Rooted in Family

Our Pride and Joy

I want to take this opportunity to thank the Virginia Healthcare Association for inviting me to share my thoughts and feelings about working in a Community Health Center.  I hope that I fairly portrayed the struggles and accomplishments of the OB/Prenatal Department at the Johnson Health Center.  It has been my privilege to serve a wonderful staff and appreciative patients.

My parting thoughts are on family, friends, or whoever provides the emotional grounding in a health center provider’s life.  For me it is my wife and children that have sacrificed so much to support me in Lynchburg.  With a family business two hours away from my job in Lynchburg, they were forced to bear many of life’s struggles long-distance.  When I was home, I was often too tired to devote to them the time and attention they deserved.  I’m sure they felt some days that my patients got more of me than they did.

Mountain Lake Hotel

On May 19, my wife and I celebrated our nineteenth wedding anniversary at Mountain Lake in Pembroke, Virginia.  You may recognize this as one of the filming sites for the 80’s movie, “Dirty Dancing.”  While I’m more of a Clint Eastwood fan, I left deeply moved by the importance of family in such a publicized place.  While Patrick Swayze and his wife, Lisa, had no children, the passion and pain (doing his own stunts, he injured his knee so bad it had to be drained) he put into the making of this iconic film made the staff of Mountain Lake feel like his family.  From the general manager to the head chef, hotel staff can recount, in vivid detail, the personal excitement and stories of being just peripherally involved in the movie.  Long after his death, the staff remembers Patrick Swayze as the unpretentious actor that spent more time in the hotel kitchen drinking beer with the staff than he did in his room.  The head chef still rides the same motorcycle to work on which he rode the actor down the mountain one evening after the studio cars left.  The actor’s ashes are spread over his former ranch in New Mexico, but he lives on in the hearts of the people he touched so profoundly, not by his fame, but by his humility and genuine persona.

My wife and I realized during our fantastic weekend that an anniversary, or cancer, or everyday life should not distract us from investing in the family and friends that put roots to our lives.  We realized that any day can be the day that we decide to invest what time, talent, and wealth we’ve been given into the things that matter to us most: our faith, our marriage, and our children.  When we are gone, our children will not likely remember what kind of car we drove, or all the mistakes we made as parents, but they will remember the evening my wife and I came home and turned off the cell phones, the laptops, and made a family dinner.  For at least one day, their lives were more valuable than our own.

So it is with warm thoughts and memories that I sign off from the Johnson Health Center.

True Wealth

Last week I focused on the challenges of working in a community health center.  This week I would like to touch on the rewards.

I have now practiced medicine for nearly fourteen years.  As an obstetrician, I have seen the cycle of life played out every day without apology for age, creed, race, or socio-economic status.  After all these years, watching a baby take their first breath is still a miracle, having a drug rep bring free Chic-Fil-A lunch is still the highlight of my day, and raising the subject of evolutionary biology is still the fastest way to start a fight.  Through the good days and the bad, I am humbled by the appreciation shown a doctor for treating all patients with respect.

A story from my work at Johnson Health Center puts serving in a health center into perspective.  I’ve used some poetic license to keep things anonymous.  I laugh about it now with my staff, but at the time, I thought one of them would have to bail me out of jail.

If you have never visited Lynchburg, it is a wonderful town, but someone must have been drunk when they laid out the city streets!  It’s like the legendary labyrinth at Knossos with a car-eating Minotaur lurking around any corner.  In my rural southwest Virginia hometown, my Ford F250 truck and I fit right in, but on the narrow winding streets of Lynchburg, I look like a combat tank on the loose.  After two weeks of work, I was still using my G.P.S. to get from my hotel to the clinic and praying the battery didn’t die.

One evening, I was driving back to the hotel in the rain and came to a particularly dangerous freeway intersection.  I hit my brakes and the truck kept on going…into the back of a compact car.  My truck swallowed the rear end of this car rendering it un-drivable, while my truck only suffered a dented bumper.  I jumped out of my vehicle, terrified that I may have hurt someone, only to find that I had hit one of my pregnant patients and her two children!  After making sure that none of them were seriously injured and accepted my traffic ticket, I followed my patient in the ambulance to the hospital.  She was observed for several hours, under my care, and the pregnancy suffered only a nervous scare. We passed the time talking about our own families.  Getting past the obvious cultural differences, we had similar humorous stories of parenting and everyday life struggles.  We both left with a newfound appreciation for each other’s walk in life.  A few weeks later, we encountered each other in Walmart.  She introduced me to her friends as “her doctor.”  To which they quipped that wasn’t I just another downtown clinic doctor?  Shaking her finger, she corrected them that: worried for her in a car accident, I sat in her hospital room and talked with her like a friend, and what regular doctor would do that?

