Learning the moral economy of commodified health care: "community education," failed consumers, and the shaping of ethical clinician-citizens

"Don't fuss at our staff": A moral economy of volunteerism in South Carolina safety net clinics

In South Carolina, a state that has foregone Medicaid expansion, working poor residents often rely on safety net clinics for medical care. This care often occurs far from major hospitals, in different, inferior, spaces where limited services are provided in lesser circumstances. The temporary and conditional aid provided in these clinics is meant as a last resort, but often serves as the only source of care for many working poor patients, who must manage the effects of sustained precarity and protracted immiseration with conditional aid provided by volunteers. Here I explore the function that volunteering plays in regulating patients' utilization, and ability to contest, the quality of safety net care. Using ethnographic examples and interview data I show how the needs of patients-referred to in the clinics as "clients"-are managed and contained by a moral economy of volunteer care. These reciprocal obligations of debt and duty preclude working poor patients from making demands of, or lodging complaints against, the free clinics' staff, due to their capacity as volunteers, and leaves the state's safety net effectively unassailable to accusations of inefficacy or neglect. Consequently, patients must defer care, ignore episodes of maltreatment, and ration and share prescription medications, lest they be considered recusant or deemed not sufficiently appreciative of the volunteer staff dedicating their time to them. As a result of this moral economy, the plight of the state's uninsured working poor residents goes under-recognized as the safety net absorbs their cases, hiding the attritional nature of the ostensibly free care they receive and ration.

Understanding the Motivations of Foster Caregivers at Animal Shelters

Foster care programs in animal shelters have been shown to benefit animals and shelters, but little is known about what motivates foster caregivers to volunteer. This cross-sectional study explored the motivations and expectations of 131 foster caregivers from five shelters within the United States who completed a pre-foster survey between March 2022 and March 2023. The most common motivations were animal- or community-based, such as the desire to provide an animal with love or do something positive for the community. Ordinal logistic regression models were used to investigate associations between caregivers' motivations and their prior foster experience, pet ownership history, age, gender, and foster animal species. The 18- to 29-year-old caregivers were most likely to expect companionship (OR 5.18, 95% CI 1.79-15.04), emotional support (OR 4.25, 95% CI 1.40-12.89), and to meet other community members through fostering (OR 5.04, 95% CI 1.85-13.74). Male caregivers were less likely to foster for emotional support than females (OR 0.12, 95% CI 0.03-0.48), while dog caregivers (OR 2.23, 95% CI 1.04-4.76) and non-pet-owners (OR 2.66, 95% CI 1.17-6.05) had greater odds of expecting companionship. This study highlights the importance of animal- and community-related benefits for foster caregivers and provides useful direction for shelters wanting to increase recruitment to expand their foster care programs.

Student Veterinarian Perceptions of Community-Based Primary Care Veterinary Clinics in Indigenous Communities in Southern Ontario, Canada

Community-based primary care veterinary clinics represent an opportunity to benefit multiple populations. Student veterinarians are afforded the opportunity to build technical and non-technical professional skills, while underserved communities are provided with access to companion animal care. The Ontario Veterinary College (OVC), as with many other veterinary colleges across Canada and the United States, has hosted community-based primary care veterinary clinics, including in local Indigenous communities. As these clinics continue and grow, it is critical to evaluate their operation to ensure that they align with community goals and values, adequately support student learning, and do not perpetuate racism and implicit bias. The objective of this study was to explore the perceptions of student veterinarians who had volunteered at community-based primary care veterinary clinics in First Nations communities in southern Ontario, Canada. We used an online survey that consisted of multiple choice and short answer questions focused on motivating factors for involvement, supports available before and during the clinics, exposure to Indigenous cultures, and the challenges and rewards associated with volunteering. Forty-one student veterinarians from OVC completed the survey in January 2020. Most students were motivated to volunteer to make a positive difference in the lives of people and animals and improve their clinical skills. In general, respondents felt adequately prepared for and supported during their experiences but did recommend additional pre-departure instructions on roles and responsibilities. Participants were ambivalent as to whether they had learned about Indigenous culture, with several strongly recommending more cultural sensitivity training. Most students found their experiences rewarding because of the gratitude expressed by clients and the feeling that they had made a difference. We reflect on the potential benefits and challenges of community-based primary care veterinary clinics in light of student responses.

One Health clinic promotes veterinarian-client trust among underserved pet owners and provides learning opportunities for veterinary students

OBJECTIVE

To determine the impact of a free One Health clinic with human and veterinary services on the veterinary-client relationship for underserved pet owners. A secondary aim was to understand the experience of veterinary students and volunteers who participated in the clinic.

SAMPLE

78 pet owners, 55 students and 32 volunteers who attended the Delaware Humane Association One Health Clinic between December 2018 and November 2019.

PROCEDURES

Pet owners completed an anonymous questionnaire prior to and following their veterinary appointment regarding their trust in the veterinary profession, feelings of enablement and veterinarian-client concordance. Students and volunteers completed a questionnaire within 72 hours of clinic participation about their perceptions of the educational value of the clinic.

RESULTS

Following the One Health clinic, client trust in the veterinary profession increased significantly (t = -5.50, P < 0.001). Clients also reported high levels of enablement and veterinarian-client concordance. Students and volunteers agreed the clinic was a valuable educational experience (97.7%) and reported increased compassion, enhanced leadership, communication and teamwork skills, and an improved ability to identify social issues and think critically.

