Examining physicians' motivations to volunteer

Examining physicians' motivations to volunteer

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Examining physicians' motivations to volunteer an applied visual anthropological approach
Ambiee, Jess Paul
Place of Publication:
[Tampa, Fla]
University of South Florida
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Subjects / Keywords:
Professional volunteerism
Access to health care
Medically underserved
Free clinics
Dissertations, Academic -- Applied Anthropology -- Masters -- USF ( lcsh )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )


ABSTRACT: In the U.S., the number of persons who cannot afford health care continues to rise. Providing a "safety net" for such persons is becoming increasingly important. Medical professional volunteerism provides access to health care for people who have little or no access to health care otherwise. At a not-for-profit free health clinic in Tampa, Florida, hundreds of physicians have volunteered their time in an attempt to reduce the health care gap in their community. The clinic sees thousands of persons who have very limited options in regards to their health care. This study investigates the reasons physicians volunteer and the barriers physicians face when providing free medical service. Through a survey, shadowing sessions, and focused in-depth videotaped interviews with volunteer physicians concerning the risks, rewards, experiences, and barriers of professional volunteering, a greater understanding of this important topic was obtained. This applied visual anthropological project was developed in collaboration with the free clinic in order to provide a product which would be of use to the organization at the end of the research process. This research led to an enhanced understanding of this population as well as recommendations in volunteer physician recruitment strategies.
Thesis (M.A.)--University of South Florida, 2007.
Includes bibliographical references.
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Document formatted into pages; contains 72 pages.
Statement of Responsibility:
by Jess Paul Ambiee.

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University of South Florida
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E14-SFE0002187 ( USFLDC DOI )
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Examining physicians' motivations to volunteer :
b an applied visual anthropological approach
h [electronic resource] /
by Jess Paul Ambiee.
[Tampa, Fla] :
University of South Florida,
3 520
ABSTRACT: In the U.S., the number of persons who cannot afford health care continues to rise. Providing a "safety net" for such persons is becoming increasingly important. Medical professional volunteerism provides access to health care for people who have little or no access to health care otherwise. At a not-for-profit free health clinic in Tampa, Florida, hundreds of physicians have volunteered their time in an attempt to reduce the health care gap in their community. The clinic sees thousands of persons who have very limited options in regards to their health care. This study investigates the reasons physicians volunteer and the barriers physicians face when providing free medical service. Through a survey, shadowing sessions, and focused in-depth videotaped interviews with volunteer physicians concerning the risks, rewards, experiences, and barriers of professional volunteering, a greater understanding of this important topic was obtained. This applied visual anthropological project was developed in collaboration with the free clinic in order to provide a product which would be of use to the organization at the end of the research process. This research led to an enhanced understanding of this population as well as recommendations in volunteer physician recruitment strategies.
Thesis (M.A.)--University of South Florida, 2007.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
System requirements: World Wide Web browser and PDF reader.
Mode of access: World Wide Web.
Title from PDF of title page.
Document formatted into pages; contains 72 pages.
Advisor: S. Elizabeth Bird, Ph.D.
Professional volunteerism.
Access to health care.
Medically underserved.
Free clinics.
Dissertations, Academic
x Applied Anthropology
t USF Electronic Theses and Dissertations.
4 856
u http://digital.lib.usf.edu/?e14.2187


Examining Physicians Motiv ations to Volunteer: An Applied Visual Anthropological Approach by Jess Paul Ambiee A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Anthropology College of Arts & Sciences University of South Florida Major Professor: S. Elizabeth Bird, Ph.D. Michael V. Angrosino, Ph.D. Nancy Romero-Daza, Ph.D. Date of Approval: November 7, 2007 Keywords: professional volunteerism, access to h ealth care, medically underserved, free clinics, altruism Copyright 2007, Jess Paul Ambiee


Dedication To my father and mother for always supporting me in all my endeavors.


i Table of Contents List of Tables iii List of Figures iv Abstract v Chapter One: Scope of the Study 1 The Research Setting 1 Purpose of the Project 4 Chapter Two: Literature Review and Theoretical Framework 6 Introduction 6 Psychological Motivations to Volunteer 6 Relevant Anthropological Theory Functionalism, Critical Medical Anthropology, and Altruism 8 Volunteerism in Todays Society 11 Issues in Health Care, Health Care Volunteerism, and Health Care Policy 12 Ethnographic Study 14 The Applied Component & Video Advocacy 15 Chapter Three: Methodology 17 In-Depth Topical Interviewing 18 Observation/Shadowing 19 Survey 20 Methodological Issues and Limitations 20 Chapter Four: Findings 23 Introduction 23 Why Physicians Volunteer & Continue to Volunteer 23 The Need for Access to Health Care 23 Spiritual Value: Makes me feel good 24 Volunteer Work Benefits the Community and the Local Emergency Rooms 26 Spiritual Value: The Relation be tween Business, Service, and Medicine 28 How Physicians Came to Be (And Can Be) Involved: Person-to-Person Recruitment 29


ii Identifying Volunteering Barriers and Overcoming Them 33 Time as a Barrier 33 Malpractice as a Barrier 35 Level of Liability Related to Specialty 36 Physicians Unsure about Malpractice Coverage 37 Prevalence of Spanish-Speaki ng Patients as a Barrier 38 Continuum of Medical Care 39 Perceived Lack of Resources/Stereot ypes of Free Clinic Facilities 41 Linkage between Good Patients, Continuity of Care, and Malpractice 43 Secondary Themes 44 Lack of Publicity for the Clinic as a Barrier 44 Judeo Christian Health Clinic Is the Name a Disadvantage in Recruitment? 44 The Young and Retired Physician Population 46 The Need to Further Engage Volunt eer Physicians with the Clinic 47 Survey Findings 48 VFI Survey Results 48 Discussion of Survey Results 50 Social Benefits to Volunteering 50 Connection between the Results fr om the Survey and Interviews 51 Chapter Five: Conclusions and Recommendations 53 Issues and Recommendations in Constructing a Recruitment Video and Subsequent Recruitment Material 53 Relating Selected Literature to Current Findings 55 Recommendations for the Clinic 56 The Anthropological Contribution and Contribution to the Community 59 Closing Remarks 60 References Cited 61 Appendices 67 Appendix A: Poverty Level Guidelines 68 Appendix B: Physician Interview Guide 69 Appendix C: Survey for Free C linic Volunteer Physicians 71


iii List of Tables Table 1 Motivational Functi ons Served by Volunteer Serv ice According to JCHC Physicians 48 Table 2 Survey Response Rate 49 Table 3 Demographics of Survey Respondents 49 Table 4 General Descriptive Da ta of Volunteer Physicians 49 Table 5 Retired and Non-Retired Physicians 49 Table 6 Median Amount of Volunteer Service by Physicians 49


iv List of Figures Figure 1 2006 Poverty Level Guidelines 69


v Examining Physicians Motiv ations to Volunteer: An Applied Visual Anthropological Approach Jess Paul Ambiee ABSTRACT In the U.S., the number of persons who cannot afford health care continues to rise. Providing a safety net for such persons is becoming increasingly important. Medical professional volunteerism provide s access to health care for pe ople who have little or no access to health care otherwise. At a not-for-profit free health clinic in Tampa, Florida, hundreds of physicians have volunteered their time in an attempt to redu ce the health care gap in their community. The clinic sees thousands of persons who ha ve very limited options in regards to their health care. This study investigates the r easons physicians volunteer and the barriers physicians face when providing free medical service. Through a survey, shadowing sessions, and focused in-depth videotaped interviews with volunteer physicians concerning the risks, rewards, experiences and barriers of prof essional volunteering, a greater understanding of this important topic was obtained. This applied visual anthropological project was developed in coll aboration with the free clinic in order to provide a product which would be of use to th e organization at the end of the research process. This research led to an enhanced understanding of this population as well as recommendations in volunteer phys ician recruitment strategies.


1 Chapter One: Scope of the Study The main research questions in this study, c onducted at a free clinic in the Tampa Bay area, are, Why do physicians volunteer their medical services, and what are the barriers for physicians in volunteering ? The purpose was both academic and applied: first, to show how anthropologically -informed method can be used to better understand the phenomenon of physician volunteerism, and sec ond, to provide tools to help the clinic improve physician recruitment. The products of the research are both a traditional applied anthropology thesis and a brief DVD developed from intervie ws and images collected in the project, and intended to help the clinic with recruitment effort s. The construction of this research project was developed in collabo ration with the clinic, so as to provide a product which would be useful to the organiza tion at the conclusion of the research study. The Research Setting The Judeo Christian Health Clinic (JCHC) in Tampa, Florida, is a free clinic that provides health care for medically indigent persons who have no other resources for their health care needs. A free clinic is defined as a volunteer-based clin ic that provides free or low-cost healthcare services to medically uninsured or underinsured people (Geller et al. 2004:44). It receives no government or Un ited Way funding but relies solely upon its own fundraising efforts through the private sector to meet expenses. The clinic operates independently and on an annual budget of approximately $500,000. The Judeo Christian Health Clinic (JCH C) was founded in 1972 by a Presbyterian minister, and is located in an urban setti ng on Martin Luther King Drive and N. MacDill Avenue. In March 1972, the clinic began in a Sunday School classroom on a one night per week basis with one physician, one nur se, and a few volunteer staff. Due to overwhelming demand, a new building was cons tructed in 1973 to house the clinic and more medical personnel were recruited to volun teer. George Bush recognized the clinic for its efforts to deliver free health car e to the medically indigent with the 1989 Presidents Volunteer Action Award. In 1999, the clinic raised one million dollars in order to build a new 8000 square foot facility with twelve examining rooms, a laboratory, a licensed pharmacy, three complete dental op eratories, and an op ticians dispensing lab (Judeo Christian Health Clinic 2006). Today, the clinic is one of the most up-to-date, largest, and comprehensive free clinics in the Southeast United States. The executive director oversees internal ope rations, professional recruiting, fundraising, and public relations. Clinic policies are se t by the JCHC Board of Directors. The executive director, receptionist and night clinic coordinato r are full time employees and


2 there are five part-time positions (pharm acist, administrative assistant, two staff assistants, and a dental assistan t) that are paid out of clinic funds. All other JCHC staff are volunteers. The funding of the clinic is e ssential in understanding the goals and nature of the clinic. The clinic does not qualify for governmental assistance in part because it serves persons that are not eligible for governmental health assistance, such as undocumented immigrants. However, this lack of governmental oversight allows the JCHC organization to provide care as it best sees fit. This is also in line with its mi ssion to serve people who have very few options in the way of health care. The clientele (i.e., patients who receive health care) have no insurance, do not qualify for Medicaid, Medicare, or any ot her public assistance program, and lack the funds to pay a private doctor or to purchase health insurance. Also, it is not mandatory for patients to be U.S. citizens. The JCHC targets people w ho are ineligible for government assistance but unable to afford private care; in other words, the persons that fall between the cracks of our health care system (Judeo Christian Health Clinic 2006). A term heard around the clinic for their clientele is the working poor or the persons who do not have access to care through the present health care delivery system in this country. The clinic handles more than 26,000 patient visits annually. In a 2005 study of the JCHC, it was found that 63% of JCHC clients were women, 92% of JCHC clients resided within Hillsborough County, and the greatest number of clients came from the 40 to 49 year age range. Most patients who qualify for the clinic work at low-pa ying jobs with little or no benefits, such as health insurance; to qualify, patients incomes must fall be tween 100% and 250% of federal poverty income guidelines (See Figure 1 in Appendix A). According to Bea Dreier, the JCHC Director (personal communication, May 2007), In Hillsborough County, we have what is called the Hillsborough County Healthcare Program, and thats for pe ople below the poverty level [below 100%, as seen in appendix I ], and they will ta ke care of those people, there is also Medicaid that will take car e of a lot of those people as well. But our patients dont qualify for those programs. The JCHC offers many services within its building and provides additional services within JCHC referral/specialis t physician offices. Department s within the clinic building include pediatrics, gynecology, asthma & allerg y, dental, eye, genera l medical clinics, podiatry, dietician counseling, Hepatitis C screening, and dermatology (Judeo Christian Health Clinic 2006). The servi ces that are provided within the clinic vary in their hours of operation depending on the type of servic e. The clinical hours for the medical specialties are less than the hours for general medicine. General medical care is provided Monday through Thursday after 5 pm, and Frid ays after 1 pm. Specialty-specific care (such as gynecology, asthma, or dermatology care) is usually provided after 5 pm one day


3 per week. Most appointments are set after 5 pm because the vast majority of physicians who volunteer at the clinic al so work full-time jobs. The amount of service provided at the clinic, for both genera l and specialty-specific care, is established based on both the number of volunteers available and the demand by the JCHC clientele. The JCHC and St Josephs hospital have a written agreement that the costs associated with all diagnostic tests a nd procedures for patients referred to by the clinic will be covered by St Josephs hospital. These are often needed with referral/specialist care. The doctors involved in providing care to the JCHC clientele were the main participants of this research study. These include both doctors that visit the clinic and referral doctors, who treat JCHC patient s in their private offices, free of charge, on a referral basis when a patient's needs exceed JCHC cap ability. According to the JCHC, there were 106 doctors who volunteered at the JCHC, and 87 referral doctors who volunteered their services in 2005-2006. When asked to define the difference betw een in-clinic physicia ns and the referral physicians, the JCHC Director explained: Well, we have hundreds of physicians who volunteer for the JCHC and many of those doctors actually come to the clinic after theyve worked all day at their own private office and they work during even ing hours here at the clinic and see patients, and help provide free health care to these people who have no other resource for their health care needs. We also have a list of hundreds of doctors for patients who need subspecialty care thats not offered at the clinic. For instance, if a patient needs surgery or need s to see an urologist or a neurologist, we have a referral agent who can pick up a phone who can call that doctor in that specialty and make an appointment for th at patient and that doctor sees that patient free-of-charge. Theyve agreed ahead of time to see X amount of patients per month, or whatever. They follow t hose patients for whatever their condition is. My internship supervisor in this research study was the ex ecutive director of the JCHC, who played an important role in the research process. To ensure the project would be applicable to the clinic, the director introduced and helped define the research topic. The clinic expects to gain something productive and he lpful out of this research project. I will provide recommendations to improve recru itment procedures, as well as a DVD video highlighting both the doctors who volunteer and the clinic itself. The hope is that the DVD may help in recruiting physicians, publicity and fundraising. The director assisted me in identifying doctors to participate in the project, and has been very helpful throughout the research process.


4 The physicians who see JCHC patients come as volunteers, receiving no pay for their services. In this way, physicians and the phys ician recruitment proces s are integral to the everyday operations of the clinic. Physicians are always in demand and the clinic can only see as many patients as there are doctors As Shapiro (2003:54) notes, Free clinics and similar voluntary efforts are likely to remain an importa nt component of the health care safety net. The executive director of the clinic, when discussing possible research topics, mentioned one of the most important things for the clinic is to recruit more physicians. Purpose of the Project Anthropology is concerned with the generati on of basic knowledge a nd the appli cation of knowledge to the solution of human problems (USF, Department of Anthropology:1). Applied anthropology is often commissioned by an organization outside of academia and the purpose is often to give clients conc rete recommendations or tools for specific purposes. The topic of research is often not selected by the anthropol ogist and this is the crucial distinction as compared to other t ypes of research within anthropology (Ervin 2005:4). The goal of this research pr oject is to understa nd the reasons physicians volunteer their time freely to help patients who cannot afford medical care. The main research question is: Why do physicians volunteer their medical services? Include d within this is another important question: What are the ba rriers for physicians in volunteering their medical services? Understanding the answer s to these questions can possibly improve recruitment procedures. It may help the clin ic advertise to prosp ective volunteer doctors by emphasizing the positive, beneficial reasons and directly addressing the main concerns in volunteering. This project also has a st rong applied component, in that if we can understand why physicians do or do not volunteer, strategies can be developed to better recruit them. Recruiting more volunteers is crucial to the func tioning of the clinic, as the executive director explains: It is important to the clinic to have ad equate staffing of physicians here during all of its clinics. We are limited by how many patients we can see, by how many, by the number of doctors we have on duty th at night. Most of our physicians work on a rotating basis, and if they are here on a Monday night, and say we have five physicians, we will schedule 8 to 10 patie nts per doctor, so if we have 5 physicians, we are likely to see 50 patients that night. If we have one physician, we can see 8 to 10 patients, so we are only limited by the number of doctors we have. You are constantly looking for more doctors as the patient load increases all the time. We actually doubl ed and tripled our patient load just during the past several years. Currently, physicians are recruited through a dvertising and word-of-mouth. The clinic advertises through the Hillsborough County Medi cal Association, and sends a newsletter


5 to local physicians in town. Addresses of th e physicians are gathered through the yellow pages, and the director believes the clinic reaches 99.9% of local doctors. Word-ofmouth is conducted from doctor to doctor, board of directors to doctors or lay volunteers to doctors. The current policy or strategy on deciding th e number of hours physicians volunteer at the clinic is quite understated or possibly non-existent. According to the director, physicians usually ask her, What kind of commitment do you expect? To which she replies, Most doctors work about once a mont h. The physicians th en usually agree to volunteer once a month. After a deeper investig ation of the physicians which this project will provide, I hope to possibly offer recommendations on how to improve current policies. In this study, I interviewed vol unteer physicians at the Judeo Ch ristian Health Clinic with the goal of understanding th eir main motivations to volunteering. I interviewed and observed/shadowed doctors who currently volunteer, and videot aped the interviews. The videotaping was done not only fo r research analysis, but also to create the video that emphasizes the rewards doctors receive when they volunteer and dire ctly addresses the perceived barriers to volunteering, in an effort to attract prospectiv e volunteer doctors. Upon mentioning my previous filmmaking expe rience, the clinic director was very enthusiastic about creating a vi deo that would somehow highlight the clinic. Refining the topic and purpose of the video came with numer ous discussions with the clinic director. The video portion of the study aims to contribute to the applied component of the project. This medium will hopefully serve as one of the tools the clinic can use to encourage more physicians to volunteer, and will also be helpful for the clinic in general because it will communicate to the larger public the type of work that is being done there. Finally, recommendations will be given to clinic st aff in order to improve functioning of the clinic, based on the findings of the thesis.