As long as there are patients willing to pay for favoritism, there will be doctors willing to take their money, but the true wealth comes from treating the lives of all people as valuable as your own.  Investing yourself in the lives of even the frustrating patients will be returned to you in kind.  You do the medicine, let God do the judging, and the odds of life will mostly fall in your favor.

Healthcare Reform

The clinical function of the Johnson Health Center is to be the primary care provider for the uninsured and under-insured of Lynchburg city and surrounding counties.  Having a primary care provider relieves the medical burden on local hospital emergency departments.  In fulfilling this function, one of the bigger challenges in Community Health Center medicine is reconciling patient expectation with available medical resources.  The American healthcare system has conditioned patients to expect perfect babies, perfect surgical outcomes, and prescription medication on-demand – with NO out-of-pocket expense!  I recently de-escalated an enraged patient that would not pay a one-dollar co-pay for a necessary medication.  I know of no other field that such standards apply.  The entitlement attitude of the American patient has driven a market that is unsustainable.  Legislation will not change this attitude.  

When the American Colonies rallied around a call for independence following the Stamp Act of 1765, I dare say that colonist, at the time, thought legislation would fix King George too.  The first Continental Congress met at Carpenter’s Hall in Philadelphia September 5, 1774, following the British naval blockade of Boston Harbor in 1773.  The colonial delegates initially were not ready to abandon ties to Britain, and despite Colonial Militia exchanging fire with British troops at Lexington and Concord in April 1775, continued to plead for Parliament to end hostilities.  When King George declared the Continental Congress traitors to the Crown, the American Colonies declared themselves a sovereign nation on July 4, 1776.  The rest is history.

Now, almost 236 years later, medicine in the United States faces a similar legislative upheaval, with the passing of the Patient Protection and Affordable Care Act March 23, 2010, by the 111th Congress.  As provisions in the law continue to be debated, Community Health Centers face the biggest challenge ever to remain clinically relevant and publically valuable.  While certainly not alone, Community Health Centers bear a sizable burden of the care for the medically uninsured and under-insured, begging the question: To what services should all people have access, and therefore, be guaranteed by government funding?  Anyone can see the economy and moral imperative to provide pregnancy prenatal care and well child care.  Conversely, anyone can imagine the economic insolvency of mandating various elective procedures.  However, who is going to tell the couple of a 24-week premature infant that their child is too costly for neonatal intensive care, or that the obese smoker doesn’t deserve cardiac rehabilitation, or that Grandmother is just too old to justify a hip replacement?

The debate puts Community Health Centers on the front line between the American free market and collective health of its citizens.  Regardless of what legal decisions are made with healthcare, medical providers are going to have to make the policy work in everyday life.  My colleagues and I frequently ask how we are going to absorb this influx of the newly “insured?  Will healthcare reform give us more or less power to make clinical decisions? With a shortage of primary care physicians, will the current network of providers be able to handle the load? Will healthcare reform end our nightmare of sitting in an exam room and explaining to a patient, that the decision to order their C.A.T. scan for a pelvic mass, or their progesterone injections for preterm labor, or their hysterectomy for fibroids, is lost in the Bermuda Triangle of “pre-authorization.”

Working at a Community Health Center may not be the most glamorous job, but it is certainly where the action is.  Our work hours are maxed out with increased patient load, more administrative responsibilities, and growing regulatory requirements.  It is obvious to any doctor that quality accessible medical care cannot be legislated.  Healthcare reform must start with the public in general accepting personal responsibility for unhealthy life choices, realizing that a healthy mind and body is hard work, not an entitlement, and acknowledging that a person’s medical provider is that best qualified to make their medical decisions.  With an enlightened public, rebuilding our medical infrastructure with passionate and qualified primary-care providers, given the autonomy to make medical decisions, freed from the fear of frivolous malpractice suits, and governed by non-conflicted regulatory boards, will fix healthcare – for our children’s children.  As healthcare reform unfolds, medical providers in Health Centers around the country are likely to shape the future of primary care medicine for generations to come.

Transitions

Recently, we saw a new mom whose husband works in the military and got re-assigned to a position in Virginia.  They had lived several years in another state and this young couple was now expecting their first child.  Mom was nearly due to deliver and she had never seen another obstetrician before.  Their stress of moving, preparing for their first child, and having to get to know a new doctor and hospital reminded me of the difficulty of transitions.

