THURSDAY NIGHT IS HEALTH CARE CHANGE NIGHT, a weekly Daily Kos Health Care Series
I was Medical Director of a charity-based clinic for six years. The Clinic was established by charity that started with a thrift store in a church, and grew to include a sheltered workshop, a day shelter, a place for free breakfast and lunches, job and family counseling, low-cost housing management, as well as the original thrift store. Unfortunately, circumstances, the immediate post-9/11 economy, and inexperienced management eventually caused the charity - and the Clinic - to close down. It broke my heart to have to give up that practice. as it was one of the most fulfilling practices of medicine I have ever participated in. This is my story of the Clinic.
When the charity's president (I'll call her "P.") imagined the Clinic, the charity was located in a warehouse in the industrial area of Dallas. It was a large two-story building and it housed the thrift store, food preparation area, sheltered workshop, showers, a day shelter area, offices and a conference room. There was a 700 square foot area on the first floor that became the Clinic - with three exam rooms (one was used for storage), a pharmacy area and a desk that was the "office".
Besides the space, the next thing P. needed was a medical professional - a nurse. She approached the Cathedral of Hope, one of the largest LGBT churches in the country for their help, and the congregation funded the salary for a Registered Nurse, and she found the perfect nurse there - the mother of one of the congregation. Jackie had served many medical missions in Africa and the Dominican Republic with the UCC. and I often teased her that as long as she had access to water and a cutting instrument, she could treat anything. Truly, she had great wisdom, experience and heart - and taught me everything about "street medicine". With an RN, P. could start creating the Clinic's entity.
Such a huge percentage of the homeless and poor that the charity was serving in the industrial area suffered from mental illness, P. and Jackie soon partnered with local MHMR services to offer supervised outpatient psychiatric medicine administration. The Clinic would fill their psychiatric medication prescription, and make sure that the patients got their medications regularly. Sometimes Jackie would have to roam the streets to find the ones who did not show up, but she made darn sure that most of them stayed on their medications. This service sort of put the Clinic "on the map" of charities in Dallas, it was unique.
But the Clinic needed a full-time Medical Director. At first, P. had made an arrangement with a local urgent care clinic to provide volunteer physicians one day a week, and this worked for awhile. but it did not offer consistent follow-up. That is where I came into the picture. I had left a very lucrative medical oncology practice because it was too sad, too corporate, and it was ruining my health, and was on "hiatus", so to speak, when a friend of mine told me about the opportunity.
P. was an energetic, driven woman who had great dreams. She managed to turn a thrift store into a successful multi-service charity through her own hard work and drive. She refused government grants, and turned to churches, corporations, synagogues as well as private individuals for donations. The food served was donated by catering departments of area hotels as well as by the North Texas Food Bank. Part of the charity was funded by the work done by the clients in the sheltered workshop. P. was a superb "shake-down artist" when it came to personal appeals for money and donations.
When I was hired, the Clinic could now become a full-service Clinic, complete with a Class "D" pharmacy, a clinical lab (I did urinalyses, blood sugar determinations, microscopic exams of fluids) and we sent out Pap smears and some simple blood tests. I was able to negotiate with Parkland Hospital to become part of their Clinic Outreach so that we could send patients to Parkland when they needed emergency care, specialty clinic referrals, or hospitalization if they needed it. It was cumbersome at times, but it was a great help to be able to have that resource available to our patients, rather than them having to go to the notoriously overloaded Parkland Emergency Room.
At the Industrial District warehouse location, most of our patients were street people, and some who lived in subsidized housing and worked, either in the sheltered workshop or low-paying jobs. As time went on, word got out "on the street" that there was a free walk-in clinic and the patient numbers grew to where I was seeing about 60 patients a week in the teeny little clinic. Foot problems were a large part of the practice, as people who live on the streets had little opportunity to change their socks, people living in shelters rarely removed their shoes (they were likely to be stolen), and folks spent all day essentially walking around. We would buy socks and Desenex spray in bulk. Often Jackie would have three or four patients with their feet soaking in antiseptic footbaths, and she would pare calluses, trim toenails, and doctor blisters - literally washing the feet of the poor.