6 Chapter Two: Literature Review and Theoretical Framework Introduction The idea that an individual would make significant personal s acrifices for another person, particularly when that person is a st ranger, has long fascinat ed students of social behavior (Clary et al. 1998: 1516). Alexander Ervin, in his book on applied anth ropology, explains that given practical problems to solve, applied practicing anthropologists have to be pragmatic. That requirement frequently forces them to dr aw upon theories from other social science disciplines social psychology, community me dicine, sociologyOften such alternative theory sources are directly informative about the problems at handpractitioners can blend these sources with insights from anthr opological theories or perspectives (Ervin 2005: 11). Marshall (1992:1) clai ms a defining characteristic of applied anthropology is a strong commitment to social change th rough the application of anthropological concepts and skills in collabo rative and interdisciplinary research. Ervin (2005) also mentions that applied anthropologists must be flexible in their theoretical framework and most anthropological academic theories were strongly influenced by other intellectual trends. Also, there is relatively little anthropological litera ture concerning the sociocultural act of volunteerism. Upon revi ewing the sociological literature concerning altruism, Piliavin and Charng (1990) stated l ongitudinal, prospective research studies on volunteers is essentially non-existent. Most of the volunteerism litera ture comes from the field of psychology. Psychological Motivations to Volunteer Given the increasing demand for volunteers, researchers have begun to explore how volunteerism is instilled in emerging profe ssionals. A better understanding of the motives that underlie professional volunteerism may be useful in recruiting and training professionals to give back to their communities (Fletcher and Major 2004: 109). In the field of psychology, the functional ap proach to understanding altruism is the predominant one. Central to this approach is that people engage in various activities for purposeful, goal-oriented r easons (Fletcher and Major 2004:110). Related to the functional approach is the Volunteer Functions Inventory, created by Clary et al. (1998), which is based on the functional approach to understanding altruism. A functional perspective towards motivations to voluntee r is chiefly concerned with the why of volunteerism (Whitt 2006:10). Understanding these reasons is important and could give


7 us concrete answers as to why members of a specific population (e.g. Tampa physicians) would participate in long-t erm volunteering. Once this is better understood, the recruitment technique of local doct ors by the JCHC may be enhanced. The doctors that volunteer at the JCHC do not indulge in short-term or spontaneous altruistic behavior. This long-term helping is called planned help ing, which calls for sorting out priorities and is a very cogn itive decision (Clary et al. 1998:1517). What sustains this long-term altr uistic behavior? In pla nned helping, there are common threads: the helper must seek out the opport unity to help, the help er arrives at this decision after a period of deliberation, the helper provides assistance over time, and the helpers decisions about beginni ng to help and about continui ng to help are influenced by whether the particular activity fits with th e helpers own needs and goals (Clary and Snyder 1999: 156). There has been much research in the fi eld of psychology to understand the precise motivations that can be fulfilled through particip ation in volunteer service. Clary et al. (1998) identified and operationalized six personal and social functions served by volunteering, ultimately refining classic theori es of volunteerism. The motivations to volunteer have their related counterparts in the functions volunteering serves. The Volunteer Functions Inventory (VFI) has been validated by factor analyses, used with various different volunteer activities, tested by numerous researchers in their own studies, and has ultimately reached a level of acceptance to where it is commonly used in volunteer studies with in the field of psychology. Okun, Barr, and Herzog (1998) empirically tested competing measuremen t models of motivat ions to volunteer: specifically, a one-factor mode l (from 1991), two-factor model (from 1990), and the sixfactor VFI model (Clary et al. 1998). Their conclusion was that the six-factor model had the best fit of the data and recommended the VFI to ascertain the importance of the various volunteering motives in their population (1998: 620). This survey will be used in this study, but will be a secondary tool to the ethnographic approach common in anthropological investigations. The results fr om the VFI will be compared to the results from the traditional ethnographic approach to see the level of corroboration. This will allow further triangulation with in the study and possibly grant further acceptance to the VFI. Clary et al. (1998), with a ssistance from previous psyc hological research, found and refined six motivational functions served by vol unteerism. Each function or factor is measured with five items within the thirty qu estion self-report survey instrument. The six motivational functions are: Values This centers on the opportunities that volunteerism provides for individual to express values related to al truistic and humanitarian concerns for others. Understanding This involves the opportunity for volunteerism to permit new learning experiences and the chance to exercise know ledge, skills, and ab ilities that might otherwise go unpracticed.


8 Social This offers opportunities to be with one s friends or to engage in an activity viewed favorably by important others. This reflects motiv ations primarily concerning relationships with others. Career This is concerned primarily with caree r-related benefits that may be obtained from participation in volunteer work. Protective In the case of volunteerism this may serve to reduce guilt over being more fortunate than others and to a ddress ones own personal problems. Enhancement This centers on personal development, personal growth, and higher selfesteem These different motivational areas show that persons doing the same activity, such as treating patients for free, may be doing it to meet different psychological functions. In a study of Italian young adults volunteering (Mar ta et al. 2006) whic h incorporated the VFI, it was found that multiple motivations underlying the activities are associated with greater satisfaction and good in tegration in the organizati on. People who are motivated by more than one factor are less vulnerable to costs related to the activity and are more likely to maintain a longer involvement. Volunteerism is sometimes seen as doing an ac t for which one has absolutely nothing to gain and sometimes even something to lose. However, numerous studies have illustrated potential benefits in volunteering. In a study conducted in 1980, volunteer workers over 65 years old were compared to retired elderl y who did not engage in volunteer activity. Volunteers had a significantly higher degree of life satisfaction, a stronger will to live, and fewer symptoms of depression, anxiety, and somatization. Th is study (Hunter and Linn 1980) illustrates the possible in tangible benefits of volunteerism. How satisfaction of motivational functions act ually affects motivati on is currently being debated. Roy Baumeister, a social psychologi st, has recently conduc ted research on how satisfaction influences motivation. Baumeisters theory states that when we get something we desire, the subsequent feeling of satisfaction reinforces and increases the strength of that desire when it returns. This is contrary to standard theories of motivation which state that satisfaction reduces subse quent motivational drive. Baumeister has conducted three psychological expe riments and has recently presented this research at the Association for Psychological Science (Elish 2007). Relevant Anthropological Theory Functionalism, Critical Medical Anthropology, and Altruism Functionalism, in the anthropological sense, is a paradigm that attempts to explain social customs and institutions through their contribut ions to maintaining the unity and survival of the society. In a functionalist view, a so ciety is able to continually exist because customs are adaptive and make it possible for pe ople to cope with their environment and one another. This definiti on is closely related to the psychological definition of functionalism, but the viewpoint is from a larger more macro perspectiv e. Critics of the


9 functionalist school of thought state that f unctionalists underlying assumption is that every custom must have some positive social or cultural function, ignoring dysfunctional customs, and an uncritical acceptance of the status quo, being blind to forms of change that can lead to greater stab ility. According to Crapo (2002:17), however, analyzing the functions of customs is probably the most common single technique used in anthropological discussions of human life, regardless of the specific school of thought. This paradigm fits well with studying the creation and maintenan ce of a not-for-profit private clinic. A free clinic can be seen as an inherently adaptiv e institution formed due to larger, possibly dysfunctiona l health policies. The free clinic can be seen as an institution which is developed so as to protec t members of society, serving as a safety net, increasing the social stability of the community as a whole. The creation of free clinics can be seen as increasing stability at the community level. Greater protection of the community and its members serves a role in improving society memb ers quality of life as a whole. While the psychological and an thropological definitions of functionalism derived separately, they can be seen to mes h, although at different levels (psychology at the level of the individual, anthr opology at the level of society). A discourse is a system of rules regula ting the flow of power (both positive and juridicial) which serves a func tion of promoting interests in a battle of power and desires (Brown 2002: 31). Discourse, according to Foucault, constructs the topic. It defines and produces the objects of our knowledge and governs the way that a topic can be meaningfully talked and reasoned about (F u Jen University 1998: 1 quoted from Hall 1997:44). The limited discourse in this res earch study is based on people living in the United States without proper access to health care and those who are willing to serve this population. For instance, this st udy discusses medical malpractice primarily as a potential barrier for prospective volunteer physicians and how policies are being enacted in order to mitigate this barrier. But should patient s who receive free health care have less right than a paying patient to sue a medical prac titioner if that practitioner exhibits gross negligence? Persons who must rely on others aid instead of having a right to health care, as in this country, must face this issue. If health care was seen as a basic human right, where all persons have a right to proper medical care, at the U.S. policy level and in the general American cultural worldview, woul d such a stance even make sense? This study does not primarily address the inherent inequality of why people, in the first place, do not have proper access to health care, a nd the need for this population to rely on altruistic medical professionals for this acce ss. This study does not attempt to combat inequality as a larger force, but focuses on th e free clinic as a st rategy to stopgap current inequalities which are the result of larger forces. The purpose of the free clinic was to mend the ga p in health care service in this country between economic classes, but the work of the free clinic and the process of this research study itself can be seen as implicitly accepting and/or further allowing current health care policy to remain as is. In part due to the fo rmative local theory approach and to realistic constraints, this projects scope does not, in itself, actively investigate the larger construction of U.S. health care policy. In ot her words, the discourse of this project is


10 quite limited and the construction of this disc ourse itself may be seen as supporting health care disparities. This construction of a topic inherent ly limits its findings. The function of free clinics can be seen as aidi ng societal stability, as developed from the anthropological functional pers pective. Critical medical anthropology is a theoretical perspective which focuses on how the distribu tion of wealth and pow er affects disease patterns and health care access. Joralemon (1999) believes this critical perspective can be incorporated into all medical anthropology research. The cr eation of the free clinic in itself highlights the poor health care access for the indigent in the local community. The need for certain people in our community to rely on altruistic medical professionals highlights the relatively poor access to health fo r these individuals. While this, in itself, is not the focus of the research, the nature of the study does incorporate this critical theoretical paradigm. Ransom (1997) declares we need to break with the myth of both the State and the Revolution that will overthrow it, decompose th e complex reality that in fact constitutes the social world, and substitute a political ethos of critique for one that aims to transform society according to a transcendent vision of fully liberated human nature: [these] are the preconditions for effective oppositional thought in a post Berlin Wall world. (Ransom 1997:60). Looking at the larger i ssue of health care and health care as a human right, an ideological shift is perhaps one of the few impe tuses that can change an issue as large as the right to health care in this country. Donald Joralemon (1999), in his text on medi cal anthropology, asks If tinkering with the system only serves to maintain its oppre ssive characteristics, is the only option an unlikely social revolution? Critical medical anthropol ogists acknowledge that their analysis of the class interest s behind health care systems can lead to, as Nancy ScheperHughes describes, a politics of despair (1999:95). In resp onse to this, Merrill Singer (1995:91) feels the day-to-day work of critical practitioners mu st be regarded as a means or as dynamic phases in a progres sive struggle and not an en d. The research done at the local level must continually highlight, document and connect the disparities prevalent at the larger, more global level. Investigating altruism and the act of volunt eering is essential in a study of physician volunteerism. Sociologist Gerald Marwell emph asizes child rearing and enculturation as significant to adult actions. Marwell proposes that we learn to be happy when others are happy and sad why they are sad because of our inherent dependence on those around us, mainly parents (Piliavin and Charng 1990:42-43) This dependence pushes people to be more oriented towards satisfying the needs of ot hers. This theory attempts to investigate the source of altruism. Is altruism, defined here as performing acts with no direct benefit to the individual or near kin, distinctly human? Is there a bi ological or genetic component tied to this behavior? At the Max Planck Institute of Evolutionary An thropology, researchers


11 Warneken and Tomasello (2006) conducted studi es with chimpanzees and humans in an effort to find if performing altruistic acts those which do not bene fit the individual or kin, might have developed evolutionarily in primates. Warneken and Tomasello found that chimpanzees and infants both will assist other chimpanzees and infants, respectively, in acts that will have no direct benefit to themselves. The researchers concluded that even young children have a natural tendency to help other people so lve their problems and our nearest primate relatives show skills and motivations in this direction, suggesting that human and chimpanzees common ancestors possessed some altruistic tendencies. Altriusm might have somehow evolved uniquely in primates. Sociobiologists have demonstrated mathematically that under ce rtain conditions, there are three separate selection processes group sele ction, kin selection, and recipr ocity selection that can actually lead to the establishment and perp etuation of altruist genes in populations (Piliavin and Charng 1990: 45). Volunteerism in Todays Society According to the U.S. Bureau of Labor Statistics (2005), about 65.4 million people (28.8% of Americans) volunteered through or for an organization at least once between September 2004 and September 2005. This monthly survey of about 60,000 households, called the Current Population Survey (CPS), also found that women volunteered at a higher rate than men across age groups and educ ational levels. This survey showed that roughly the same percentage of volunteers became involved with their organization on their own initiative (40%) as were asked to volunteer by someone in the organization (43%). This survey also illustrated a dispar ity on volunteerism based on education level. While only 21% of high school graduates with no college volunteered, 46% of college graduates volunteered. This s hows that health care professionals, in general, may be more likely to volunteer than the general population. This survey found the primary stated reason non-volunteers had for not currently volunteering. 45.6% stated lack of time, 15.2% stated health problems, and only 2% stated burnout a nd/or the previous volunteer experience was not enjoyable. Ted Cox (Chester 1990:30), in his practical guide to volunteer mana gement, remarks that volunteers expect: 1) To know where their work fits into the organizations mission 2) To be heard 3) To know how well or how poorly they are doing in their job, and to be given the chance to correct weaknesses 4) To be able to use the experience and knowledge that they have acquired over a lifetime 5) To grow in their responsibilities if they choose to do so Walter Pidgeon Jr, a nationally recognized c onsultant in volunteer management, believes that not-for-profits have not fully used the marketing advantages that could be presented to prospective volunteers on the personal bene fits received from the volunteering process


12 (Pidgeon 1998:52). The National College Gr aduate Study on Volunteering, conducted from 1990 to 1991, concluded that individua ls do receive return value from volunteering including a number of personal and career skills (1998:44). Return value is defined as the overall benefit that an individual can receive from the volunteer experience. Also in the National College Graduate Study on Volunteering, 1094 of 1305 (83.2%) of respondents stated self-satisfac tion/helping others was the primary reason why they volunteered (1998:37-38). Issues in Health Care, Health Care Volunteerism, and Health Care Policy There are specific problems or issues within health care that must be addressed. Medical malpractice, in general, is a large problem physicians face in practicing medicine. In their examination of medical malpracti ce, Studdert, Mello, and Brennan claim, Physicians revile malpractice claims as ra ndom events that visit unwarranted expense and emotional pain on competent, hardworki ng practitioners. Commentators lament the "lawsuit lottery," which provi des windfalls for some patients, but no compensation for the vast majority of patients injured by me dical care (2004: 283). There is also a perception among physicians that poor pati ents are more likely to sue. Rising malpractice insurance costs and fear of litigation are thought to reduce physician availability in poor neighbor hoods and create access barriers for the medical indigent (Burstin et al. 1993: 1697). From an economics standpoint, th e poor would be less likely to claim than others. This is partly due to the perception that a claim from a poor person is not as economically attractiv e to a lawyer as that of a wealthy person, and thus one would expect fewer suits by the poor. Also addi ng to this, legal services lawyers, often the only attorneys available in poor neighborhoods, are prohibited from taking on malpractice cases unless the client has first been turned away by two private attorneys. In addition, Burstin et al. (1993), in their study of socioeconomic status and filed malpractice claims, conclude that the poor, elderly, and uninsured are less likely to sue than other groups. As of 2005, 46.6 million people, or 15.9% of the population, were without health insurance coverage in the United States (DeNavas-Walt 2006:20). 24.3% of households with incomes lower than $25,000 had no health insurance coverage and 43.6% of foreign-born non-citizens of the U.S. ha d no health insurance coverage in 2005 (2006:22). Also, there are a si gnificant number of people in the United States who are underinsured. Previous research has documente d decreased access to health care services and increased burdens of economic hardship, il l health, and mortality that the uninsured and underinsured experience (Donelan et al. 1996: 1347, Burstin et al. 1992). Blumenthal and Rizzo (1991) found that th e proportion of the average physician's patients who are uninsured is substantially below estimates of the proportion of the general population that is uninsured. The expense of health care and the lack of health care coverage are great. According to Emmons (1995), uncompensated care costs in 19 94 were estimated to be as high as $11


