Research Report

Examining the Educational Value of Student-

Abstract
Purpose Initiative by University Students SRC situations unlike those offered in
Student-run clinics (SRCs) are increasingly at the University of British Columbia classroom and case-based learning
recognized as an educational experience in participated in 2 focus group interviews: environments—students gained insights
many health professions’ curricula. Several the first after their first clinic day and into the intricacies of incorporating
benefits have been documented, including the second on their final clinic day. the patient’s perspective into their
students with SRC experience using patient- Open- and closed-ended questions were definition and management of the
centered approaches to care, showing used to explore participants’ learnings patient’s problem, and (2) by working
interest in working with marginalized from the SRC. Using a grounded as a team instead of focusing on
populations, and more fully appreciating theory approach, the authors iteratively delineating scopes of practice, students
the care provided by interprofessional analyzed the transcribed interviews, gained a meaningful understanding of
teams. Yet, few studies have explored adjusting questions for subsequent focus the roles of practitioners from other
student experiences within SRCs or groups as new themes evolved. Three health professions.
examined how these experiences affect investigators each separately coded
and shape these documented attitudes. the data; the full team then collectively Conclusions
This study explored the experiences of consolidated the themes and developed This study provides insights into the
students at an SRC and the effect of these explanatory models for each theme. unique opportunities SRCs offer
experiences on their learnings. health care students early in their
Results training, enabling them to develop a
Method Two themes were identified from richer understanding and appreciation
From November 2016 to July 2017, the focus group input: (1) through of holistic and interprofessional
23 students in the Community Health managing real, complex patients—in approaches to patient care.

S tudent-run clinics (SRCs) are health address several key objectives in health increased students’ likelihood to work
care clinics in which interprofessional professions education. These objectives with underserved populations, 2 increased
teams of health care students engage include an improved understanding of their knowledge of the responsibilities
in the primary care of patients who are the patient experience in marginalized of other professions, 3 and cultivated
typically from marginalized populations, populations and an increased empathy. 9,10 However, there are few
with licensed preceptors available for commitment to future engagement studies in the literature exploring how
consultation. 1 SRCs allow teams of with these populations, 2 greater students’ experiences in the SRC produce
students early in their clinical training patient centeredness and enhanced these changes. The intent of our study,
to engage directly with patients without understanding of the holistic approach therefore, was an in-depth exploration
preceptors taking a primary role in the to patient care, 2 and improved skills and of the experiences of students in a
interaction. Because they enable clinical attitudes related to interprofessional longstanding SRC to better appreciate the
acclimation and exposure to marginalized collaboration and teamwork. 3 nature of what students learn through
populations early in students’ training in their participation and the processes that
the context of interprofessional learning enable this learning to take place. Our
Although SRCs first arose through the
teams, SRCs are uniquely positioned to primary goal was to understand what
initiative of small groups of students
approaches used at the SRC were working
motivated to better serve marginalized
Please see the end of this article for information well and contributing to the changes in
populations, they are increasingly an
about the authors. participants that have been documented
accepted part of health professions
in previous SRC outcome studies.
Correspondence should be addressed to Kelly education. 4 A 2007 study in the United
Huang, Department of Emergency Medicine,
University of British Columbia, Diamond Health States documented that 49 out of 94
Care Centre, 11th Floor, 2775 Laurel St., Vancouver, schools that had responded to a survey
British Columbia, Canada V5Z 1M9; email: kelly. had at least 1 SRC, with 111 such Method
huang@alumni.ubc.ca.
clinics identified in total. 1 Despite the As our goal was to understand how
Acad Med. 2021;96:1021–1025. increasing popularity of these clinics, experiences in the SRC context generated
First published online January 12, 2021 however, many publications about the learning outcomes that students
doi: 10.1097/ACM.0000000000003922
Copyright © 2021 by the Association of American
SRCs are predominantly descriptive. 5–8 had reported in previous studies, we
Medical Colleges The few studies that have examined employed a constructivist grounded
Supplemental digital content for this article is the outcomes of SRC experiences for theory approach, which uses inductive
available at http://links.lww.com/ACADMED/B64. students have demonstrated that SRCs reasoning to build a theory around data

