Service Learning in a Homeless Clinic

As long as medical education has existed, it has provided care for the poor. The relationship between students needing experience and patients needing services should be mutually beneficial, but there is always the danger of abuse or exploitation. For example, concerns about “learning on” the poor were given eloquent expression by George Orwell in his essay “How the Poor Die.”¹ They resurfaced in the United States during the sixties as part of the rising social consciousness of poor communities.

To address these concerns, medical educators are developing new methods that promise a solution to the seemingly insoluble dilemma of balancing the needs of patients with the needs of learners. “Service learning” is one term used to describe these methods. Service learning couples community service with formal teaching about that activity. When educational goals are centered only on increasing the learner’s knowledge and experience, the relationship between student and patient will be one-sided. Service learning focuses on skills and attitudes as well as knowledge and thus has the potential to break down social and cultural barriers between patients and health professionals. Instead of learning at the expense of the poor, with proper pedagogical guidance, students and faculty can learn from, with, and for the benefit of the poor.

Medical educators only recently have been giving service learning the attention it deserves. Now that they are, they need data to move beyond platitudes, opinions, and rhetoric to design service-learning experiences. For this reason, the Center for Research on Health Care at the University of Pittsburgh is to be commended for its report in this issue.² The authors describe how a required experience in a homeless clinic motivated primary care residents to continue volunteering in the clinic after their rotations were completed. They also describe the attitudes of the medical students who volunteered to work in homeless shelters.

As useful as it is, the report illustrates how difficult it is to do academic work in this field. There is not a lot of precedent, and the setting where the work must be done is complex, hectic, and changing. Because of these issues, there is much more we need to learn. The intervention for residents was a brief 15 hours, and it is uncertain what it was about this intervention that motivated residents to volunteer. It could have been the intensity of those 15 hours or role modeling by the faculty. It could have been simply that the experience helped residents understand how concern for the health of the homeless can be a legitimate sphere of interest for primary care physicians. Perhaps it was the patients themselves, who shattered stereotypes, taught the residents the influence of socioeconomic issues on health, or simply said “thanks” (a far too infrequent occurrence on most inpatient services). I finished the article wishing I knew more about the faculty and the patients.

I also wanted to know more about the medical students. I wanted to know, for example, how many volunteered in an effort to enhance their clinical skills. This reason for volunteering is valid, as long as patients are well-served in the process. In fact, experiencing what it is like to be a doctor in service to the underserved is an important antidote to the drudgery of being a first- or second-year medical student, just as service learning is an enhancement to the rest of the curriculum, which emphasizes rote memorization. Service learning teaches biomedical facts, but because of the opportunities for beneficence, collegiality, and social responsibility, service learning just might be the most important part of a volunteer’s medical education. How ironic that students received no credit for volunteering.

Finally, I wanted to know which services the students and residents provided and how they were accepted by the patients. Volunteers must be willing to do tasks that are not part of their usual responsibilities. These responsibilities range from treating medical problems outside the volunteer’s specialty to nonmedical activities, such as collecting medicines for the clinic dispensary, filling out disability forms, and transporting sick patients to and from the hospital. The more that volunteers practice differently than their colleagues who treat the very poor at most teaching hospitals, the more these services will make a difference. When service learning works, patient satisfaction and learner satisfaction are mutually intertwined, which may explain why such a brief exposure to service learning in a homeless clinic so profoundly promoted future volunteerism.

The homeless represent a dramatic, poignant subgroup of a much larger population of poor uninsured, whose health care needs are going largely unmet. In academic circles, there is talk of developing a “fourth leg” to the traditional academic missions of teaching, clinical care, and research-community service. To my mind, it seems long overdue that faculty who teach and role model community service should be recognized for their effort. If we do not teach social responsibility to our students and residents, how can society be assured that our profession will extend its healing art to all its members? I hope we will be reading a lot more about service learning in the future.