13 billion. According to a previous study (C unningham et al. 1999), there may be a linkage between physicians volunteer services and economics. Cunningham and colleagues state the rise in managed care plans imposes greater price discipline on health care practitioners through discounted fees, capitated payments, sel ective contracting, and other methods, and thus they experien ce increased financial pressures. This lessens the ability to shift the costs of uncompensated care onto other payers. This study found that regardless of the physicians level of involve ment with managed care, those who practice in areas with high managed care penetrati on provide roughly 25% fewer hours of charity care than physicians who practice in areas with low managed penetration. This shows the economic environment of physicians to be a possible barrier to physician volunteerism. These issues in health care and specifically in health care of the underserved need further study. There have been policy changes in Florida to protect volunteer workers so as to encourage more people to provide their volunt eer services. In an effort to encourage health care volunteerism, the Florida Access to Health Care Act (Fl Statue 766.1115) was passed in 1992. Protection under this act gave participating health ca re volunteers statesponsored sovereign immunity (Barnhill et al. 2001: 2178). Sovereign immunity limits the amount of damages that can be awarded. Florida's sovereign immunity laws limit the amount of damages that can be awarded to $100,000 per claim and $200,000 per incident (Barnhill et al. 2001: 2179). This protection is based on the vol unteer serving as an agent of the State of Florida. This means that the State of Florida assume s responsibility for the treatment of patients eligible under this pr ogram (Volunteer Health Services Program 2007). This law has no current bearing to the JCHC, since the law only protects doctors who sign up as agents with the health depart ment and see patients within the states income guidelines. Since the clinic sees pe ople who fall through th e cracks of health care given by the state, the clinic and th e states patient income guidelines are not compatible with each other. JCHC patient s incomes must fall between 100% and 250% of poverty income guidelines. According to the JCHC director, however, the clinic attorney is looking into the possibility of the health department coveri ng retired doctors who volunteer at the JCHC (letter to author, July 12, 2007). The JCHC requires pa tients to sign a release form agreeing to some preconditions: In considerat ion of said present and future services, treatments, medications and ot her activities received from the JCHC and without any other representation, promise or agreement, oral or written, I hereby fully and completely release and discharge the said JCHC and any and all other pa rties in interest from all claims, demands, grievances and causes of ac tion of every kind and nature whatsoever, including, but without limitation of the foregoing all liability for damages or injuries of every kind, nature or descri ption, known or unknown, perman ent, or otherwise, now existing or which may hereafter arise from or out of the above mentioned services, treatments or medications received at the JCHC, state of Florida. Even with the patients signature, which is required before treatment, this form does not protect the


14 clinics physicians from a la wsuit based on gross negligence. It may, however, make the patients of the JCHC less likely to initiate a claim. According to Barnhill et al. (2001), since the Florida Access to Health Care Act has passed, the number of health care volunteers has incr eased from around 4,000 in 1992 to 18,000 in 2000. Barnhill et al. conclude that medi cal malpractice is a great fear and acts to lessen this fear have resulted in an e xponential increase in th e medical volunteer work force. Related to this is public policy en acted to protect volunt eers serving both nonprofit public and private organizations. The Vol unteer Protection Act of 1997 was created in response to the withdrawal of volunteers from service to nonprofit organizations because of concerns about possible liability (Runquist and Zyb ach 1997:1). This act only provides a defense for the volunteer but does not prohibit lawsuits against volunteers. Runquist and Zybach state that the policy is quite ambiguous and still leaves the volunteer at risk for significant legal fees ev en if the case is thro wn out. According to this Act, a volunteer is not liable for harm if they are not guilty of gross negligence or reckless misconduct. Gross negligence and reckless misconduct, however, are the most common in medical malpractice lawsuits. A plaintiff needs only pl ead indifference on the part of the volunteer to the safety of th e individual harmed (1997:2). Therefore, this policy act does not provide any real coverage Runquist and Zybach conclude that the intention of the law is laudable, but the la nguage of the Act is flawed. The Florida Volunteer Protection Act is modeled after the fe deral act and similarly offers very little protection and does not absolve volunteers fr om litigation. As can be seen, volunteerstatus medical liability pr otection for JCHC physicians is little to non-existent Ethnographic Study This study suits itself to be an ethnographic study. Ethnography is a scientific approach to discovering and investigating social and cultural patterns and meaning in communities, institutions, and other social settings (Schensul et al. 1999: 1). In an ethnographic approach, ethnographers discover what people do and why before they assign meaning to behaviors and beliefs (1999:1). The naturalistic approach to ethnography imp lies an inductive analy tical strategy that explanatory theories grow out of the experien ce as it is observed in real life (Angrosino 2002:2). Ethnography effectively builds local theory theories that explain events, beliefs, and behavior in the special site an ethnographer is studying which may be adapted for use elsewhere (Schensul et al 1999:7). Ethnographic research always involves face-to-face contact between th e ethnographer and the community of study (1999:7). This project is based on formative loca l theory in that it st arts with a research topic to be addressed in a localized population and the population is involved in identifying it (1999:17). The need for qualita tive data for this proj ect is essential. Chester (1999:74) states that it is difficult to get a feel for the effects programs have on people at the level of the individual, and ethnography is well suited to this purpose.


15 Ethnographic research that involves video and multimedia representation of visual research to support the disse mination of research products within organizations is identified as within the emergent field of applied visual anthr opology (Pink 2006:128). There is a direct relationship between the vi deo and written components of this research study. The data, analysis, and conclusions ga thered from the research study will be included in a traditional academic-style written format but also will be incorporated into a video format. This will allow the resear ch findings to be more accessible to the community involved in the study and allow fo r a greater applied component of the research study. The video and written components should not be a detriment to each other but enhance the qual ity of the overall study. The Applied Component & Video Advocacy The functional approach to understanding vol unteerism allows for a strong applied component, specifically mentioned by Clary et al. (1994) as the matching hypothesis. This is the idea that persuasive messages will succeed in engaging volunteer intentions and actions to the extent that they fo cus on the relevant motivations underlying volunteerism. In other words, persuasive messages can motivate people to initiate volunteer service to the extent that the messages are tailored to the specific motivations important to individual reci pients of the messages. A recruitment video was developed based on the findings of this project. This video was created after the data, from both the ethnograp hic research and the VFI, was analyzed. This allowed for the messages to be more tailored to what this specific subgroup, physicians, sees as important in their vol unteer service. In the book, Recruiting and Training Volunteers, Ilsley ( 1981) suggests that an excellent recruitment tool or recruiter must identify with the target group and ha ve knowledge of the folkways, mores, and history of the group being r ecruited. The ethnographic data gained from this study greater informed the researcher about the target group and this can only positively influence the production of the recruitment video. Increasingly in visual anth ropology, the video medium has b een used in part with the applied component of a research study. Pink (2004: 4) asserts the current demand stems from three key interests: the users of app lied anthropology, graduate students seeking to utilize their skills outside the confines of academic visual anthropology, and academic/professional visual and applied anthropologists who seek to share their theoretically informed practices of research and repres entation with non-anthropologists. There have been numerous recent applied vi sual anthropology projects. Rich and Chalfen (1999) developed a pediatric research project and used the video medium to educate clinicians on how patie nts interact with disease on a day-to-day basis. This allowed clinicians to better plan patients medical management. The Steps to the Future Series (Levine 1999) brought to light the issue of HIV/AIDs in South Africa and challenged societal attitudes and percepti ons about the disease. Stadhams (2004) developed a television series based on an thropological tenets concerning poverty and


16 tourism research she was conducting in Gambia With these previous projects in mind, this project will util ize the video medium not only to analyze why physicians volunteer their medical services and the barriers in volunteering, but al so to create material which will directly aid and improve the current situation. As can be seen, a number of social science disciplines have produced research that is relevant to the project at hand. Having an understanding of U.S. health care and policy, volunteerism, topic-related ps ychology, and appropriate me thodological approaches is essential to this study. As an applied anth ropologist investigati ng a practical problem, being aware of relevant research from other disciplines is essential.


17 Chapter Three: Methodology Before starting the research, I was a volunt eer at the clinic for about 10 months. Establishing myself as a clin ic volunteer allowed me to have a better understanding of the everyday functioning of the clinic, gain a more emic perspective of being a volunteer, and to build trust and rapport with the clinic staff. I assist ed the JCHC director with audiovisual materials and also assisted the pharmacy department by sorting out pharmaceuticals. As a volunteer, I produced a photoDVD project to hi ghlight the clinics current volunteers and their work. The DVD was eventually shown at the annual fundraising dinner and has also been used as background footage in other recruitment activities. I developed the re search topic while volunteering at the clinic. The director and I had numerous discussions concerning a possible study topic and we eventually agreed on studying physician volunteerism as this is essential to the everyday functioning of the clinic. Within the rese arch setting, my main role a nd responsibility was that of a researcher as well as the producer of the vide o. I was given permi ssion to use archival JCHC materials as well as all areas of the clinic. I feel the previous time spent as a volunteer at the JCHC made the conduction of the research occur more seamlessly. It was important to maintain the collaborative na ture during the project as when the original idea for the project was develope d. I regularly gave project upda tes to the JCHC director. Data collection was conducted from January to May 2007. The main method used in this project was in -depth interviewing and qualitative analysis of the interview data. Secondary methods utilized in this project were a psychological and demographic survey (calle d the VFI Survey) and obser vation/shadowing. The VFI Survey was sent out to all current volunt eer physicians the JCHC had on file, which amounted to 194 possible respondents. At the end of the survey, th e final question asked if the participant would like to also part icipate in a voluntary in-depth videotaped interview and/or shadowing session. Aski ng for interview participants with this technique allowed everyone in the JCHC current physicia n pool to have an equal opportunity to participate or be chosen for th e interview. Due to the voluntary nature of the study, this opportunistic sampling tec hnique was used to obt ain the largest number of participants. Thirty vol unteer physicians chose to par ticipate in the survey (15.5% response rate). Of the 30 volunteer physicians who participated in the survey, 15 agreed to participate in the in-depth videotaped in terview (50% response rate). The first ten physicians to agree to participate were involv ed in the interviewing phase of the research study. Multiple methods are used to gain different perspectives of the phenomena and triangulate the data. Also, these forms of data collection (survey, observation, and


18 interviews) will help illuminate the emic pe rspective of the volunteer doctors. It is logical to assume that the best source of information about doctors and their motivations is the doctors themselves. There was diversity within the local JCHC physician population, and I made every effort to repres ent this in the res earch products so prospective doctors may see how they best f it at the clinic and which role would serve them best. As the researcher, I reviewed all responses a nd determined what statements or ideas were being emphasized by the participants in respon se to the main research questions. At the completion of data collection, the video footag e was transcribed and analyzed, so as to produce conclusions about physician volunteeri sm and provide recommendations as to how to improve recruitment and better maintain volunteer physicians. The main goal of the video production was to enhance the applied component of the research study and give back something of value to the participating community. The videotaped interviews were used to create a video that speaks to prospective volunteer doctors and possibly student doctors. This is done to complement the more traditional written format of this resear ch study. A similar procedure was used in an applied visual ethnographic project in which I participated previously, the USF Visual Anthropology Prodigy project. The goal of understandi ng the emotions and passionsvisions and dreams of Prodigy (a non-profit institution), and displaying these on video was reached by performing similar open-ended structured in terviews with Prodigy participants (Bird n.d.:14). Methodologically, the applied co mponent of the research process is in many ways the most difficult to perform successfully. This project is a community-based research study. In anthropological community-based studies one must address the balance between doing objective anthropologica l research and being a condu it for the agenda of the community partner (Bird et al. 2007: 151). The research process and the production of the video must be constantly discussed a nd negotiated between the researcher and the community to allow for a beneficial product for the community and a truly applied piece of research to take place. As an anthropologist, I have moral obligations to members of the research population, the wider society and culture, as well as to the profession. It is necessary to keep data confidential and private to protect the member s of the research population. It is also necessary to make sure th e population under study understand s the research project and gives consent to be a part of this study. I have gone through the IRB process at the University of South Florida and have fo llowed IRB guidelines throughout the project. In-depth Topical Interviewing I constructed a list of open-ended interview questions from background research in this area and assistance from key informants wh ich helped answer the main research


19 questions. I attempted to ask the questions directly relevant to the research study consistently to all participants, so as to a llow for comparison and deeper analysis of the subject at hand. The open-ended interview que stions complemented the closed-ended questions that were asked with in the survey. I interviewe d 10 physicians who currently volunteer at the clinic and two staff members. All inte rviews took place either at the JCHC or the specific physicians place of em ployment. All current volunteer physicians were given the opportunity to participate in the interview; a total of 15 agreed, and the first 10 who consented were interviewed. The interviews were one-on-one and all of th em were recorded. During the interview, I guided the discussion to keep on target and obtain answers relevant to the research question. The interviews ranged from 15 to 40 minutes. Eleven were videotaped and one, with a clinic staff member, was audiot aped per the persons request. All of the interviews were later transcribed. Observation/Shadowing Also in line with ethnographic methodol ogy, I observed six of the 10 doctors I interviewed during their volunteer work at the clinic to gain another perspective of what it is like to be a volunteer doctor. Shadowing all 10 of th e physicians who consented to an interview was not possible due to sche duling/appointment diffi culties. We would frequently discuss issues related to the re search subject during these sessions. Often physicians would give somewh at deeper responses to th e questions asked during the videotaped interview duri ng the shadowing sessions, ha ving more time for further reflection. I gained a deeper understanding of the physicians volunt eer experiences by shadowing them through their service. Du ring the interviews, physicians would explain what it was like to volunteer for the JCHC. These experien ces of volunteering were often confirmed during the shadowing sessions. Upon entering each examining room, the physician I was shadowing would introduce me to the patient and inform the patient about th e purpose of my presence. Oral consent was obtained before any recording or observing t ook place. Initially, I wanted to film the physician-patient interaction to enhance th e edited video by showi ng actual footage of what is done by volunteer doctors at the Jude o Christian Health Clinic. However, the camcorder and tripod were too intrusive in the office rooms where physicians would see patients. The patients, as well as myself, felt uncomfortable with the large equipment and the process of recording what is usually a priv ate interaction. Therefore, with permission from the clinic director, patients, and the physician, I took a small digital camera and took still photos of the interaction to use in the edited video. These photos will complement the communicated responses by the volunteer doctors during the inte rviews. The photos were taken in such a way as to only identi fy the physicians. The patients privacy was secured. No patients will be able to be identified from the video.


20 Survey In numerous studies concerni ng volunteerism, the Voluntee r Functions Inventory (also known as the VFI) has been given to participan ts to understand what functions the participants gain from volunteering. The VF I is accepted and used particularly in the field of psychology. The VFI was a large subs ection of my survey, with 30 of the 38 questions on the survey being drawn from it. The other component of the survey was demographic-type questions. The survey was us ed to gain a better se nse of the physicians volunteering at the clin ic (see appendix for the full survey; see chapter two for more information concerning the VFI). The main use of the VFI survey was to help triangulate the data. The results from the VFI were compared with the ethnographic results. The clinic retains the mailing addresses of all physicians currently volunteering. All current volunteer physicians were notified by mailing of the survey and were given a link to the online survey. I had to adjust the su rvey distribution method due to the low initial response. A fraction of the physician pool ha d previously provided email addresses to the JCHC and this group received both a mailed letter and an email. The JCHC director personally gave out surveys to current JCHC physicians whenever possible, and the more direct personal approach in su rvey distribution turned out to be most effective. The VFI survey was available on zoomerang.com, an online survey website, and a paper form was also available at the JCHC physician lounge area. This survey asks closed-ended type questions. From previous persona l experience, I have found that most participants do not write in gr eat detail in surveys, so a short answer survey was seen as more suitable and producti ve. The executive director of the clinic supported the idea of an online su rvey and agreed to help notify JCHC physicians of our study. This is stage one of the research pr ocess. There is a statement on the survey asking if the survey participants would be co mfortable with participating in an in-depth videotaped interview with que stions structured around their work at the Judeo Christian Health Clinic as well as vi deotaped observation/shadowing sessions. This would make it simpler to recruit participants for this portion of the project as well as give everyone an equal opportunity to further pa rticipate in the study. Ther e was also a statement letting the participants know that portions of the vi deotape may be used in creating an edited video for the clinic. Methodological Issues and Limitations One methodological limitation of this study is best related to Erving Goffmans dramaturgical approach concerning interac tion analysis. Goffman states the actor consciously plays a certain role (predefined by societal norms) and plays this role to meet societys standards. In Goffmans (1959) Presentation of Self in Everyday Life, his impression management thesis dictates that i ndividuals constantly e xude expressions that impress others who are present. While individuals do not learn scripts that allow them to know in advance what they will do, everyday co nduct derives not from a script but from


21 enacting the standards of conduc t and appearance of their soci al group and people of this group are implicitly soci alized to fill in and manage any part they assume (Smith 2006:42). According to Goffman, much of our day-to-day social interaction is aimed at promoting and protecting our own face (social standing) and the face of other members of our group (Crapo 2002:131). The physicians who are being interviewed may slip into a role they think is appropriate to the e nvironment the white coat they are wearing and the social identity they carry. Being interviewed may bring out more of an expert commentary. This is not a deceptive interaction but this environment limits or defines the experience. Due to the limitations in time spent with the pa rticipants, we are unabl e to see the person in different settings which might cause th e person to act in a different fashion. This idea is also in line with the looping effect or labeli ng theory as described by Ian Hacking (1999). This theory denotes, for instance, that the act of classifying someone as a deviant might reinforce devi ant behavior. The act of cal ling a person a Judeo Christian Health Clinic volunteer physician will reinfor ce the individual to behave in a manner in line with their perception of the meaning of that title. Each participant had to sign the IRB form to participate in the project and one of the stated goals is to recruit more physicians. Therefore, they have an idea of what is expected of them and how they should portray themselves. The surrounding atmosphere always plays a role in the process of conducting an interview. The videocamera, microphone, and general environment involved in the in terview may further reinforce the feeling of a physician to take on a role, to follow a familiar script, a nd evoke responses that seem appropriate to meet the environmental standards and be representative of the social group he or she is a part. This may result in physicians resort ing to comfortable par ty lines instead of thinking about the issue at greater depth. This is why it was necessary to probe and ask a question repeatedly in somewhat different ways to possibly get beyond the party lines. For example, I asked how they (the JCHC physicians) began volunteering, the factors that caused them to volunteer, what caused them to volunteer at the JCHC specifically, and what they would do if they were in charge of recruiting physic ians. All these help answer the question, Why do doctors volunteer th eir medical services? one of the main research questions. A good example is during an interview with Dr B. When asked what rewards she gets, she initially proclaimed none and this activity is purely to assi st others. But after probing further, the response differs. This variation in responses illustrates further information about the topic at hand. Ambiee: Can you tell me, maybe a specific event, or maybe in general, about rewards in volunteering, or rewards a physician would get in volunteering here? Dr. B: Well, I mean, I dont look at voluntee ring here as something that deserves a reward I dont look for reward in this. (A few minutes later in the interview)


22 Ambiee: Can you tell us more specifically about that is there a social network that develops here with physicians? Or you have gained any friends through this consortium? Dr. B: Well, I guess one of the benefits, some of the other internis ts and family practice physicians that volunteer their time here se nd me patients because they know they know me from here, they know what kind of physic ian I am, and they are happy to send me patients, and that might not have occurred otherwise. While all current volunteer physicians of the JCHC were given a chance to be interviewed, only a small percentage agreed. Therefore, there is most likely a bias in this pool towards the more dedicated volunteer phys icians. However, this might help in understanding how these physicians became so involved. While the sampling technique was opportunistic, the ratio of primary care to specialty care physicians who volunteered to take part in the study ended up being fairly representative (1.3 to 1, respectively) of the JCHC physician population at large (roughly 1.2 to 1, respectively). Physicians preferred to do the interview first and then have th e observation session. Establishing rapport was more difficult due to issues of time with this population. This is a common problem in studies that involve studying up. Studying up is when informants have more capital or power in the researcher-informant relationshi p and often limit or cont rol the researchers participation. Adding to this problem was th e somewhat sporadic volunteer service of the majority of JCHC physicians. Some will vol unteer only once or twice a year and most volunteer either once a month or every other month. Due to the difficulty of scheduling appointments, it was necessary to allow fo r a longer period of data collection.


