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Features May 2007: Volume 4, Number 2

Community Medicine
Student-Run Free Clinic By Scott LaFee
Street Medicine By Maya Kroth

UC San Diego medical students and doctors bring health care to underserved populations around the city and county.

We had a bake sale to buy equipment. Everybody was there because they wanted to be there. It was our first chance to meet patients face-to-face, most without any health care. We treated them, advocated for them. We held their hands. We watched them cry. We got to see the power of healing.

Student-Run Free Clinic By Scott LaFee

The setting sun still glints golden yellow off the upper reaches of San Diego's skyline. Down below on the shadowed streets around First Lutheran Church at Third and Ash streets, people are gathering.

In the church's courtyard, men, women and children cluster in groups before entering a large room filled with chairs, tables and noise. It's Monday, which means the UC San Diego Student-Run Free Clinic is open. These folks have come in search of medical care, everything from treating simple sores and aching teeth to managing chronic, debilitating diseases like diabetes, hypertension and asthma.

The clinic, one of only 24 such programs in the nation, is run entirely by students from the UC San Diego School of Medicine, working under the direction of faculty and volunteer physicians, dentists and health professionals. There are, in fact, four UC San Diego student-run free clinics in the county. The first was opened in Pacific Beach in 1997, the vision of a group of medical students, and Ellen Beck, M.D., a clinical professor in the department of family and preventive medicine. They believed a free clinic was desperately needed to address the obvious, unmet health needs of a burgeoning homeless population.

"There was another goal, too," says Beck. "Medical students begin with a passion and a compassion that the system tends to eventually beat out of them. We try to nurture it, in part by teaching students how to be teachers themselves, to communicate and interact with patients in a way that is humanistic, honest and real. That's something they don't necessarily learn in a classroom."

Opening night of the first clinic in 1997 attracted 10 patients. Sunny Smith, M.D. '01, was a first-year medical student at the time. She is now an associate clinical professor of family and preventive medicine at UC San Diego and co-medical director at the clinic. She remembers the early days vividly.

"We had a bake sale to buy equipment. Everybody was there because they wanted to be there. It was our first chance to meet patients face-to-face, most without any health care. We treated them, advocated for them. We held their hands. We watched them cry. We got to see the power of healing."

From the first clinic, the program grew rapidly. The Lutheran Church location opened a few months after Pacific Beach. A clinic based at Baker Elementary School, in the Mountain View neighborhood of southeastern San Diego, debuted in 1998. The latest clinic, which opened in 2010 in Lemon Grove, is relatively new. It is also unlike the others, serving a very specific clientele: the predominantly low-income students and families of Golden Avenue Elementary. "It's a different model," says Smith. "We wanted to try to serve a community with very distinct and specific issues."

This past summer, a new free clinic opened in Tijuana, Mexico, the brainchild of fourth-year medical student Amy Epstein. It is a transborder collaboration with the medical school at the Universidad Autónoma de Baja California (UABC). Students from both UC San Diego and UABC run the clinic, under the supervision of Jose Luis Burgos, M.D., an assistant professor of medicine in the division of global public health.

Business is booming at the clinics. The economic recession has added more and different kinds of patients, "including former middle-class people who have lost everything," says Smith.

The U.S.-based clinics are open on specific days at specific times, limited by the number of medical students available. Approximately 250 students from the medical school and the Skaggs School of Pharmacy and Pharmaceutical Sciences serve more than 2,000 clinic patients each year, assisted by 100 volunteer physicians, dentists and pharmacists. "These are professionals who want to give back. They want to step back into their communities and help sick people who have nowhere else to go," says Michelle Johnson, M.D. '03, an assistant clinical professor at UC San Diego and co-medical director of the clinic. "Theirs is not just lip service about caring."

The singular rule of the clinic is that only the neediest patients are treated. If someone is eligible for health care elsewhere, students will help them get it, even providing assistance with the necessary forms. "This is a clinic for patients who have fallen through the cracks," says Beck, "who don't have anywhere else to go."

Clinic patients pay for nothing, including dental treatments. "We have two chairs," says Sussi Yamaguchi, Sixth '03, a local dentist, and co-director of the clinic's dental program. "We can take a tooth out, but we can also repair it. We can provide pretty much every service, except implants."

Most patients qualify for free prescriptions. The remaining prescriptions are low-cost, as little as $1.50 for a 90-day supply of some drugs. The clinic writes 12,000 prescriptions a year on a budget of $17,000. The bulk of the drugs are donated by pharmaceutical companies or subsidized by the School of Medicine.

"For many people, this is their last stop," says Eduardo Fricovsky, Marshall '02, who grew up in a poor neighborhood nearby and now oversees the clinic's pharmacy. "If they can't get the medications they need here, they won't get them anywhere. That causes a lot of desperation. I've seen people cutting prescribed doses in half to make them last longer, skipping days, licking the insides of bottles and, of course, just going without."

The sun has set and the church lobby thrums with patients registering for treatment, describing their ailments, symptoms and concerns. In a small room upstairs, the clinic's doctors, students and staff prepare for several hours of work-to-come. They won't close shop until every patient has been seen. A white board lists the patients waiting, their problem and the language they speak. Doctors and students survey the board. Patients will be sent to different parts of the church for clinical services.

As staff and students prepare, the room becomes warm and crowded, like a complete health system writ small. "I like the idea of having one place for people to go," says medical student Nat Minh Pham. "I like the idea that I can make sure people get the medical screenings they need, but also point them to the legal clinic table [a partnership with the California Western School of Law] downstairs if they need help there, too.

I like the idea of helping people get better not just in health, but in life."

