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Healing the Poor

The New Physician March 2004
When Brenda Grant, a third-year at Texas Tech University Health Sciences Center School of Medicine, arrived for work one morning at the San Elizario health clinic where she was doing a summer preceptorship in family medicine, she was not surprised to see an elderly man waiting in the shade of the clinic’s sign. The morning’s temperatures had already begun to climb in this small Texas town southeast of El Paso, along the Rio Grande. Lupe Ramirez’s* appointment wasn’t until the afternoon, but because he had to walk many miles from his home to the health center, he wanted to make the journey before the day became unbearably hot. Grant says she found unusual patient behaviors like these common at the border clinic.


San Elizario, a Kellogg Community Partnership clinic sponsored by Texas Tech University, serves some of the poorest people in the nation. Working in an impoverished community like this can be one of the most challenging ways to practice medicine. It can also be one of the most rewarding. It is likely, however, that nothing you learn in medical school will fully prepare you for this environment. When you get to the border clinic, the inner-city emergency room or the rural community health center, you are most definitely not in Kansas anymore.


WALK A MILE IN MY SHOES


Because of their poverty, patients at clinics like the one in San Elizario often make decisions and develop behaviors that seem strange to the predominately middle-class professionals who try to provide them with health care.


Beverly Williams, Ph.D., a medical sociologist at the University of Alabama at Birmingham (UAB), recently concluded a three-and-a-half-year study examining the ways low-income individuals handle the social problems accompanying illness. She says “physicians have to walk in the shoes of the poor before they treat them.” There are so many differences that without an understanding of the people and their communities, any attempts to serve them are likely to fail, she says. That’s because middle-class health-care providers are unfamiliar with the accommodations the indigent must make and the strategies they must employ to survive.


In poor communities, patients rarely seek health care until they are very ill. They are frequently late for appointments or miss them altogether because their access to transportation is precarious and taking time off work to visit a physician may mean losing a hard-to-come-by job. They often do not get prescriptions filled until payday or until they can sell a piece of furniture to pay for the medicine, and even then they are likely to save some of the medication for later or share it with family members who may be experiencing similar symptoms. Parents will frequently take one sick child to a physician and then distribute the medicine among several others at home.


For many reasons, including feelings of embarrassment and alienation, poor patients are less likely to be honest with their physicians. And even when they are, communication can fail in ways so subtle the physician may never know it failed. Grant remembers caring for an older man with high cholesterol who assured her he always cut all the fat off his meat before eating it. Only later did the medical student learn he lived on the one meal a day he received from a local soup kitchen. “He didn’t want to say, ‘I eat what I am given; I have no control over my diet,’” Grant says.


The challenges in caring for this unique community of patients reflect deeply entrenched social issues. In Health Work With the Poor: A Practical Guide, Christie Kiefer, Ph.D., an anthropology professor at the University of California, San Francisco, School of Medicine, says that the poor are particularly vulnerable when it comes to health care. Their choices of providers and treatment options, along with their ability to question or influence treatment decisions are all compromised by their lack of resources. In addition, he says, the power relationship between the physician and the poor patient is particularly unbalanced. The poor patient typically sees his physician, a well-educated, well-dressed authority figure, as someone representing an alien and oppressive culture.


DR. SOCIAL WORKER


Many of the difficulties experienced by caregivers are practical in the extreme.


When the staff at the San Elizario clinic discovered that a kidney transplant patient, Maria Garcia, had received no specialty follow-up care after her operation, they knew something needed to be done. Many phone calls and hours of paperwork later, a nurse practitioner managed to arrange for a charitable foundation to pay for Garcia to visit a nephrologist across town. After navigating three buses and a long walk to get to the specialist’s office, Garcia was told she couldn’t be seen because she could not pay. So she made the long journey back to the clinic. The problem was finally resolved after a nurse spent three hours on the phone with the specialist’s office.


This is just one example of how nonclinical concerns can greatly interfere with a poor patient’s health care. Making creative payment arrangements, juggling medications to take advantage of free pharmaceutical samples and overcoming language barriers are all routine aspects of this type of medical practice.


Of course, most of this is new territory for young physicians. “You don’t learn this kind of thing in medical school,” Grant says. “But in this kind of practice, you often do more social work than medicine.”


Dr. Matt Symkowick, a chief resident in family and community medicine at San Francisco General Hospital, a low-income health center, agrees. “I spend lots of time writing letters, making phone calls, tracking people down when they miss appointments, doing home visits….”


Being an advocate for patients is part of every physician’s job, but for those who work with low-income patients, the advocacy doesn’t stop with following up on referrals and researching new techniques and therapies. For the underprivileged, medical problems are intertwined with and often the result of social and political concerns.