23 Chapter Four: Findings Introduction The main research questions for this proj ect were: Why do physicians volunteer their medical services? and What are the barri ers for physicians in volunteering their medical services? In the analysis stage, statements were extracted from the interviews and questionnaires that directly pertain to the investigated phenomenon. Meanings were formulated from the statements. They we re arrived at by the researcher reading, rereading, and reflecting upon the pertinent statemen ts in the original transcriptions to get the meaning of the clients statement in the original context (Creswell 1998: 281). Clusters of themes were organized from the meanings. This will help the clinic in that they will understand why doctors volunteer and create a better advertising campaign. Atlas.ti, a qualitative analysis software program, was used to code and maintain organization of the data. The format of this chapter reflects the an alysis methodology. While I have created and organized the themes that have emerged fr om the research, the participants of the research project speak for themselves. The participants appropriately and eloquently discuss the emergent themes themselves so my subsequent discussion of why a theme is significant would be over-interpr etation. I believe this format complements the formative local theory and ethnographic framework on wh ich this project is based. Although not all statements by JCHC physicians addressing ea ch research theme are represented within this chapter, the numerous quotations highlight the subtleties and variety within each theme and also display the significance of the theme in itself. In the following section, only the interview results are presented. W hy physicians choose to volunteer and the factors that sustain their service will be discussed first, followed by the barriers and perceived barriers physicians face when it co mes to providing free medical services. Survey results will be discussed following this section. Why Physicians Volunteer & Continue to Volunteer The Need for Access to Health Care What can be seen in the physic ian interviews is their strong belief that our society needs better health care and health care should be a basic human right. This belief seems to propel many to volunteer.


24 Dr. X previously served on the board of directors for a large Tampa hospital while practicing medicine concurrently, so has seen issues of health care from both an executive and practitioner level. Dr. X: The plight of health care and access and quality is at such a dismal low in this country and Tampa is just part of the problem. Out in the L.A. area, more recently, it was just horrible, there were a lot of doctors taking care of the in digent there. While I was in Colorado, there was a bunch of doctors taking ca re of the indigent, its just, [volunteer work] allows us to do what we are trained to do and those of us who have a volunteering make-up to us, then it feeds that. Dr. L focuses on internal medicine and geri atrics and also has practiced medicine overseas. Dr. L: Well, the patients we see here, as Iv e said before, are the working poor. Most of them had no contact with a medical pers on for many, many years. If they do have problems, many come here much later than we would really see them in private practice. And often, I feel like Im working in a 3rd World country where we see classic textbook cases, especially diabetes, Ive seen people walk in here with sugars in the 400s, and they have been going like that for a couple of months. You know, people walk in here with extreme chest pain and have a heart attack. And they have chest pain on and off for months, but they dont have access so this is their last reso rt where we hear about it. When asked about the root causes for people not having access to me dical care in this country, Dr. L responded, Because of the cost number one, and there is not a national health care here. I mean, thats a huge probl em in this country. You know, it should be, as we discussed earlier, it should be basic. Everybody should have access to health care. Spiritual Value: Makes me feel good All physicians stated that the work makes them feel good. So me emphasize it more than others, but all, in some fashion, state it as a reason as to why the volunteer. This theme shows that physicians are not just selfless people who do th ings without getting anything back, but displays that they are receiving some sort of function, or gain, from this service. I have grou ped these types of responses under a thematic group called spiritual value. This is a definite value that is gained by these physicians. Physicians often tie in this internal satisfaction w ith the gratefulness of the patients. Dr. N, an obstetrician-gynecologist, has seen patients in the Tampa Bay area for over 33 years. Obstetrician-gynecologists specialize in womens health and primarily deal with complications and problems associated with the reproduction capacity and also deal with a patients emotional, psychological and psychi atric needs. Dr. N has volunteered at the Judeo Christian Health Clinic for over twenty years.


25 Dr. N: The most important reason that I pe rsonally volunteer at the JCC is the rewards I get repeatedly. The smile on the faces and the handshake and the Thank you, Doctor in several different languages that gives me a good sense of well -being. It makes me feel like there is a purpose for me to existing on th is earth. It makes me feel good that these patients know that I spent my time to come down that evening and see them without expecting anything other than their gratification and the hope s that I can improve their quality of health. Dr. M is an obstetrician-gynecol ogist with a private office near the free clinic and sees JCHC patients there on a referral basis. Dr. M: Well, volunteering is very rewarding, the population here at the JCC is very grateful. Theyre always nice people and they are always ha ppy to see me, and whatever I can offer them, they seem pleased with. I like the feeling of helping out, of giving back to the community. I have always felt rewa rded by the patients gratitude and I have always felt like I have made a difference in somebodys life after I have done the surgery and helped them out. Dr. L: One of the most important reasons (I volunteer) is I always feel good. It doesnt matter what kind of lousy day I have had, and I have had a lousy day today, and its been a long day, and I know that when I leave here, I always feel fantastic. It doesnt matter how bad the patients are, how good the patients are, you just get a wonderful feeling that you are doing something, that you are helping somebody else. Dr. E, a general adult neurologi st, has volunteered at the clinic for over ten years. When asked what sustains her volunteer service to the JCHC, she responded, The patients. The patients sustain me. The patients are very appreciative. They cant believe that they are coming to see a doctor for free. They do what I ask them to do. They are good patients. The following comment by Dr. B, an otolaryngol ogist, details how the spiritual value gained at the JCHC was lacking at her regular practice primarily due to the difference of the gratefulness of the patients. Dr. B: Ive had several patients here who have had cancers, who Ive operated on, and its nice to know that Ive done something that hopefully will prolong their life, and most of them have been very grateful which is nice I came from a practice in Ft. Lauderdale where it was extremely rare to have a patient who thanked you for taking care of them. So it is nice to have patients who are truly appreciative of what you do. This theme that emerged in this study is cl osely paralleled to what sociologist Rebecca Allahyari found when studying volunteers a ssisting the homeless in Sacramento. Allahyari (2000) found that volunteers cont inually pursued self-betterment when performing their actions, aiming to create oneself as a more virtuous, often more spiritual


26 person. This pursuit was termed by Allahyari as moral selving, a nd it involves working or improving on the inner emotional self. Interestingly, while the volunteer work itself is focused on the recipients, one of the main rewards of the service perceived by volunteers is improving themselves. Simila r findings were obtained in this study. Physicians in this study mostly highlighted the spiritual value gained from the work, while improving oneself economically, sociall y, or career-wise were scarcely mentioned. While physicians aid patients mostly physically, or tangibly, they themselves seem to be aided by their own se rvice internally. Volunteer Work Benefits the Commu nity and the Local Emergency Rooms Volunteer physicians often mentioned in the in terviews that one of the key motivators for them to initially volunteer was the want to give back to the community. The JCHC director has also heard this often when physic ians sign up to volunteer, stating, A lot of them have told me that the community has been very good to them and theyd like to give back. But in what sense? Is this in a Fa rmer class ideology sense, as mentioned above, in order to provide more resources for th e non-dominant class in order to reduce the inequality inherent in a class-based soci ety? This somewhat vague response by physicians required additional probing to gain an understanding of how they felt they were actually, tangibly, giving b ack to the local community. Upon analyzing the data, a common trend was that seven of the ten physicians mentioned the emergency room specifically in relation to how they felt they were giving back to the community, and this phrase was mentioned by physicians within the interview transcripts a total of 22 times. There is a definite relationship between physician volunteer service a nd the state of local emergency rooms. Dr. B, a otolaryngologist (a doc tor that specializes in the anatomy, function, and diseases of the ear, nose, and throat), sees patients at the clinic once a m onth and has volunteered for six years. Dr. B: Well, I like to think (my volunteer work) helps the community. In fact, I know that it does, because if we can take care of peoples medical problems before they become acute, they wont be filling up the emergency rooms and that provides a benefit to all of us. Dr. M: I think (the clinic) benefits the community because its less taxing on the emergency rooms and it makes more productive members if they ar e not at home with pelvic pain they can actually function. Dr. L: They do go to the ER, and they get these huge bills and they never pay them. Sometimes you will have people that are paying o ff people that will pay off, that have a conscience, pay off $25 a month for the rest of th eir life. But here, for most of the people we see here, they go to the ER, nobody sees the m oney from them ever. First of all, most of them are untraceable.


27 Dr. X: The community has these patients a nd theyve got to go somewhere or nowhere, and it has been well shown they go nowhere if th ey have to pay and th ey just get sicker and sicker and end up in the emergency room, or worse. Dr. W practices urgent care at a Tampa walk-in clinic. He has been volunteering for five years. Dr. W: I do believe this type of clinic f ills the niche where people are working, but they dont have insurance, and they need signifi cant medical care and high quality medical care. With this clinic taking up a lot of that n eed, a lot of that slack there, I think it allows the other areas of our medical care around the country to cont inue what they are doing too such as the Emergency Room, a lot of people here are s een and their chronic problems are taken care of and monitored and they basically are stabilized so a lot of times they dont have to go to the Emergenc y Room, they dont have to show up in the ER because they are here, they have been taken care of here, and therefore our emergency rooms, a lot of the burden that is there is taken off because the people that are in this situation have gotten medical care and dont need to show up in the ER for their routine care. The positive effect of medical volunteerism and the free cl inic is seen by the JCHC director to lessen uninsured peoples severity of dis ease and the much-publicized problem of increasing healthcare costs. JCHC Director: I think (the clinic) has a tr emendous impact on this community. I think it keeps many, many people out of the emerge ncy rooms, which is the most expensive healthcare setting of all. I think it makes for a, I know it makes for a healthier community, because these people come for us, before they reached a critical stage in whatever their problem or illness may be, a nd we can treat it before its gotten out of hand and requires hospitalization or so me major type of treatment. As can be seen, there are many reasons as to how physicians explain their work as being helpful to the community in relation to th e emergency room. Physicians mainly felt either their service helped improve the status of local emergency rooms, the health and financial status of patients who would otherw ise frequent emergency rooms, or both. The emergency rooms will be less taxed, allowing for greater quality of emergency care for all members of the community that truly n eed it. People whose only recourse is the emergency room will tend to go when their illn ess is really advanced, resulting in a less healthy population. While supporting local emergency room s, improving peoples health and financial status, and serving the needs of the community as a whole can be seen as a result of free clinic volunteer work, it can also be seen as reasons physicians sustain their service and the motivators for physicians to initially volunteer. This paradigm of thought, improving or giving back to the co mmunity, is in line with a functionalist perspective or ideology. The physicians see th eir work as providing a function to allow


28 the greater system at large (i.e. the commun ity) to run more seamlessly. The emergency room theme is important for current voluntee r physicians, is a for ce in sustaining their service, and should be mentioned to prospective volunteer physicians. Spiritual Value: The Relation betwee n Business, Service, and Medicine A current person of fame, Dr. Hunter Patch Adams, discusses the relation to business, service and medicine from a physicians perspective: The major voices in American medicine seem to suggest that soluti ons lie more in taxes or in universal health insuran ce than in restructuring the provi sion of care. They seem to say, Just give us more money and the crisis will blow over. In the rising panic, the very foundation of medicine is being forgotten. There is loud rhetoric about medicine as a right, and silence abou t medicine as a service to society. I believe that the concept of service has become misplaced in the madness of operating medicine as a business. We cannot really reduce the costs, or lessen the sorrows of patients and caregivers, until medicine is removed from the business sector (Adams 37: 1998) The discussion of business, medicine, and service is seen throughout the interview transcripts. Dr. W: In my private practice, Im actually in a urgent care facility, the patients are very appreciative, but they are also paying for it so they expect a lot more about, they expect something back, and sometimes they can be a little demanding that way. The patients here are just so appreciative, you ju st want to do everything for them. The interwoven nature of business and medicine at this physicians day job displays the somewhat lessened spiritual value of providing medicine for those that are sick. The following quote elucidates a possible strong motivating factor as to why physicians would crave the spiritual value gained at the clinic. Even though phys icians treat people during their day jobs, the business climate ma y not give them the spiritual value they desire. Dr. N: Well, volunteerism is important to me, it is important to most physicians I think. The majority of us went to medicine with a goal that we ultimately were going to be able to assist individuals who are having problems a ssociated with health care. That they may have diseases or they may need preventive care that we can do for them. Often times in the private practice of medicine, it is difficult to dedicate a fu ll day or a full evening or that sort of thing to individuals with thos e needs and the JCC, of course, gives us the opportunity to do thatSo its time well spent, it makes one feel good about themselves and what they do and what their profession can do for the community. Dr. Z is a JCHC referral doctor that speci alizes in asthma, allergy, and immunology.


