The New Colossus

In my previous blog entry I wrote that community health centers provide comprehensive care. For my final entry, I’d like to focus on recipients of that care- our patients.

When I was in elementary school, I had to learn the final lines of Emma Lazarus’ poem, “The New Colossus” which is inscribed on the base of the Statue of Liberty:

“Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tossed to me.
I lift my lamp beside the golden door.”

While the words originally reflected the state of immigrants to our country, I feel that they also reflect the physical and emotional states of many of people who I see each day. Community health centers serve as harbors for people who have an unmet need for health care.

· We provide care to people who don’t have insurance, and those who do.
· We provide care to people who are very young, those who very old, and everyone in between.
· We provide care to people regardless of their sexual orientation, religious beliefs, or political affiliation.
· We provide care to people who are very healthy, and those who are very ill.
· We provide care to people who are looking for employment, and those who have jobs.
· We provide care to people who live within walking distance, and those who come from over an hour away.
· We provide care to people who are living under the federal poverty line, and those who are living well above the national average.


There is no typical patient in community health care because we see EVERYBODY. Our waiting room is a cross section of the area in which we live, and as a result, we are able to effect changes that are felt in all aspects of the community. We provide care for our neighbors, our friends, our relatives and ourselves. When new patients come to our practice, I freely tell them that my husband, son and I are all patients here. I share this not only to let the patients know that they will receive excellent care here, but that like them, I am a member of this community, and like them, I belong here, too.

So, what more can I say about choosing a career in community health care? If you are tired of denying access to potential patients because they don’t have an insurance accepted by your practice, then come on. If you are frustrated because your patients are having to choose between seeing you, and affording prescriptions, then come on. If you have ever felt pressured to see more patients in order to meet an unrealistic goal based on numbers, and not people, then come on? If you simply want to do something worthwhile with your time and talents, then come on.

After all, community health offers a harbor to providers too. So, come on!

A little of this, a little of that...

One of the reasons that I became a family physician was that it allowed me to see a wide spectrum of patients. In a single morning I might take care of a mom, her aging father, and her toddler son. I love working across the life span, and my patients (and front desk schedulers) are happy with my desire to “take on all comers.” Each day, I look forward to the opportunity to dabble in different specialties. Whether the focus of the appointment involves pediatric neurology, gynecology, orthopedics or dermatology, I’m glad to flex my mental muscle to provide the best care to my patients.

Okay, so what exactly does that specifically have to do with why I love working in community health? Well, if you expand that concept of providing comprehensive care, to really providing COMPREHENSIVE care, then you’ll understand the hidden gem that is community health.

In my days before working in community health, I sometimes felt helpless, as my patients had limited opportunities to access the care that they needed. For example, if a patient came in with tooth pain, and I thought they required a filling or extraction, there was little that I could do if they didn’t have insurance, or weren’t already under the care of a dentist. Or, if that same patient was seeking mental health counseling services to help in the treatment of depression, my hands were tied. Sometimes the problem wasn’t access to a specific type of provider, but a patient wasn’t able to afford the medications that were recommended (not everything is on a $4 list, is it?). It seemed that despite my best efforts, there were some things that I couldn’t do for my patients.

As a physician at a community health center, I am able to offer many more services to my patients than I could have in my prior practice. If a patient has tooth pain, I can see if Dr. Mirmonsef, our on-site dentist, can make a space on her schedule. As I develop a treatment plan for depression, I tell patients that Ms. Mountcastle, our on-site licensed clinical social worker, would be glad to provide counseling services. When my patients need medications that they can’t afford, I am usually able to access our pharmacy’s services, and if the patient is eligible, obtain their medications at a significant reduction in cost.

In short, I have found that community health centers remove many of the barriers to care that prove to be stumbling blocks for most primary care providers and their patients. By offering so many levels of care under one roof, I can focus on my primary goal- offering so many aspects of care in my exam room.

Advocacy!