Academic Medicine, Vol. 96, No. 7 / July 2021 1021

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Research Report

generated from complex cognitive and by a physician preceptor and indirectly see Supplemental Digital Appendix 1 at
social processes. 11 We started the study supervised by preceptors of each of the http://links.lww.com/ACADMED/B64.
without well-formed theories about SRCs other professions represented on the
or their effects on learning for students student team, who, though not present Analysis
in interprofessional teams. However, for the patient interview, are available to Each focus group discussion was
because constructivist grounded offer guidance during the consultation audiorecorded on a secure recording
theory places value on the subjectivity and recommendation portion of the device and transcribed by K.H. and
of investigators as they interact with shift. This approach is designed to give M.M. onto a password-protected
participants and make meaning from students maximum independence computer. We removed all identifying
participants’ narratives, it is important and responsibility. Participation in the information about participants, except
to note that, at the time of the project SRC is voluntary. No assessments of for scopes of practice, and used codes to
(November 2016 to July 2017), 2 of the performance are conducted, but students indicate each participant’s professional
investigators (K.H. and M.M.) were who complete the experience are given program. Consistent with grounded
second-year medical students in the interprofessional education (IPE) credit theory methodology, we analyzed
University of British Columbia (UBC) in their professional programs. transcripts iteratively throughout the
medical undergraduate program and data collection period. Analysis began
were involved in organizing patient Procedure with 3 members of the research team
experiences for the student teams We recruited teams of participants during (K.H., M.M., and H.M.) each separately
at Community Health Initiative by the first day of their orientation to the SRC. coding the transcripts and developing
University Students (CHIUS). At that We gave all team members an information themes to enable multiple perspectives
time, they were mentored by H.M. (a sheet explaining the study; they could then on the data to emerge. As a team, we
UBC clinical faculty member associated ask questions and complete the informed then consolidated the themes through
with CHIUS) and received additional consent form. Declining to participate discussion; these themes guided the
guidance from G.R. (a researcher in in the study did not affect their ability to direction of subsequent focus group
health professions education with no participate in the SRCs. interviews. Through our iterative
direct affiliation to CHIUS). analysis, we adapted the focus group
We conducted 12 semistructured focus questions to expound on themes that the
This research was approved by the groups, 2 with each of the 6 teams we participants had not discussed in depth.
UBC Research Access Committee at had recruited. We conducted the first Upon completion of data collection,
the Faculty of Medicine and the UBC focus group after each team’s first shift we revisited the themes as a team and
Behaviour Research Ethics Board together and the second after their third generated explanatory models. We used
(certificate H16-02092) and carried out in (final) shift together. Conducting 2 focus Microsoft Word 2013 for Windows
adherence to their guidelines. group sessions with each team allowed (Microsoft, Redmond, Washington) for
us to further examine the topics that had data transcription and coding.
Educational context arisen from the first session as well as
CHIUS is an extracurricular program to identify any additional learning that
created by UBC students that offers may have taken place. Each focus group Results
learning opportunities to health care was composed of 4 to 5 students from We conducted 2 focus groups for each
students, including workshops and different health disciplines (medicine, of the 6 participating teams—the first
SRC placements. CHIUS, established in pharmacy, occupational therapy, social after the team’s first SRC shift together
1998, was the first Canadian SRC4 and work, and nursing). Either K.H. or M.M. and the second after their final shift.
is currently situated at Three Bridges conducted the focus groups. Not all team members were present for
Community Health Centre located in the interviews, resulting in a total of 23
downtown Vancouver, British Columbia. Each focus group session started with students participating in the study. There
CHIUS provides students—including open-ended questions about the SRC were 5 medical (MD) students, 5 social
second-year medicine, pharmacy, social experience, with the investigators allowing work (MSW) students, 5 occupational
work, and occupational therapy students the participants to take the lead in the therapy (MOT) students, 4 pharmacy
and fourth-year nursing students from discussion. Then the focus shifted to (PharmD) students, and 4 nursing (BSN)
UBC’s health professions training specific experiences the participants had students. We anonymized quotations,
programs—a unique interprofessional while engaging with patients and with with the indicated abbreviations for the
and clinical experience with marginalized students from other professions. The focus students’ programs of study as the only
and inner-city patients. In the SRC group guide evolved over the period of the identifying factor. The focus groups
program, 4 to 5 students work as a team study in several ways. First, we removed generated 2 predominant themes that
at the clinic for 6 weeks, spending 5 questions that generated repetitive or demonstrate the value of SRCs to student
hours there every other week for a total vague answers from participants. More learners: (1) the SRC provided realistic
of 15 hours on 3 different shifts. During importantly, as it became clear that experiences that were unique with respect
each shift, the student team interviews students were comparing this experience to those of classroom-based and other
a patient, who is participating on a to other classroom-based experiences and clinic-based learning opportunities and
volunteer basis; consults with preceptors; other traditional clinical experiences, the that offered new understandings about
determines recommendations; and works questions became increasingly focused on patient-centered care, and (2) the SRC
with the patient to implement these plans. this distinction in learning modalities. For helped students understand roles without
These sessions are directly supervised our final version of the focus group guide, delineating scopes of practice.

