DukeMed Alumni News
Winter 2008

Cover Story

A Clinic for the People
Duke Students Provide Care in Rural N.C.

By Bernadette Gillis

Duke’s relationship with Fremont, N.C., goes back to the late 1980s, but 2007 marked a year of new beginnings for both the rural town and the Duke medical students who volunteer their time there.

Not only did the student-run Fremont People’s Clinic reopen after being closed for two years, but two students received a grant that will help purchase much-needed supplies for the free, once-a-month clinic located about 70 miles east of Durham.

In July fourth-year students Andrew Pogozelski and Patty Convery were awarded a Caring for Community Grant from the Association of American Medical Colleges (AAMC). The $15,000 grant will be used for the clinic over four years. Each year the AAMC
awards grants to support community projects initiated, developed, and run by medical students. The last time Duke received the grant was in 2002.

“The money will allow us to improve the clinic and provide new, quality equipment to examine the patients,” says Convery, who along with Pogozelski is responsible for determining what supplies to order. “A new exam table will make a world of difference.”

Three other students who have since graduated—Sara Condron, MD’07, Tracy Robinson, MD’07, and Sunny Wang, T’01, MD’07— are not named in the grant but all played a significant role in writing the proposal.

For the past year Pogozelski and Convery have served as cochairs of Duke’s chapter of the N.C. Student Rural Health Coalition, and each month they recruit a small group of first- and third-year students to travel to Fremont. They recently handed over the reins to third-year students Hamza Aziz, Donald Lucas, and Greg Osmond.

The clinic is held from 9 a.m. to 1 p.m. on the third Saturday of every month inside a trailer that does double duty as a community center. The students provide basic medical screenings for patients, including pregnancy tests, urinalyses, and blood pressure, diabetes, and cholesterol checks. The students’ preceptor, Jeff Margolis, MD, a physician with the nonprofit organization Goshen Medical Center, writes prescriptions for patients as needed.

If patients need follow-up care Margolis refers them to the Goshen site in Goldsboro or another health care facility in the area. Margolis says it is often difficult to determine whether patients actually go where they are referred, but he still feels the clinic is valuable to a community with few health care options.

Community advocate Doris Hall (left) takes a break from her administrative duties to have her blood pressure checked by Donald Lucas.

The town of 1,400 people has no practicing physician, and many residents have no health insurance. Finding transportation to see doctors at the hospital in Goldsboro or in other neighboring towns is an obstacle for some, and rising gas prices haven’t made traveling long distances any easier.

“It is my perception that the patients feel positive and enthusiastic about what we’re trying to accomplish,” Margolis says. “(The clinic is) really meant to be an entry point that introduces health care services to a population of folks who might not darken the door of a health care facility.”

Varion Williams is a patient who also volunteers at the clinic.“It’s been a blessing,” she says. “I don’t have transportation. I wouldn’t have anywhere else to go.”

Though Monatina Wells has a primary care physician, she says getting simple services such as a health physical can still be a challenge. Neither of her two employers offers health insurance so she has to pay out of pocket for care. “It is so expensive to go somewhere else.”

Since reopening in March the clinic has shifted its focus from providing primary care to providing patient education. Margolis and the students give the patients information on the importance of preventive medicine and caring for chronic illnesses.

Convery says she takes every opportunity she gets to stress the importance of self-breast exams. “I always make an effort when women come in for physicals to teach them how they should do this every month.”

Robinson, who volunteered at the clinic as a student, says she once saw a patient in his early 20s who was not caring for his type II diabetes. “He had no insight into his disease,” she says. “I hadn’t really seen patients at Duke who had no education about this disease. I spent a lot of time talking with this gentleman, and by the end (of the conversation) he understood better what he needed to do to improve his diabetes.”

At the Fremont clinic patients also learn about programs available for low-income individuals and families, such as the Partnership for Prescription Assistance program, which can help the uninsured fill their prescriptions at little or no cost, and Goshen Medical Center, which charges patients using a sliding scale based on income.

In addition to helping the patients, the clinic also offers a unique learning experience for the students, particularly the first-years who normally don’t get to interact with patients until the second year of medical school.

The third- and fourth-year students, who act as advisors to the first-year students, learn mentoring skills, which will prove useful later in their residencies. “It’s a great opportunity for the third years to take a leadership role,” says Barbara Sheline, MD, MPH, faculty advisor for Duke’s chapter of the N.C. Student Rural Health Coalition.