When I was in medical school, I frequently served as a student interviewer for the admissions department. While I tended toward a laid-back, conversational style of interview, I was frequently teamed with practicing physicians who were a bit more interrogative in their approaches. Regardless of the strength of the applicants, they looked for chinks in the armor, then zoomed in for the attack. They would ask questions like,"Why did you only earn an A- in Conversational Babylonian?" or "Under what circumstances is it okay to lie to a patient?" It was sometimes very painful to witness the stammering and stuttering of hopeful future physicians as they attempted to craft the 'right' responses to these questions.

After one particularly grueling series of interviews, I asked my team members why they chose to be so challenging. I was told, "If they can't stand up for themselves, they won't be able to stand up for their patients." I couldn't argue with that kind of logic, so I filed that bit of insight away, and thanked the stars that my own interview had been fairly benign.

Fast forward ten years, and I have become that physician who understands the importance of advocating on behalf of my patients. I have had the opportunity to go to Washington D.C. to share with our nation's congressmen and women the positive impact of community health centers. Last month, I headed to my state's capital to request that the General Assembly vote to maintain funding for community health centers, as part of supporting the Virginia Health Safety Net. I frequently encourage my patients to call their representatives to share their personal stories about the care that they receive at our site, and I also ask my staff, my parents, my husband, and my friends on Facebook to call or email, too. I know that many of my patients are reluctant to speak up for themselves, so I have chosen to do it for them.

As physicians, we work so hard to provide the best care that we can for our patients, and we can accomplish that goal in many diffent ways. For me, that means working both inside and outside of exam rooms to ensure that health care will be accessible to my patients today, next month, and next year. I recognize that not every physician is going to feel compelled to "go political,'" and that's okay as long as we are willing to stand up for what is important, and can recognize when it is most important to do so.

Decisions, decisions...

While cleaning up the icons on my computer desktop recently, I came across a spreadsheet named "Louisa.xlsx.' As anyone who knows me can tall you, I am a master list-maker, and will create spreadsheets for just about any occasion-wish lists for my next home, address books for Christmas cards, to do lists for my wedding, bringing home my baby, etc. Anyhow, there sat the spreadsheet that I had created and consulted when I was considering my current job.

As I reviewed the document, I was initially surprised by it simplicity. To give an idea about how elaborate my creations can become, I had evaluated potential residency programs on a l000-point system, considering more than 60 different factors. (Excel rocks!)  Instead, I based this equally great decision on a simple list that evaluatedthe 20 qualities that were most important to me.

Surprisingly, my current position had a lot in common with my former practice. They both offered a collaborative working environment, reasonable hours, some level of autonomy, and a good salary with reasonable benefits. Actually, I shouldn't  be too surprised-my former practice wasn't a bad place, just not the best place for me. Also, considering lifestyle for my family, both areas offered a good cost of living, racial diversity, and a Catholic church nearby.

So what made me choose to leave my community of seven years? While there were several factors (five in all) in Louisa far outshone my old position, it really came down to the one non-negotiable factor that sat at the very top of my list-valuing people over numbers. I needed to work in a place where the mission serve was at the forefront. Community health embodied that mission, and I knew that I would finally be able to practice the type of medicine that I believed best reflected my core values.

(To satisfy your curiosity, the other four qualities that assisted my decision to start a new career were: limited call, a sense of altruism, the opportunity for professional development, and community safety. Pretty impressive, in my opinion.)

Did Louisa have everything on my list? Well, no, but that's life. There just aren't a lot of shops or restaurants in this small rural town, and I was moving into a much smaller medical community where I didn't know anyone. But to have 17 out of 20 qualities on a list? I don't need to create a formula to know that's pretty darn close

