Caring for the Underserved: The Art and Science of Community-Based Medicine

Inside one of the examining rooms in the pediatric unit of Upper Cardozo Community Health Center, a clinic that treats an underserved community in Washington, D.C., one can hear laughter and intermittent conversations in Spanish. There, an American doctor with light eyes and softly freckled skin conducts one of the day's examinations while talking to monolingual patients in their native language.

Although Rachel Wallace, M.D., is not a native Spanish speaker, the words flow rapidly out of her mouth. But even if they didn't, it probably wouldn't matter. "The patients here really appreciate the fact that we can, or at least try to, speak their language," says Dr. Wallace, a staff pediatrician at the clinic.

Doctors like Wallace, who not only have the necessary skills but also the willingness to work in this country's underserved areas, are relatively rare. This is in part because the training that prepares physicians for this line of work is scarce. Working in underserved communities, or practicing "safety-net" medicine, requires not only primary care training but also cultural competency and in many cases a good working knowledge of this country's public health structure and services.

For approximately 30 years, the federal government has recognized the importance of safety-net medicine training and has provided a variety of grants supporting student teaching and faculty development in primary care. These grants, listed under Title VII of the Public Health Service Act, were designed to improve the ethnic diversity, geographic distribution, and quality of the healthcare workforce.

In February, President Bush proposed the virtual elimination of Title VII programs from the FY 2003 budget, and his proposal has sounded panic alarms in the healthcare community.

"By American federal standards we have not invested appreciably in Title VII programs," says Fitzhugh Mullan, M.D., a staff physician at the Upper Cardozo Health Center and a clinical professor of pediatrics and public health at George Washington University (GWU) in Washington.

"Now, such programs might be facing extinction. If that happens, many community-based teachers, and others involved in minority health, who rely on small amounts of money from Title VII, will have their enterprises either eliminated or negatively impacted," he says.

Community orientation

Dr. Wallace is participating in a Title VII fellowship titled "Community Oriented Primary Care and General Academic Pediatrics" that focuses on primary care for the underserved and that would be eliminated under the president's budget proposal.

"This is a very unique fellowship, with its combination of public health advocacy, health policy, and pediatrics. This type of training opportunity doesn't exist at any other site in the country," says Dr. Wallace. Only one or two fellows receive the fellowship annually, she adds.

Under the fellowship, Dr. Wallace has not only received training in clinical care in an underserved community, but has also increased her knowledge of public health and learned the trade of health lobbying and advocacy. She walks the neighborhoods of Columbia Heights, the community in which the Upper Cardozo clinic is located, and she talks to local leaders on a regular basis.

"The outreach part of my fellowship has completely changed how I would enter a new clinic in another underserved community," she says. "I have learned so much about the environment where the children live, what they are learning and what their parents are doing, because I have gone out into the community and talked to the people here. Had I not done that, I would not have any idea of the many issues affecting Columbia Heights residents."

'Safety-net' clinic

Along with community outreach efforts, Dr. Wallace is also heavily involved with public health research and campaigning, and is coordinating a program targeting childhood obesity. Part of her fellowship includes spending time at the American Academy of Pediatrics federal affairs division, where she receives training in lobbying and child health advocacy.

A common day at Upper Cardozo involves multitasking on the part of doctors like Wallace, whose duties include translating and, along with the other pediatricians at the clinic, guiding the resident and medical student training there twice a week. "We see about 18 patients a day here, less than what you generally see in a private practice setting," explains Dr. Wallace. "But the patients we serve are a little more complicated, bringing additional issues that need to be dealt with when they come in."

Although the majority of Upper Cardozo's patients speak Spanish, Columbia Heights has a growing immigrant population that includes Africans, Asians, and even some Eastern Europeans. In the clinic's waiting rooms one sees patients of diverse ethnicities and nationalities, most of whom share at least one thing in common: a lack of health insurance.

Upper Cardozo is part of Unity Health Care, which serves mostly underserved patients in the nation's capital.

