Wednesday, November 7, 2007

Back from Peru...

My wife and I are back from our Peru mission trip: And a couple of things struck me from this experience...

There is a "national health care system" in Peru. That is, each of the graduates from the medical schools of Peru serve in a national system as primary care providers. Sort of like our "National Health Service Corps", but with an important difference - the patient is expected to pay for this care, and the poorest of the population simply go without care.

Or, maybe that's not really different at all. I have many patients who have deferred care until they have advanced disease due to cost, and they certainly do NOT have access to primary health care without cost here in the US. Many patients do not qualify for Medicare or Medicaid, and even our "safety net" of Community Health Centers expects payment of a nominal fee.

We did a lot of traveling during our trip - Lima, Trujillo, Chao, Cascas, Iquitos. We saw the coastal desert, the foothills of the Andes, and the Amazon jungle. During that time, we saw very few Americans. But, while waiting to leave the country at the Lima Airport, we saw two different medical teams as well. We shared the American Airlines flight back to Miami with one team, a surgical team who'd spent two weeks in Northern Peru, and were looking forward to their first hot shower! It struck me that mission teams must be a fairly common sight, arriving and departing from Lima's Jorge Chavez airport.

We also had the chance to meet three medical students while in Peru. I have some mixed feelings about their professional goals. Two of the three intend to come to the US for residency training after finishing their seven years of medical school. The US can certainly use the help; 3700 of the 10,000 physicians-in-training in US family practice residencies are International Medical Graduates, according to the American Academy of Family Physicians. We just can't find enough US-trained physicians to take care of our own.

But, what about Peru? These three medical students represent the concern of many "developing" countries - the talent that is needed to move the country forward is leaving for the US or other "developed" countries, which offer their own version of the American Dream.

While the US struggles with what has been called "expensive medioctrity", the Peruvian government has pledged to provide access to primary healthcare services for all citizens, regardless of income. This is seen in this article, published in the Spring. I'm not sure what progress has been made since that time... but I do know that there are still many Peruvians who are suffering. I've met them. And the language of suffering if universal. I've met them here, too. We are spending way too much for a system that doesn't work. And, Peru is movnig forward with a national health plan to cover everyone.

So, who's really "Third World?"

Thursday, October 18, 2007

My Mission Work...

I've had some great experiences in my work as a physician...

For several years, I worked with a partner in my prior practice in a group called the Christian Medical Response Team. This team served as a volunteer medical team for the Washington Department of Emergency Management, and we "trained" by providing medical care at large group events. We did many, many events, including several years of EndFest, Bumbershoot, Creation Festival, local rock concerts (some as a part of Rock Medicine, including the last five Grateful Dead concerts in Seattle), and large national Youth for Christ events in DC and LA. We provided safety for well over 1M people.

I've also had a few truly life-changing experiences as a missionary. In 1998, I spent seven weeks on four different trips to Latin America. I participated in El Nino flood relief in Peru with Mac Med, worked with families in Mexico with Northwest Medical Teams (now Medical Teams International), and lead a team in response to Hurricane Mitch in Honduras with World Vision.

My wife and I are preparing for a mission trip to Peru - we leave in ~24 hours. We are traveling to northern coastal Peru with Mac Med, working with the same pastors that I met nearly ten years ago on my first mission trip. In the past couple of weeks, I have revealed to a few patients that we are planning this trip. And, most of them have said something that indicated that they were somewhat, well, impressed by my plans to serve in a developing country. But one longtime patient of mine responded, “What, there aren’t enough poor people in Bremerton for you?”

There it is! My work is a mission. I work with a missionary team of 137 other people, the employees of my Health Center.

I certainly have reason to be impressed with missionaries who serve for years, like my old Doctors Clinic partner Perry Jansen and his family ( who have been working in Malawi for the past few years. And, we have a nurse practicioner who works with us for a few weeks each year, during her "break" from her and her family's work during the rest of the year in Nepal.

And, I'm impressed with my partners (providers and support staff) who have been dedicated to this longterm mission for nearly twenty years. And proud to be a part of that.