“If a doctor really cares, he or she needs to think seriously about becoming an ally, an advocate, an activist outside the clinic,” Kiefer says. Many physicians caring for the poor find that they can’t do their jobs any other way.


DIFFICULT, BUT NOT DISMAL


Though the problems and challenges are enormous, it is a mistake to think of this work as depressing. Physicians say it can be frustrating and exhausting but also energizing and entertaining. One only has to visit an indigent-patient health-care facility to witness this.


A day spent at St. George’s Clinic at Cooper Green Hospital in Birmingham, Alabama, is full of heart-warming moments: An elderly patient dances in the hall to demonstrate how he’s improved since his last visit. A nurse calls to him, “Oh, Mr. Harris, you better watch out! I think you may be feeling too good!” Another nurse fondly addresses an AIDS patient who is walking around until his turn to have blood drawn: “Don’t you go too far—I don’t have time to come looking for you.”


Patients often wander casually in the halls here, chatting with each other and the staff, who ask after patients’ relatives. Laughter is frequent; yet when tears do come, patients as well as staff are on hand with tissues and shoulders to cry on.


As in most low-income, inner-city clinics, waits can be long at St. George’s. This problem is not unique to indigent care, but perhaps how patients and caregivers react to it is. On this day, the staff is further behind than usual, and patients are piling up in the waiting room. A nurse sits down with them to explain that a patient who had come in earlier had serious health problems and took longer than expected. She apologizes for the delay in the manner one might express regret to hungry guests when the Thanksgiving dinner isn’t quite ready—with sincerity, but with the expectation that everyone would understand and the knowledge that everyone was a part of what was going on. The patients seem to accept the situation. They understand that when their time comes to see the physician, they will not be rushed. It also helps that a midday visit to St. George’s includes having lunch sent up from the cafeteria.


Dr. Susan Ferguson, the clinic’s director, explains that a desire for a meaningful and quality life isn’t diminished by a lack of income. “The poor are open and humble, and gracious and grateful. They enjoy life as much as people with money do.” Ferguson appears to thoroughly enjoy her life at the clinic. Her small, messy office is filled with pictures of her family, her patients and her patients’ families, and she’s known to give spontaneous hugs to patients and other visitors.


Kiefer agrees that the poor are often surprisingly well adjusted to life. “The sheer difficulty of surviving—and helping one’s loved ones survive—in a harsh environment seems to give a sense of purpose to the daily activities of many,” he says.


Williams warns, however, that it’s important not to romanticize the poor. Romanticizing or identifying too strongly with them can cause physicians to deny their natural anger and frustration should a patient be demanding, irritable, manipulative, disagreeable or ungrateful—behavior problems encountered in all types of practices. Such denial can seriously compromise the physician’s relationship with her patients and her own mental health.


THE ART OF CARING FOR THE POOR


This kind of medicine can be done well, if one learns the art of practicing in poor communities. Just like the poor, physicians must develop strategies and accommodations to better deal with their situations. The three key strategic areas to develop are: communication, community involvement and trust.


Communication. Of all the tricks to practicing successfully, effective communication is the most important. At its most basic level, this often means translation. Many poor communities have large populations of non-English-speaking patients. At the San Elizario clinic, Spanish is the second language of many of the patients, the first being their Native American tribal language.


While it’s not necessary to be fluent, health-care workers must make an effort to learn the languages of their patients. Translators are helpful, and Dr. Darryl Williams, the executive director of the Office of Border Health at Texas Tech, recommends enlisting the help of community members. Patients’ languages often contain subtle meanings that can make cross-cultural communication difficult without good translation by those who are familiar with the patients and their circumstances.


Communication requires more than speaking the same language, however. “You have to ask the right questions and phrase things in the right way,” Beverly Williams says.


For example, following conventional medical wisdom, many physicians suggest their patients get more exercise and eat plenty of fresh fruits and vegetables. That’s good advice, but for someone who works two jobs and cares for three grandchildren, finding time to exercise might not be a priority, and fresh fruits and vegetables are expensive. A physician who is aware of this can take a different approach.


“Trying saying, ‘How can you work in more exercise? Do you have a stroller so that you can take walks with the children? Can we see about getting you one?’” Williams suggests. She also points out that you shouldn’t be condescending about nutritional matters. “Their diets aren’t all bad. What they eat is affordable and comforting, and that can be worth a lot.”


Ferguson says another important rule to remember is listening. “Medicine requires active listening. You are always listening. And patients will usually give you the most important bit of information when you aren’t expecting it. You have to stay focused.”


