John Harvard's Journal
Doing Community Medicine
A few years ago, instructor of medicine Pieter Cohen, a primary-care physician at the Harvard-affiliated Cambridge Health Alliance (CHA), began noticing a strange pattern of symptoms among some of his Brazilian immigrant patients. A number of young women complained of anxiety, heart palpitations, sleep problems, and nausea, and some showed signs of abnormal thyroid. Cohen suspected that their conditions might be connected, but he had no leads on a cause.
The breakthrough came during a session with a 26-year-old female patient who had made several trips to the emergency room for chest pains and dizziness. A full battery of hospital tests had revealed no abnormalities, but during her visit with Cohen, she showed him a bottle of prescription diet pills from Brazil. She hadn’t mentioned the pills during any previous medical check-ups. Cohen, who speaks and reads Portuguese, saw that the tablets contained at least eight different medications—including antidepressants, benzodiazepines (tranquilizers), diuretics, laxatives, and a widely banned amphetamine called Fenproporex—none of them recommended for weight loss under accepted medical guidelines. Lab tests on the pills confirmed that the mix of prescription ingredients causes potentially hazardous side effects consistent with what Cohen had been seeing in his patients. Once the women stopped taking the drugs, their symptoms abated.
The discovery set Cohen on an investigative journey. With support from fellow clinicians and community-health officials, he surveyed 300 women (in one clinic and two church settings) in order to determine the extent of pill use, the rate of side effects, and the primary means of access to the drugs within the Brazilian community in Massachusetts. Of the 15 percent of women who admitted using the drugs, two-thirds had suffered at least one adverse effect, and more than half had acquired the pills in the United States, either at a neighborhood convenience store or from an acquaintance.
The findings, published in the Journal of Immigrant and Minority Health, received coverage on National Public Radio and resulted in a state-wide campaign to educate Brazilian women about the dangers of imported diet drugs and to alert physicians to the propensity of this patient population to resort to hazardous weight-loss techniques. An on-line medical reference for doctors now carries information about the ingredients in compounded diet pills and their interactive effects. The message has also made its way back to Brazil. Warnings about the popular diet aids have appeared in a São Paulo-based scientific journal and, more recently, in a national newspaper.
Cohen’s study reflects a unique form of community-based academic medicine that is thriving at Harvard’s only publicly funded teaching hospital. CHA trains physicians to understand their patients in cultural context and to connect clinical observation and care to larger public-health concerns. “Here it’s not enough to advocate for the patient in front of you,” explains assistant professor of medicine Daniel McCormick, who supervised Cohen’s residency training and is a coauthor of the diet-pill study. “You need to understand and try to improve the larger healthcare system.” At a time when market pressures and shrinking budgets have squeezed primary care around the country, the Cambridge model offers a view of what can be achieved when doctors are able to invest themselves in the communities they serve—not only as caring clinicians, but as researchers, educators, and healthcare activists.
CHA evolved from Cambridge Hospital, a public facility long devoted to caring for the city’s diverse low-income residents. The hospital became an affiliate of Harvard Medical School (HMS) in 1965, but retained its focus on the needs of the surrounding community, emphasizing primary and psychiatric care for vulnerable populations, rather than highly specialized tertiary care and biomedical research, the hallmarks of the University’s larger and wealthier teaching hospitals. In 1996, Cambridge Hospital merged with Somerville Hospital to form the alliance, and in 2001 it expanded to incorporate Whidden Memorial Hospital in Everett. Today, besides the three hospital campuses, the system encompasses the Cambridge Department of Public Health and operates 20 neighborhood health centers in Cambridge, Somerville, and the metro-north communities of Everett, Malden, Medford, and Revere.
In recent years, public hospitals across the country have been foundering as healthcare costs have outstripped government reimbursement rates, and patients with insurance have opted for better-equipped private hospitals. CHA is the only remaining public-hospital system in Massachusetts, with 85 percent of its funds coming from federal and state sources, including Medicare, Medicaid, Medicaid Managed Care, Commonwealth Care, and the state’s Health Safety Net Trust Fund (formerly the “free care pool”). Despite continuing financial uncertainties, the system continues to provide a major safety net of services—not only physicians and nurses, but social workers, mental-health providers, and cultural interpreters—to large numbers of uninsured and under-insured patients who would otherwise have to rely on emergency-room care.
Since its founding, Cambridge Hospital, now CHA, has attracted a distinct breed of doctors: those who tend to be less interested in high-paying, medical-specialty career paths than in the chance to improve the well-being of those at the bottom of the healthcare ladder. Daniel McCormick joined CHA as a full-time faculty member in 1997, eager to combine his interest in family medicine with “a passion for social justice.” In his primary-care practice in Somerville, he treats a steady stream of low-income patients, many of them immigrants from Haiti, Brazil and elsewhere in Latin America, and the Middle East. With help from on-site interpreters employed by CHA, he takes time to discuss patients’ family situations, working conditions, and daily habits—recognizing that much of the optimal care of patients takes place outside the doctor’s office. “Sometimes there’s economic stress or a mental-health condition that keeps patients from complying with a drug regimen or following up on appointments,” he explains. “Other times it can be a matter of cultural resistance.” If a test or treatment sounds frightening, some patients opt for home remedies instead. McCormick works closely with patients’ family members (many of whom are also his patients), and with staff social workers, to address the life issues that may be impeding treatment.