Friday, October 5, 2007

"So, what's a Community Health Center?..."

After my residency program, I started my practice by joining a large medical group here in Kitsap County. I worked there as a family physician, including the delivery of OB services, for eight years. I then took a job as Medical Director at my current practice, a Community Health Center.

I must admit that I had no idea what a Community Health Center really was until I started having lunch with Dr. Bob Rozendal, our previous Medical Director. At that time, I had been working in the community for a few years, and thought I had a good understanding of the health status and needs of our community; I couldn't have been more wrong.

A Community Health Center is a practice which is partially funded by the Federal government as a grantee of the Bureau of Primary Care, one of four bureaus of the Health Resources and Services Administration. Other names which might be applied to this practice model include:
  • Federally-qualified Health Center ("FQHC")
  • "Safety Net Provider"
  • Federal 330 Clinic - named for the section of the Public Health Service Act which authorizes funding for this program.

To quote the Bureau of Primary Health Care's website:

"Health Centers are community-based providers of comprehensive primary and preventive health care and enabling services to medically underserved populations. Many Health Centers also offer comprehensive dental care and mental health and substance abuse services."

What we are NOT as a Health Center:

  • We are not "owned/run by the government." - We are an independant, nonprofit agency, which is "owned" by the community and run by an all-volunteer Board of Directors, the majority of which must be patients whom we serve.
  • We are not one national system. - There are ~1,000 different Community Health Center systems across the country, with about ~6,000 delivery sites. Because of local ownership and patient-driven Boards, each Center works to meet it's own community's needs, and may offer markedly different services.
  • We are not a "free clinic" - There are wonderful people doing remarkable work in Free Clinics across the country, as seen at the website for the National Association of Free Clinics. We charge patients on a sliding fee scale based upon their ability to pay.

Thursday, October 4, 2007

Notes from the daily life of a "specialist for the poor"...

When I entered medical school, my father would often offer me his advice about the choice of a specialty. He would say, with a chuckle, that I should specialize in "diseases of the rich." (Perhaps this was not just a joke - he was paying for college and helping with medical school costs, and I owe him a debt of eternal gratitude for the gift that he and my mother gave me in allowing me this life.)

I recall during my application for medical school that I, like many of my competitors in the interview process, responded to that expected question by saying, "Of course, I want to be a family physician, so I can serve the community, the needy, relieve suffering,..." But, perhaps unlike many of my colleagues, after enjoying each of my rotations, I did decide on family medicine. And, I had no idea that it would lead me here.

I took my two-month anesthesiology elective rotation first, so that I could force myself to get over my fear of poking people with needles. I achieved that goal, and enjoyed the intellectual stimulation of the daily physiology experiments, and considered that as a great option for a career.

I took rotations in cardiology, and pediatric oncology, and psychiatry. Each with the excitement of learning from remarkable men and women, becoming part of a truly noble profession. And, imagining myself as wise and compassionate as these mentors. But, ultimately, it was family medicine that kept me. I completed my residency, as Chief Resident, at the University of Kansas School of Medicine in 1992. With much of my education still to come...

I am the Chief Medical Officer for Peninsula Community Health Services, a "safety net" provider in Kitsap County, Washington. And, despite my father's repeated advice, I now know that I have since specialized in "diseases of the poor."
I'm starting this blog so that I have a place to tell the stories of my daily work. It is named for the book "Health Care Meltdown: Confronting the Myths and Fixing Our Failing System", by Robert LeBow, MD. Dr. LeBow was a Peace Corps doctor in Bolivia, the Medical Director for the Terry Reilly Health Services in Southwest Idaho, and a past President of Physicians for a National Health Program. As described in this USA Today article, Dr. LeBow came to know about the Health Care Meltdown from "both sides of the bed", having suffered a head injury from a bicycle accident which ultimately resulted in his death. I had the great privilege of getting to know him and his wife Gail via email after his accident, and consider his book an excellent primer on the issues of our failing health care system.