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.

Family of Ten!

One of the joys of being a pediatrician is being able to care for an entire family. You get to know one child and then when a new sibling is born, you get to follow them too! It is definitely wonderful to have even a closer bond with the parents.

However, at times it can be challenging...especially when there are lots of siblings! This week, I was able to see a total of 5 families with siblings. Of those visits most had 3 children for me to see and others had 5 children to see. Here's a picture of one of my families that have 4 siblings, but I examined 3 for that visit. What's the largest number of siblings in one family that I care for? Ten! These numbers can create an obstacle due to limited examination space as well as not having children (or their parents) get tired through all of the histories and examinations. The other huge hurdle is scheduling, as if you block off an entire half day for a large family, and then they don't show up, you may end up with no patients. The flip side of that is double to triple booking the appointment slots and then everybody shows up!

These are are just some of the joys and challenges of working in a community health center. Its been a pleasure sharing the month of January with you. I hope that you were able to get a glimpse of what life is like as a provider at Hampton Roads Community Health Center.

Creative Medicine

Here is a glimpse into one of our patient rooms. As you can see the pediatric rooms are vibrant, fun, and hopefully enticing to our patients. We have different cartoon themes in each room...and no they are not all pink! What we have tried to do is make our community health center just as inviting to our kids as any other pediatric office.

However, there are some realities that we, as providers, must face. We don't have all the resources that private or larger offices have. We don't have a social worker, a nutritionist, child life specialist who could help entertain/ distract patients while getting painful lab draws, and many times we are short on nurses and medical assistants. To top it off, many of our patients don't have any insurance.

How do we deal with these limited resources? We get creative. We have to be ready to do whatever it takes to provide quality care. This could mean spending extra time with a patient reviewing their diet to help fight off obesity. It could also mean treating medical conditions that are typically referred to a specialist due to the fact that the patient can't afford the co-pay at the specialty office. Many times it means dealing with multiple complaints in one visit so the patient doesn't have to find transportation or pay another fee to be seen.

Working at a community health center has definitely pushed me to be more creative, but where else can you have this much variety in your day? :)

A Medical Home

Here's a picture of me and my pediatric colleague, Dr. Raji. I have the pleasure of working with her part of my week, but she shares her time working at our other site in Norfolk, VA.

I'm not sure what I expected when I started working at our community health center, as I was just so excited to be here. Some of my preconceived thoughts were that I would be alone in the middle of nowhere, without support. Don't get me wrong, there are days where you feel helpless...but you are never alone. One of the best aspects of my transition has been having Dr. Raji to show me the ropes and help me get acclimated to working here.

Aside from having support from other providers, you must put things in perspective as far as what you feasibly can do for a patient. I went into this career wanting to do underserved medicine, but what would that mean in practice? I'll share one story, which has helped keep me grounded.

A teenage boy came in with abdominal pain that had lasted months and when asked stated he was "stressed out." Now, teenagers aren't the easiest to get a history from, so I started asking questions. Are your friends stressing you out? Are you in a relationship with someone that is stressing you out? Has school been really tough on you? He just shook his head no to all of my questions. I asked him "Well, what is it then?" He looked down and mumbled "I don't have a bed, and I haven't had a bed in years." Definitely not the response I was expecting.

Granted, we dealt with his abdominal pain and were able to control that, but what about his bed? I could not fix that and that really frustrated me. I thought I was here to help people...why can't I provide basic needs? I carried this with me for days and knew that I had to change my perspective. The only thing that gave me comfort was the thought that despite my patients' unstable worlds of no beds or moving from shelter to shelter, at least they could have a place of stability for their medical care. They at least had a medical home...our community health center.

Journey to Hampton Roads

From reading my bio, you know that I've already felt like I'm "in the right place," but really there is so much more behind those words. Behind those words is a story that only a miracle of God, fate, and some gracious people could make happen.

I dreamed about becoming a physician, I also dreamed of being a wife and mother. Could I really have it all? While in medical school, after I signed on with the National Health Service Corps (NHSC), I met my husband. Perfect, another doctor that I could share this jouney with...well almost. There were some obstacles in our way. He aspired to be an orthopedic hand surgeon, had comitted himslef to serve in the US Navy, and was 3 years ahead of me. How were we going to make this work?

Well, we made it through our first set of hurdles. My husband got a deferment to do civilian training and matched in Toledo, Ohio for orthopedic surgery. Then, I later joined him there to start my pediatric training. Later, my husband got a deferment to do a hand surgery fellowship in Cincinnati and we were prepared to do long distance marriage and parenthood as we had a one year old at the time. We knew that it was pretty much unheard of to transfer residencies in the last and final year of training, especially starting at a community based program to then attempt to get a spot at one of the best children's hospitals in the country. However, the stars aligned and Cincinnati Children's had an opening and I was able to transfer.

That entire year we stressed about how we could assure we could be together for the next three to four years, as both my husband and I had about that much time to serve in our respective commitments. Being a NHSC scholar, there are a select number of sites that would qualify for my service. With the military, we knew my husband may only get 6 months notice of where he would be stationed. So how did I even start looking for a job? Very carefully and most importantly I had to be very proactive. We got some unofficial guidance within the military that my husband could be stationed in one of three cities including Portsmouth, VA.

