American College of Physicians: Internal Medicine — Doctors for Adults ®

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Physicians reach out to help the underserved

From the April ACP Observer, copyright 2004 by the American College of Physicians.

By Janet Colwell

Most physicians are very familiar with the practice of providing free patient care. In fact, a study published in the November-December 2003 Health Affairs found that almost 70% of practicing internists extend charity care, typically to existing patients who have lost their health insurance.

However, many physicians also reach out beyond their private practice to larger communities, both at home and abroad, to volunteer their skills and time. They have various motives, from caring for uninsured patients to ensuring that Third World countries can take advantage of modern medical technology.

Every year, the College recognizes physicians and institutions for their commitment to volunteer service. Here are profiles of three College award winners who will be honored for their efforts at this month's Convocation Ceremony at Annual Session in New Orleans.

A community effort

Nestled at the base of the Rocky Mountains, Missoula, Mont., seems far removed from the national debate over affordable health care. But with 23% of the local population lacking coverage, access to care is as big an issue in Missoula as anywhere else. What sets the city apart is the fact that its residents, health care providers and government have all pulled together to confront the problem.

The now-thriving Partnership Health Center, a clinic that handles 17,000 visits a year from mostly uninsured patients, had its beginnings in a grassroots effort by the local medical community and government to provide care to the uninsured. Most of the center's patients—roughly 80%—are either uninsured, on Medicaid or homeless.

The center, which employs eight nurses and the equivalent of 1.5 physicians, has a volunteer staff of about 25 providers (mostly specialists and a few dentists) who together contribute 100 hours of service every month. Two licensed clinical psychologists, two psychiatric nurses, two dental hygienists and three registered nurses also volunteer on a regular basis. Personnel from two local hospitals donate staff time, as well as lab and X-ray services.

The center is a testament to the dedicated leadership of longtime Missoula resident Harold A. Braun, FACP, this year's recipient of the College's Oscar E. Edwards Memorial Award for Volunteerism and Community Service. Planning for the now-thriving center began back in the early 1980s, when Dr. Braun and others became concerned that more and more working families were going without health insurance.

According to Dr. Braun, Missoula in the 1980s and 1990s saw an influx of low-wage service workers without insurance. That placed a burden on local physicians, who faced an increasing number of non-paying patients. At the same time, more low-income patients began using hospital emergency rooms for routine care.

"The emergency room is unable to give high-quality, comprehensive care for ongoing problems such as diabetes, hypertension, depression and preventive services," Dr. Braun noted.

Dr. Braun began by chairing a fact-finding committee. After hundreds of meetings, a "Partnership for Access" was established in 1991, with local physicians, hospitals and county government together volunteering close to $650,000 a year in time and services.

The project first relied on space shared with the health department. But it soon became clear that the partnership needed its own facility and more funds.

"After only six months, the need was enormously greater than we had estimated," said Dr. Braun, who recently turned 80. "We needed administrators, social workers, nurse practitioners and a salaried full-time physician to run it, but that exceeded our local resources."

In 1992, Dr. Braun and others began working on securing grants and raising money in the community. Operating funds and the center's permanent site, which was dedicated in 1999, were made possible by a seed grant from the Robert Wood Johnson Foundation, ongoing HHS support (the center receives an $850,000 community health center grant every year), and smaller grants and private gifts. The center's annual operating budget is now $2.8 million.

While the funds keep the doors open, it is community spirit that makes the center possible, Dr. Braun pointed out. Health care providers in Missoula have a strong sense of collegiality and a shared commitment to working together-the kind of teamwork that Dr. Braun said is now becoming more rare as health care becomes increasingly commercialized.

"My sense is that there is more anxiety today and people don't see each other as often," he said. "One of the reasons I'm a booster of ACP is that it's trying to stimulate and maintain collegiality and professionalism as medicine becomes more of an industry."

Training physicians to improve care

In 1995, Mark H. Johnston, FACP, spent his first trip to Albania cutting tiles, painting walls and playing with children at a local orphanage. It was obvious, he said, that the children in this poverty-stricken country needed medical attention. However, he didn't realize how desperately needy the country was until he visited a nearby hospital.

"It was unbelievable," recalled Dr. Johnston, who is chief of gastroenterology at the National Naval Medical Center in Bethesda, Md. "There was blood on the floor, people screaming, broken light bulbs, piles of needles thrown about, and an eight-year-old boy about to have his leg amputated after being bitten by a viper."

He decided to return to Albania as a physician volunteer and contacted the Albanian Health Fund, a nonprofit humanitarian group. He was told that gastroenterologists were in critical demand in Albania, where many patients suffer from peptic ulcer disease and gastric cancer. At the time, Albanian physicians were treating all gastrointestinal (GI) bleeding with surgery instead of endoscopy, the standard of care in the United States.