29 Dr. Z: I think the rewards of volunteering outweigh the barrie rs, its the same comment I have made through and through the interview, which is to be a doctor, you become a doctor to help people first. Secondly, to make money. In the process of doing that, when you feel like youve been given a gift, and you ve been compensated fairly, you have to try to give back to the community. Whethe r you do that with monies, where you donate to institutions or whether do that with your time, I think doing a little of both is always necessary. Dr. Z states the relation of bus iness and medicine. While he states that when you become a doctor to help people first and secondly to ma ke money, this is contradicted in the next sentence. He explains that when you feel like you have b een compensated fairly, you then have to give back to the community. Even so, this statement shows that this population wants to give back to the commun ity, or practice medicine for the sake of helping people without business-world attachments. Dr. X: I have always been interested in the ca re of the indigent. I think thats one of the reasons why I went into medicine. So my private practice evidenced that because I was the only neurosurgeon in five counties to take Medicaid except th e medical school, and they often made it difficult for Medicaid patients to get in to see them. I just know, I guess I found out about the clinics existence, and other doctors that have volunteered here, and it just seemed like a good idea, and th ats one of my the purposes of my life, the meanings of my life is access and quality of care, in particular neurosurgery allowed me to work on access and quality, which are my two main driving forces right now. In the interviews, many physicians state the r eason they chose medicine as a profession was to serve people. Therefore, the physicia n population may have more reason to need this function or value. While in the daily realm of medicine physicians do serve people, the business aspect of medicine can be seen as interfering with that direct service relationship. Physicians commonly work in private practice and ma y begin to feel like they are merely providing a product or good to th eir customers. The need to retract to the idealist state of pure service wi thout ties to business can be seen as providing a rich value or function to this population in particular. How Physicians Came to Be (And Can Be ) Involved: Person-to-Person Recruitment The general blanket approach to recruitment versus more personalized contact was an issue throughout this project. Which is mo re effective? From the physicians we interviewed, eight of ten doctors and both JCHC staff members discussed the importance of personal contact in recruiting. Most physicians felt that personal contact would best aid recruitment far more than general blanket statements via television and the mail. During this project, we experienced a small cas e study related to this issue. The annual JCHC fundraising dinner is atte nded by many current volunteer physicians. Bea told the host to make a general announcement that surveys for volunteer physicians were available at the front of the room. Despit e this announcement, no physicians decided to


30 fill out the survey. We also mailed the su rvey to all volunteer physicians and had a minimal number of returns. We got the best return when the JCHC director personally contacted physicians. This experience co rroborated the feeling that person-to-person contact would be the best way to recruit. Dr. W knew about the clinic since its incep tion, but did not choose to volunteer until much later. Dr. W: I always thought that this clinic would be good because I had heard of other doctors who had gone to the clinic to vol unteer and they had a very positive, good experience. It was important for me to know someone who has volunteered before because when I talked to them, I found out it was an enjoyable experience and that they got a lot of satisfaction by doi ng it, and that my time wasnt going to be wasted in any way doing things that werent helpful to people. Dr. E knew both the facility and some member s of the JCHC before getting involved. Dr. E: I found out about the clin ic and went over there and saw what a great place it was, and I like to go over there whenever I can, sometimes I take samples there, samples of medicine and that sort of thing. And I kne w the medical director, who I had known since I was a little girl, and I guess I talked to him about it initia lly, and got involved, and then I met the JCHC executive director and tried to find out how best I could serve the people at the clinic. Dr. M, now a JCHC board member, is greatly involved with the cl inic and has had a long-running connection with the institution. Dr. M: Well, I actually cant remember w hy I started but I have always known about the JCC. My best friends father founded it. That was Reverend Jim Holmes and I have known him since I was a teenager, so I have always known that I wanted to be connected with the JCC and I got back in town and somebody asked me, I cant remember who it was, if I would volunteer here, and I thought thats gr eat, thats just what I want to do. Even with Dr. Ms personal knowledge of the clinic as a teenager Dr. M recalls being asked to participate as the origin of her involvement. This story highlights the significance and influence of the pers on-to-person recruitment technique. Dr. F, an obstetrician/gynecologist with sp ecialty training in re productive endocrinology and infertility, recalls here how he be gan volunteering at th e clinic in 1974. Dr. F: At that time physicians were regular ly providing services back to the community in areas where they were needed. All of the doctors in my specialty participated in the Judeo Christian Clinic, giving in their professional time on a rotating basis. And as I entered the community this was something th at my colleagues were already doing which


31 I felt was appropriate and I pa rticipated along with them My experience at the JCC is largely been integrated with the remainder of the obstetric and gynecologic community. And until recently, virtually everybody who practiced ob/gyn in this community did volunteer their timeI think individual physic ians, if they are approached directly, would probably be willing to volunteer a r easonable period of timeWell, Ive always found direct person-to-person communication to be the best way to solve any problem and I think that by going out and sitting down with the physicians and 1) showing them the need 2) giving them some understanding of the process that exists and 3) having them understand they will be part of a large community providing this so that they will not be overburdened, I would find it surprising if most physicians didnt respond. Peer influence is a stated r eason as to why Dr. F began vol unteering. Peer influence can be seen as related to having a more persona l contact in regards to recruiting. In the following excerpt, the director lays out the clinics current recruitment techniques. JCHC Director: The things th at are in place to try to recruit additional physicians is, number one, I try to talk to th e doctors individually and ask th em if they can talk to their friends or if they know any physician friends who might be interested in working at the clinic/ volunteering at the clinic. That, to me, has been the most effective way. We also send out letter periodically to all physician s listed in the phone book, and we have a good rapport with the Hillsborough County Medica l Association. And every time they published their bulletin, which I think is 9 or 10 times a y ear, they always put a little blurb in that bulletin requesting/informing pe ople that we need additional physicians, and Im always asking the board members if they have asked their doc tors if they would consider volunteering here or anybody else I can talk to, and we put out a newsletter three times a year and I always put a little blurb in there asking for healthcare professionals to volunteer. While several methods are used in the effort to recruit physicians, taking a personal direct communicative approach is seen by the director as most effective. When I asked a longtime JCHC staff member her opinion of the mo st effective manner in recruiting doctors, the response was quite similar. JCHC Staff Member: (The best way is) going to their office and talking to them personally and just asking them. Ambiee: More personal, not like blanket ge neral mailings? Danielle: Not like the le tter like we are mailing out. I real ly dont think half these doctors get their letters. Dr. N, a volunteer for over twenty years who has also personally recruited many physicians for the JCHC, also feels person-to -person recruitment is the most effective technique. However, Dr. N feels the t echnique should be implemented in a more organized approach.


32 Dr. N: How to attract more individuals in health care to volunteer at the JCC is a problem that we all deal with its not spec ific to the JCC, its the volunteerism issue altogether. The approach I think should be a proactive approach. The clinic that needs volunteers needs to get key people in contact with key physicians and ideally key physicians and key groups. What the Judeo Ch ristian Clinic has not done actively in the past is find some way to get spokespeople into the specialty section meetings that occur monthly at private hospitals where all the doctors of a specialty convene and discuss administrative and clinical matters involving the office and are certainly, if not to listen to a 20 or 30 minute powerpoint presentation, certa inly to one single individual who wants to talk about and to give out literature on volunteerism for a specific cause. So getting into areas where doctors are meeting is diffi cult but not impossible. And it works better in my view than mail appeal, if you see the bulk of mail that doctors get every day, and you categorize it into four or fi ve different categories, whethe r or not they even see that appeal is somewhat questionabl e at times. Telephone contacts with individuals of the health care profession for that, that is not very worthwhile but for every time you have a personal contact within a formal setting wher e doctors are sitting and willing to review and think about things like that, I think it works. Dr. X and Dr. L both had similar responses th at focused on a personal touch when asked what they would do if they were in charge of recruiting physicians to volunteer. This demonstrates in a different manner how infl uential physicians think the person-to-person recruitment technique is. Dr. X: Well, if I was in charge, I would be the champion, Id make sure I spoke to the hospitals where the majority of physicians work, where physicians are, and Hillsborough County Medical Association, talk to them, and knock on doors, and go around and meet physicians, and say Hey, we need your help, can you help us out? If I was King, thats what I would do. Dr. L: If I was in charge, I would actually like them to come in and spend some time with me here. I dont know if that would be possible but I think that would be a great time. Just come and spend half an hour at the clinic here on your way home from work that day and see what it is all about. When discussing how to utili ze the recruitment DVD, the director perceives using it alongside a personal approach. JCHC Director: Im very optimistic about this project. Im hoping it enables us to recruit more physicians. Im hoping we can show it to various groups. A lot of physicians have their own specialties and they meet on a regular ba sis and Id love to have the opportunity to take this video and show it to those groups. Id also like to pass out the DVDs to doctors to show to their frie nds in hopes that they ll try to recruit their friends. Its going to be shown in Sept ember (2007) at the Hillsborough County Medical Associations Annual Dinner, and so we ll see what kind of impact it has there.


33 As can be seen from the data, person-toperson contact is seen by current physician volunteers and JCHC staff members as integr al in recruiting poten tial volunteers. Identifying Volunteering Barriers and Overcoming Them Time as a Barrier As with any volunteer activity, time is a ba rrier for the participant to volunteer. Volunteering in its nature is a non-essential, or non-require d, activity. Physicians are often strapped for time within the current heal th care environment. All interviewees in this study were non-retired. Time, and lack of it, is mentioned in all interviews and often repeatedly throughout an i ndividual interview. Dr. N volunteers at the clinic one evening every other month. Dr. N: (A) restricting factor is time. Doctors in todays world work very hard. They work from dawn to dusk, seeing their patient s wherever their primary place of care is, and for them to take their day off, their af ternoon off, their evening off, and to come down and spend the rest of that time doing wh at theyve done day in and day out for the entire year, I think it takes a special sort of sacrifice and dedica tion on the part of the individual. A hidden time-associated barr ier is lack of planning Also flexibility in particular, is seen as vitally important for physicia ns to volunteer. If the clinic is too rigid, they might be less likely to volunteer. Dr. O trained in otolaryngol ogy and head/neck surgery and currently practices as a facial plastic surgeon. Dr. O was fa miliar with the JCHC as he participated as part of the USF College of Medicine curriculum for medical students. Dr. O: Everyones time is very valuable, and it does take time, but thats something that I choose to set aside in my schedule, so I gue ss I would say lack of planning would be a barrier. If I didnt plan, if I didnt make plans to say I would be there on this day, then I would never get around to it, so you really have to make the commitment and you have to plan to serve, or otherwise its not going to happen. Other than that, the clinic makes things very easy for physicians to participate. Really, all I have to do is just show up. So I think the clinic does an out standing job of making it as ea sy as possible for physicians to come here and be a part of the clinic and serve. Dr. W: One of the barriers might be that you would think, you think you dont have enough time. Im sure that this clinic would allow people to, doctors to volunteers their time for any time that they have available, whether its once a month or once every other month or whether its one or tw o hours of availability here or there. This clinics been very lenient, I dont want to say lenientthis clinics been very open to my ability to schedule one month I may schedule for a M onday night and another month a Thursday


34 night. It may be early in the month, it may be late in the month but some people who volunteer may be worried that while theyve go t to be there once every other week, or once a week, or once a month on a certain da y, and it doesnt always go along with their schedule. I think with this clinic, there is a lot of variability and availability of different times to volunteer. The clinics policy on the scheduling of physicians is that it is strictly up to the physician how many hours or days he or she wants to volunteer. Most doc tors volunteer one evening a month, or 12 times a year, but ther e is definitely a spectrum on the number of days a year different JCHC doctors voluntee r. Dr. M volunteers twice a year and has been volunteering for seven years. Dr. M: I think to recruit other physicians, it is important to tell them it is not that big of a time commitment. If we get enough physicians to volunteer, then its only you know, once or twice a year possibly. The clinic currently offers various options for doctors who would like to volunteer and allows a great deal of flexibility. An exam ple of this are the referral doctors who see patients in their own office during their re gular working hours. Dr. E, a referral physician, sees about one to two JCHC patients a month. Dr. E: Well, the barriers I would imagine for doctors to feel that they cant volunteer is that they think they need to go to the clinic, thats one thing. Its a time issue for a lot of people, like for me, that doesn t work for me to go to the clinic, to have a neurology clinic there. Or to go and see two or three patients, so I w ould encourage doctors to know to be a consultant, like I am, on a referra l basis where patients can come to them. Dr. Z is a JCHC referral doctor that speci alizes in asthma, allergy, and immunology. Dr. Z: I think that it is very flexible at the JC clinic, as you can see were in my office. Doing this in your office versus doing it in thei r clinic, there are options. I think there are probably a lot more flexibilit ies in all sorts of areas. Dr. B, a otolaryngologist, sees patients at the clinic once a month and has volunteered for six years. Dr. B: I only have so much time and if Im not seeing patients in my office who are generating income, that is a financial drain for my practice. So I kind of have to balance how much time I devote to seeing the clinic patients. Time is often a significant barrier. However, the availability of time is often mentioned as the reason why physicians got involved in volunteering. Time in relation to volunteer service is an important relationship.


35 Dr. W: Ive always known about the JC clinic even at the time that I did my residency and internship. I think the clinic was just gett ing started at that time and I never felt I had enough time to do that, to volunteer at that poi nt, because I was just getting my practice started and working a lot of hours, and seeing/working in th e emergency room part-time, seeing patients, and try to build my practice for many years, but I always had it in the back of my mind that I wanted to do some kind of volunteer work(Now) I got a little bit more time, my kids are grown up, they ar e out of college, I dont have to push as hard, you know, in my practice. In fact, I have taken a job where I dont work as many hours as I did when I was in private practice and I felt that it was my time to go ahead and do some volunteer work. So basically it was a matter of timing, it was good for me at that point and Im glad that Im ab le to do it at this point. Dr. L has been volunteering at the c linic for roughly seven years. Dr. L: Nothing really makes it more difficu lt for me to spend time here. If I want to spend time here, I can make the time to spend here. Its just a matter of juggling your work hours and what you have to doI actually always thought of volunteering after my kids left home, because when you go home at night, there are lots of other things to do, so that is a big barrier. Malpractice as a Barrier The possibility of being charged with a ma lpractice claim is something all physicians dread with the current medical-legal environm ent in this country. Also, the perception that the poorer socioeconomic population is more litigious is seen by current volunteer physicians as a barrier for non-volunteers. Dr. N: The biggest barrier particularly in th e recruitment of physicians to work at the JCC is that the medical-legal climate in this country and in partic ular in the state of Florida makes it difficult at times for doctors to feel comfortable giving extra time to volunteer in a clinic. One physician relays a story of a malpractice cl aim unrelated to the clinic. However, this shows the disapproving viewpoint of malpract ice from the perspect ive of a physician. Dr. O: And, lets see, during my experience with indigent care, I have not had any malpractice lawsuits. I had a patient we took care of him in my training that was a taxi driver and two kids ran and ski pped the fare, and when he went after them, they shot him. He came to the hospital, and he was in the hos pital for quite some time and then he ended up dying before he left the hospital. He was, you know, he died in the hospital, and then I was kind of involved as a witness because th ey tried to blame his death on malpractice with the hospital rather than the children, the kids that shot him, so that was a case I was peripherally involved in, but was not named in.


36 The following remarks highlight the perspec tive of current volunt eer physicians that liability risk cannot be totally eliminated but it can be put in a more realistic perspective. Dr. O: I think the biggest barri er is the constraint on a phys icians time, and their, you know, cautiousness about the types of liabil ity they may take on, would be the two biggest concerns. But they are easy to overcome. And overall, as long as you are documenting well, and considering this is a free clinic I think the liability is relatively low. Dr. B: Well, for those who are in practice, and are carrying medical liability insurance, theres a perception that this population of patients is more lik ely to sue. That has not been my experience. And I think the fear of being sued because you are taking care of someone gratis is probably not valid, and I know that is one con cernI think that in general, the patients that I have had here have been appreciative of the care thats been provided to them. Its rare to see somebody wh o has a sense of entitlement that comes to this clinic. There are some, but they are ra re. And those are the people who I am a little more weary of, in terms of, would this person be likely sue me if th ings didnt go well in their care. And like I said, I just dont see that many people like that here. There is always a concern about liability. I dont really think about it much because it hasnt been an issue, and I dont think it will be, but its always in the back of your mind if you are practicing in Florida. Dr. N: The concerns about the medical-legal cl imate, I can only reas sure individuals that the average patient, at least, the patient I see at the JCC will be the least litigious patient that I could ever see. You can see the gratefulness and appr eciation in their eyes when youve seen them, the fact that they leave that clinic with a sense of satisfaction that this doctor has taken his or her time to come down and spend time with me and the likelihood that that can result in litiga tion, of course it is not impossible, but in my view, is very unlikely. Level of Liability Related to Specialty Dr. W: I think its probably, most malpracti ce carriers would want to encourage people to volunteer, and they wouldnt make it too difficu lt for them to get coverage for this type of clinic. If you were doing some high-risk cl inic work, volunteer work, then that might be a different thing, but I dont consider th is clinic a high risk for malpractice. Dr. O: Considering this is a free clinic, I think the liability is relatively low. Dr. O and Dr. W believe liability is relative ly low for medical pr ofessional volunteer work. However, as can be s een in the statements below, it is not the same for every specialty. Liability, just like malpracti ce insurance rates, varies depending on the specialty. The JCHC referral sp ecialist states the most needed volunteers are surgeons. Surgeons carry the highest level of liabilit y. As mentioned above, liability is a major


37 barrier in recruiting volunteers which could be the reason why surgeons are the scarcest in the volunteer population. JCHC Staff Member: Whatever doctors are there, I use completely, and its the same ones over and over again. Because we dont ha ve that many doctors in each specialty, or have such a great variety. We only have thr ee surgeons for twenty people. We only have two or three for each specialty, sometimes only oneThere is usually not a wait for anything, unless its surgery or gynecology, or gastroenterology. There are just so many people that need those three specialties that it gets backed up and we only have so many doctors that do each thingWe dont have certain specialists, for instance, neurosurgeons or orthopedics, if a patie nt needs them, we dont have it. Dr. Xs statement below shows the relatively high risk of liability in a field like neurosurgery: Dr. X: The issue of physicians taking care of patients that dont pay and putting themselves at risk for taking care of those pa tients because they can be sued for whatever reason, forget if something is going wrong, even if nothing went wr ong, particularly in neurosurgery. There is not much room in the brain for tumors and blood vessel problems and other things while operati ng on them, so doctors can be at great risk financially by doing good, you know. They put themselves at risk, thats another barrier. Dr. Z confirms Dr. Xs sentiment that the inhe rent dangers of surger y are often high, both physically and financially. Dr. Z: The concerns for volunteeringis the potential infringement affecting my malpractice. I see it more, not in my field, but my colleagues in surgery, theyll often find themselves between a rock and a hard pl ace. Theyll have someone, not related to JC Clinic, with a thorn by a fish in the carotid artery, after rem oving it, they dont make any problems except a secondary infection, an abscess occurs, and with poor follow-up there is a complication, all of a sudden there is a extenuati ng circumstance and an older patient, and when you are doing that, you are doing anesthesia, they come out with something else. They are the risks that are involved, as I said more so in the surgical field that occur a percentage of the time, not due to neglect or a mistak e, it is one of the risks factors. You might not make it to the end of the day, it is a risk factor. The lack of physicians in these specific ar eas is most likely not random or by chance. The issue of medical-legal liability is significant for all physicians, more so for physicians that are at higher risk due to their specialty. The lack of volunteer physicians for surgery is likely directly related to malpractice. Physicians Unsure about Malpractice Coverage Many physicians seem to be uncertain about if and how their malpractice coverage


38 covers their work at the free clinic. This uncertainty can be a barrier for prospective doctors and cause extra concern or worry for current doctors. The following quote exemplifies the often unsure replies physicians give when asked about their malpractice insurance covering thei r volunteer service. Dr. O: I do not know if this type of medical practice falls within the (pause) whats it called, the.because the clinic is affiliate d with the university there may be an exemption from liability affiliated with th e university institution, Im not sure, but obviously my malpractice insuran ce would be a fall-back if th ere were (pause) a claim. Usually it does not require any change in malpr actice as long as its in the same county as your current malpractice coverage. The physicians that are assured their malpract ice insurance covers their volunteer work only needed to ask their employer or insurance company. The following quote exemplifies this. In addition, in all the interviews I conduc ted, no physician stated their insurance coverage has directly told him or her they will not cover their medical volunteer work. Dr. W: I know some doctors have said th at they might have medical malpractice problems with this type of clinic, but to my knowledge, there havent been any concerns with that here. I know with my job, I am lucky enough that my employers made sure that any coverage that I might need is available wh en I work at the clinic here. Not only am I covered in my job, I am covered in any volunteer work that I do. Ambiee: Is that common for your c overage to cover work done here? Dr. W: Well, I think it is common if you let your malpractice carrier know what you are doing. In my experience, if you were to just volunteer anywhe re and not tell your malpractice carrier, then there might be a c oncern there that you would not be covered it would depend on your policy. Prevalence of Spanish-Speaking Patients as a Barrier Current volunteer physicia ns believe that due to the majo rity of their patient clientele being solely Spanish-speaking, this hinders a significant number of physicians to volunteer. This fact is men tioned extensively in current ph ysician volunteer interviews. Dr. F, who has volunteered for the clinic for over thirty two years, has seen the changes in the patient population thr ough decades at the clinic. Dr. F: Another barrier, I think in recent times, has been a language barrier. We see more Hispanic patients who dont speak Eng lish, and if you are not a Spanish speaking physician, then that does not only make it hard er to do a good job but it takes longer to do the job. So, more Spanish-speaking physicia ns would be useful and more Spanish speaking help.