In addition, good listening requires an understanding of the cultural context of the message. Without that understanding, physicians eager to redress injustice can lose sight of the real problem and do more harm than good. For example, when a woman is living with an abusive husband, the tendency of a middle-class person might be to get him out of there. But his income, no matter how meager, may make the difference between whether or not she can feed her children. The problems of the poor are often more complicated than outsiders understand, even when they are trying very hard to listen.


Get involved with the community. If you want to talk with clinic director Dr. Tony Islas and can’t find him at San Elizario, you might try looking on the soccer field at the local high school. Islas doesn’t limit his interactions with his patients to the exam room. He is the physician for the high-school soccer team and involves himself in many other aspects of the community.


“The key to practicing effectively in an underserved environment is getting to know the townspeople,” he says. He suggests physicians attend local events, such as fairs, bazaars and festivals. “Seek out the people who are in the booths, the folks who are working the fair—not the tourists.”


He also recommends making house calls as a way of getting to know how your patients live. “Go see the elderly woman who can’t walk, has no car and is confined to her home. She’s 104 years old and the matriarch of the family. You’ll get to know her, but you’ll also get to know everybody else in the family.” Knowing your patients better will help you come up with creative ways to get them the care they need.


Earn their trust. Communicating, getting to know the community, learning to be a social worker—all are key tools for practicing effectively in underserved communities. And they all contribute to what may be the most difficult challenge of practicing medicine among the poor: earning their trust.


It is not easy for a middle-class, professional authority figure in a white coat to gain the trust of people who have little control over their lives and less reason to trust those who do. “Poor people are often intimidated by doctors,” Beverly Williams says and adds they may have good reason to mistrust them. “A lot of research suggests that the socioeconomic class of the patient determines how the doctor relates to that patient. The socioeconomic inequality is so great that doctors can treat poor patients differently without even realizing that they are doing it…. Often the doctor doesn’t even have a clue [what life is like for the patient].”


Good communication and an understanding of patients’ cultures are essential in gaining trust. However, a true relationship goes deeper than this. It requires subtle changes in attitude and a unique kind of understanding. According to Kiefer, the way to achieve this is by developing humility.


“It takes a tremendous amount of hubris for a physician to set him- or herself up as a healer. You can’t know everything; you can’t do everything,” he says. “There are many tragedies in life we can’t avoid. When you face that fact, you’ll develop a humility that will bring you closer to your patients. When the doctor truly sees that we are all co-sufferers in a universe that we did not make and cannot control, he or she is on the way to earning the trust of his or her patients.”


CARING FOR THE CARETAKERS


Though all this extra effort is necessary to practice effectively in underserved areas, it can have a great emotional, psychological and physical impact on the conscientious physician. “The burnout rate is high in this environment,” Darryl Williams says. But just as there are strategies and accommodations for taking care of patients, there are also strategies and accommodations for taking care of yourself.


Part of this is accomplished with the right attitude. “I never bought into the idea that medicine is a business,” Ferguson says. “I feel that this is my purpose in life—what I was born to do. I’m here because I’m supposed to be here…. Those who aren’t passionate about it won’t stay.”


The St. George’s director has a deep commitment to her job and her patients, but she also knows her limits. “I don’t buy trouble. I know what I am responsible for and what I’m not,” she says. Being aware of what you can change and what you can’t is essential to surviving in this environment.


Like Ferguson, Symkowick chose medicine as a career because he saw it as a way to help people. But maintaining a balance between his patients’ needs and his own is a constant struggle. Exercise and meditation help him cope, but much of his support comes from other people. “My spirit is continually replenished by relationships with colleagues,” he says. The resident’s biggest support system, however, is his family—a wife and two young children. “Spending time with my children is a forceful decompression.”


As with any demanding profession, creating boundaries between work and home, between the personal and the professional are essential to success and survival. In this kind of practice, however, those boundaries may be even more necessary. The question of where to live is a case in point. Physicians who practice in underserved communities are often criticized if they do not live in that community. How connected can you be to the people you serve, some might ask, if you leave it every night for better quarters? While acknowledging the potential for criticism, Darryl Williams says living outside the community may be necessary for some physicians. “Going home to a different part of town every night can be a good way to decompress.”


Caring for the poor is challenging, requiring skills beyond those developed in medical school and demanding levels of energy, creativity and patience that can test even the strongest souls. So why do people do it? Because, it seems, the rewards are as extreme as the demands.


“You can’t buy what these people give me,” Ferguson says.
Avery Hurt is a contributing editor with The New Physician. Direct comments and questions about this article to tnp@www. amsa.org.