Hi Guys,

Hope you're all well. Thought it'd be good to try and spark some discussion. So....

A big dilemma I often face as a student volunteering with vulnerable populations (homeless people, asylum seekers/ refugees, those trapped in poverty in developing countries) is that as I student I have plenty of enthusiasm and find myself diving in and trying to help as much as I can, however I may lack experience and expertise in doing this. With the best will in the world, can this cause harm? How can we reduce this risk? And is there any way we can evaluate our input to modify it in a way that may help more?

Does anyone have any thoughts/ comments/ stories/ examples/ further questions?

Lucie

Post edited by: Lucie P, at: 2008/02/29 11:54

Post edited by: Lucie P, at: 2008/02/29 11:54

Hey everyone,

I share in the sturggle Lucie Speaks about and am always up for some good discussion. As student volunteers, I do believe we can and often do cause harm to the populations we volunteer with. We tend to fall on the more passionate, enthusiastic, opinionated side of most issues that affect the populations we work with. But in the idea of education, mistakes, while they should be limited, are often accepted as part of the process. What classes have ever said only people who are 100% correct will move on? In medical school, what student by the time clinicals are finished hasn't improperly pulled a chest tube or missed a pertinent detail on an H&P?

My question pertains to acceptable risk. There will always be some amount of risk to harm when we volunteer. How much volunteer time do we sacrifice to educate ourselves and reduce risk? Or is the question how much education do we sacrifice to volunteer, learning on a higher curve, but increasing the risk of harm to the population?

Where is the balance between keeping our passion while working in the field and educating ourselves?(whether it be by classroom, a more secondary hands off role in the field or developing relationships with seasoned volunteers)

It would be great, as Lucie put it, to hear any other thoughts/ comments/ stories/ examples/ further questions yall might have.

Hope yall are all doing well,
-Kevin

Hey Lucie and Kevin,

These questions remind me of a comment a student made during reflections at our clinic ("Reflection" is the period at the end of the clinic day when students discuss their impressions and experiences). The student was upset because she felt we were allowing medical students to practice medicine at an inappropriate level with a population that was not in a position to refuse our services. It struck me, at the time, as being an overreaction. Now I find myself wondering the same thing sometimes. How much do we help a patient who gets diagnosed and referred but never gets into a system for follow-up? What if a diagnosis is just wrong?

I tell myself that what really matters is that we have people there every Sunday who care and want to help. That is the best way we can deliver aid to those who need it. Then it is just a matter of converting intention into outcome (no big deal right?), and the clinic does a great job I think. Certainly I think there are things we can do individually to reduce harm to our patients (like be the best students we can be and not acting without preceptor supervision). Primarily, I've found myself interested in the organizational/structural means to ensuring good care is provided (its a public health thing)... I'd love to hear what kinds of thoughts other people have on this, or problems they've run into in their own programs.

Thanks,
Ben

Hey everyone,

some really good points raised by Ben and Kevin.

Ben I was wondering if you could elaborate on "the organizational/structural means to ensuring good care is provided"? Do you mean by this a sort of macro analysis or audit of the care provided? Mainstream medicine constantly has to audit and review its practices- shouldn't this quality control also be afforded to vulnerable populations? This could not only provide evidence for concerned people such as the student Ben mentioned, and be able to quantify that what we do is within "acceptable risk" as outlined by Kevin, but also to ensure our efforts and energies are focused on areas where we can do most benefit.

Come on people jump in the debate!

Hope everyone's well, England finally has some sunshine!

Lucie

Again I apologize for missing this post.

I just spent a long time developing a response and it didn't post correctly. I'll try again:

First, I really agree, and love your comparison of mainstream and street medicine. The concern was that of a lack of safeguards I suppose, something that is well-used (over-used according to some) in other areas of health care.

Evaluations, chart reviews etc. are one way to do this. Around the time your reply was posted, we were in the middle of developing a patient satisfaction survey for the clinic which could be used to give us an overall report on patients' impressions of the clinic and also immediately identify any negative experiences that we could respond to. We can ask John and others now running the clinic how that is going at the conference...

Structural/organizational means for ensuring quality care also refers to systems in place to provide checks to medical decisions and protect patients. For example, in a field where a complete medical history is a fictional concept, it is possible that care is not as targeted as it might be. Although efforts like Dr. Buck's tablet-PC EMR (a structural means) that we saw at the last conference are making complete histories more tangible now.

I also, personally, believe that having public health (and social work) students in the clinic is another example of these (organizational mechanism), but that's for another time.

Ben

Post edited by: benking, at: 2008/09/06 22:02

Sorry too for missing this thread. Thanks for talking about this stuff, it is really awesome.

By the way, Ben, I feel your pain. My post was also just erased so I’m writing it all over again.

I agree that we must really think about the damage we have the potential to do without proper knowledge or experience. Although I have less of the medical side to offer, I have a story I’d like to relate. While working with Operation Safety Net, I was on rounds with 2 other students. We approached a very shy woman, who at the time was leaving a church. We greeted her and told her who we were and asked if she needed any help. She rushedly replied, “I know where you are, I’ll come to the office when I need anything,” and literally ran out of the church. Later, she called the office to tell them, “Please don’t follow me anymore.”

I felt horrible. What had we done wrong? Why wouldn’t she want help? We were just trying to reach out to her and offer her socks. She clearly did not want our help, and maybe we had made it worse by approaching her. Initially I was totally frustrated, not understanding what had happened, or what we could have done differently. Everyone decided that we would just have to give her some space.

Although I thought we had totally screwed up all hope of reaching this person, after a few weeks, the woman voluntarily came to the medical van for help with her feet. We simply had to respect her need for privacy, and I was forced to recognize people’s need for control over their lives. When we allowed her to seek help on her own terms, she did. In the end, no permanent “harm” was done to this woman; in fact, what seemed like an “error” really became a way for us to better understand a person’s desire to be alone and independent. I came away with a new sensitivity to privacy and autonomy, which I have come to see are key in outreach.

Basically, I think it is important for us to recognize that we are here as students. The interactions we have on the street now are going to help us help others in the future, and hopefully, the experiences we gain from the classroom of the streets make up for the mistakes we make along the way.