Even in Lynchburg, patients are often bounced around between private practices and our Health Center.  Sometimes it is their choice and sometimes not.  Either way, the doctor-patient relationship between a couple and an obstetric provider is a very personal, strong bond.  The stress of re-establishing that bond with a new doctor often makes a patient or couple seem frustrated, or even rude, but we know that being honest and calm about the transition is the best call.  After the fact, many people come back and thank us for being kind through their transition.  Don’t forget, the transition is as difficult for the provider too.  Having to quickly assimilate and process an unknown pregnancy and ensure the best outcome is just as stressful for a dedicated doctor.

In the end, we are all human and fallible.  Even providers may fail to meet the expectations of all patients.  As a Health Center we may not have the resources of a wealthy private practice, but we have great people with a passion for their special place in medicine.  If you have the time, get to know your local Health Department, Federally Qualified Health Center, or other subsidized medical provider.  If you meet the staff and see what they do with the little they are given, I’m sure you will thank them for the service they provide their community…

Huddle Up

What a good looking team!

Joining Johnson Health Center, the goals of my position seemed daunting enough: raise the standard of women’s healthcare at the Health Center and build continuity of patient care across the inpatient and outpatient system.  To meet these goals, I began with the foundation of a health center: not its building, but rather, its staff.

Is it a boy or a girl?

I respect the OB/GYN staff that worked before me to keep the women’s health services functioning, but it took months to reorient existing staff, and replace ineffective positions to create an integrated care model. Before me, a lengthy time of revolving leaders caused skilled staff to retreat into self-preservation mode to keep the doors open and provide basic services.  It would take great determination to build trust in the sustainability of our program and inspire the staff to take ownership of their jobs.  For example, when I came to the Health Center, the reception and scheduling staff had no communication with the clinical staff.  Each made their own decisions without regard for how those decisions impacted a patient’s visit experience.  This caused frustration for both patients and staff with long wait times and conflicting patient information.  During these months of transition, I suggested installing a beer tap at the nurse’s station to get everyone through the day!

NST's are so much fun.

Prior to Johnson Health Center, I had worked across the spectrum of obstetrics and gynecology; from private practice, to hospital employment, and public health.  I learned to adapt patient care algorithms and staff resources to the needs at hand.  I had previously worked alone and with physician partners, with Women’s Health Nurse Practitioners and Certified Nurse Midwives, and supervised medical students, nursing students, and resident physicians.  I would draw from all of these experiences to build the OB/GYN Department we have today.

I will spare you the cliché sports analogies, but the best snapshot of our building process was initiating a morning “huddle.”  Being born and raised in Pittsburgh, I thought of Chuck Noll, former head coach of the Pittsburgh Steelers.  He was the architect of the “Steel Curtain,” a virtually impregnable defensive line, built on extraordinary drafting and teamwork development.  In the 1974 NFL Draft, Noll picked four future Football Hall of Fame players in his first five draft picks…a feat never repeated.  Our morning “huddle” lasts only a few minutes, before the doors even open.  Our focus is a planning look at the day’s schedule from all logistical positions: patient registration, nursing, medical providers, sonographer, equipment, and behavioral health.  We review the previous day’s hospital admissions and identify the current day’s challenges.  Our purpose is to consider all patient-care areas and coordinate their activities into a seamless flowing patient visit.  This encourages everyone to identify problems beforehand and remain focused on our mission: the best possible patient care outcome.

A smile lowers your blood pressure.

Looking back on our first year, I believe we have met our department goals with the hard work of an excellent team. From the front desk, to the medical providers, to the allied health staff, our department works tireless to coordinate daily out-patient visits, obstetric and gynecologic ultrasounds, in-house laboratory, antenatal testing, mental healthcare, case management, and both in-patient and out-patient hospital procedures.  Everyone works together, patients are happy, and we use all our resources efficiently to provide excellent quality of care.

Go Team!

Blessing Way

Shiprock Pinnacle, NM

When People ask me how I became the Director of OB/GYN Services at the Johnson Health Center in Lynchburg, Virginia, I tell them I came from Southwest Virginia...by way of New Mexico...

In 2010, I lived for ten months on the Navajo Indian Reservation as a locums obstetrician/gynecologist.  The high desert of northern New Mexico was one of the more unforgiving places I have ever lived.  The summer was blistering hot, the winter was bone-chilling cold, and the sand storms could block out the sun.  For the first month, it defied my common sense that anyone would choose to live there, but the first monsoon rain would change my mind. Overnight, the desert went from brown to the lushest green, covered in desert flowers.  An instant oasis bloomed for a whole month, before retreating back into the desert sand.

