The Primary Problem

The blood pressure numbers glow on Dr. Jennifer McLean’s laptop screen. At 168 over 110, they’re high—too high, especially for a pregnant woman in her third trimester. McLean, who is pregnant herself, quickly scans the rest of the chart and toddles to the patient’s room. A lovely woman of Hispanic descent sits on the exam table; she’s obviously uncomfortable. McLean smiles warmly at her, but it’s the kind of smile that means there’s something wrong.

Although McLean, 39, knows her patient has high blood pressure even when she’s not pregnant, the doctor is concerned about preeclampsia, a condition characterized by a rapid rise in blood pressure that can lead to seizure, stroke, organ failure, and death of the mother and baby. “I can’t let you go home with your blood pressure this high,” McLean says in a gentle voice. “I’m going to give you a pill here to see if we can get it to go down. If not, I have to send you to the hospital, OK?” It isn’t really a question.

As McLean closes the door behind her, leaving her patient to rest in the dark, she says, “Good, that one was quick. We only have 20 minutes to see each patient. If the first one of the day runs long, it can become a difficult day really fast.”

In the subsequent four hours, McLean sees 12 more patients at Clinica Family Health Services at Pecos, a community health-care provider for low-income and other underserved populations in north Denver. McLean’s second patient of the day has migraines, numb hands, and a dependency on painkillers. Patient number three has insulin-dependent diabetes, hypertension, and emphysema. Patient four is 34 weeks pregnant and has pica disorder, which makes her want to eat things like dirt, chalk, and metal. (McLean tells her to suck on white Life Savers, which have a metallic taste.) Patient seven has depression. Patient nine is a young boy with eye irritation. Patient number 10 has severe asthma. Patient 12 has kidney disease. Patient 13 is a teenage mom with a toddler who isn’t eating.

In between these patients, the doctor takes a call from a radiologist at St. Anthony North who has MRI results for her and tries to keep up with the electronic “paperwork” she’s required to complete for each patient. When she finally sits down, her feet no doubt killing her, McLean pulls a Tupperware of sliced strawberries from her bag. She runs her hands through her prematurely graying but still mostly brown wavy hair, takes a deep breath, and looks at the time. It’s 1:15 p.m. She takes three bites of strawberry before a physician assistant asks her to help with the diagnosis of an anal abscess.

Three-and-a-half hours away, at Glenwood Springs–based Mountain Family Health Centers, Dr. Amy Brown is complaining about colonoscopies. “The hardest part of medicine is that you’re responsible no matter how well—or not—someone is taking care of his own health,” she says, explaining the difficulties she has in getting her patients to undergo procedures like colonoscopies, ultrasounds, and CT scans.

Of course, it’s just a momentary gripe. Brown, 43, knows all too well the people she serves often don’t have the money, time, language skills, medical insurance, education, or citizenship to access health care beyond what she offers in her community clinic. She knows that if she can’t ameliorate a patient’s medical issue in her office on the one day that patient makes it in to see her, it’s likely that the patient simply won’t get help at all.

It’s a predicament, because although family practice physicians like Dr. Brown have a wide breadth of knowledge, there is a natural limit to what they can offer. In a setting where patients have access to insurance, Brown would quickly send a patient to a specialist when the situation exceeded her knowledge base. But the tomes on Brown’s office bookshelf—Human Labor & Birth, Primary Orthopedic Care, Rapid Interpretation of EKGs, and Color Atlas and Synopsis of Clinical Dermatology—illustrate that she must be all things to her patients. This is not only because her patient base is either uninsured or underinsured, but also because there simply aren’t all that many specialists practicing in Glenwood Springs.

Brown’s typical day, much like McLean’s in Denver, includes a roster of 20 or more patients. They have similar complaints and familiar medical conditions: diabetes, hypertension, pregnancies, mental-health issues, viruses, and chronic back pain. Unlike McLean, whose patient base is about 60 percent Spanish-speaking only, Brown’s practice skews as high as 80 percent Spanish speaking. Brown learned the language while living abroad in Chile as a child, and except for a noticeable lack of accent she’s clearly comfortable with the language. As we head toward an exam room, a smile spreads across Brown’s face as she reads the electronic medical record on her laptop. “This is one of my very favorite patients,” she says. “She’s a delight.”

“Cómo está usted?” Brown says as she walks into the room, her short blond bob tucked behind her ears. The patient, an elderly woman with borderline diabetes and a nagging pain in her side, smiles and points proudly to two small packages on the counter.

“Dos regalos. Uno para ti y uno para su niñita,” the patient says.

Brown grins, her blue eyes lighting up, and opens the small regalos—gifts—including the one the patient had brought for Brown’s four-year-old daughter.

“Qué bonito—how beautiful. Muchas gracias,” Brown says, turning the small, inexpensive jewelry boxes in her hands. The look on Brown’s face says it all: This is why she spends her days in a rural community clinic making tens of thousands of dollars less than she might at a private practice in a bigger city. Her patients obviously appreciate her.

McLean’s desk in Denver is spare, save a few sticky notes, an Obama “Change” badge, and a pin that reads, “I work at a community health center and I vote.” McLean exudes a confidence that comes from knowing what she does is important. “I always wanted to work in an underserved urban area,” McLean says. “I feel like an advocate for those who don’t always have a voice.”

It’s a job that should demand respect, yet across the United States, primary care physicians, working in community health centers or in private practice, are vanishing. America has 352,908 primary care docs today, and the Association of American Medical Colleges estimates that 45,000 more will be needed by 2020. Unfortunately, the number of medical students choosing family medicine dropped by more than a quarter between 2002 and 2007.