1022 Academic Medicine, Vol. 96, No. 7 / July 2021

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
 Research Report

SRCs provide realistic experiences that …to be exposed to that [the influence of Participants felt the process of working
are unique with respect to those of social determinants of health on patients’ closely with students from other
health concerns] and to start reflecting on
other learning formats disciplines in every aspect of patient
it and realizing that illness is complex, and
In many of the focus groups, participants there are so many different intersections care clarified the skills, abilities, and
mentioned that their time at CHIUS between, like, how someone is feeling approaches that each profession brings
was their first experience interacting and doing.… [These are] things medicine to the table, as they learned about
and negotiating care plans with a patient never talks about, like, how can a chief teammates’ roles naturally through
complaint be homelessness? No one observation and negotiation:
who reacted to them and, at times, has ever said that before in class! [But] I
disagreed with them. Students reflected think, probably, a lot of folks have that as I think having a chance to … spend
on how the challenges of applying their their primary concern. (MD) time working with students in other
classroom knowledge to the in-person health professions really helps give us a
management at CHIUS enabled a richer In addition to the complexity of the better grasp of the abilities, talents, and
understanding of patient-centered patient presentations, students indicated knowledge that other health professionals
that they valued both the authenticity of do bring to the table.… This, in turn,
care as a practice, beyond what was helps us define what are the boundaries
possible with the patient cases presented meeting patients whose expectations were
of the medical doctor and what things
in the classroom. This increased different from the priorities of health care are just really better handled by other
richness arose in part because the workers and having to negotiate with people. Because you don’t really get a
classroom-based cases were sparse on patients regarding their own health care sense of that just by reading dogmatic
information, creating a 2-dimensional needs. They expressed that their previous faculty statements about the role of
classroom-based didactic teaching and interdisciplinary collaboration. (MD)
representation of the patient. As a
social work student described: case-based sessions did not prepare
However, the students’ learning seemed
them for such experiences, which forced
I think it’s [the SRC experience is] to extend beyond merely understanding
them to see medical issues from the
extremely valuable because we’re taught what each professional group does and
patient’s perspective and consider context
that the best practice in health care is to its independent roles and responsibilities
when recommending treatments. As a
be patient centered and to explore what in the multiprofessional team. Because
is most important for the patient and pharmacy student stated:
students worked together and interviewed
how it fits into their own lives. But we I can tell a patient, “You’re supposed to fix patients as a team, responsibilities were
can’t really do that with a case study or a
fabricated story because you don’t get all
your diet,” but is the patient actually going not simply distributed to representatives
to follow that plan you give them? Is it of each profession. Rather, students
the real pieces. So, the opportunity to sit realistic for that patient?… [I]t was eye
down with a real person with a real story brought in their perspectives and
opening to see that you have to modify
and a real history and use the skills we’re your plan for the patient; it’s not just a educated each other on their professions’
learning in the classroom is amazing. straight A to B concept. (PharmD) perspectives, priorities, and abilities.
(MSW) In doing so, the students were able
Students also noted that the real to truly experience how the various
SRCs help students understand roles skills, perspectives, and approaches
patients they were faced with in the without delineating scopes of practice
SRC were experiencing more complex complemented each other and collectively
and multifaceted problems than those In the focus groups, students also enhanced everyone’s understanding of
typically represented in the classroom. emphasized the value of learning the patient, thereby better enabling each
Participants reported that such about each professional’s role through to contribute effectively to holistic patient
experiences highlighted the necessity collaboration (i.e., working as a team) care as a team. A social work student
for problem solving and creativity in and co-construction (i.e., building a described the experience this way:
developing care plans for complex common mental model). Having access
I think the complex disorders situation
patients, as articulated by a pharmacy to colleagues from other professions works really well in illustrating the need for
student: while developing an understanding of interdisciplinary care. It’s a really unique
the patient’s health challenges helped experience to come together with so many
[In class,] usually it’s only a few medical students see the patient from the different disciplines to fully develop the
conditions you’re looking at. But with perspectives of those in other professions. wraparound plan to consider the different
patients with complex backgrounds, aspects [of the patient’s care]. (MSW)
you have to take everything into
Students were able to understand the
account. That’s pretty helpful in patient in a holistic manner with the help An occupational therapy student’s
teaching me how to approach these of the interprofessional team. Through comparison of the SRC experience with
situations and not be narrow-minded. this process, students also learned about that of more typical curricular practicums
(PharmD) the professions of their teammates in the hospital setting highlighted the
organically from interacting and unique value of the SRC experience:
The complexity of the patients’ issues providing care as a team.
forced some students to consider new The main difference is that [in typical
perspectives in health care. For example, It’s been really helpful to spend some time practicums, while] it is also an
one medical student articulated a greater with an OT student. It really helps me to interdisciplinary team, we give updates
think more of the functional aspects of a as the profession, and each team already
appreciation for the social determinants patient’s life. We get to look at aspects of has the reasoning behind the updates. But
of health and the limits of biomedical the patient’s life where medical issues are here we go through it [the patient care
framing of patient problems that were causing difficulties.… For me, that’s just so plan] as a team, doing the critical thinking
emphasized in the classroom cases: incredibly valuable to be privy to. (MD) and doing the reasoning together. (MOT)

