Doctors train to serve needs of inner-city populations

At SeaMar Clinic, Drew Malloy confers with Victoria Barrio, a resident training there. Photo by Doug Plummer.

Most of the nation's best urban hospitals rise in the skyline above the inner city. In their shadows live many people who lack access to basic health care.

“Payback programs, such as the National Health Service, were not generally successful in retaining physicians for medically underserved urban populations,” said Dr. Sam Cullison, director of the Providence Family Practice Residency. “Physicians worked off their educational debt after two or three years, then left.”

Providence, and several other Seattle hospitals in the UW's Family Practice Residency Network, have a different approach. Their physicians-in-training consider the care of disenfranchised urbanites as worthy to prepare for long-term.

“People in unfortunate circumstances deserve stability in providers. Continuity in their health care is especially important to people whose lives are already disrupted by other difficulties, ” observed Dr. Bob Crittenden, director of the Family Medicine Service at Harborview Medical Center.

According to Dr. Drew Malloy, a physician at the SeaMar Clinic in southwest Seattle, medical students who are exposed early to the gratification of inner city practice and who continue with residency training on how to handle day-to-day realities of such a practice will often finish their training believing this is a path they can pursue.

“Dr. Sharon Dobie [assistant professor of family medicine] has excelled in introducing medical students to care of the underserved by placing students with physicians in actual settings,” Malloy said. Several Seattle family practice residencies expand on that model.

SeaMar is one of five Seattle clinics that have cared for the urban underserved for many years and that now train resident physicians. SeaMar and the Seattle Indian Health Board are joined with the Providence Family Practice Residency. Swedish Family Medicine has The 45th Street Clinic and The Downtown Clinic, and University of Washington Family Practice has opened a Harborview satellite.

These sites try to make health care more amenable to patients and physicians alike. From their first phone call to SeaMar and at each appointment, patients can communicate in Spanish, and interpreters are on-call for other languages. Two nights a week, teenagers living on the streets can get a ride from a local church (which also cooks them supper) to The 45th Street Clinic for free health care. The Seattle Indian Health Board reflects the Native American cultures of its patients.

In Harborview's new family medicine service, Crittenden said, “Many of our trainees are finding that it is truly enjoyable to treat people from diverse backgrounds.”

“At the same time,” Cullison pointed out, “doctors with an open door policy sometimes face situations that are troublesome — the chronic no-show patient — or downright dangerous.” Confronting violence or substance abuse is as much a part of the job as treating patients who are trying to do the best they can.

Some people can't take time off from their jobs to recover, don't have any food in the house, or may not be able to afford medication. Residents must learn how to fit a treatment plan into their patient's means, Malloy said.

“There's no cookbook for providing quality care to the underserved,” he explained. “Residents use their imagination and the advice of experienced physicians. Some residents, for instance, ask pharmaceutical companies to donate medications for their patients.”

With the demands of patient care, it would seem that training residents would be an added burden. On the contrary, some community physicians say teaching renews them.

“The residency link has increased our physician retention,” Malloy said, “We view it as a bonus to have our residents here with us.”

Graduates of the Providence residency, in particular, not only enter practices for the urban underserved at a high rate (more than half do), but also tend to stay.

Cullison believes that further solutions to urban health problems may lie waiting in the minds of those growing up in the inner city.

When a child in an examining room sees Cullison instructing a resident, and asks about becoming a doctor, he takes the time to answer. He tells older children about the University's summer programs to help disadvantaged teenagers succeed in school.

“Inner city kids,” Cullison said, “could be a source of talent for improving the future of urban medicine.” ¶
Leila Gray