Albanian physicians knew about endoscopy, Dr. Johnston said, but they lacked access to educational resources, training and modern equipment. "The first endoscope I saw in Albania was ancient, with bare metal exposed at the tip," he recalled. "The doctors would wrap the end with electrician's tape and then wipe it with antiseptic to clean it." It was not uncommon, he added, for a gastroenterology fellow in Albania to finish a three-year fellowship without ever performing a single endoscopy.

"We can treat 95% of GI bleeds by just putting a scope through the mouth and treating the bleeding," Dr. Johnston continued. "It was obvious that I needed to introduce therapeutic endoscopy in Albania."

Armed with a colonoscope, an upper endoscope, an electrocautery unit and suction pump, Dr. Johnston returned to Albania in 1995 to work with an Albanian surgeon. He recently returned from his ninth trip, and he spends two weeks each time he visits training medical students and physicians in endoscopy procedures.

As a result of those training efforts, surgeries on patients with GI bleeding dropped by 75% in Tirana, the country's capital, in just one year. And Dr. Johnston was instrumental in creating a state-of-the-art endoscopy center at Tirana's University Hospital Center, the country's only academic medical center.

Dr. Johnston is being awarded one of the College's Richard and Hinda Rosenthal Foundation Awards for increasing clinical and/or economic effectiveness in health care delivery or facility design. He admitted that it is hard for him to maintain his extensive overseas commitment and his career here at home.

In addition to heading his medical center's gastroenterology department, he is director of an initiative to create a new colon cancer center at Bethesda that will use traditional and virtual colonoscopy for screening. He is also working on a device for early treatment of Barrett's esophagus and esophageal cancer.

To make time for his volunteer efforts, Dr. Johnston uses a combination of personal vacation time and unpaid leave, which the Navy has been liberal in granting. He pays for all his own travel expenses, and said he is as committed to continuing his volunteer efforts as he was eight years ago.

"The need in Albania is so overwhelming," he said, "that it's hard not to go back."

Need among affluence

The average price of a home in Montgomery County, Md., exceeds $350,000, making the county an unlikely place for a free clinic.

But the founders of Mercy Health Clinic in Germantown, which is 30 miles northwest of Washington, discovered that extensive poverty lurks just beneath the area's affluent veneer. After a report found that 120,000 uninsured, low-income people—many of them working adults—lived in the county, a local church group launched a community effort three years ago to help establish a free clinic.

Last year, Mercy had more than 4,000 patient visits from uninsured low-income adults. It operates three days a week with an annual operating budget of $250,000. With the exception of three paid administrative staff, the clinic is staffed almost entirely by volunteers, relying on a community network of 150 physicians, nurses, administrators and translators.

Mercy Health Clinic, this year's winner of the College's Edward R. Loveland Memorial Award for a Distinguished Contribution in the Health Field, is a true community effort. A local hospital provides free laboratory services, while local radiologists donate procedures such as ultrasound, X-rays and scans. The county government donates office space and pays for physicians' malpractice insurance, said James A. Ronan, FACP, a cardiologist who helped found the clinic.

That has been a crucial factor in keeping the clinic open, he noted, because about two-thirds of the volunteer physicians are retired and no longer have their own coverage. Volunteers at the clinic are considered county employees for insurance purposes.

Providing drugs to uninsured patients is another major hurdle, Dr. Ronan said. The clinic receives some donations of brand-name drugs from manufacturers' pharmacy assistance programs. A part-time clinic nurse meets regularly with drug company representatives and asks local physicians to donate drug samples.

For generic drugs, the clinic relies on donations from a lay Catholic charity and a local pharmacist, who sells medications to the clinic at cost. Eventually, Dr. Ronan hopes the county will use its clout to negotiate bigger discounts and become a generic drug distributor for all the free clinics in the area.

He coordinates the recruitment of 45 physicians who volunteer, many of whom are in their early 60s. Since retiring from his own full-time practice, Dr. Ronan spends three days a week volunteering at Mercy and two inner-city clinics in Washington.

Signing on volunteers has been easier than he expected, he said, because physicians are anxious to help.

"They enjoy the camaraderie of working with other doctors," he said. "And they don't have to worry about billing because no one is getting paid."

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The unique challenges and rewards of volunteering overseas

Physicians say that international service allows them to see the world and rediscover basic medical skills

Physicians who volunteer overseas say they are struck by the vast challenges patients in developing countries face, from a lack of potable water to scarce medical supplies. But they also say that working overseas has unique rewards. Chief among them is the immediate satisfaction of practicing basic medicine and seeing instant, life-saving results.