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Research Report

Interestingly, students also commented expectations about the type of learning scope of practice. Rather, they learn
that the experience enhanced their own that needed to occur. Cristancho has about each profession’s approach to
sense of confidence as a practitioner referred to this type of learning as a practice organically from interacting as
because they no longer felt they had “process of inquiry,” in which the effort is a team. Students are brought together in
to know everything themselves. Thus, as much dedicated to problem definition a dynamic experience with a real patient
rather than feeling the need to be an as it is to problem solving, similar to the and the goal of producing a collective
independent representative of their own processes of problem management found care plan. This approach challenged the
profession, students came to understand in soft systems engineering.15 Didactic students to represent their profession,
and appreciate the value of being part of teaching and other traditional methods learn about each other’s perspectives and
an interdependent team, connected to can only partially teach students to deal competencies, and address the patient’s
and able to access a range of practitioners with complex and shifting situations. issues together as a team working with
from other professions. This point was a real-world patient problem. In other
nicely articulated by a nursing student: words, because no formal direction was
The real-time participation in a patient
given, the students were forced to engage
I feel more supported, more connected, encounter also seemed to force students to
in “role intersection,” which Lingard
and more capable to really support recognize and acknowledge the importance
patients when we do hit the end of what has identified as a powerful and unique
of the patient’s perspective, values, and
my profession can do—now I have all aspect of effective practice-based IPE. 16
goals. Teams searched for resources,
these resources and these people I can
turn to and lean on. At least I know that consulted health care experts available
There appears to be a common
they will be an arm’s reach away to really on-site, and developed tangible solutions
assumption in IPE that if all team
pull on and grab that extra knowledge to for the patient. Then they were required
members understand each profession’s
support the patient. (BSN) to deal with the patient’s acceptance or
role, then the team is competent.
rejection of the proposed plan. Several
Indeed, the National Interprofessional
students noted the patients’ active
Discussion Competency Framework developed by
participation in the team as a useful and
the Canadian Interprofessional Health
In this study, we explored how the SRC unique attribute of the SRC. In contrast
Collaborative lists “role clarification”
pedagogical method provides a unique to the approach in didactic or case-based
as one of the core elements in IPE. 17
opportunity for learning about patient- learning, SRC students were required to
Moreover, many IPE models and the
centered care. The 2 themes that arose accept the discomfort of patient pushback
current medical education around
from this study are (1) SRCs enabled and to learn to collaborate on the patient’s
interdisciplinary teams highlight the
learners to better understand patient- health care plan with the patient. Thus,
need for understanding and clarifying
centered care by providing realistic through the engagement with patients
roles as an objective in teaching. 17,18
patient interactions that are unique with who had their own opinions about their
However, understanding roles is not,
respect to those used in typical case- situation and their care, the principles
in itself, sufficient to guarantee team
based or didactic teaching, and (2) SRCs of patient-centered care came into sharp
competence. Furthermore, having a fixed
allowed learners to understand each focus in a way that would be very difficult
understanding of scopes of practice may
other’s professional perspectives without to replicate in a highly structured and
even be problematic, as roles are not
reifying scopes of practice. Our findings somewhat artificial classroom-based case.
static; they have overlapping components,
both affirm and extend other research 12–14
and in reality, there is flexibility in the
that has examined how the experiences The SRC experience also contrasted
scope of practice among health care
of the SRC might produce and shape with students’ experiences in clinical
disciplines. Thus, having an overly
previously documented learning practicums, where clinical problems are
prescriptive representation of the roles
outcomes. 2,3,9,10 As we discuss below, our addressed only from a profession-specific
of our team members risks stereotyping
findings challenge assumptions in current perspective. The CHIUS SRC gave the
our expectations of what others “should”
models of classroom and clinical training. students the opportunity to address the full
do and devolving teamwork to each team
patient with all his or her subtle nuances.
member enacting his or her scope of
Learning about the complexity of By engaging with and considering the
practice. 18
individual patients patient’s concerns as a multiprofessional
team, the students were forced to develop
Traditional classroom-based learning In the context of the functioning of
their understanding of the patient with
models often involve a predigested case health care teams, Lingard has coined
multiple perspectives in mind (including
that the team works on together to arrive the term “collective competence” as
the patient’s). This defocusing from a
at a “correct” answer. In comparison, the the distributed capacity of a system,
single disciplinary perspective further
SRC model engaged the students with a not reducible to the sum of individual
emphasized the richness of the patient and
real patient without specific learning goals practices or competencies.16 She argues
thus allowed students to better appreciate
or preset answers. Students felt the weight that when each individual sees the patient’s
patients as experts in their own illness.
of the full complexity of a patient’s story. problems exclusively through a specialized
Therefore, students were free to navigate lens, individually competent efforts at
working with the patient through his or Learning about other providers’ patient care may combine badly, leading
her multidimensional health problems, perspectives without reifying scopes of to “collective incompetence.” Similarly,
knowing there were no predetermined practice Cristancho has pointed out that when
solutions. In these scenarios, students In the CHIUS SRC, participants are not specialists bring multiple, conflicting
engaged in learning with no specific formally educated on each professional’s perspectives to patient care efforts, teams