The decline isn’t a surprise to anyone in the medical field. According to the American Medical Association, the average educational debt of indebted graduates in the class of 2010 was $157,944. McLean, who trained at St. Anthony North, was saddled with $105,000 worth of debt; Brown, who did her residency at Rose Medical Center, shouldered about $230,000. These high debt burdens force many medical students to choose specialties other than primary care, which can pay 50 percent less than a career in, say, cardiology.

That discrepancy in dollar signs results in disturbing statistics: Just 30 percent of U.S. doctors practice primary care, while 66.7 million Americans live in places that are federally designated as having a shortage of primary care physicians, like Glenwood Springs. In fact, 53 of Colorado’s 64 counties are designated as Primary Health Professional Shortage Areas, and the Colorado Department of Public Health and Environment says that the Centennial State requires approximately 180 full-time primary care docs to meet the health needs of its underserved regions. This scenario makes McLean and Brown part of an even rarer breed: primary care docs who practice in medically underserved areas. While both say they would work where they work no matter what, McLean and Brown acknowledge that they’ve found a way to reconcile the financial downsides of primary care medicine.

After nine solid hours of seeing patients, Amy Brown is relishing a glass of organic Merlot while mixing a batch of salad dressing. Her four-year-old daughter, Olivia, plays in the living room; her husband, Dan, is firing up the grill on the back patio. The couple’s two-bedroom, new-build home looks like it could be in Denver’s Stapleton neighborhood. Instead it rests adjacent to the Grand Mesa National Forest, just a few miles outside downtown Glenwood Springs. It’s a modest but nice house. Brown shrugs when I tell her I like her home. “Real estate here in Glenwood is really expensive,” she says. “We can barely afford it. Without the loan repayment we wouldn’t be living here.”

Brown is referring to the Colorado Health Services Corps (CHSC), a program run by the Colorado Department of Public Health and Environment. The program, for which the Colorado Health Foundation is the leading funder, helps primary care physicians—as well as other primary care health professionals like nurses and dentists—defray their loan debt. But there’s a catch. To receive award money from CHSC—which doles out up to $35,000 per physician annually—a doctor must sign up to work in a Federally Qualified Health Center (FQHC), rural health clinic, or a safety-net facility in rural or underserved urban communities in Colorado. So far, the foundation has supported 104 awards totaling more than $7 million. Exactly $130,000 of that went to Amy Brown; another $88,000 went to Jennifer McLean.

“The money from the foundation helps,” Brown says. “It makes it easier for me to continue to do what I want to do, which is be an innovative healer in this community.” Brown’s affinity for the type of patient she sees no doubt helped her when she applied for the CHSC money. But that alone would not have garnered her the award. There are quantitative and qualitative criteria that each applicant—and each applicant’s current clinic—must meet to be considered.

“The demand for these awards is insatiable,” says Colleen Church, a program officer with the Colorado Health Foundation. “We have more applicants than available awards.” Brown, with her Spanish language skills (she’s also competent in Italian) and experience with different cultures (she’s lived in Chile, Brazil, and South Africa), had what the CHSC would see as an enhanced ability to accommodate an underserved population. Mountain Family, the clinic she’s worked at since 2004, is located in a federally designated medically underserved area, serves a patient base that has negligible access to medical insurance, and delivers high-quality primary care.

It was also likely Brown’s insistence that she would prefer not to work in private practice that helped her cause. The goal of programs like CHSC—there are other similar programs at the national level like the National Health Services Corps as well as in other states like Massachusetts, California, and Texas—is to give doctors and other health professionals enough financial support that they will want to continue to practice in these medically underserved areas for far longer than the three-year stint for which they signed up. “National data says that more than half of loan-repayment recipients stay for eight years,” Church says, “which means these grants are a significant tool for addressing our medically underserved populations.”

Church believes they are also a means to helping medical students and young doctors make choices without the psychological burden of huge loan debt. After all, by and large, American doctors say the reason they chose medicine as a career was to help people—not because of the money. Yet, reality has a way of changing even the most selfless intentions.

Yes, there’s the smaller salary to consider, but there are other elements to bear in mind. In rural communities, there’s less access to a network of other doctors who can be professional contacts or personal friends. In any underserved community, health-care providers have to take their patients’ finances into consideration—sometimes the necessary care isn’t a viable option when it comes to a patient’s economic status. On top of those things, these doctors have to be extremely culturally aware and incredibly flexible. “It’s not uncommon for a patient to schedule an appointment to, say, take out some stitches,” Brown explains, “and then bring in her entire family for me to look at during that appointment. It’s hard to tell someone that I can’t check her husband’s blood pressure and refill her kid’s meds because that’s not in my schedule. That’s bad customer service. It’s a challenge.”

Brown and McLean like to tout the positives of their work. Like many community clinics that receive federal funding and a steady influx of grants to treat the underserved, both doctors enjoy technologically advanced offices that use tablets or laptops and employ electronic medical records. Both Mountain Family and Clinica Pecos also use team-based models, which means the doctors aren’t the only ones delivering care. A well-choreographed effort between physicians, medical assistants, physician assistants, nurses, therapists, and other caregivers allows the doctors to focus on higher-level medicine instead of spending time administering vaccinations. “I was looking to work with people who know they can’t do it all alone,” McLean says. “Working here I feel like I can practice medicine and then go home at 6 p.m. and have a life.”

And that’s the crux of it: Primary care doctors in America need to be able to have a life without crushing debt and with the chance to choose to practice however—and wherever—they want. If America needs another 45,000 family medicine physicians in the next 10 years, someone might want to have a long chat with Amy Brown and Jennifer McLean.

For more information, visit www.cdphe.state.co.us/pp/primarycare/chsc.