Since March the clinic has averaged eight to 10 patients each month. Though he is hopeful the numbers will gradually increase, Margolis says there are some advantages to having a small flow of patients. The students have more time to practice their skills and develop their own style when interviewing patients. “They feel more relaxed about engaging in conversation (with patients),” he adds.

Sheline, who is an associate clinical professor of community and family medicine and assistant dean for primary care at Duke, says working in the clinic gives students a better understanding of and appreciation for community medicine. “It allows students to be in a community that does not have adequate health care. It’s just good to get out of Duke and Durham and see a rural North Carolina community that struggles with that issue.”

The students learn to work with community advocates as well.“I think talking with people like Doris Hall who has worked for her community for years is powerful,” Sheline adds.

Preceptor Jeff Margolis, MD, (right) with Hamza Aziz (left) and Donald Lucas.

During the 25 years Hall has lived in Fremont, she has served the community in numerous roles, including director of Fremont’s chapter of the N.C. Student Rural Health Coalition. The Fremont chapter, which was established before the clinic originally opened, works in conjunction with the Duke chapter. It is made up of a small group of Fremont residents who have a genuine interest in the health of their community.

“The main reason we started the clinic was to help the community realize that they had some say in what happened to them, and how they treat their problems,” says Hall, who herself learned that she had diabetes at one of the monthly clinics.

Hall’s wide range of responsibilities at the clinic can include anything from registering patients to helping the students find a local contractor to make building repairs.

“Doris is the heart and soul of the Fremont chapter and it is her commitment that has allowed the students to continue to have a presence in her community,” Sheline says.

When the N.C. Student Rural Health Coalition first formed in the 1980s, medical students from Duke, UNC-Chapel Hill, and East Carolina University offered health fairs during the summer in three low-income, predominately African-American communities in North Carolina. The health fairs would normally last two or three days. Sheline, who at the time was one of the UNC students, says it was as much as a community effort as it was a medical student effort.

“The community had to make a big commitment,” she says.“They had to find housing for the medical students, find a place to have the health fair, and advertise it.”

Pleased with the turnout of the health fairs, the three communities, including Fremont, decided to continue their relationships with the medical schools and open monthly clinics. Hall and others in the Fremont chapter of the N.C. Student Rural Health Coalition took aparticularly active role in making their clinic a reality. They worked to find a building and handed out flyers door to door to help spread the word.

In addition to the clinic and yearly health fairs, the local chapter of the N.C. Student Rural Health Coalition also established a precareer health internship program. The program allowed Fremont high school students interested in health careers the opportunity to visit Duke’s medical and nursing schools and to shadow medical students at the Fremont clinic.

The Fremont clinic stayed open until 2005 when the preceptor, a Duke faculty member, had to step down. Administrators told the students the clinic would remain closed until they found a new preceptor.

The Fremont People’s clinic is held in a trailer that also serves as a community center.

Condron, Robinson, and Wang had just taken over as leaders of the N.C. Student Rural Health Coalition at Duke. Wang says they were disappointed but determined to do whatever they could to keep their commitment to the people of Fremont. “We wanted to show the community we were still with them, that we hadn’t pulled out completely,” she says.

The town’s residents shared the students’ determination. “The people in Fremont expressed their concerns (about the clinic closing) to us loud and clear,” says Wang. “They were not waiting for handouts. They were more than happy to do fundraising or help make calls.”

However, Wang and the other students quickly learned that reopening the clinic would be a lot harder than expected. They encountered several risk management issues. And some Duke faculty members were concerned that having a preceptor based two hours away at Duke may not be in the best interest of the patients’ longterm care.

But after establishing a relationship with Goshen Medical Center, Robinson says things began to fall into place. Goshen agreed to provide the students with a preceptor. “The Goshen doctors know that community,” Robinson says. “And having an organization involved rather than an individual doctor makes (the clinic) more sustainable. If a physician can’t go one month, there’s someone to go in his place.”

Goshen currently has 22 sites in five counties, and Fremont may become the twenty-third. Goshen CEO Greg Bounds, PhD, has applied for two grants to establish a sliding scale fee clinic in Fremont. If the grants are approved the clinic would be open several days during the week and would offer services such as mammograms and X-rays that currently aren’t available at the Fremont People’s Clinic.

A Goshen clinic in Fremont would not necessarily mark the end of the Fremont People’s Clinic. “Goshen is offering for the students to still come on a Saturday at that clinic and provide care to people who can’t get it Monday through Friday,” says Sheline.

Regardless of what happens, fourth-year student Pogozelski says meeting the needs of the community is most important. “My goal is for people to get the most affordable care they can in Fremont.”