Let's just say that there were hardly any openings in any of those cities, and worst of all nobody was contacting me back in places where vacancies were available. Luckily, I met some wonderful people at the Virginia Community Healthcare Association at a NHSC job fair and I had my ultimate resource and advocate. Once we got the official orders for Portsmouth, I found out there were only two sites within driving distance that could qualify for me, but again neither were hiring. So my advocate from the Virginia Community Healthcare and myself tried doing everything we could to convince Hampton Roads Community Health Center that they needed me. Okay, fine...so, it is also possible that my husband also came to the health center to hand deliver my resume to the Medical Director. Regardless, all of our efforts worked! I had a job doing what I dreamed of and I could be with my family!

It has been a journey getting here, but everyday as a physician in an underserved area brings more stories and experiences than I could ever imagine. I am so greatful to be where I am and I hope you enjoy some of the stories I share this month.

Mission and Passion in Action

In just four months as a National Health Service Corps Scholar in Portsmouth, Dr. Firoza Faruqui already definitely knows that she is “in the right place.”  Dr. Faruqui thoroughly enjoys working at Hampton Road Community Health Center (CHC) and says there is a “surprise every day.”   Proactive and enthusiastic to the core, Dr. Faruqui is effectively using her time and skills in a dizzying array of projects:

• Developing relationships and preceptorships with the local Children’s Hospital of the Kings Daughters pediatric hospital - http://www.chkd.org/
• Working on outreach to more patients who can walk from the local housing developments to the CHC
• Doing rounds at the hospital with newborn babies and their parents to immediately begin their introduction to her high quality healthcare and outpatient follow up
• Even “enjoying” the time and opportunity to make follow up patient calls because it reminds her “what community medicine is all about.”
• Being featured on a local news channel -  http://www.wavy.com/dpp/community/bottom_line/bottom-line-10_2_11                                

Sometimes it’s not such a long way from a small town in Michigan with a grand total of three stop lights, to the “right place” in the bustling community of Hampton Roads.  Firoza was born and grew up the rural town of Dowagiac, Michigan located 30 minutes from South Bend, Indiana.  In this small town of approximately six thousand people, Firoza’s father was a surgeon, but because there was no family practice in the community he served that role as well.  Although Firoza had two older brothers and two older sisters not in medicine, she knew early on she wanted to be a physician, so the only question was what type of physician?  Firoza was attracted to the family medicine her father had practiced by default in this small Michigan community.  She knew she didn’t want to be a surgeon because she liked family practice and the unique relationships that develop in that type of practice.  She also liked the challenge of being a “Jack of all Trades” focused on the broad perspective of Family Medicine, and later decided that Pediatrics was the best fit.

Throughout her education, Firoza’s father may have had the “surgeon mentality” but he supported her and helped her look into other options.  It was his “brilliant” idea to explore and apply to be a National Health Service Corps Scholar due to the financial advantages and her long standing commitment to work with underserved communities. Today Dr. Faruqui describes herself as a more “holistic” physician and not exactly like her dad - although she knows he is proud.

After attending the University of Michigan and Midwestern University of Arizona College of Osteopathic Medicine, Dr. Faruqui made the unusual mid-residency move from University of Toledo’s Pediatric Residency to Cincinnati Children’s Medical Hospital to accommodate her husband and daughter.  Dr. Faruqui enjoyed Cincinnati, Ohio but she is exploring and enjoying Portsmouth, Virginia too. Dr. Faruqui lives in Chesapeake and comes over the bridges to the “Old Town” atmosphere in Portsmouth.

Dr. Faruqui is also learning and exploring the distinctions between the urban and rural medically underserved.  Given her passion and creativity, Dr. Faruqui is easily developing new ways to meet the demands of this urban environment and community.  Firoza describes this practice as having to be more medically “creative” due to challenges like transportation.  Sometimes a pediatric patient may come in and have five complaints in one visit that all need to be addressed.  In many other medical settings, typically only one complaint is addressed at a time. Here the reality check is that patients may not have the transportation, time off work, or finances to visit more frequently. Right now, Dr. Faruqui’s patients are more adolescents than newborns, but with some of her creative measures in outreach and attending newborn deliveries, this may change.

On a “typical” day Dr. Faruqui may start the day with four patients.   With walk-ins and add-ons the schedule could swell to eighteen. Some days the schedule is triple booked and then all the patients show up.  Other days may have a robust schedule and only a handful of patients actually show. One area Dr. Faruqui is working on is how to improve both access and develop a more consistent show rate. For patients unfamiliar with healthcare, Dr. Faruqui sees this as an educational opportunity for patients to learn both about the process and about how to improve their own health.

Dr. Faruqui thinks it is optimal for patients when they can walk in and be seen.  Responsiveness and access remind her about what community medicine is or should be.  Dr. Faruqui sees some challenges in providing healthcare to the underserved such as reduced resources and the high turnover of ancillary staff.  In line with her personality, Dr. Faruqui does not let these challenges deter her from providing high quality healthcare.
 
Certainly, the main concern of pursuing a medical degree was cost and the National Health Service Corps Scholarship was a “huge incentive” so she could pursue her goal.  Dr. Faruqui thinks that often a physician’s choice of medical specialty is highly based on the financial concerns of loan repayment.  But working in a Community Health Center crystalizes why Dr. Faruqui chose to be in medicine in the first place– because she is an idealist and highly appreciates the relationships with patients.

Today, Dr. Faruqui is married with a 2 year old and expecting their next child in April.  In addition to her work creatively ensuring access to high quality healthcare and developing vital relationships with her patients, Dr. Faruqui still teaches in the community and even spends weekends with her family (a concept she did not have during residency).  Dr. Faruqui embraces the dream she is realizing - personally, professionally and financially by being a National Health Service Corps Scholar at Hampton Roads Community Health Center and being “in the right place.”