In lectures and in the clinic, McCormick and his colleagues impart this “big picture” approach to students. “Those who choose to train here know that they are going to gain exposure to a patient population and a teaching philosophy that differs from other hospitals in the Harvard system,” explains Davidson associate professor of medicine David Bor, who heads the department of medicine at Cambridge Hospital.
Under new curriculum guidelines, all HMS students receive some instruction in the “social context of medicine”—in topics such as health policy, clinical epidemiology, and medical ethics—and in “patient-centered” care. (The new “integrated clerkship,” for instance, allows third-year students to follow an individual patient over a period of months; see “The Pulse of a New Medical Curriculum,” September-October 2006, page 64). But at CHA, these themes permeate all levels of training and are geared in particular toward the challenges of treating underserved and “socially complex” patients: the very poor, the homeless, recent immigrants, political refugees, those with substance-abuse disorders, and those with a history of incarceration. “This focus doesn’t replace the teaching of traditional clinical medicine,” McCormick explains. “Rather, it allows the medicine we teach to be effective in the real world.”
Fourth-year HMS student Jane Lowe was grateful to land a spot at CHA for her second-year “Doctor-Patient” training. “Cambridge is always oversubscribed, because of the unique population it serves,” she says. Before entering medical school, Lowe spent summers working as a patient interviewer at Grady Memorial Hospital, a public safety-net facility in Atlanta. The Cambridge assignment offered her the chance to pursue her interest in healthcare disparities and in “the social aspects, rather than just the scientific aspects, of medicine,” she says. “I learned things that I couldn’t learn elsewhere, like how to achieve medication compliance in homeless patients, how to work with interpreters, and how to interview and examine patients from other countries who may have had traumatic experiences.”
The staff’s approach to medical care also sets the system apart, Lowe adds. “The doctors are uniquely engaged in their patients’ lives. They go way beyond the clinical complaint that may have brought the patient to the hospital, taking time to find the right interpreter, referring patients for substance-abuse treatment, and following up with social workers to make sure patients don’t fall through the cracks.”
This level of patient involvement provides the basis for CHA’s brand of academic activism. As director of the alliance’s division of healthcare policy and research, McCormick is part of a working group of CHA internists and psychiatrists committed to investigating and publicizing a range of inequalities in the country’s healthcare system. Many of the group’s papers have been widely publicized and have helped shape health-policy debates. A 2007 study led by associate professors of medicine Stephanie Woolhandler and David Himmelstein, for example, revealed the rising numbers of uninsured veterans in the United States and led to Woolhandler’s testifying before Congress on the issue.
A simple clinical observation prompted the study. “We noticed that a lot of uninsured vets were showing up at our clinics,” McCormick explains, “so we decided to look at the actual data.” The numbers were astounding: 1.8 million non-elderly veterans were uninsured in 2004—an increase of 290,000 since 2000. The researchers found that most uninsured veterans have middle-class incomes that disqualify them for Veterans Administration (VA) care, while others can’t afford the co-payments or don’t have access to VA facilities in their communities. (The CHA group has produced similarly high-impact studies addressing the steep rise in emergency-room wait times, the distribution of free drug samples to affluent rather than needy patients, and the lack of knowledge among U.S. medical students about military medical ethics; see www.challiance.org/news/news.shtml).
“Plenty of other places conduct research on these kinds of public-health issues,” McCormick says. “The difference is that we don’t stop at getting our studies into peer-reviewed journals. We get on the phone, start talking to reporters, hold press conferences, and write editorials. Our view is: What’s the point of doing research if you’re not going to do anything with it?” McCormick himself teaches an annual month-long seminar to medical students on evidence-based healthcare advocacy, providing some background in biostatistics and epidemiology and requiring students to design a research study addressing a current medical-care problem. Jane Lowe focused on the shortage of primary-care physicians in Massachusetts: “The elective taught me the concrete steps to take,” she explains, “from recognizing a problem, to collecting data, to formulating solutions, and then reaching the audience that can make a difference in healthcare policy.”
At a time when community-focused, public hospitals are in short supply (there are 300 fewer today than 15 years ago), CHA provides a valuable training ground for HMS students. “Municipal hospitals offer students the chance to learn about disease in a population that they wouldn’t ordinarily see,” says Ronald Arky, Davidson Distinguished Professor of medicine and master of the Francis Weld Peabody Society at HMS (charged with oversight of the general medical-education experience at the school). “Today CHA is Harvard’s only thread to this population,” Arky points out. “At the same time, students get to rub shoulders with faculty who are frankly making less money than doctors in specialized fields at other hospitals, but who are wholly dedicated to serving the poorest patients.”
The fate of CHA and other public safety-net hospitals will largely depend on how the nation resolves the question of universal healthcare. In the meantime, financial woes are unlikely to curb the energy and commitment of the people who drive the alliance’s mission. “The idea of advocacy just wells up out of this place,” says David Bor. “There’s a strong belief here in the physician’s role to give voice to those people whose voices are not heard, and there’s a shared understanding of illness and health that goes beyond clinical diagnosis to address the complexity of patients’ lives.”