CLINICAL RELEVANCE

The results support the utilization of One Health clinics to improve access to veterinary care for underserved pet owners. Clients reported high levels of trust, enablement and concordance following the clinic which could have long-lasting effects on their willingness to seek veterinary care and comply with veterinarians' recommendations. The positive experiences of students and volunteers also highlights the potential of low-cost veterinary clinics as unique educational experiences.

Freedom of choice, expressions of gratitude: Patient experiences of short-term surgical missions in Guatemala

Lack of surgical care has been highlighted as a critical global health problem, and short-term medical missions (STMMs) have become a de facto measure to address this shortfall. Participation in STMMs is an increasingly popular activity for foreign medical professionals to undertake in low- and middle-income countries (LMICs) where their clinical skills may be in short supply. While there is emerging literature on the STMM phenomenon, patient experiences of surgical missions are underrepresented. This research addresses this gap through thirty-seven in-depth interviews with patients or caregivers who received care from a short-term surgical mission within the three years prior to the four-week data collection period in July and August 2013. Interviews were conducted in Antigua, Guatemala and nearby communities, and participants came from 9 different departments of the country. These first-hand accounts of health-seeking through a surgical mission provide important insights into the benefits and challenges of STMMs that patients encounter, including waiting time, ancillary costs, and access to care. Patient agency in care-seeking is considered within the pluralistic, privatized health care context in Guatemala in which foreign participants deliver STMM care.

The pharmaceutical regulation of chronic disease among the U.S. urban poor: an ethnographic study of accountability

The Massachusetts experience of health care reform before the Affordable Care Act of 2010 reveals a moral economy of care in which expanded access was met by neoliberal demands for accountability and cost control. Publicly-subsidized health insurance programs in the U.S. are deeply concerned with managing and regulating low-income residents' access to and coverage for medications. By focusing our attention on the new forms of social relations invoked by specific techniques of governing, analyses of accountability can help us understand the ways in which subjectivities are shaped through their encounters with overarching social and economic structures. This paper presents qualitative findings from a four-year, prospective study that combined two waves of survey and chart-based data collection with four qualitative methods. Medicaid patients are made accountable to their medication regimens as they must track their supply and obtain refills promptly; regular blood tests carried out by health care providers verify their adherence. Both patients and their physicians are subject to cost savings measures such as changing lists of covered medications. Finally, patients struggle to pay ever-increasing out-of-pocket costs for their medications, expenses which may keep patients from taking their medications as prescribed. The fraught relationship between trust, accountability and verification finds emphatic expression in the moral economy of health care, where the vulnerability of the sick and their hope for a cure confront policies designed to hold down costs.

Teaching Structure: A Qualitative Evaluation of a Structural Competency Training for Resident Physicians

BACKGROUND

The influence of societal inequities on health has long been established, but such content has been incorporated unevenly into medical education and clinical training. Structural competency calls for medical education to highlight the important influence of social, political, and economic factors on health outcomes.

AIM

This article describes the development, implementation, and evaluation of a structural competency training for medical residents.

SETTING

A California family medicine residency program serving a patient population predominantly (88 %) with income below 200 % of the federal poverty level.

PARTICIPANTS

A cohort of 12 residents in the family residency program.

PROGRAM DESCRIPTION

The training was designed to help residents recognize and develop skills to respond to illness and health as the downstream effects of social, political, and economic structures.

PROGRAM EVALUATION

The training was evaluated via qualitative analysis of surveys gathered immediately post-training (response rate 100 %) and a focus group 1 month post-training (attended by all residents not on service).

DISCUSSION

Residents reported that the training had a positive impact on their clinical practice and relationships with patients. They also reported feeling overwhelmed by increased recognition of structural influences on patient health, and indicated a need for further training and support to address these influences.

Integrating Theory, Content, and Method to Foster Critical Consciousness in Medical Students: A Comprehensive Model for Cultural Competence Training

Many efforts to design introductory "cultural competence" courses for medical students rely on an information delivery (competence) paradigm, which can exoticize patients while obscuring social context, medical culture, and power structures. Other approaches foster a general open-minded orientation, which can remain nebulous without clear grounding principles. Medical educators are increasingly recognizing the limitations of both approaches and calling for strategies that reenvision cultural competence training. Successfully realizing such alternative strategies requires the development of comprehensive models that specify and integrate theoretical frameworks, content, and teaching principles.In this article, the authors present one such model: Introduction to Medicine and Society (IMS), a required cultural competence course launched in 2013 for first-year medical students at the Perelman School of Medicine at the University of Pennsylvania. Building on critical pedagogy, IMS is centered on a novel specification of "critical consciousness" in clinical practice as an orientation to understanding and pragmatic action in three relational domains: internal, interpersonal, and structural. Instead of transmitting discrete "facts" about patient "types," IMS content provokes students to engage with complex questions bridging the three domains. Learning takes place in a small-group space specifically designed to spur transformation toward critical consciousness. After discussing the three key components of the course design and describing a representative session, the authors discuss the IMS model's implications, reception by students and faculty, and potential for expansion. Their early experience suggests the IMS model successfully engages students and prepares future physicians to critically examine experiences, manage interpersonal dynamics, and structurally contextualize patient encounters.