39 For physicians, losing the one-onone patient-physician relations hip due to the need of a translator somewhat diminish es the satisfaction of volunt eering. During my observation sessions with physicians, I found that when a tr anslator was necessary, the patient history and communication could still be done but it was not as effortless and it definitely complicated matters. This is seen in the following quote. Dr. L: The only thing Id like to talk about is the big la nguage barrier and I think we should try and reach out to some of the Spanish-speaking doctorsbecause they would be a big plus here, because that is my bigge st problem working with. You dont get, you know, all the nuances when you are dealing with a translator, its very hard to getyou can get an accurate history, but there are certain things that Im sure you miss out on. The JCHC staff also feel having a large Span ish-speaking clientele as being a barrier in recruiting physicians. JCHC Staff Member: Ive had people waiting six or eight months because there is such a shortage of surgeons and then some surgeons dont want to take Spanish-speaking patients because they dont want to work through a translator, so it becomes more difficult The thing is when you tell them mo st of our patients are Spanish-speaking, thats the reason a lo t of doctors dont wa nt to volunteer. Continuum of Medical Care The want of physicians to have continuity of care is mentioned in several interviews. Obviously, this is an important issue in trea ting patients and within the field of medicine in general. Continuity of car e is clearly defined by Dr. F. Dr. F: Well, my personal belief is that the best medical car e is one which has continuity and thats best conducted betw een one patient and one doctor. As society and medicine gets increasingly complex, thats harder and harder to do, and one has to often work as part of a group or part of a team to eff ectively provide medical care to more peopleIt certainly isnt possible for any one physician to be there at all times, that would be better, but we dont live in an ideal world and given the circumstances we face, physicians contributing a reasonable amount of their time for the public good is appropriate, and I think this is the best way we can handle that continuum of care given th e state of things in 2007The principal issue that I have is one that I am not sure is solvable. And that is the continuity of patient care. I see that as the biggest problem for a physician because you go there and you know that the next week so meone else is going to have to pick up what you have done and so the patient doesnt have the advantage of seeing the same doctor time after time after time. In an envi ronment like this, shor t of some mechanism of employing a small core of physicians who are there regularly w ith supplement from volunteer physicians, Im not sure that I see any solution to that.


40 Volunteering a relatively small amount of time to a free clinic exposes the lack of continuity of care to a greater degree. As will be seen later, this continuum of care relates to other risks or barriers to volunteering, namely compliance and medical-legal liability. As Dr. L outlines below, the irregular freque ncy of the patients visiting the clinic, on a non-routine basis, exacerbates the issue more so. Dr. L: Sometimes it is very frustrating that you do see these patients and you try to help them the best you can, and the follow up is a huge problem because a lot of them dont come back, some of them are migrant work ers, who are working here for a while, and then they are moving somewhere else. A nd you dont know what happens to them. And today was a typical example. That lady has just come in here, clearl y very ill, probably a drug addict, tells me she has got hepatitis C and has got pain all over and is probably wanting pain pills. But I wont do it, and becau se I wont give her pain pills, just ordered blood work and some tests, the chances of her coming back are very low. Dr. O outlines similar problems in working with patients that have irregular health visits. Dr. O: Working with the indigent populat ion is a little more challenging because the follow up is a little more difficult. You don t always get the whole story and you always worry about if you order a test, is it going to get followed up, will the patient show up, because they dont always have the means or resources to follow through to what we recommend to them. So it is a little more challenging, they may not be as compliant, so thats a challenge you face with the indigent populationIts up to the patient to make due with their resources and try to follow th rough with the compliance at that pointso it is important to take a thorough history, because they are at risk for low compliance. You do have to be very alert for getting a comple te history and little signs or symptoms that may seem small, I do try to be very careful a bout the history I take here, because I dont, because if this is the patient that isnt going to be seen by a doctor for another three to six months, I want to make sure I dont leave anything out. The above excerpts display the negative components of not having continuity of care. The excerpts below demonstrate how having a continuity of care with a patient is positive and rewarding for the physician. JCHC referra l doctors in particul ar can have greater continuity of care and see patients in their own private practices. Dr. M: One thing that I find helps is if I see a patient with a definitive problem, Ill have them follow up in my office, and thats way the patient knows she is going to get taken care of instead of just pushed in the system and lost. If JCHC patients need surgery or follow-up specialty care, JCHC referral physicians in particular can continue to s ee that patient and follow them through. This is also seen through a particularly memorable experience expressed by Dr. N.


41 Dr. N: I think one of the greatest remembrances I have is a patient I saw one evening at the JCC who needed rather urgent gyneco logical surgery for some pretty serious problems. And she needed a pre-op and a work-up, she could go right straight to the hospital for this sort of thing. I remember s eeing her in the clinic and saying I need to get you referred to a doctors office for a workup a nd then get you for surgery. And she said in another language with an in terpreter, Could you please do all of this for me? And under the JCC guidelines, I was able to self-re fer that patient to my office, where I worked her up extensively in the office. And then I admitted her to St Josephs hospital, St Josephs Women Hospital and performed urgent surgery for her and she made a full recovery and she came and saw me for a 6 w eek checkup. And I think it was by far this was the most grateful patient that I had ev er seen where we had total and complete continuity of care. And that was not only because I was volunteering of my time, but so was my office, office personnel, the hospital, and the hospital personnel. The excerpt below demonstrates how the medi cal personnel at the JC HC assist physicians and patients in scheduling follow up appointments, even if they are with different medical professional than the patient saw originally. This is necessary when continuity of care from one physician is not possible. Dr. W: My biggest concern for volunteering in a clinic such as this is Im only here once a month or so, and I dont have the follow-up sometimes that I would like with some of the patients I see. There may be someone who I am concerned about regarding tests I have ordered and so forth, and because I dont have the ability to follow up on every patient, sometimes you worry about them, you dont know whats going on with them, but knowing the system here, and knowing the cl inic, I really feel that they are getting good follow up and they are getting help. I havent had any cases that Im aware of that have fallen through the cracks and you know, test s were ordered and studies were ordered and they either werent done or the pa tient wasnt taking care of properly. Perceived Lack of Resources/Stereotypes of Free Clinic Facilities Current volunteer physic ians often mention their belief in the perception among nonJCHC volunteer physicians that working at a free clinic will be problematic or not satisfying because of the lack of resources. The JCHC director has seen this firsthand, I think a couple of fears that Ive seen among the doctors that Ive talked to is first of all, when they come to the clinic they are very impressed with the build ing that we have, and all the equipment that we have. They may ha ve a picture in their mind of what a free clinic is going to look like, and feel like, and when they get he re, they like it and they feel comfortable, and they know we have all the equipment that they need, they dont have to bring anything with them. Lack of resources available is particularly untrue for referral physicians because they see JCHC patients in their own offices. The negative perception of the quality of free clinics itself, however can deter potential volunteer physicians. Often physicians during the interview will attempt to debunk that stereotype.


42 Dr. N: One other barrier that I didnt men tion is that I hear when Im out recruiting doctors, Well, the clinic doesnt have the same type of equipment that I have in my office and because of that I feel encumbered when I get down to the clinic and I just dont have what I need when I need it. And I an swer that in two ways: Volunteers who really work hard find the equipment to go to the JCC or there are more than one option for volunteerism at the JCC and the other is you can see patients in your office with your own equipment all on your time, so you dont ne cessarily have to come and pack up and come to the clinic and not have what is appropriate for you to do, or for you to have. When discussing the production of the recr uitment video with Dr. W, the theme of general negative percep tions of free clinics emerged once again. Dr. W: (Prospective physicians) would be able to visualize what they would be doing there, and what kind of clinic it is, instead of, thinking oh, it s a free clinic, its probably dirty, its probably not well run (laughs) Im just going to be wasting my time there, they can actually see the clinic and visual ize whats going on and make a better decision that way and not have so many negative thoughts to begin with. Dr. E emphasizes in the following quote not on ly the efficiency of the clinic, but its ability to cover even expensive tests. Dr. E: I have found that the clinic is really very resourceful and being able to get tests that I need done, even expensive test s, like MRIs, even lumbar punctures or echocardiograms, or things that I might need, they can figure out a wa y to do it, so I dont really have to jump through hoops to get those things done. I send the report back to the (JCHC) doctors who sent the patient here and they find a way to get them done. Dr. M: Definitely when you volunteer here you ha ve to be more conscious of the expense of all the tests you are ordering. When some body has insurance, you just order whatever you want, but without insurance you have to be more careful. (Pause) But I havent had any problems, I can always get the tests that I need, I just write a prescription, I know St. Josephs hospital has been wonderful about helping out and dona ting their services. This quote is especially telling. Dr. M qui ckly responds that you have to be more conscious of the expense of tests. But af ter thinking about her experience and getting beyond the party line or what seems to be th e appropriate response, she realizes she has not had any problems with any of the tests th at she has wanted to run. Upon observing Dr. M at her specialty office, the support sta ff seems to be more aware of who is a JCHC patient than the physician. Upon seeing me in her office waiting room, she had a surprised look and stated, Oh, am I seeing a JC HC patient? This denotes that treatment of a JCHC patient must be quite similar to that of a regular paying patient of the physicians private office. In sum, physicians that currently volunteer at the JC HC perceive the clinics resources as high-quality and repeatedly voice this throughout the interviews.


43 Linkage between Good Patients, C ontinuity of Care, and Malpractice In many of the interviews, doctors would all ude to the patients at the Judeo Christian Health Clinic being good patients, respons ible, or compliant. Physicians often mention the goodness of patients when they ar e trying to recruit other doctors. This is prevalent in many of the physicians interv iews, so patients being good may play a significant role as to why the volunteer or why they con tinue to volunteer. Another significant issue mentioned by all physicians was malpractice. In a few of the interviews, a linkage can be seen between these two prevalent themes, and this may be the reason why physicians emphasize the goodness of the patients. Ambiee: What do you think are barriers for you in volunteering your time here? Dr. O: Patients, there is a c oncern, that if patients arent compliant, or dont follow what you do, that they can have a delay in diagnosis or a bad outcome, and then, as in todays world, there is the reality of medical-legal liability, so that is something that, you know, its a risk that we all take. In this physicians thought pr ocess, if patients arent comp liant or dont follow directions, there is an elevated risk of malpractice or liability. A lack of compliance is a possible barrier because it relates to malpractice insurance. Dr. L: I think the negative c onsequences that we always have in the back of our head is litigation. That is always my biggest fear about working in this country as against in working in South Africa where I initially traine d. There was not a lot of litigation. You never felt that the lawyers were on your bac k. I feel which, especially working in the clinic here, its very hard to get some of the tests you would do in private practice, and you dont have the same follow up, thats the only concern I have, but at the same time I feel that these patients are so grateful to be seen by doctors, nurse practitioners, whatever, for nothing, that I just hope they would never think of suing if ther e was a big mistake. There is a linkage between good, grateful patien ts, continuity of care, and malpractice. This physician believes the lack of continuity of care may directly increase the chance of being charged with malpractice. However, the patients being grateful can offset this chance. The increased chance of being sued is communicated in the quotes below. Dr. M: I think some physicians are afraid of the medical-legal issu es for volunteering. They dont want to get involved with any mo re possible lawsuits. And each patient equals a possible lawsuit, so I think some doc tors will stay away from that. Also, these are patients that dont have good histories of health care. They dont go to the doctor every year, like our private patients, so thats more risky. Dr. N: Some professional liability insurance carriers are somewhat nervous if a doctor spends a great deal of his or her time in a volunteer situation. But its not so much the


44 financial part of the professional liability part of the situation, its just fear of lawsuits, and seeing patients, for instance, in which you havent had the opportunity to establish a doctor-patient relationship with over time. Some doctors a nd health care givers feel increase their liability or ris k, and this level of concern, it does restrict our ability to recruit at times. The lack of follow-up in a free cl inic setting is a perceived ri sk to physicians. This lack of continuity of care, mentioned several times, is more so important due to its relationship with perceived litigation or ma lpractice. Physicians seem to feel that emphasizing the goodness of patients will mitigat e the fear of malpractice to prospective physicians. In order to significantly alleviate the fear of malpractice charge s being filed against volunteer physicians, policy ch anges at the state or national level would be needed. Secondary Themes The themes within this section did not emerge as frequently and were not discussed as intensely within the in-depth interviews as the primary them es above. However, this may be due to the primary focus of the research study and/or the nature of the methodology. Lack of Publicity for the Clinic as a Barrier A secondary barrier, one that was not mentioned as often, was the lack of publicity or knowledge of the clinic. However, greater publicity in order to improve recruitment and funding is a common need with volun teer non-profit organizations. Dr. L: One of the barriers is I think a lot of people dont know about the clinic. I think youve got to get the word out. The only place I have really seen the clinic advertised is in the Hillsborough County Medical Association magazine and Im sure it is advertised elsewhere. I am not aware of it, but I think a lot of doctors dont know about it. Dr. W: Well, in order to get doctors to volunteer for a free clin ic like this, first of all, they need to know about it. I know a lot of phys icians that I talk to are vaguely aware or slightly aware that there might be some free c linics in the area, but they dont even know where they are, the names of them, whats av ailable for volunteer wor k. I think that just getting out the message that there is a clin ic available where y ou can go and volunteer on a regular basis on your own schedule and its don e with high quality and its available to anyone, to anyone who would like to comeI dont know if they are aware of the JC clinic. Judeo Christian Health Clinic Is the Name a Disadvantage in Recruitment? Due to the methodology, this subject could not be fully explored. The physicians that offered to be interviewed were already current volunteer physicians. If the names religious connotation is a si gnificant barrier for a subpopulation of physicians, they


45 would not be current volunteers. Due to the size of the study, we were not able to recruit non-volunteers. However, current phys icians may know non-volunteer physicians affected or have experience and knowledge a bout this situa tion. What advantages and disadvantages does the name itself, Judeo Ch ristian, have on r ecruiting physicians in particular? was asked to current volun teer physicians during the interviews. Overwhelmingly, the current JCHC physicians felt the name was not a disadvantage in recruiting or otherwise. The origin and development of the clinic name is explained by the JCHC director. JCHC Director: I think the disadvantages that some people think we are a religious organization, and it is a faith-based or ganization, you know, it was started by St John Presbyterian Church by Rev. Jim Holmes. But Judeo Christian Health Clinic, its named JCHC because of the connotation of the Judeo Christian ethic from the Old Testament, of man helping his fellow man and thats as much as it has to do with religion. I get asked that question so many times, Why is it named JCHC? Well, it started out being named St. Johns Clinic because St. Johns started it, but as more churches joined, they changed it to the Christian Coalition Clinic, is what it is, and then synagogues and Jewish groups, and they decided to name it, Judeo Christian Coalition C linic and they stuck with that coalition for the longest time, and people used to ask me weird questions about it like, What do you do down there? Build bomb s or something? What kind of coalition are you? So finally the board decided they would drop the coaliti on, insert health, so people would at least know we ar e a health clinic (laughs). It is an altruistic name, its a solid beautiful name, but its not always very apparent as to what we do here. So people have questions about it. Dr. M: Well, the disadvantage is it makes it se em like it is a religious facility, and it is in a church, and it could be a disadvantage mixi ng that religion with medicine. But the advantage is that it really is a Judeo Christian value to help other people. That is I think the basic value of religion in general, any religion. Dr. L: In terms of the name Judeo Chri stian clinic, I have never had anybody say anything negative about it. I th ink it is a wonderful name. It s attached to a church, Im very comfortable with that. I think it en compasses everybody, and I dont think it is a problem. Dr. N: I do not think the name Judeo Christian would be a barrier at all. I havent seen it be such. I have never seen it or heard of a s uggestion that for the fact is a Judeo Christian effort, appropriately named, for what it stands for, or what its mission is, that anyone has taken offense to that or suggested otherwise. Dr. X: No, it has a reputation, I dont think so you need to ask one of my colleagues, I suppose if I was a Muslim, I would be a little concerned, so maybe they ought to, I never thought about that, maybe they ought to think about changing their name, Judeo