1024 Academic Medicine, Vol. 96, No. 7 / July 2021

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
 Research Report

may actually make more mistakes.15 Rather of patient pushback and allowing them experience to improve pharmacy and nursing
than this approach, Cristancho argues for to develop a deeper understanding of students’ competency in collaborative
practice. Am J Pharm Educ. 2013;77:197.
a systems engineering approach to health the tenets and implications of patient- 4 Holmqvist M, Courtney C, Meili R, Dick
care teams, one that allows the team to centered care. Moreover, it provided an A. Student-run clinics: Opportunities for
step back and focus on the interconnected opportunity for students to be part of an interprofessional education and increasing
issues the patient navigates as his or her interprofessional team, enabling the team social accountability. J Res Interprof Pract
Educ. 2012;2:264–277.
health story. Such an approach requires to achieve collective competence rather
5 Buckley E, Vu T, Remedios L. The REACH
the team to explore the situation together than merely delineating scopes of practice project: Implementing interprofessional
and reach conclusions together, rather and reinforcing professional stereotypes. practice at Australia’s first student-led clinic.
than simply delineating scopes of practice The involvement of the patient in these Educ Health (Abingdon). 2014;27:93–98.
or boundaries. This systems engineering collective, multiperspective discussions 6 Konduru L. Access clinic: A student-run
clinic model to address gaps in the healthcare
approach to collective competence seems encouraged students to view the patient needs of the homeless population in
to fit well as an explanatory framework for in a holistic manner and to consider Adelaide. Aust J Gen Pract. 2019;48:890–892.
understanding our students’ experience the patient’s perspectives as well as their 7 Weinstein AR, Dolce MC, Koster M,
with the CHIUS SRC, where students interprofessional colleagues’ perspectives et al. Integration of systematic clinical
interprofessional training in a student-
were constantly “bump[ing] up against in ways that other IPE experiences may
faculty collaborative primary care practice. J
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delineating each professional’s scope of program offers critical insights into the 8 Simmons K, Klein M, Stevens C, Jacobson T.
practice, students were encouraged to ways in which an SRC experience can Implementation of a student pharmacist-run
talk as a team and consult each other as offer unique opportunities for developing diabetes education and management clinic
in a federally qualified health center in Texas.
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Funding/Support: None reported. 10 Modi A, Fascelli M, Daitch Z, Hojat M.
structured so that each professional has a Evaluating the relationship between
clearly delineated role, and the team comes Other disclosures: None reported. participation in student-run free clinics and
together only when individuals have solved changes in empathy in medical students. J Prim