I accepted the locum position after my private practice succumbed to the Global Recession of 2008.  It would take months to understand how a job that was supposed to be recession-proof could end in such chaos.  After so many years of private solo practice, I realized that increasing expenses and decreasing reimbursement demanded an integrated healthcare model.  Bitter from this reality, I arrived in New Mexico with all the frustration of an American doctor not living the American Dream.  I expected to teach the Natives a thing or two about real medicine, but ended up getting taught myself the place of medicine in a community in a most amazing way.

The “baby business” at the Northern Navajo Medical Center was busy from the start.  The regional hospital covered a service area across four states, and the medical resources were integrated to meet a challenging healthcare demand.  It was here that the futility of my private practice became apparent: The Navajo accepted that no system could meet ALL the medical needs of ALL the people ALL the time. Tribal representatives were integrated into the healthcare delivery system and available resources were directed to the greatest needs.  Each service unit featured a point-of-care ambulatory clinic, which funneled into a regional hospital with rotating specialty clinics.  Each hospital was affiliated with a university teaching hospital, accepting the most complicated cases.  Patients with jobs off the reservation (and commercial insurance) used private providers, in a multi-disciplinary practice model.  It was all neat and community driven.


The community attitude was best seen in the Navajo Blessing Way Ceremony: uniting community, culture, and wellness.  Thousands, from across the Navajo Nation, met annually to celebrate family, culture, and wellness. To watch a people brought near to extinction, displaced to the most inhospitable part of their former tribal lands, and exploited for uranium and oil, only to be thankful for their culture and community put medicine in a new perspective.  In the end, I would be forever thankful for most caring people, showing me the way from self-righteous bitterness to a new sense of purpose in my medical career.  I would take these experiences and perspective to my new home at the Johnson Health Center in Lynchburg, Virginia.

Dr. Matthew Denti - “That’s My Doctor!”

One of the most gratifying experiences Dr. Matthew Denti has encountered is a patient exclaiming to a friend while out shopping: “That’s my Doctor!” It is a statement of both constancy and relationship, and for many patients, it’s the first time they have ever felt cared for and connected to a physician. And that’s exactly what Dr. Denti wants.

Dr. Denti is the sole OB/GYN at Johnson Health Center in Lynchburg. He began with them in March of 2011. No aspect of his work is what he had foreseen for himself as a child or teenager, but it is what he considers to be “the perfect fit.”

Dr. Matthew Denti was born and raised in Delmont PA, a small farming town of less than 1000, not far from Pittsburgh. He had lots of family in Pittsburgh as well, and so enjoyed the best of both worlds – growing up in both a small town and a big city. He loved horses and considered being a veterinarian. Initially he attended college to pursue an Equestrian Education program. Partially through his studies, the school was sold and the new owners dropped his major from their program. He changed his focus to pre-vet and planned to go on to vet school. He soon learned that veterinarian programs were much harder to get into than medical schools. Then West Virginia School of Osteopathic Medicine (WVSOM) contacted him during his third year of undergrad work, and he was accepted into their DO program. His first year of med school credits completed his BS degree, and he went on to complete his medical education. As a DO, he was always Family Medicine focused and thought he would pursue Family Practice. But he worked very closely at WVSOM with an OB who became his mentor and a great source of support; ultimately Dr. Denti moved into OB/GYN because of that relationship.

After WVSOM, Dr. Denti completed his residency in OB/GYN at Lancaster Community Hospital in PA. He was also fortunate to be awarded, through a lottery system, three paid clerkships: one with an Indian Hospital in ND, focused on rural health and public health; one at Johns Hopkins focused on high risk OB; and one with Pinnacle Health Systems in PA, which gave him the surgery experience. These clerkships influenced both his career and his life. In particular, the month-long clerkship at Fort Yates Indian Hospital in ND was a defining experience that sparked his passion for work in public health.

Post-residency, Dr. Denti was recruited to serve in the same town in WV as his mentor, which was hugely attractive. Also, by serving the underserved in the community, WV forgave some of his medical school debt. He built a solid private practice in OB/GYN in WV until the cost of malpractice tripled in a single year (with no claims). At that time, 1100 doctors left WV; practicing there just wasn’t economically feasible.

Dr. Denti joined an OB practice in NC with the understanding that he would take over the practice for a physician who was about to retire – only the retirement had not happened after 2 years and was not on the horizon. So he returned to private practice, initially in NC and later in Wytheville VA. During that time he delivered 201 babies to indigent patients in a single year. After a few years, he realized the medical economic model of private practice was no longer viable. He closed the practice and served as a locums OB/GYN with Indian Health Services in NM. While he loved public health work and was deeply committed to his patients and the community, his family was back in Wytheville. It was a great job but in the wrong place. Virginia Community Healthcare Association contacted him and recruited him to Johnson Health Center (JHC) in Lynchburg.