One of P.'s great accomplishments was negotiating with Dallas's Community Charities and various donors to get a new building built for the charity in a location east of downtown, in an area of low-cost apartments, used car lots, and immigrant communities. This move put the charity where families became the focus of the charity's efforts - not so many street people there. She even managed to get a brand-new X-ray suite built in the Clinic, where I could do my own chest x-rays and bone films. The new building had a lockable pharmacy area, and Jackie and I had our own real office. Another feature of the new location was that there were five elementary schools within walking distance. I met with all the school nurses to let them know that sick children would be given first priority, so that their parents could bring them directly to the clinic from school, get whatever treatment they needed, and not have to miss too many days from work. All too often, families would be one strep throat away from joblessness and homelessness. This was one of the better things I felt that I could do in that community.
The new location brought in patients with a different set of ailments. Rather than treating foot problems and trauma, I found myself back in Internal Medicine (my first love!) treating the health issues of the largely Hispanic population of the neighborhood - diabetes, hypertension, heart disease, arthritis and the like. Type II diabetes is all too common in Hispanics who start eating the American diet; the transition away from the traditional food of their countries to high-fat, high-sugar and salt fast foods made many of them obese and they developed diabetes at an alarming rate. Dental problems were rampant, as preventive dental care was non-existent. Fortunately for me and the patients, Parkland's indigent obstetrical services are outstanding, so I did not have to deal with pregnancy problems. There were also a number of half-way houses in the neighborhood, and I treated many parolees and their own set of health problems - like tuberculosis and other infections.
I would often get referrals from social workers discharging indigent patients from hospitals like Baylor University Medical Center and Methodist Hospital - their free clinics were overloaded, and they did not choose to increase their budgets for those patients unable to pay. These patients were often very sick, and often the best I could do was to get them into the Parkland system.
Another community outreach activity we did was local Health Fairs, where we would set up to give out information, offered free school and sports physicals, vision screenings, blood pressure screenings - and offer follow-up to people who needed it. I became the Health Fair "Queen", able to gather the set up and people to man a booth with less than 24 hours notice! We were able to reach a large population of people who needed Clinic care this way.
The problem was not getting physicians to see these patients - the problem was the expense of the indicated tests, procedures and medications. Doctors were eager to volunteer their services. The psychiatrist I recruited to oversee the many clients on psychotropic drugs said to me after his first day seeing patients there, "I love this place! These people are really crazy!" Now, this may seem odd, but after years of treating rich kids with ADD or their drug-demanding parents, this psychiatrist felt like he had the opportunity to help people who really needed his skills. Each week, he'd arrive with large garbage bags chock-full of samples of the medications he felt his patients needed.
In fact, physician samples - those much-maligned gifties handed out by drug reps to physicians in private practice - became a lifeline for many of my patients. Our pharmacy could only afford the most basic of generic drugs, and we could not afford the expensive asthma medications, the antibiotics, the newer diabetes medications that these patients often needed. When one of these angels would bring huge sacks of samples, Jackie and I would sort them out, sometimes hollering "Whoop! Someone sent Avandia (or Actos, or Celebrex, or any one of a number of expensive brand-name drugs) and we would call that patient to be sure and come get their meds before they were gone. We also got most of our office and medical equipment donated to us. People are happy and pleased to give, as Kossacks have proven over and over.
The Clinic applied for and was finally given, authority to bill Medicaid, but we rarely got any money from that source. For those who could afford it, we charged $20.00 for women coming in for routine pap smears. The only people who were turned away were those who HAD insurance; we had no business office. One day, I calculated our costs per patient - including space "rental", liability insurance, drug costs, salaries, operational costs, and the like, and the accountant and I came up with the figure that it cost us about $35.00 for each patient seen. This cost included drugs, lab, and any x-rays that we did. Mind you we were a non-profit, our liability insurance rates were low because of our charitable status, and Jackie and I both worked for peanuts, but it proved that low-cost quality health care can be delivered in an out-patient setting. It took an incredible amount of legwork and paperwork. We were complete novices when we started out, and I'm sure that we made any number of mistakes along the way, but I'd do it again in a heartbeat.
Sadly, the charity collapsed in 2004. There were a number of reasons that the entire operation imploded. many of them had to do with our CEO trying to do too much by herself, not paying attention to details, and not fully involving the Board of Directors. After we closed, I got calls from the head of Emergency Medicine at Parkland, telling me that their traffic had increased noticeably, particularly among "my" patients with diabetes, who were coming in with complications that they did not have before. It still breaks my heart that the Clinic is gone. As far as I was concerned, the medicine I practiced at my little free clinic was the best medicine I have ever practiced.
But it CAN be done. Health care does not have to be inaccessible, and it should not have to drain the resources of those people whose lives depend on it. One little clinic could and did make a difference.