Street Medicine By Maya Kroth

It's a chilly day in North Park, a revitalized community north of downtown San Diego, the morning after the first rain of autumn. A U-Haul-sized truck is parked in a lot behind Covenant Presbyterian Church, painted with a mural of cartoon doctors treating cartoon patients. The door of the trailer opens and out strides Chris Searles, Muir '92, M.D., a tall 41-year-old, with sandy blond hair worthy of a shampoo commercial and eyes the same shade as his crisply pressed glacier-blue shirt.

Last night's rain made for a rough night for the homeless people that this truck—a free mobile medical clinic run by St. Vincent de Paul and staffed by UC San Diego physicians—is here to treat. In the three hours the truck is parked here each Thursday, Searles and the UC San Diego intern he's supervising usually see about eight patients, but today there will be fewer. "Sometimes people are just drying out and they don't feel like taking three buses to go to the doctor," he says, rubbing his hands together against the cold. "But they know we're here."

The first patient Searles will see today in his 25-square-foot exam room at the rear of the truck is Laura (not her real name), who is in her late 40s and lives in a shelter. She is worried about the bruises on her shins. They are normal, right at coffee-table height, but Laura has been a patient here for a while, and Searles knows how she works. They'll talk about the bruises for a while first—checking and re-checking her blood pressure, ruling out more worrisome diagnoses like a thyroid condition or non-Hodgkin's lymphoma—before she can open up about the suicidal thoughts she's been having. The meds aren't working, she says, and she still hears the voices. Thinking about her family is the only thing stopping her from really doing it.

As co-director of the combined family medicine and psychiatry program at UC San Diego, Searles spends a lot of time teaching other doctors about integrating the mental and physical aspects of medicine. He is both a physician and psychiatrist, and the two days a week he spends working with the homeless requires both of those skill sets and more. "You have to learn to be part-psychiatrist, part- permanent-care doctor, part-case manager, part-social worker, all in one white coat," he says after Laura has gone. "Because if you're not, you're not doing anybody any good."

Treating these patients requires a doctor to adjust. "In a regular mental health clinic, if they're hearing voices, you might be able to write a prescription that can make them very sleepy," he says. "You don't want to give them that if they're outside, in harm's way underneath a bush, where they can get hurt if they're sedated. For the people that we're seeing, that math is very different."

Sarah, the UCSD family medicine intern working on the unit today, comes in to consult with Searles about her patient, Ray, a 28-year-old man who has never been to the clinic before. He's hearing voices, taking a variety of antipsychotic drugs and doesn't seem to remember much about his medical history other than being beaten up with baseball bats two years ago.

Like any good teacher, Searles quizzes his student—What happens if you put someone who has bipolar disorder on an unopposed SSRI? What's the diagnosis for paranoid schizophrenia with a mood disorder?—and she fields each question expertly, until one of them stumps her.

"So, what does he want to do?" he asks. She flusters. "What does he see for himself? What's the big picture?" "I'm not sure of all the details..." "Sometimes it helps to just get him thinking about it," Searles explains. "What do the next six months look like for you? What does a better life look like? Often they'll say, 'Nobody's ever asked me about that before.'"

Searles' approach comes from personal experience. He didn't figure out what he really wanted to do until relatively late in the game. As an undergraduate at UCSD, he was more interested in "exploring the themes of life" as a literature/writing major while his now-wife, Eleni Capetanakis, Muir '92, was on the fast track to a career in pediatric medicine.

"She basically said, 'If you want to hang out with me, you'd better get your act together,'" he says with a laugh. After graduation, he enrolled in the UC San Diego School of Medicine's postbaccalaureate program, completing in one year what some students do in two or three. He financed his education through odd jobs, loans and credit cards, and for a few months was so financially strapped that he even lived in his Honda Civic hatchback.

"Because I was a lifeguard, I knew where to park along La Jolla Shores Drive," says the six-foot-two Searles. "I would surf in the morning, take a shower with shampoo from the back of my car and then I'd go to class. Med school was a breeze compared to that year."

After finishing medical school at UC Davis, Searles began a five-year residency at the highly competitive program he now co-directs at St. Vincent de Paul, treating cases some might describe as hopeless. For Searles, it's just a matter of perspective.

"I see people that others might think are at the bottom, reasoning, 'how can you lose more than what this person's lost?' That person might've fallen through someone else's bottom five years ago, but they haven't hit theirs yet. They're just not ready to make a change."

Searles' attraction to underserved populations was not accidental. Raised by a single mother, he knew what it was like to have an earache and not want to tell mom because it would cost money. "I wanted to be the guy who could help people in that position not have to worry about that," he says.

Today Searles is dad to three daughters with Capetanakis: 8-year-old Ellie, 6-year-old Zoe and Kalista, almost 4. He still writes, and has one novel in the can and another in the works. He's fond of quoting from his favorite novel, David Copperfield, whose opening line informs his approach to patients: Whether I shall turn out to be the hero of my own life, or whether that station will be held by anybody else, these pages must show.

"We are partially responsible for writing our own stories," he explains. "And the people we surround ourselves with, whether they're loving and supportive or not, they also write pages in our book."

With Laura, Ray and 3,000 other patients writing pages in his book each year, Searles' own story is shaping up to be quite a tome. Some chapters are bleak, filled with stories of meth addiction, despondency, schizophrenia and dangerously out-of-control diabetes.

"There are people I see a couple of times and never see them again, and I wonder, 'Where are they?'" he reflects. "It's not just in here in the mobile unit. It's in La Jolla; it's in Scripps Ranch."

Are they hopeless cases? Searles, for one, is optimistic—maybe you have to be in his line of work. "I've seen people bounce back in incredible ways," he says. "I think there's always hope, for everybody."

Scott LaFee, is senior public information officer, UC San Diego Health Sciences Research.

Maya Kroth is based in San Diego and has written for New York Magazine, World Hum and the San Diego Union-Tribune.