction and involvement in clinic operations. Preclinical medical students had many competing electives from which they could choose, including those with direct patient contact, and thus, it is promising that so many students were interested in this elective.
A unique aspect of the curriculum was its emphasis on interprofessional collaboration in the clinics and on the leadership board. During clinics, we attempted to create interprofessional pairs for all aspects of patient care, allowing students from different health professions to learn from one another. Ultimately, we believe this allowed for productive teamwork, development of mutual respect, and shared learning among students from different health professional backgrounds, outcomes which have been borne out in other interprofessional clinical settings42–44
While our curriculum was successful in its broad scope of community outreach and student involvement, we faced challenges in its development and implementation. Finding permanent clinic sites for the clinical practicum took 3 years, requiring faculty, institutional, and community support, student-written grants, and student persistence. Although our initial grants enabled us to provide free screening and free or low-cost vaccinations to all of our patients, long-term sustainability of our clinics will require additional funding. In terms of quality of care, although enrolled students participated in two clinical skills training sessions, all but a few were novices at performing phlebotomy and intramuscular injections. Therefore, balancing student learning and patient discomfort, an ethical dilemma of many student-run clinics, required vigilance from student coordinators and clinic preceptors45
. For clinical procedures, we paired students with different experience levels, hoping to enhance both student and patient comfort. Finally, ensuring a consistent flow of patients into each monthly clinic required regular promotion within the API community, which we were able to do successfully through partnerships with community-based organizations and the city’s DPH.
A limitation of this curriculum is that during the first year of the permanent clinics, we did not formally survey students or patients about their experiences, although students conducted volunteer debriefings after each clinic. We have since begun to evaluate the impact of the curriculum on students’ knowledge and attitudes toward health disparities and interprofessional education, and to implement a formal reflective component into our service-learning curriculum. We will also evaluate the effect of our clinics on patients’ knowledge and their attitudes toward student-run clinics.
The challenges to developing an interprofessional service-learning curriculum were not insurmountable and are akin to common challenges reported by other student-run free clinics throughout the country—each requires careful planning, preparation, faculty involvement, and community and institutional support46,47
. Student engagement was critical to overcoming many of our challenges, as students’ collaborative energy, enthusiasm, and perseverance resulted in fruitful outcomes, such as bringing together faculty and community groups and securing funding. Similar to how the voluntary, student-led nature of service-learning programs at Rush University were fundamental to their success over the past 2 decades, we believe our integrated didactic and experiential service-learning curriculum will continue to flourish under student leadership12
. Our successes support the idea that engaging preclinical students in health screenings, outreach, and advocacy is one powerful way to reduce health disparities while training students to address them11