Dr. Denti knew he wanted two things: to work in a public health capacity, and to be close to home. He has a large family (9 kids, ranging in age from 26 to 4), and he wanted and needed to be with them. JHC already had an OB practice running so he would not be starting from ground zero. He had an opportunity to grow the practice with a foundation already in place. The key to success was in the relationships – with the patient population and with the local hospital. And Dr. Denti has excelled at improving both.

Dr. Denti now works and lives in Lynchburg during the week and on the one weekend per month he is on call, and spends the rest of his time with his family in Wytheville. Ultimately they will move the family to Lynchburg; meanwhile he waits for the economy to improve to sell his house. And his wife and oldest daughter have a bakery business (“Cinnamon Sage Baking Company”); they’d like to have that a little more firmly established before they move.

The Johnson Health Center OB patient population is predominantly underserved – mostly Medicaid or sliding scale paying patients. Dr. Denti also serves the Liberty University student population, many of whom are missionary students. Most are young - typically 16-25 years old. JHC serves two large ethnic communities – Hispanic and Korean. While they have good translator assistance with the Hispanic community, there is very little in the way of a translator or cultural liaison with the Korean patients. This has been a challenging issue JHC continues to address.

There is a very seasonal cycle to OB. Patients seem to get less care during colder winter months, and the natural birth cycle is that more babies are delivered during warmer months. So during May-October Dr. Denti is swamped, sometimes seeing as many as 28-45 patients per day. November-April are much quieter months. Taking the seasonal cycle into account, he averages about 20 patients a day. A typical day for Dr. Denti begins with rounding at the hospital, if needed. Each morning at the Center begins with a “huddle,” including everyone from the front desk through the providers, to go over what’s coming in the day ahead. He may have incarcerated pregnant patients to attend. He follows up on any pregnancy complications with hospitalized patients; those with major complications are sometimes sent to Charlottesville overnight and he will provide continuity of care with providers there. Dr. Denti had not been seeing as many GYN patients initially, but that is now increasing. Their focus is on family planning and STD education, areas of critical need. He is scheduled with patients 24 hours a week, and in addition has rounds, surgeries and is on call 5 days per month. He delivers 5-12 babies a month, and schedules/attends the higher risk OB/complicated births while he is on call. He sees a significant number of diabetic, hypertensive pregnant patients, and about half of his patients have had no prior medical care. The Center also provides behavioral health / case management to their OB patients, who are often dealing with other challenges in addition to pregnancy including drug and crime issues. The Center focuses on ensuring the Moms are clean, stay clean, and keep their babies clean.

Dr. Denti’s biggest surprise working in community health has been the culture within Johnson Health Center. The practice is very tight-knit, and the staff, from the front office through the providers and executive leadership, truly care about each other and their patients, and are all fully supportive as a team. Dr. Denti states that he has never experienced this atmosphere in other practices; typically the mentality had always seemed to be “everyone for themselves.” The JHC environment is like a family, and a second home. He couldn’t do what he does without them.

OB as a specialty is hard on family time, and it is often challenging to maintain a good work/family balance. But working in a CHC environment has greatly enhanced that for Dr. Denti. One area that has definitely improved is his time off – when he’s off, he’s usually really off. He doesn’t get called while he’s not on call – like he did once with a prior practice and spent hours on the phone through a difficult delivery while on vacation with his family at Disneyworld.

Dr. Denti sees his biggest greatest contribution thus far as bridging the gap between the Center and commercial medicine: he has been central in strengthening the relationship with the hospital, and has transformed the challenge of women arriving at the hospital 30 weeks pregnant having received no prior pre-natal care and at high risk. The mission to serve and improve access for the OB community has made solid progress, and early pre-natal care benefits the entire community, most of all the babies. And the Center, in partnership with the hospital, has done a tremendous job of providing people improved healthcare and keeping them out of the ER. Until now, most patients have never “had” a doctor before – now they can have a relationship with a physician they see on a regular basis. And it is truly heartwarming to hear a patient tell a friend “That’s my doctor!”

Dr. Denti loves his job and loves coming to work each day. He knows he’s helping people and contributing to the community, taking care of those nobody else really cares for. There is a strong sense of providing for the community but also at the same time providing for himself. “This is a perfect fit,” says Dr. Denti. He believes he is where he was meant to be.