Andrea Alvarez ’20

San Francisco Free Clinic, San Francisco, CA

Me and MA mentor, Sumner Leyson.

This summer I had the amazing opportunity to shadow and intern at the San Francisco Free Clinic. The free clinic (SFFC) was founded by Drs. Patricia ’82 and Richard Gibbs in 1993, in an effort to provide affordable healthcare to those for whom cost proves to be a barrier. Thanks to the help of physicians, hospitals, volunteers, and generous donations, the clinic delivers care to over 2,000 patients every year. In addition, through its network of providers and volunteers, the clinic also serves as a center for teaching. Several MAs and volunteers that I had the opportunity to work with learned and practiced skills they would later use in PA or nursing school, just as residents and medical school students built on skills during appointments to apply their learning and better serve patients. Regardless of everyone’s specific roles at the clinic, communication, compassionate care, and eagerness to teach and help one another made for an encouraging work dynamic that challenged my previous perceptions of clinical settings as inherently cold and curt.

From my first day, the SFFC team instilled a commitment to both teaching and exceptional patient care. In past summer shadowing experiences, I had been given minimal tasks or stood mostly on the sidelines 
until almost the very end of the summer, when things were more or less wrapping up. At SFFC however, 
having just arrived, I was asked to explain a urine test to a younger patient. Surprising myself with a lack 
of nervousness, I listened carefully, popped into the room, handed the patient a collection cup and explained what we needed from her. After that, I couldn’t have been more excited; I was jumping right in.

Gradually, I learned a variety of tasks ranging from scheduling and triaging new patients over the phone to labeling and spinning blood samples to send out to the lab for testing. I saw the management of vaccines, medications, and imaging. At the nurse’s station, I was taught how to take vitals and set up rooms for exams and routine appointments. At times I served as a chaperone and assistant for procedures such as breast exams and PAP smears, and sometimes I was even called in to interpret for patients who spoke only Spanish. In other words, not only did I learn and observe, but the majority of what I was taught, I was able to apply soon after, and ultimately use to contribute to the clinic’s mission.

As I became more comfortable improving my skills to serve the needs of patients at the free clinic, I began 
noticing more about our patients. The clinic serving San Francisco’s uninsured individuals, those coming 
to us were often immigrants, visitors staying on short-term visas, and/or non-English speaking. However, 
others were homeless or in between jobs. In other words, the issue of health insurance—whether it was 
accessibility, clarity, or affordability—affected a broad range of people, all composing the 9% of 
Californians who remain without coverage today.

As part of my internship, I shadowed physicians following diabetic and hypertensive patients. Diabetes and Hypertension are chronic illnesses that are preventable in their early stages. However, given their progressive nature, by the time patients made their first appointment in the clinic, the disease was often uncontrolled and had to be managed primarily with medication—a result that early access to consistent check-ups and preventative measures could have slowed or eliminated. Seeing people question the importance of their well-being revealed a personal need to contribute not only to higher quality care but to accessibility to care as well in my future career as a physician. After all, socio-economic status has been seen to strongly correlate to risk and incidence of chronic illness, and what was the point of exceptional care if it was not available to those who often needed it the most?

My first day at the clinic, with premed colleague Johanna Castaneda.

My time at the San Francisco Free Clinic, beyond providing me with opportunities to shadow and learn useful skills for clinical settings, opened my eyes to the greater issue of accessibility in healthcare. However, it is important to note that while access to health insurance is a barrier to care, once at the doctor’s office, there are other ways in which healthcare remains inaccessible, with respect to language and cultural competency for example. Part of what I deeply appreciated at the free clinic was the SFFC team’s dedication to making every patient feel heard and comfortable. However, in some cases kindness is not enough, and a language or cultural barrier can mean the difference between temporary improvement and long-term improvement for a patient. It was this observed difference in clinic demonstrating the importance of language and communication between patients and providers, and their direct link to patient outcomes that led me to choose the topic of my final project.

As a valuable unifying final project, I chose to focus on motivational interviewing (MI) and its importance to behavioral-change-based treatment at SFFC. Motivational Interviewing is a counseling approach founded upon techniques originally developed for use in clinical psychology, primarily for alcohol abuse. Over the years, its techniques have been developed and modified to serve needs in many fields ranging from addiction and substance use disorders to use in schools and judicial settings. At the free clinic, principles of MI such as empathy and affirmation are used frequently, but other, often lengthier elements such as frequent follow-ups and closer monitoring are harder to implement. MI is particularly important to dietician counseling and medical adherence counseling at the clinic for diabetic and hypertensive patients. That being said, the focus of my presentation was to share past studies conducting MI on different cohorts and treatments and extracting what elements of this technique would be most useful to adopt with patients struggling with lifestyle changes and/or medication adherence. Although there was a shockingly small number of studies involving culturally adapted MI, or MI used with underrepresented groups, I appreciated most of all, the discussion that followed my presentation, as the SFFC team shared different perspectives on ways to improve MI counseling tools and language, making specific note of the clinic’s ongoing efforts towards better interpretation and translation resources during appointments, especially those involving counseling.

Despite being a primary care facility, the patients at the free clinic benefit from a wonderful network of physicians and specialists from several nearby hospitals. Many patients I saw would otherwise not receive treatment until much later or would otherwise be unable to consider treatment given costs. Because of the immense impact I have seen made by the free clinic, I am now more than ever reassured of my desire to pursue medicine, and now also inspired to devote time to coursework and/or research in public health. I would like to extend an immense thank you to Drs. Patricia and Richard Gibbs, for giving me the unforgettable opportunity to learn from, shadow, and work alongside the amazing SFFC family. The work that this clinic does and the care and compassion of the team are inspiring and have proved to me that exceptional, individualized care truly makes all the difference.