46 Christian Muslim.wouldnt bring more doctors but it might make the Muslim patients feel a little better, course it might make the Judeo Christians feel worse, its a crazy world we live in. Dr. W: No, I dont think there is any disadvantage to the name I think that if the name actually tells why the clinic is here, and how it was originated in many ways, but with regard to the name, I really cant see where there would be a problem with regard to prejudice against the name pe r se. When you are talking to a free clinic, I mean there may be some people that maybe feel they ar e left out because they are not Judeo or Christian, but thats not the case, in this clin ic, so I dont think that comes to a I dont think that would be a valid problem. The Young and Retired Physician Populations Out of the 30 surveys given back from the clinic, no physicians chose retired, even though the age range was from 32 years old th rough 70 years old w ith the median age being 54 years old. In interviews, the issu e of retired physicians was not addressed because they are not themselves retired, alt hough this is a significant issue in volunteer health policy in Florida. This might be a significant segment of the population that JCHC is missing and could actively recr uit. In regards to this issu e, the director of the clinic stated that most JCHC physicians are in priv ate-practice, but Our attorney, however, is looking in to the possibility of the health dept covering retired doctors who might be covered under sovereign immunity while wo rking at JCHC (pers onal communication). Due to the scope and methodology of the st udy, however, this issue was not actively investigated. There are not a significant num ber of retired physicians at the JCHC. Further study in the general retired vol unteer physician popula tion is needed. Below, Dr. N and Dr. B both discuss the extra wo rk retired physicians must do in order to volunteer as a physician at a free clinic such as JCHC. Dr. N: For instance, retired physicians have to get certain waivers in order to volunteer their time without carry ing professional liability insurance. Dr. B: Malpractice insurance is a big barri er, because there isnt any protection offered to retired physicians who volunt eer here. And thats unfortuna tely kept a lot of people who would like to work here, because theyre retired from their active practices, away. A few physicians feel there is a lack of young volunteer physic ians, defined as physicians who have recently complete d their residency. Many cu rrent volunteer physicians explained they felt too busy trying to get thei r practice started or providing for themselves and/or their family when they were younger to volunteer. However, Dr. F and Dr. B both mention that improving skills and gaining e xperience is beneficial for young physicians and this function could be served by volunteeri ng at the clinic even though they are not getting paid. Dr. F said, I am 66 and I dont have that much to learn from it, but


47 younger doctors do. Dr. F explained that while medical students are more of a hindrance than an asset in a clinical sett ing, residents should come to volunteer at the JCHC because they know enough to be productive members and they can gain experience. Dr. B: Well, I think that, you know, the university does a great thing by having the medical students come and spend time here And I think it would be difficult to get residents out of the hospital a nd volunteer at a clinic but I think that because of the clinics relationship with the university, if they could figure out which residents will be sticking around after their training they might ask them to consider coming here, you know, as they get started in their practices. The Need to Further Engage Volunteer Physicians with the Clinic When I conducted in-depth interviews with sp ecialists, I asked basi c questions about how they receive a patient, who pays the costs, etc. Most physicians were quite unaware of how the referral system works. This can be seen as a positive because they do not need to be aware of how the system works and they only have to focus on the patient that has come in to see them. Specialists that see patients in their own office know significantly less about the running of the cl inic then doctors who treat within the clin ic building. Many specialists showed interest in learning more about the de tails of the referral system and more about the clinic in general. This commonly came up among specialists, but Dr. Z best summed this up: I dont know that any of us that particip ate have the whole picture as to how many physicians are participating as we sit right here today and the group of patients that are taken care of, what that population, what group do you extend this care to, you know. We pretty much allow, as physicians, for the JC clinic to determine that But to have a fuller picture of this would also benefit in the recruitment and the keeping of those physicians that are still participating. Kind of an end-of-the-year video of what you have seen that you are doing this vi deo, the opposite way, to say this is some of the patients we saw, some of the clinics, first time at the e nd of one year where they are at, that I think acts both ways, to help educate those of us that are participa ting, those of us that want to participate, those that haven t participated but want to in the future, and to show the patients that are there. Related to this is that sin ce physicians only volunteer a re latively small amount of time and specialists are not tightly connected to the clinic, this combination can have volunteer physicians gradually participating less with th e clinic. The JCHC re ferral specialist does not refer JCHC patients to all of the doctors currently within the JCHC physician referral binder. The referral specialist explained that all of these doctors (p ointing to the referral binder) are not current voluntee rs, you know? The referral specialist claims physicians can be lost gradually because the physician s staff will not set up appointments for the


48 JCHC patients. The executive director of JCHC explains sometimes the doctor does not even know the staff is not referring or sche duling JCHC patients a nd directly contacting the physician is usually the solution. Someone in the staff serves in the gatekeeper role, and is an important unseen figure. When talking to another anthropologist who has previously been affiliated with physician offices, she said this gatekeeper often feels that he or she is doing a favor for the doctor, li miting the number of patients to lessen his or her burden, even while sometimes not telling them. Ambiee: Do you have any recommendations on how to improve recruitment of these specialties that are needed? JCHC Staff Member: Just getting our name out to doctors. Its almost like having somebody going to their office in person. No t sending the letter, because does the letter really get to them is the question. There ar e so many people in a doctors office, there is so much staff. You know, the office mana gers filter the mail, they dont give them everything, they (physicians) probably dont read half of it. This is an issue because physicians may be lost due to this interaction. This is a hidden loss, presumably, because the doctor fades away. However, the referral specialist maintained that gradually losing docto rs in this manner is not typical. Survey Findings VFI Survey Results Although the most significant data was gather ed through the qualitati ve interviews, the results of the survey also served to confirm some of the most important themes developed in the interviews, as well as providing some limited demographic data. The categories listed below are clearly defined in th e Literature Review chapter above. Table 1. Motivational Functions Served by Volunteer Service According to JCHC Physicians Benefit category Mean 1 Understanding 4.14 Enhancement 3.55 Values 6.27 Protective 2.59 Career 1.92 Social 3.30 1 Means from 7-point Likert Scale, 1 = strongly disagree, 7 = strongly agree.


49 Survey Descriptive Statistics: Table 2. Survey Response Rate VFI Survey Total Number of Possible Respondents Actual Number of Respondents Survey Response Rate (%) Volunteer Physicians at JCHC 194 30 15.5% Table 3. Demographics of Survey Respondents Respondents Males 18 Primary Care (Family Practice, Internal Medicine, Pediatrics, OB/GYN) 17 Total # of Survey Respondents30 Physicians Total Possible Respondents 194 (Total JCHC Physician Population) Females 12 Non-Primary Care 13 Table 4. General Descriptive Data of Volunteer Physicians # of Respondents Average length of volunteer service Average Age of Volunteer Physician Average Number of Hours at Day Job 30 9.8 years 53.1 Years 53.38 Hours Table 5. Retired and Non-Retired Physicians # of Respondents # of Retired Volunteer Physicians # of Non-retired Volunteer Physicians Did Not Respond 30 0 28 2 Table 6. Median Amount of Volunteer Service by Physicians Number of Respondents # of Hour s Volunteered a Month at JCHC Median Value 21 9 Did Not Respond 3 Hours a Month


50 Due to the low response rate, I was not ab le to compare subgroups (i.e. young physicians VFI scores versus older physicians VFI scores) within the physician volunteer population. This was originally wanted so as to compare subgroups in their motivations to volunteering. Discussion of Survey Results As seen by the data, the typical physician volunteers for the clin ic about three hours a month. This is affirmed by the JCHC director of the clinic. With time being a large barrier for volunteer physicians, this data shows the flexibi lity in scheduling. This also confirms the need for a large pool of volunteer physicians so as the responsibility does not fall on a few volunteer physicians. Due to the low response rate, I was not ab le to compare subgroups (i.e. young physicians VFI scores versus older physicians VFI scores) within the physician volunteer population. This would possibly show differe nt motivations among different subgroups of the volunteer physician population. However, the survey was used primarily to allow all JCHC volunteer physicians an equal opportunity to part icipate in the in-depth interview (the primary research instrument) and to have a simple method to recruit participants for the in-depth interview and obser vation process. In this regard, the survey was a success as more physicians volunteered to take part in the interview and observation process than was needed. The survey also helped to tria ngulate the data from the research study. Social Benefits to Volunteering One category of the VFI is the social category. This is defined as offering opportunities to be with ones friends or to engage in an activity viewed favorably by important others (Phillips et al. 2001: 49). This reflects mo tivations primarily concerning relationships with others. Volunteer literature maintain s that a successful vol unteer organization will recognize and reward their volun teer base (Ilsley 1981). Pr eviously, the JCHC held a volunteer recognition dinner but this was cancelled for two reasons: 1) Lack of attendance at the dinner. Volunt eers stated they were too busy to attend. 2) Volunteers did not want the clinic to sp end money on them. They wanted the clinic to spend their money on the patients and the clinic itself. This is affirmed by the results of the VFI the strongest motivating factor was values which centers on altruistic and humanitari an concerns of the volunteer. Dr. N mentioned off-camera that he knows doctors who go on these medical missions for two or three days out of the year and feel they ha ve volunteered enough and have little interest in volunteering local at the JCHC. He str ongly believes this subgroup of physicians feel volunteering internationally is more glamorous than volunteering locally and thus, more beneficial or satisfying to those physicians. Receiving awe and attention


51 is definitely a positive benefici al function in regards to volun teering and this is certainly fulfilled in these international missions The degree to which this motive is received at the JCHC is unknown. The VFI survey results show the social score among the thirty current volunteer physicians to be the f ourth ranked volunteering function (3.30 on a 7 point Likert scale). This shows that the glamour func tion or receiving attention by important others is not a str ongly influential motivation or significantly important to current volunteer physicians. Connection between the Results fr om the Survey and Interviews The Values category was ranked the highest (6.27 out of a 7 point Likert scale) by volunteer physicians. No other value was close to this score. Average scores of 4.5 or higher reflect a strong influence of a particular motivation to volunteer (Phillips et al. 2001: 49). Within the in-depth interviews, physicians often cited their intrinsic belief that the value of the service, to give heath care in those in need, was the most important and primary reason they volunteer. The Volunteer Functions Inventory results support this. According to Clary et al. (1998), this is often characteristic of those who volunteer and distinguishes volunteers from nonvolunteers. It may be diffic ult to recruit persons that are not intrinsically motivated by the values function. However, the values function should still be highlighted in recruitment materials as it may motivate those who are likely to be volunteers. Although no other category had a score of 4.5 or higher, the Understanding and Enhancement functions were the next highe st values (4.14 and 3.55 out of a 7 point Likert scale, respectively) The understanding value i nvolves the opportunity for volunteerism to permit new learning experiences and the chance to exercise knowledge, skills, and abilities that might otherwise go unpracticed. This value, ranking second out of six functions, does not fit ex actly in line with the results of the open-ended interviews. Physicians very rarely mentioned that their service allowed them to exercise skills and knowledge they otherwise would not use. On the contrary, they primarily discussed positive aspects of volunteering that balanced the somewhat repetitive experience of volunteering in the same capacity as they work within their day job. The enhancement value centers on personal development, personal growth, and higher self-esteem. This is the third ranked categor y and is in accordance with the results from the qualitative research. Th e spiritual value of the service was a consistent theme throughout the interviews. As seen in the section Why Physicians Volunteer, the primary emergent themes are the need in this community for access to health care, benefits to the community and specifically the emergency rooms, and the spiritual value of the volunteer work. These three specifi c motives garnered from the qualitative research correspond with the first and third hi ghest ranking motivati onal functions in the VFI Values and Enhancement.


52 The lowest motivational function rated by vol unteer physicians was the career function, scoring 1.92 out of a 7 point Likert scale. This is also in complete accordance with the open-ended interviews as physicians, as a w hole, rarely mentioned any career-related benefits obtained from participation in volunt eer work. This may be due to the average age of a JCHC physician being 53.1 years old, according to the survey, and this population may have little to gain caree r-wise from volunteering their professional services. The career motive is often highly rated in groups where the population is in the beginning stages of their careers. The su rvey result may display the lack of young physicians within the survey and the clinic in general. Over all, the in-dep th interviews and the VFI survey generally conf irmed the results of the other.


53 Chapter 5: Conclusions and Recommendations This section will discuss the video component of the study and draw conclusions based on the findings of the study and in relation to the literature. R ecommendations gained from both the literature and the research study will be presente d in this section and to the clinic. The contribution of the study to th e community will be discussed as well as the anthropological contribution to the research study itself. Issues and Recommendations in Constructi ng a Recruitment Video and Subsequent Recruitment Material The results of this study were used to help develop the recruitment video. In other words, the themes and ideas that emerged from the interviews and observation shaped the style, content, and format of the video. Throughout th e course of the resear ch, physicians often mentioned the lack of time they would ha ve to watch a lengt hy video about physician recruitment, and many recommended produci ng a short video, from about 5 to 10 minutes. Since running time is so important, I feel it is necessary to stamp the running time of the video on the DVD disc so physicians will know how much time to allot to watch the video. These time constraints played a factor in what can be shown; only the most significant themes were mentioned. Through the survey and interview data, the va lues motivating function (specifically, the need for access to health care and the benefits to the community) seemed to be essential in motivating current physicians to voluntee r. What can be seen in the physician interviews is their strong belief that our society needs better health care and health care should be a basic human right. This be lief seems to propel many to volunteer. Therefore, this theme is highlighted in the video and should be in any other recruitment materials. Also, the spiritual value gained from the volunteer work was important to current volunteer physicians and is discusse d. Current volunteer physicians constantly mentioned that prospective physicians may not be aware of the flexibility JCHC offers. This flexibility comes both in regards to time and to place that doctors can see patients in their own office practice. This informa tion should be developed in future brochures and is mentioned in the recruitment video. Also, if written brochures ar e produced, direct quotes fr om physicians should be reproduced. These can be derived from transc ripts, with permission from the doctors. This ties in to the personal touch that is essential in recruiting effectively. An example would be addressing litigation a nd using this quote by Dr. N:


54 Dr. N: The concerns about the medical-legal cl imate, I can only reas sure individuals that the average patient, at least, the patient I see at the JCHC will be the least litigious patient that you could ever see. You can see the grat efulness and appreciation in their eyes when youve seen them, the fact that they leave that clinic with a sense of satisfaction that this doctor has taken his or her time to come down and spend time with me and the likelihood that that can result in litiga tion, of course it is not impossible, but in my view, is very unlikely. Continuity of care is of great importance to physicians. All recruitm ent materials should emphasize that a referral physician for the JCHC can have greater contin uity of care with a patient. Supported by interviews in this study and by the literatur e review, it is seen that the poorer population is less likely to sue. Prospective do ctors should be informed of this finding. It is necessary to include on r ecruitment materials that Spanish translators are accessible at clinic. It is also essential to show the facility itself and details its connections with St. Josephs hospital in recruitm ent materials to de bunk the stereotype of a poor free clinic. This me thod of creating the vi deo is in line with the Clary et al. (1994) matching hypothesis. This is the idea that persuasive messages will succeed in engaging volunteer intentions and actions to the extent that they focus on the relevant motivations of the specific population. It is necessary to discuss possible barriers or limitations so the video will be believable to prospective physicians as well as directly address possible concerns in volunteering. Time, malpractice, and perceived lack of re sources were the most important volunteering barriers or issues with current physicians, so these issues are also discussed. Again, due to the need to shorten the length of the video, all themes cannot be effectively included in the video. It is integral to highlight the phys ical features of the c linic for informational purposes as well as to help debunk the stereotype of a free clinic without appropriate resources. It is important to show what a prospective volunteer will do, so shots of current volunteers at work in the clinic were pres ented throughout the video. This also created movement in the video and a diversity of visual images. This is important because within the last two decades resear chers have found that the simple formal features of television, such as cuts and edits, activate the orienting response (the instinctive visual or auditory reaction to any novel stimulus) which improves a persons memory recognition and focus on the stimulus at hand (Kubey and Csikszentmihalyi 2002:76). Originally the video was created to attract physicians watching in a general audience via television or large meetings, such as the Hillsborough County Medical Association. This would be a general blanket approach which atte mpts to reach a large number of people. This was just an initial assumption wh ich arose from how videos are generally distributed. However, another method of delivery was strongly recommended by previous recruitment literatu re (Ilsley 1981) and current JCHC physicians within the study a direct hand-to-hand de livery approach of the DVDs in an attempt to recruit physicians with a more personal approac h. Having current JCHC physicians help


