Health services administration

To the Editor: Student‐run clinics (SRCs) empower students to employ logistics, operational management and clinical skills to provide free or affordable health care to underserved populations. SRCs have the dual benefits of student learning and care for underserved patients and promote health equity, interprofessionalism and student leadership.1,2 These clinics are well established in North America but are nascent in Australia. Some sections of the Australian population still face challenges accessing health care, including Aboriginal and Torres Strait Islander people, refugees and rural and homeless populations;3 SRCs not only meet this need but also assist with the growing demand for clinical placements for medical and allied health students.4 In 2012, the first Australian SRC began providing medical, nursing, social work and physiotherapy services in Melbourne,3 and similar clinics have also sprouted in New South Wales and Queensland.2,5 In the same vein, medical students from Flinders University in Adelaide piloted the Flinders Student Run Clinic (FSRC), with the support of faculty and of the Vinnie's Men's Crisis Centre, which provides crisis accommodation, meals, showers and case management for up to 47 homeless and vulnerable men aged over 18 years. From December 2016 to January 2017, student volunteers staffed weekend shifts providing consultations to residents. Clinic days were well subscribed, with about a dozen clients attending each session. Students were surveyed before and after volunteering on aspects of clinical training, preparedness and motivation. Out of 24 medical student volunteers, eight responded to the pre‐survey and six to the post‐survey. Before volunteering, students believed their clinical knowledge and skills would improve and they would be able to manage problems and unexpected events. After volunteering, students were less confident in their abilities and felt less valuable to the clinic, but were more prepared to work with vulnerable individuals, face morally challenging issues and achieve their goals. Volunteering also clarified students’ motivations and values, demystifying primary care with underserved populations, and they were motivated to be involved in similar programs in the future. Feeling less prepared may stem from exposure to responsibilities as primary health care staff on the ground. Further studies can explore expectation‐matching for different parties and the financial impact of similar programs. Furthermore, the use of SRCs in Australia to both teach and serve the community should be encouraged.

Andrew IH Phua · Yvonne K Parry

To the Editor: I refer to the opinion piece by Brewster and Waxman.1 The authors defined collegiality as “a work environment where responsibility and accountability are shared by colleagues, with mutual respect”. However, in a health care setting, professional competency and patient safety are paramount; medical collegiality is desirable, but should not trump these goals. Collegial courtesy can compromise good patient care, despite concerns of competency in clinical judgement or skills. Poor communication contributes to most sentinel events,2 particularly during clinical handover. SBAR (Situation, Background, Assessment and Recommendation), which was what ISBAR (Introduction, Situation, Background, Assessment and Recommendation) was known as in 2009, was promoted to reduce dangerous transitions in the patient's journey in health care.3 Unfortunately, when first introduced in Australia, unnecessary local adaptations were applied to this simple tool — at least seven versions of SBAR existed across six states between 2009 and 2011.4,5,6,7,8,9,10,11 In 2002, SBAR was introduced by retired United States Navy Captain Doug Bonacum, while working at Kaiser Permanente on patient safety, to address the lack of effective communication in sentinel events similar to nuclear submarine incidents and airplane crashes. A quality and safety expert, he drew on his handoff experience from nuclear submarine crews needing to discuss strategies quickly during shifts changeover, thus improving communication, reducing unnecessary narratives and assisting decision making. SBAR improves communication both within the craft group and in interdisciplinary interaction as it flattens the hierarchy.12 ISBAR can fail when the giver (person providing ISBAR) neglects to prepare or perform ISBAR effectively; this is often due to inadequate training, preparation or consideration of what the receiver requires before initiating the handover. Hence, the success of ISBAR rests more on the giver rather than the receiver of the handover. Kindness should be part of ISBAR, but it starts with the giver initiating the handover. Adequate consideration should be made by ensuring thoughtful preparation and organisation to deliver relevant information professionally and competently.13 Less experienced givers should be ready to furnish any specific details upon request. Such reflections enhance communication, reduce errors and improve confidence and morale. Few can perform ISBAR properly “on the run”; formal re‐accredited requirements involving ISBAR should be mandatory for all health care professionals to ensure this critical clinical handover is done well. Slavish adherence to collegiality should not blur the fundamental issues of professional competency and patient safety.

Shyan Lii Goh