Physician assistant volunteers belong in free clinics

Ann Davis, PA-C

The author is Director of State Government Affairs at the AAPA.

About 15 women and two men (the customary ratio in my experience) sat around tables that were covered with blond Formica in the music room of my son’s middle school. It was the monthly meeting of the Music Boosters’ club. Our job was to raise money so that this public school can have a music program.

A woman by the dry-erase board was giving a presentation on a new fund-raising activity. People purchase tea on a Web site, and a portion of the profit is donated to a designated school arts program. She gave a tedious description of the product and packaging. “And we’re going to include relevant facts and quotes on the packages,” she said. “Things like, ‘Students who play an instrument do better in math,’ and ‘Arts education helps students develop a positive work ethic and pride in a job well done.’ ”

The mother in the next chair leaned toward me. “How about replacing all those ‘relevant facts and quotes’ with ‘Repeal Prop 13?’ ” she whispered.

We were actually all attending this meeting because of “Prop 13.” Although California has a full-time legislature, our state still seems to do the important law-making by ballot initiative—also known as the blunt-instrument approach. In 1978, California voters passed Proposition 13 by a slim 53% to 47% margin. The proposition decreased and restructured property taxes and made other changes in the state’s ability to tax its residents. Schools have borne the brunt of the resultant chronic revenue shortfalls. We need the Music Boosters because of Prop 13. If Prop 13 were repealed, we could forget about selling tea and go home and actually listen to music.

PAs and free clinics

In this issue of JAAPA, Talmadge and Joslin present a comprehensive view of the free clinic movement in the United States and of the barriers to the full participation of physician assistants as volunteers in clinics designed to care for the uninsured and underinsured (see “Barriers for PAs volunteering to serve indigent populations”). The current need for free clinics is indisputable. Forty-five million people in the United States are uninsured.¹ People without health insurance live sicker and die younger than those who are not faced with similar economic barriers to health care.²

Our profession was founded on the notion that PAs could assist physicians in extending health care into areas of need. PAs should be fully utilized in free clinics. This is, in a sense, our birthright as a profession and an obligation stemming from our origins. It is the professional identity equivalent of noblesse oblige.

Not only are PAs obligated to volunteer in free clinics, we are ideally suited to this kind of work. The generalist focus of PA education, coupled with the profession’s acceptance of the concept that the PA career path may include more than one location or specialty, facilitate our ability to fit in easily and hit the ground running in a free clinic.

As a profession, PAs have proved to be adaptable. Those who are attracted to the PA career are, in general, willing to deal with some degree of challenge and uncertainty. PAs tend to be creative problem solvers. Squeeze one more kid into a full schedule? Scrounge for samples in the cupboard if a patient isn’t able to pay for medication? Do a home visit? We tend to say Yes. These tendencies and skills make PAs ideal for the complexities associated with providing health care in free clinics.

PAs should volunteer because everyone should volunteer. People should bake a pie for a sick neighbor, sing in the church choir, swing a hammer for Habitat for Humanity, or provide health care at a free clinic. Volunteering is not only good for the recipient of the pie, the song, the house, or the medicine, it is enormously enriching for the volunteer.

PA volunteers belong in free clinics. Barriers in a number of state laws inhibit the full utilization of PAs on free clinic provider teams. Talmadge and Joslin provide a compelling rationale and recommendations for amending state laws. The changes they advise (based on the Academy’s Model State Legislation³) would not only improve PA availability in free clinics, they would facilitate flexible utilization of the members of our profession in a wide variety of settings.

So what’s wrong with this picture?

As health care providers, we have a duty to do our best for each patient we encounter. We enter into a covenant with the patient. We are bound to give them our full attention, the benefit of our entire intellectual and clinical inventory, our compassion.

This part is actually easy. It’s what we are born for, what we love. The hard part is what to do about patients as a group. When an apostrophe moves, it gets complicated. We generally know what to do to meet a patient’s need. Patients’ needs are vastly more complex. A PA volunteering at a free clinic will know what to do for a patient who presents. But what do we do about all of the patients who turn to a free clinic for their medical care?

Free clinics staffed by volunteer providers are an essential part of the health care safety net. But they must be seen only as a short-term solution. The reason patients need free clinic care is that the American health care system has failed them. Free clinics are fine for treating minor trauma, upper respiratory tract infections, and gastroenteritis. But no one would defend them as the ideal place for treating a patient with diabetes or cancer. Free clinics should exist, and PAs should volunteer in them. But we must not accept volunteerism in free clinics as the solution to the inequitable distribution of health care resources in the United States.

It is so tempting to be immobilized by this issue. The problem seems so big, the solutions so complicated, and the political will to enact change so small. But the first step toward change is agreement that the status quo is wrong. And it is wrong. It is medically wrong, and it is morally wrong. Forty-five million people are uninsured. Shame on us.

Should PAs volunteer in free clinics? Absolutely. Should we change state laws to allow this to happen? Without a doubt. Is that enough? No.

So what can we do? We can start on the bigger problem by looking it in the eye. Even without consensus on a solution, we can elevate the importance of the problem of the uninsured. Everyone can assist with enhancing its visibility. The methods to do this are legion.

So volunteer at the clinic and write to your Congressman. Bake a pie and talk to your neighbors.

And the Music Boosters? We will sell the tea, and we will start a “Repeal Prop 13” petition drive.

REFERENCES

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