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Medical students from Ponce Health Sciences University provide health care at a May 3 clinic in Clausells, a neighborhood of Ponce, Puerto Rico. (Ana Umpierre/Direct Relief)
PONCE, PUERTO RICO – The medical students begin the day by arranging tables and partitions in a circular layout. They’re most likely setting up in a basketball court or community center, but the goal is to create a clinic-like flow.
Monthly free clinics, which Ponce Health Sciences University (PHSU) offers in communities across southern and central Puerto Rico, address several issues at once, from reducing pressure on emergency services to combating an island-wide shortage of medical providers.
But the most important goal is to make sure people in hard-to-reach communities, where the nearest clinic is often impossibly far away, are getting the health care they need, for free, in a place where it can be easily accessed.
“Puerto Rico does not have an effective public transportation system, and we have an elderly population lacking transportation,” said Dr. Malynie Blanco, a family medicine practitioner and director of the Family and Community Medicine program at (PHSU). “You can have 10 specialty medical offices, but if the patient is unable to go to the appointment, well then, you need to move to the community.”
For medical students, the clinics are an opportunity to build hands-on expertise. Students are responsible for logistics and operational management. They also provide medical, dental, and mental health services, overseen by faculty supervisors.
These roving community clinics have been providing free care since 2022, and they’ve reached more than 1,400 underserved patients thus far.
Since 2017, when Hurricane Maria killed thousands and caused unfathomable damage across the island, Puerto Rico has experienced an ongoing loss of medical providers, adding pressure on an already hardworking medical system.
For some students, the clinics offer a unique exposure to the health care challenges that face Puerto Ricans, and an opportunity to see firsthand the positive impact their work can have.
The student-run health clinics give providers-in-training first-hand experience and allow people needing care to access a consultation close to home. (Ana Umpierre/Direct Relief)
“Everything that I learn in the classroom, I see it in the communities. The clinics have helped expose the problem to the students,” said Paola Rullán, a second-year medical student at PHSU. “I see that there are a lot of students who wish to stay in Puerto Rico and who want to work here.”
Making the Rounds
The clinics go far beyond triage. Students and faculty supervisors from nursing, dentistry, family medicine, psychology, public health, and dermatology departments each contribute their expertise, providing patients with comprehensive care.
Students interact one-on-one with patients, record demographic data, supervise the taking of vital signs and laboratory specimens, and discuss medications and approaches to treatments together. Others are charged with escorting patients through multiple consultations and documenting their medical histories.
The collected information is presented to supervisors, who oversee treatment planning and follow-up strategies.
Social workers also participate to ensure follow-up, helping patients secure health insurance, find food assistance programs, and obtain transportation, among other support measures.
These clinics have been a safety net for patients who have fallen through the cracks or are in danger of doing so. Both Dr. Blanco and Rullán said that the most prevalent conditions observed during these clinics are high cholesterol, hypertension, and diabetes. Sometimes these conditions aren’t being managed well, and there’s a lot of misinformation on how to store and administer insulin.
“We have seen many patients that get used to having the symptoms. They modify their lifestyle because of the symptoms they show, and that is something that they gradually get used to without knowing and is mostly because they don’t visit the doctor,” Dr. Blanco said.
Dr. Joan Colón, an assistant professor at PHSU, supervises the psychology students at the clinics. She notes that depression and anxiety are common, exacerbated by stressors like lack of transportation and food insecurity.
Clinical interventions are necessary, but they’re not enough: A major focus for Dr. Colón’s team is to provide education and coping strategies while also working with social workers to meet the socio-economic needs that worsen mental health issues.
Stigma is a major obstacle to mental health care, as is the case around the world: Patients are sometimes unwilling to seek it out and hesitant to accept it if offered. At the free clinics, the mental health station is an integral part of the clinic layout. The goal is to treat it like any other component of health care.
Community Solutions, Island-Wide Problems
There’s no question that Puerto Rico’s health system, like the rest of the United States more generally, is under pressure.
Long wait times to see a specialist or mental health provider are a growing problem. The number of available specialists is expected to decrease, as an older generation retires and smaller numbers of students in training stay on the island. These problems have the potential to increase medical emergencies as health care issues go undiagnosed or unmanaged for long periods.
“Many professionals are leaving. It’s not just the difficulty of finding appointments: The issue is that there are too few providers available, and those who are available are overwhelmed,” said Rullán. “On the one hand, we are contributing to training future health professionals and on the other, we are expanding access to much-needed health care services.”
Medical students from Ponce Health Sciences University provide health care at a May 3 clinic in Clausells, a neighborhood of Ponce, Puerto Rico. (Ana Umpierre/Direct Relief)
The student-run clinics are an important piece of the puzzle: They foster prevention by addressing symptoms at a primary care level and creating a path to continuous care for precisely the people who are least likely to have one.
“A patient with high blood pressure might avoid a stroke and a trip to the ER if community clinic doctors can assess and begin treatment early, preventing complications,” Dr. Blanco explained.
No one intervention can solve every problem, of course. But the PHSU clinic is unusual in the way it’s taken different priorities, from health care access to hands-on training, and found a way to make them work together in the communities where the need is greatest.
Direct Relief has awarded $52,000 in grant funding to the Ponce Medical School Foundation to support the student-run free clinics. Additionally, the organization has donated $443,000 in medical products to support clinic operations.
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