Dr. Diamond-Myrsten’s Great Discovery

“I wanted to work somewhere where the patient needs were paramount,” says Dr. Sharon Diamond-Myrsten. “I knew I wanted to be a doctor for as far back as I can remember.” But finding the right place to practice took some searching.
Dr. Diamond-Myrsten was born and raised in New York City. She made the shift south to attend The College of William and Mary for her undergrad degree – in English Literature. She says she “pursued some other loves first,” to be sure the desire to practice medicine would stick. She spent a couple of years teaching as a substitute and another couple as an extension teacher, always working jobs at the low end of the pay school so the money never became a deciding factor (or trap) in her long term career plan. In 1996, she made the leap to pursue medicine, beginning with a second undergrad degree, a BS in Biological Sciences from CNU, and then completed a MS in Biomedical Sciences at Eastern Virginia Medical School (EVMS) the year thereafter. She went on to medical school at EVMS, followed by Family Medicine residency in Lynchburg.
Post-residency she stayed in Lynchburg, working as a 3rd shift Hospitalist (a job she refers to as a “nocturnalist”). Realizing that she felt led toward Primary Care, and that it was “challenging to discuss prevention with a patient at 3 am,” she moved to a hospital-based Family Practice. She liked the work and the on-going patient contact but felt the emphasis was wrong. “It was much more business-focused than patient-focused.” She knew that was not the right “home” for her.

Dr. Diamond-Myrsten began to search for alternative practice options. She saw an internet ad for the Virginia Community Healthcare Association about family medicine practice jobs in community health. She “had never actually heard of community health before, and certainly never thought of it as a career alternative,” prior to seeing the ad and discussing CHC opportunities with the Recruitment Services Team. Dr Diamond-Myrsten knew she wanted to “reach people who otherwise would never be helped, who would never receive healthcare” until there was a crisis, “those who couldn’t get their foot in the door elsewhere,” due to their financial situation. So after discussing opportunities and reviewing a map of community health practice sites, Dr. Diamond-Myrsten and her husband chose Louisa. “Basically we just looked at the map of (Virginia CHC) practice sites, picked a location that was geographically close to family and friends” and ultimately found a great practice match with Central Virginia Health Services (CVHS) at the Health And Wellness Center of Louisa. She has been with them since 2010.

Dr. Diamond- Myrsten was offered the role of Site Director even before she began working at CVHS – which has made for an even more meaningful experience. Her focus not only includes patient care but also the bigger picture view – things like how the site is regarded in the community, community outreach, expansion of service offerings to better meet the community’s needs, and the ideal practice model for Louisa and how to best migrate the site towards it. She says she “never would have pursued a site director role in any other type of practice.” But in community health, that additional responsibility is welcome, allowing her to have an even greater impact on the lives of people in Louisa.

Even given the added duties, most of Dr. Diamond-Myrsten’s work weeks are 40 hours, and there is very little on-call time. Because there is a Pediatrician at the site, she does not see many children. Most of her patients are middle-aged, some are family groups, and a few are older patients. Most are unemployed, as the area has been hit with a significant number of layoffs by small, local businesses.
One of the terrific things about working in community health has been the variety. “No two days have been alike.” Some days are swamped and hectic; others are slow and sometimes even a little too quiet as the practice gains a following in Louisa. Dr. Diamond-Myrsten’ s patient encounters run the gambit from procedures to adult physicals, to acute care as well as chronic care follow-up and overall prevention. One of her greatest frustrations is the lack of complete (re: specialty) care that she can provide to her patients. “Referrals to specialists are expensive and many patients can’t afford it.” So she provides not only primary care but often more specialty care as well.

The biggest downside of community health is that “nobody knows we’re here!” The community is often not aware that they provide healthcare for all, regardless of their financial situation or insurance status, and many in the area do not even know they exist. One of her biggest surprises was sitting on an interagency council with other community resources including social services, local libraries, education personnel, etc. Those resources “didn’t know about the CHC or what it can provide to the community,” says Dr. Diamond-Myrsten. She feels it’s a well-kept secret that needs to be made more evident – not just in Louisa but throughout Virginia and the country.

Some of the unexpected pluses of working in a CHC include a loan repayment award provided through the National Health Service Corps (NHSC), the opportunity to regularly precept medical students, and the terrific team with whom Dr. Diamond-Myrsten has been blessed to work. But the best thing about working in community health is the “warm, fuzzy feeling” she has at the end of each day, knowing she has made a difference.