After maintaining a private practice for 12 years about 40 miles north of Boston, Suzanne J. Abkowitz, ACP Member, was well-versed in treating the diseases of American patients. When a patient presented with fever, for example, her typical diagnoses included flu, pneumonia or urinary tract infection. But in the developing countries where she travels as a medical volunteer, the same symptoms more likely indicate malaria, typhoid or parasites.

For more than a decade, Dr. Abkowitz has been making treks every two years to remote areas—including Bhutan, Vietnam, South Africa and Tanzania—to provide medical care. The trips are family affairs that she takes with her husband, Glen Crawford, MD, an orthopedic surgeon, and their three children, ages 6 through 16.

"Our first trip with the kids was to Indonesia in 1991," said Dr. Abkowitz, who opted out of private practice two years ago to take care of her family and devote more time to volunteering. "People thought we were completely crazy to bring along a 3-year-old and a 1-year-old, but they're pretty adaptable and they've learned all kinds of interesting things."

She and her family travel with Health Volunteers Overseas (HVO), a nonprofit, nonsectarian group. HVO, which sponsors programs in many developing countries, advocates combining teaching and basic care in host countries. (More information is online.)

Paying its own travel and living expenses, the family spends one to two months at a time in each foreign country, treating patients, training local physicians and getting a unique view of the developing world and its diseases.

In Bhutan, for instance, Dr. Abkowitz routinely treated patients with tuberculosis of the lung, spine, brain and abdominal cavity, as well as typhoid fever and various gastrointestinal diseases. When she is there, she is one of only three internists in the entire country, which has a population of 1 million. Her husband is the sole orthopedic surgeon.

Working in the outpatient department of a local hospital there, she had to rely on her own abilities to diagnose, with no echocardiograms, CT scans or ultrasound. The lack of sanitation greatly increased the risk of infections, while patients had no appointments or standard medical records. Instead, people typically kept their paper records with them—and often traveled long distances and stood in line for hours for treatment.

Dr. Abkowitz has worked out of the back of a truck in South Africa. In Bhutan, she treated a febrile patient in a coma who turned out to have cerebral malaria and tubercular meningitis. In her travels, she has come across wounds from a lion mauling and a case of rabies.

She and Dr. Crawford became enthusiastic about volunteering overseas in 1985 after spending the last five months of medical school doing infectious disease rotations at a medical center in Tanzania. At the end of their residencies in 1991, they signed with HVO for a three-month trip to Indonesia. The trips, she said, have sparked a love of traveling in their children and made them more accepting of different cultures and religions.

Dr. Abkowitz, who speaks fluent French and Swahili, is now using her international expertise at home as a volunteer for International Medical Equipment Collaborative, a nonprofit that donates modern medical equipment to developing countries.

"We assess what equipment they need and come back and design a 40-foot container to send to them," she explained. "Because I've spent so much time practicing medicine in these countries, I know how hard it is to do without the right equipment."

Frank P. Duggan, ACP Member, first became drawn to overseas service after spending a two-month surgical rotation in Colombia during his last year of medical school. The 37-year old internist, who now works as an emergency physician in Washington, has traveled to Honduras 10 times over the past four years with the Texas-based nonprofit group Medical, Eye, and Dental Internal Care Organization (MEDICO).

The group dispatches monthly volunteer medical teams to Latin America to set up mobile clinics, perform minor surgical procedures and dispense medication, with the group supplying all of the necessary pharmaceuticals and equipment. Twice a year, MEDICO sends specialized volunteer surgical teams to Latin American hospitals.

Dr. Duggan chose to work with the group partly because of its Latin American focus. "I love to travel and experience different cultures, and see diseases that you wouldn't normally see in the United States," said Dr. Duggan, who is fluent in Spanish. He also likes the fact that MEDICO's trips last a week, giving physicians a realistic alternative to long-term commitments overseas.

He recently spent 10 days setting up a clinic in a remote section of Honduras. Through MEDICO, he brought in $500,000 worth of medications, intravenous fluids and equipment, and trained the local physician in basic procedures such as suturing, repairing and cleaning wounds, episiotomy repair, and inserting an intravenous tube.

"When you go to a country, they might have electricity for four hours a day and no potable water, and the nearest physician is a three-hour drive away," he said. "Anything you do is significant. You really do have a very immediate impact."

Working overseas has also had another unexpected benefit, he pointed out: Allowing him to practice a wide range of medical skills.

"Increasingly, American health care is specialty driven," he said. "My experience volunteering has allowed me to continue to be involved in areas of medicine that I find interesting, but perhaps fall outside of my current scope of practice. I find that very appealing."

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Other overseas opportunities

The College's Board of Regents recently voted to establish an ongoing relationship with Project Hope, a nonprofit organization that is now working in more than 30 countries. In those countries, Project Hope provides medical training, education and assistance. For more information, visit Project Hope's Web site.

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