I was first introduced to the concept of a community health center (CHC) during residency. There were certain things about the experience that stood out to me: The waiting room was always full, patients had to take numbers like customers at a deli and the door that led from the waiting room to the exam rooms only opened if a staff member pushed a button to buzz someone in.
But beyond the seemingly cold atmosphere of the waiting room, the overall ambiance of the clinic was warm, and patients and those I worked with were joyful.
It was at that CHC that I witnessed firsthand the barriers to health that many Americans face every day. Although I didn’t know the phrase at the time, I was learning how the social determinants of health impacted the work we do. I became determined to dedicate my medical career to tackling these barriers head-on, so I joined a CHC after I graduated from residency.
I love the work I do. In fact, while many of my peers working in other settings struggle with burnout, I find great professional and personal joy in my own career. My hope is that more medical students, residents and family doctors already in practice will be drawn to this satisfying work.
CHCs come in different shapes and sizes, ranging from rural practices with only a handful of physicians to multispecialty offices with multiple sites in urban areas, but they are all rooted in the 1960s civil rights movement and War on Poverty, and they share a common aim: to serve the underserved populations of our country. Many aspiring medical students express a desire to serve the underserved in admission essays and interviews, yet that honorable goal is often lost in the mix of training and medical school debt.
Health centers are an ideal place to serve the underserved, but research shows that almost 70 percent of all CHCs are in need of more family doctors. This is unfortunate not just for the health centers but for patients who arguably have some of the greatest needs in health care.
There are many reasons why some family doctors might not be interested in working in a CHC, but I find they can be distilled down to two: The pay might not be as lucrative as other settings, and the patients can be challenging.
I recently spoke with some of my colleagues who also work in CHCs and also contribute to this blog, and I would like to share with you the main reasons we love working in CHCs and why the pay and the challenge shouldn't deter you from working in this model.
My organization's primary mission is "providing quality, compassionate primary medical and dental care and social services to those who need it most."
My co-workers fully embrace this mission, and in doing so, we are united behind a singular purpose of improving the health of our community.
Lalita Abhyankar, M.D., M.H.S., who helps teach medical students at a CHC in Brooklyn, N.Y., told me, "The medical assistants, social workers, mental health clinicians, care navigators, diabetes educators and nurses that we have at our practice are exceptionally competent, often going out of their way to ensure patients get the care they need. We value working with the underserved and find our particular site to be a place for continued learning."
Kimberly Becher, M.D., who practices in a CHC in Clay, W.V., said, "We don't just provide health care, we work to make achieving health possible. My office is filled with people who go out of their way to help patients get the care they need, whether that means physical help getting through the front door or emotional support with difficult family dynamics or contributing their own time and money for incentive programs for colon and breast cancer screening."
I never know what is going to walk through my door, but isn't that part of the excitement of medicine? I recently saw a 26-year-old woman who has never had a period. She had never undergone a full workup for reasons that can be summed up in one word: poverty. Another patient had several months of abdominal pain that was unexplained -- that is, until a CT scan showed multiple hepatic abscesses consistent with amoebiasis. He had traveled to his home country in South America several months earlier and brought back a few "friends." Patients with Marfan, Prader-Willi and Kleinfelter syndromes have all presented in our office after being misdiagnosed elsewhere. Needless to say, I have been challenged in a good way, and my differential steps outside what may be seen in a typical family medicine office.
Chris Baumert, M.D., who works in a CHC in Billings, Mont., told me, "I never get stuck in a boring routine or mental rut at my job. I get to provide prenatal care, including first trimester ultrasounds, do well-child care, perform procedures and counsel on end-of-life decision-making -- a real broad scope of practice."
Dr. Becher said she doesn't see much racial or ethnic diversity in rural West Virginia, but she has a huge variability in patient complexity and health literacy.
"It is common for me to see a patient who has either never seen a doctor or not seen one in decades," she said. "I see people who can't read, while in the next room I may see someone who has an iPad with an app trending their blood sugars who is reading primary literature."
Because we're motivated by our mission to improve the health of a population that faces many challenges, we've had to think outside the box to deliver the best care we can. Every CHC innovates differently based on patient needs.
Many CHCs, including mine, provide services that include medication-assisted therapy for drug and alcohol abuse, in-house behavioral health and psychiatry, and even nutritionists to guide our patients. My practice has been screening all adolescents and adult patients for substance use disorders using the Screening, Brief Intervention and Referral to Treatment tool, which has revealed many cases that would have otherwise gone undiagnosed. Additionally, when a patient is struggling to get food or transportation to a subspecialist appointment, we have care navigators who can facilitate access to these resources.
"Through my home visits, I often provide complex acute care when patients refuse ER or hospital care," she said. "I manage IV antibiotics at home and have even done biopsies and sutures in patients' living rooms."
Dr. Baumert's office recently started screening patients for social determinants of health. In being able to identify and assist with those factors, they have seen a decrease in A1c levels in patients who received targeted case management.
Perhaps most rewarding in our type of work is the positive change we can make in our communities. Every year, my organization has challenged clinicians and staff to help improve a handful of patient-specific quality measures, and every year, we've succeeded in increasing the rates of our cancer screenings and appropriate therapies.
Dr. Abhyankar told me, "I can't begin to describe how happy I am when I see blood pressure controlled or A1cs improving."
For Dr. Baumert, even more than the measurable clinical impacts, it's the gratitude he receives.
"Our patients are beyond grateful for our help; thank you cards for helping patients quit smoking or for caring for their mother at the end of life dot my wall and remind me what an important role I play in their lives," he said. "Identifying the reason behind poor health of the CHC patients is like an intriguing puzzle, and finding and addressing the missing piece -- chronic financial stress, poor health literacy, history of sexual or emotional trauma -- can be a rewarding process."
The broad scope of CHC practice, the variety of patients we see and their socioeconomic barriers to good health are certainly challenging. All the same, I believe that if we're not challenged in our practice, our work can become stale and we can lose our skills as physicians. The variety is exciting and helps us enjoy learning from our patients; in doing so, we can also build strong relationships with them.
Making "achieving health possible" is really the primary mission of CHCs. Those of us who have taken this mission to heart have found a great purpose in our lives. Since we are driven by a mission that focuses on patients who are most in need, this creates a sense of unity and family.
Finally, CHCs are centers of innovation that also recognize that every individual patient has a story. They are well positioned to give patients the tools they need to write new chapters of greater health and well-being and to make a difference in both the lives of patients and in the delivery of health care in our country.
We are passionate about the work we do and find it incredibly fulfilling. We are leaders in primary care delivery, and we want you to be a part of it. Visit the Health Resources and Services Administration to find a CHC near you.
Luis Garcia, M.D., is a family physician in York, Pa., working at Family First Health, a federally qualified health center. He focuses on caring for the Spanish-speaking community and spending time with his wife and two daughters. His hobbies include gardening and photography.