But despite the fact that many adults in this underserved community are uninsured, most of the children share a different fate, because of initiatives such as the State Children's Health Insurance Program (SCHIP), which gives grants to states to provide health insurance coverage to uninsured children up to 200 percent of the federal poverty level. Dr. Wallace tries to utilize all available resources to fully treat the ones who are not insured, she says. During the course of her interview, she has to leave the room twice to treat one such child.

Insurance issues

"The child had asthma, no health insurance, and no medications at home," says Dr. Wallace. "So we had to arrange a way for him to get the medicine he needs." The clinic has a limited pharmacy within pediatrics for cases like the one just described, she explains.

"I have a lot of patients who come in and whose visits are over as soon as the examination is done, but I also have quite a few patients whose visits aren't over when they walk out the door," says Dr. Wallace. "Oftentimes, I have things to follow up on such as doing health insurance referrals, making phone calls to the patient's family, among other things. That's the part of the job that makes it a little more complicated."

Dr. Mullan describes safety-net medicine as "the art and science of providing health care to people who are too poor, or too disconnected, or too new to this country to get what they need." It's no easy task, admits Sarah Schooler, a second-year pediatrics resident at Children's National Medical Center in Washington, D.C., who trains at Upper Cardozo once a week.

"I would like to learn more about community-based medicine, judging from what I've witnessed in the few months I have trained here," says Schooler. "This type of medicine involves a lot of paperwork and public health expertise that I haven't been taught or exposed to. I don't even understand it all: Medicaid, all the things that need to be done if kids here need to see a specialist. It's not as easy as I wish it were.

"I don't think they teach us enough about the public health aspects of medicine, especially medicine for the underserved. In my training, we encounter some of these issues involving Medicaid and public health insurance, but I don't think we get educated enough about how the paperwork goes. It would be helpful to have more teaching in those areas, even for the students who aren't specializing in public health or going into a fellowship," she says.

Schooler can name at least one valuable skill she has acquired during her time in Upper Cardozo: a greater familiarity with medical Spanish terms. "All of the main staff doctors who work here speak Spanish fluently, so they do most of the talking and translating," she explains. "But even so, just by being exposed to this environment, I feel like my medical Spanish is improving."

Bridging cultural gaps

James Walsh, a third-year medical student at GWU, agrees. "I don't speak any foreign languages, but I am learning medical Spanish, at least to get me around in the medical practice," Walsh says. "Considering this country's population, it's crucial for doctors to have at least a working knowledge of medical Spanish." Community-based medicine, especially in areas like Columbia Heights, offers the opportunity to practice this language in a real-life setting, he says.

Although he has enjoyed the training he has received in safety-net medicine, Walsh is not sure if he would like to pursue this type of medicine full time. "I don't know if I want to do primary care per se; I am still looking at all my options," he explains.

"But I have no doubts about wanting to be involved in treating underserved patients in some form. There's a huge gap in the healthcare system for people who are insured and for those who are under-insured or not insured, and you have to find a way to close the gap," he adds.

Dr. Mullan worries that the idealism of students like Walsh might wither when confronted with the world's and, more specifically, the profession's harsh realities. "The young tend to enter medicine, as they enter any profession, with their idealism at the highest level," says Dr. Mullan. "Then, the realities of professional work, family life, debt, and all of the things that go with moving from being a young person with less responsibilities to being a middle-aged person with more responsibilities tend to work hard against idealism."

The fact that the primary care specialties, and especially community-based primary care, are not the best-paid of medical disciplines could at times play a role in doctors' choices to specialize in more remunerated specialties, he says. Considering the average medical student's debt level, choosing a specialty other than primary care can be a question of strategic financial planning, he adds.

The formula for encouraging the practice of safety-net medicine, argues Dr. Mullan, includes recruiting medical students who have professed an interest in safety-net medicine, encouraging faculty who work and model this type of practice, and giving students excellent clinical opportunities in community-based teaching. "These strategies would provide a legitimization as well as a vision for students interested in community-based health care," he adds.

By Suria Santana

AAMC Reporter