their piece of the puzzle. Ethical approval: This research was approved Care Community Health. 2017;8:122–126.
and carried out in adherence to the guidelines 11 Charmaz K. Constructivist and objectivist
set by the UBC Research Access Committee at grounded theory. In: Denzin NK, Lincoln Y,
Limitations
the Faculty of Medicine and the UBC Behaviour eds. Handbook of Qualitative Research. 2nd
Our findings must be interpreted in light Research Ethics Board (certificate H16-02092). ed. Thousand Oaks, CA: SAGE; 2000;509–535.
of our design choices. We conducted the 12 Sheu L, O’Brien B, O’Sullivan PS, Kwong
Previous presentations: The core results of this A, Lai CJ. Systems-based practice learning
study at a single center with self-selected opportunities in student-run clinics: A
work were presented as a poster at the Canadian
participants. The participants were all qualitative analysis of student experiences.
Conference on Medical Education, May 2019,
students who had enrolled themselves in Niagara Falls, Ontario, Canada. Acad Med. 2013;88:831–836.
an SRC for the purpose of participating 13 Lie DA, Forest CP, Walsh A, Banzali Y,
Lohenry K. What and how do students learn
in IPE; therefore, the study may have a K. Huang is a second-year resident, Department of in an interprofessional student-run clinic?
selection bias toward students inclined Emergency Medicine, University of British Columbia, An educational framework for team-based
toward interprofessional learning or Vancouver, British Columbia, Canada.
care. Med Educ Online. 2016;21:31900.
working with marginalized populations. M. Maleki is a second-year resident, Department 14 Passmore A, Persic C, Countryman D,
Moreover, our decision to conduct focus of Family Practice, University of British Columbia, et al. Student and preceptor experiences at
Vancouver, British Columbia, Canada. an inter-professional student-run clinic: A
groups built from working teams may have physical therapy perspective. Physiother Can.
limited our participants’ ability to describe G. Regehr is professor, Department of Surgery, and 2016;68:391–397.
scientist, Centre for Health Education Scholarship,
concerns or difficulties they experienced 15 Cristancho S. What can we learn from a soft
Faculty of Medicine, University of British Columbia,
in the context of their teammates. Thus, sister? A complementary lens to the systems
Vancouver, British Columbia, Canada; ORCID: https://
engineering approach in medical education
our findings bear replication and extension orcid.org/0000-0002-3144-331X.
research. Med Educ. 2014;48:1139–1141.
in different contexts and using different H. McEwen is clinical associate professor, 16 Lingard L. Paradoxical truths and persistent
data collection methods to determine the Department of Family Practice, University of British myths: Reframing the team competence
transferability of both the findings and our Columbia, Vancouver, British Columbia, Canada. conversation. J Contin Educ Health Prof.
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17 Orchard C, Bainbridge L, Bassendowski S, et
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