55 distribute the DVDs and recruit prospective volunteer physicia ns is necessary in this recruitment strategy. I see that it is essentia l to give current vol unteer physicians multiple copies of the video and other recruitment mate rials to give to other physicians in their day-to-day network. The physician could personally communicate what it is like to volunteer at the JCHC and give the video as supplemental information. Personal contact and person-to-person recruitment was a signi ficant theme across the interviews. The medium would add a separating layer to the pe rson-to-person contact but it would still be a more personal construction since physicians will be discussing issues related to the topic at hand. The prospective physicians could watch the video given to them by someone they trust and stil l keep that personal feel: JCHC Director: Weve interviewed so many of the physic ians that volunteer here. Its not the personal 1-on-1, but it almost is, in a way, because the doctors are talking about their story and their experience here and asking others to join us. Originally, the video was solely to be used for physician recruitment. The JCHC already has a general video that is used for fundr aising and publicity purposes. However, the physician recruitment video eff ectively displays the clinic the efficiency of the nonphysician staff, and the contribution the clin ic has on the local community. Therefore, this video may also be used for fundraising, publicity, and recruitment of non-physician volunteers. In addition, the comments of the physicians as to why they volunteer can be generalized to physicians elsewhere, not ju st the JCHC. I will soon develop a more general video that will highlight physician vo lunteerism in general and this will be given to the National Association of Free Clinics ( NAFC), so they can distribute the video to other free clinics to aid their recruitment of volunteer physicians. Relating Selected Literature to Current Findings In the field of social psychology, there is a schism in theories re lating satisfaction and motivation. Historically, it is believed that satisfaction reduces subsequent motivational drive. Roy Baumeister, a social psychologist has recently presented a theory explaining that once we get something we want or desi re, the subsequent feeling of satisfaction reinforces the strength of that desire (Elis h 2007). In this study, the average number of years spent volunteering at the clinic by a current volunt eer physician is 9.8 years. Throughout the interviews of this qualitative research st udy, physicians often cite their satisfaction and feeling good about their service at the JCHC. They also state that this feel good feeling is what motivates them or causes them to volunteer. The findings of this study are in line with Baumeisters theo ry since volunteer physicians surveyed at the clinic seem satisfied with their work and are still eager to serve. Barnhill et al. (2001) conclude d in part that medical malp ractice is a great fear for potential medical volunteers and documented that a change at a state-level increased medical volunteerism. This study affirms that medical malpractice is a barrier to recruit volunteer physicians, but unlik e Barnhills results, this study demonstrates that it


56 continues to be a great fear. A ccording to Burstin et al. (1993:1697), rising malpractice insurance costs and fear of litig ation are thought to reduce physician availability in poor neighborhoods and create access barriers for the medical indigent. Current volunteer physicians also see this fear of litigation as a problem. Runquist and Zybach (1997) demonstrated that the Florida Volunteer Prot ection Act offers very little protection and does not absolve volunteers from litigation. The repeated concerns and statements concerning malpractice during this study s upport this conclusion. Current JCHC physicians feel stronger protection would make it easier to recruit more physicians to volunteer. This is a change n eeded at the state or federal policy level. A policy change regarding universal health coverage for pers ons within the U.S. would also solve the problem and lessen the need for volunteer physicians. Isaacs and Jellinek (2007) conclude from their study focusing on volunt eer health care progr ams across the nation that national health insurance would so lve the problem of the uninsured more productively given the multiple limits of volunteerism. Clary and Snyder (1999: 156) explain that in planned helping, the helpers decisions about beginning to help and about continui ng to help are influenced by whether the particular activity fits with the helpers own needs and goals. Through the in-depth interviews, the values of the physicians were the key motivating fact or and it was certain that they felt that voluntee ring at the JCHC fit with thei r needs and goals. From the interview data, it was seen that many of the long-standing physicians volunteered for both the values function and the enhancement f unction (the benefit to the community, the intrinsic belief in access to health care as a human right, and the spiritual value gained through volunteer service). This corroborates the Marta et al (2006) finding that people motivated by more than one motivation may be less vulnerable to costs related to the activity. Recommendations for the Clinic 1. Specialists need to know mo re about the details of the refe rral system and the clinic in general. The JCHC referral specialist, awar e of this, agreed that it woul d be beneficial to create a brochure or informational piece of paper, updated each year, so the referral physicians will know more about the clinic and possibly further engage them with the clinic. 2. As a policy suggestion, each volunteer physician should be given a yearly personal update about the clinic, clinic events, and a fo rm stating their intent to continue their volunteer service. While physicians are short on time, they would li kely be more engaged with the clinic if they knew more about how it runs and thei r importance within the organization. Currently, the clinic provides a mass-mailing newsletter to inform their participants, but physicians often complain about how much ma il they receive and in their offices, they


57 might not even get all of it. A more pe rsonal contact is recommended to update the physicians. This would also be a good opportun ity to ask physicians for suggestions and their level of satisfaction with the JCHC. 3. Further recognize curr ent JCHC volunteers. I recommend an inexpensive project that wi ll recognize or reward the current health professional volunteer base. Pr evious volunteer recognition activ ities were not successful because volunteers stated they were too bus y to attend an actual function and volunteers did not want the clinic to spend money on the m. They wanted the clinic to spend their money on the patients and the clin ic itself. This is affirm ed by the results of the VFI the strongest motivating factor was values wh ich centers on altruist ic and humanitarian concerns of the volunteer. I recommend taki ng photos of current volunteers and placing them together on a hallway wall of the JCHC. This process is inexpensive but the volunteer may feel more physically linked to the clinic and also feel their work is being recognized. I recommend in-clinic volunteers have their p hotos put up first followed by referral volunteers. This also may attract or satisfy physicians that are primarily motivated by social factors receiv ing attention by important others. 4. Person-to-person physician re cruitment is most effective. As can be seen from the data analysis, pe rson-to-person contact is seen by current physician volunteers and JCHC staff members as integral to recruit potential volunteers. A larger proportion of time and energies in relation to physician recruitment should be allocated in the form of personal contact. Mass mailing is not effective. Spokespersons are needed and they can be equipped with effective DVD and recruitment brochures tailored specifically to recr uiting health care professionals. 4.2 The current volunteer physician base must he lp recruit other physicians to the JCHC. Often current physicians are unaware the im portance of recruiting other physicians to volunteer at the JCHC. The cu rrent volunteer physician base must be informed of how important recruiting more physicians is to th e clinic and take on the task of being a recruiter. Paul Ilsley (1981) suggests that an excellent recruiter must identify with the target group and have knowledge of the mores and history of the group being recruited. The physician lifestyle would be very familiar to a physician recruite r. Often in this study, physicians stated how important it was to know someone who was already volunteering and receiving satisfaction from their time at the clinic before they themselves got involved. This could be practically done by maki ng a clinic brochure informing current health care professionals of the need to have them recruit other health care professionals. As seen in the study, current JCHC physic ians personally and directly communicating with other physicians is like ly to be the most effective method in recruiting physicians.


58 5. Place a suggestion box in the physician lounge area of the JCHC so the JCHC administration may continually be linked to an essential important segment of the clinic. A suggestion box may make current physicians more involved with the clinic. Ted Cox (Chester 1990:30), in his practical guide to volunteer management, remarks that volunteers expect to be heard. 6. Maintain flexibility in re gards to scheduling physicians. The clinics current lenient policy in rega rds to scheduling is supported by the findings within this study. When initiating voluntee r service at the JCHC, the physician should make the choice based on what is most suitab le and realistic for hi m or her. Also, the amount of volunteer service should be continua lly refined so as to best suit the physician involved. The study findings show that one of the most positive aspects of the JCHC clinic, according to current volunteer physicians is the flexibility they allow in time commitment and service of the physicians. Lack of planning is also seen as a barrier to volunteering. Having a JCHC member help re mind and plan schedules with doctors that work personally best fo r them is recommended. 7. Enlist a few emergency translators on call on a weekly or specific weekday basis. Some days there are no translators volunteeri ng at the clinic and some days there is a surplus of translators. Translators should schedule their shifts 24 hour s in advance, so as if there is a gap in translators, the emergency translator can be reached to help translate at the JCHC. While flexibility is importan t in volunteering, a fail-safe is needed. 8. Target groups that are in need or lacki ng at the JCHC and create direct messages that will be of interest to the particular group. Spanish-speaking physicians, physicians of specific medical subspecialties (surgery and orthopedics), young physicians, and retired physicians are in need or are currently lacking at the clinic. The clinic must find curre nt volunteers that are within the needed population and utilize them as spokespersons. Dr. B recommends contacting the medical school to recruit young physicians: if they (the University of South Florida College of Medicine) could figure out wh ich residents will be sticki ng around after their training they might ask them to consider coming here (the JCHC) as they get started in their practices. Current JCHC physicia ns that have close ties or are part of the medical school would be best suited as recruiters. 9. Concrete information is needed about individual physicians malpractice coverage. Through the study, a common theme to emerge wa s that current volunteer physicians are unsure if their malpractice coverage will pr otect them from a claim at the JCHC. A brochure detailing malpractice coverage issues and helping physicians out how they are


59 covered would comfort some of the physicians that have this uncertainty. Or a JCHC volunteer could work with physicians malprac tice insurance providers to determine the type of coverage the physician would receiv e if a claim took place at the JCHC. This grounded knowledge would ease the physicians concerns much more. Although most physicians believe they are covered, this measure would put them further at ease. The Anthropological Contribution and Contribution to the Community This study used a standard psychological a ssessment, the Volunteer Functions Inventory (VFI) and compared this data with trad itional ethnographic methodology. Thus, this study helped triangulate and compare the two me thodologies. While the qualitative data was the main part of the research, the quant itative data also helped contextualize the qualitative results. The applied framework allowed the researcher to gain access for the study as well as give back to the participating community. The process of the in-depth interviews itself contributed to the research goal, by shedding li ght on the need to recr uit physicians. The rigor of the research, performing numerous in -depth interviews on the specific topic of volunteerism was essential in cl arifying the themes associated with medical volunteerism. Qualitative research is essential to address the why and how questions for a study of this sort. Performing the research study itself highlight ed the need for more volunteer physicians. Often physicians, after the interviews, stated they did not think previously of the importance in recruiting but they know physicia ns that might be interested and would now actively recruit people for the JCHC. Dr C, after the interview explained, I work with 18-20 physicians that dont volunteer at this clinic, and I didnt really bring it up, I never thought, I just never brought it up with them, but I think that I should and I think that I will, pretty soon I will. So the act of performing the study alone may have aided in physician recruitmen t at the JCHC. The audiovisual tools used for both resear ch purposes and for the applied component were essential to the study. At the end of the project, I am givi ng the JCHC an edited video that will help recruit volunteer doctors. All decisions about any further distribution of the video will be left to the JCHC admi nistrators. The JCHC executive director has already allotted a time to show the video at the Hillsborough County Medical Association annual meeting in September 2007 in an attempt to recruit more local physicians to volunteer at the clinic. Isaacs and Jellinek ( 2007:875), in their study of volunteer health care programs across the U.S., claim that clin ic leaders have little interaction with directors of volunteer programs in other communities and are often unaware of the ways in which other programs have addressed similar problems. The video may be shared with the National Association of Free Clinics (NAF C) so other free clinics can access and use the video in a similar fashion.


60 The anthropological methodology attempts to analyze an issue from a wide range of vantage points. Incorporating audiovisual equipment, medical anthropological, visual anthropological, ethnography, psychological literature and methodology, and volunteerism literature allowed me to do so. This project can highlight the diversity of tools one can use in the field of anthropology in analyzing a si ngle issue. This project is also able to show a segment of the range of possibilities of what can be done in the growing field of applie d visual anthropology. Closing Remarks This purpose of this study was to furthe r understand why physicians volunteer their medical services and the main barriers to their volunteering, as well as to provide recommendations and a product that would be directly applicable in assisting the free clinic in physician recruitment. I found physicians schedules, malpractice, language barriers, the lack of continuity of care in the free health car e setting, and perceived lack of resources at a free health clinic were themes physicians felt were significant as barriers to their volunteering. The value or belief-system of physicians was significant in why they volunteer, specifically their belie f in the need for access to health care for all, as well as their belief that their work at the free c linic will benefit the community and the local emergency rooms. The spiritual value that physicians gained when offering free medical service was also inte gral to their volunteering. The st ated purpose of this study was achieved in that recommendations and a vide o were developed in order to assist the organization in recruiting, and a greater understanding of physician volunteerism was obtained.


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67 Appendices


Appendix A: Poverty Level Guidelines Figure 1. 2006 Poverty Level Guidelines. (U.S. Department of Health and Human Services 2006) 68


69 Appendix B: Physician Interview Guide Question Sets: Descriptive: Tell me your name and your specialty. Tell me your length of volunteer service. Can you tell me what kind of patients you s ee when you volunteer as a (insert specialty) and what it is like to be a volunteer (insert specialty). Antecedents to volunteering. 1) How did you begin volunteering? Tell us about the impetus (the factors that initially caused you) to your volunteering. 2) Have any previous events in your li fe influenced you to volunteer? 3) What caused you to specifically choose to volunteer here, at the Judeo Christian Health Clinic? Experiences in volunteering: 4) Why do you volunteer your time as a doctor? Why is this important to you? What sustains your volunteering here? Why do you continue to volunteer? 5) If you could only give me one reason, the most important reason, as to why you volunteer, what would it be? 6) Tell me what it is like volunteering here at the JCHC. 7) What is it like to see patien ts as a volunteer physician? 8) To give me a specific, real example, one we can visualize, tell me of a specific interaction or event as a vol unteer in which you think encapsulates what it is like to be a volunteer physician. Or a rewa rding experience as a volunteer physician. 9) How do your efforts, as a vol unteer health care provider, benefit the clients of the clinic? 10) How do they (your efforts) affect our community/society? Consequences in Volunteering: 11) What do you think are barriers for you to volunteer your time? Tell me of a specific event in which you experi enced a barrier to volunteering. 12) What is your biggest concern a bout volunteering as a physician? 13) Are there any negative consequences or ri sks to volunteering as a doctor? What are they? 14) What do you think are barriers for doctors generally in volunteering?


70 Appendix B (Continued) 14.2) Do you have any recommendations to reduce these barriers? 15) What do you think are the greatest perceived barriers for doctors that do not volunteer? 16) What would you do, or say, to assuage these fears of fellow physicians? 17) Tell me about any rewards/benefits (pers onal or otherwise) to volunteering as a doctor. 18) How do the rewards compare to the ne gative consequences, in your opinion? 18-2 As a current volunteer, why do the benefits of volunteering outweigh the risks/concerns in your specific situation? 19) Would you recommend volunteering at this clinic to othe r physicians? If so, How would you influence other physicians to vol unteer here? What are the specific reasons you would expand upon? 20) If you were in charge of recruiting doctors to volunteer their time, how would you do so? What procedures would be most effective? 21) In your opinion, what are the advantages & disadvantages in the name Judeo Christian in recruiting physicians? Do you know any colleagues of yours that do not feel comfortable due to the name of the clinic? 21.2) How does the name affect you, if at all? How do you think it affects the clients? 22) Is there anything that you would like to mention that we have left out?


71 Appendix C: Survey for Free C linic Volunteer Physicians Part 1: Descriptive Statistic al Information (7 Questions) All data will be aggregated. 1. How many hours a week do you work at your regular job? 2. How many hours a week do you volunt eer at the free clinic? 3. How long have you been volunteering at the free clinic? 4. Are you currently retire d or not retired? 5. Please list your age. 6. Please list your gender. 7. What is your medical specialty/medical field? Part 2: Volunteer Functions Inventory This is a quick-to-answer 30 question assessmen t. This should take no more than 5-6 minutes. Please answer all of the questions. No individual identifiable information will be used. All data will be aggregated. Indicate how important or accurate each of the following reasons for volunteering are for you in doing volunteer work. Please list on a sl iding scale from 1 to 7 (1 Not at all important/accurate 7 Extremely important/accurate) how important each of these reasons are to you 1. Volunteering can help me to get my foot in the door at a place where I would like to work. 2. My friends volunteer. 3. I am concerned about those less fortunate than myself. 4. People I am close to want me to volunteer. 5. Volunteering makes me feel important. 6. People I know share an interest in community service. 7. No matter how bad I have been feeling, vol unteering helps me to forget about it. 8. I am genuinely concerned about the particular group I am serving. 9. By volunteering I feel less lonely 10. I can make new contacts that might help my business or career. 11. Doing volunteer work relieves me of some of the guilt over being more fortunate than others. 12. I can learn more about the cause for which I am working. 13. Volunteering increases my self-esteem. 14. Volunteering allows me to gain a new perspective on things. 15. Volunteering allows me to explore different career options.


72 Appendix C (Continued) 16. I feel compassion towards people in need. 17. Others with whom I am close place a high value on community service. 18. Volunteering lets me learn things through direct, hands-on experience. 19. I feel it is important to help others. 20. Volunteering helps me work thr ough my own personal problems. 21. Volunteering will help me to su cceed in my chosen profession. 22. I can do something for a cause that is important to me. 23. Volunteering is an important activity to the people I know best. 24. Volunteering is a good escape from my own troubles. 25. I can learn how to deal with a variety of people. 26. Volunteering makes me feel needed. 27. Volunteering makes me feel better about myself. 28. Volunteering experience will look good on my resume. 29. Volunteering is a way to make new friends. 30. I can explore my own strengths. Would you like to participate in an in-depth videotaped interview (15-20 minutes) regarding your work at the Judeo Christian Health Clinic? This would be helpful for this research study and for the clinic. An edited video will be created to help the JCHC communicate the wo rk being done at the clinic and recruit prospective volunteer physicians. If you answer yes, please provide contact information below. The executive director of the clinic will contact you when we begin this phase of the project. Most interviews will be performed at the clinic and will be arranged to best fit your schedule. We will also be conducting videotaped shadowin g sessions after the interviews. This will be used to add B-roll or action footage to the video. Participants may choose to participate in the videotaped interview but not the shadowing session. Both the interview and shadowing session are completely voluntary. End of Survey


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