As an osteopathic medical student in Arizona, I had a lot of classmates and professors question why I wanted to go across the country to New York City for my residency in family medicine.
The West Coast -- where I grew up -- has a strong family medicine tradition, whereas New York City is perceived to have a strong focus on specialty care. Not only have I met several New Yorkers who did not even know that family physicians exist, I have worked with medical students whose school has no family medicine department and with other medical students who question whether they can find a good job in NYC if they pick family medicine.
So why choose to be in an environment that might, at best, be skeptical of family medicine?
My residency, the Mount Sinai Beth Israel Residency in Urban Family Medicine offers a diversity and complexity of patients that is unique to New York. With patients from around the globe, we had to keep a broad differential in mind as we also learned to treat the "bread and butter" family medicine cases.
But there was something far more important to my learning as a physician than the diagnoses that I made. My patients not only came from different countries, had different socioeconomic backgrounds and spoke different languages, they often had differing views of disease processes and expectations of the patient-physician relationship.
In medical school, we learned the textbook ways to diagnose and treat, but in residency I learned how much patients' cultural backgrounds can influence their recounting of symptoms and their relationship with their own body. We know how crucial the history is to finding the right diagnosis, particularly as we try to minimize extraneous and expensive tests that add burdensome costs for our patients and our health care system. When the patient and the physician have wildly different life experiences, language is often not the only barrier that needs to be recognized in order to appropriately diagnose and care for the patient.
After residency, I continued with the same family medicine organization that my residency was affiliated with. I have spent nearly three years in the Bronx with an international patient population, many of whom have language, health literacy and socioeconomic barriers that make it difficult for them to navigate our health care system.
I am surrounded by all the subspecialists that New York has to offer -- several of whom are rated top in their field -- but the majority of my patients simply cannot access them. Their need for a family physician and a patient-centered medical home (PCMH) to support their health and the health of their family is dramatic.
When they enter my clinic and find friendly staff who know their name, speak their language, and do not judge them for a lack of insurance, employment or even basic reading skills, my patients begin to feel hope.
When we ask them questions about their ability to access healthy food and whether they feel safe in their current housing situation, my patients begin to realize that we in family medicine understand how much social determinants of health impact our community.
When our clinic goes to great lengths to obtain records from outside clinics and to call patients to come in for a visit after their recent trip to the emergency room, my patients begin to understand what it means to have a family physician and a medical home.
There are many community clinics throughout the country that have made a commendable effort to gain PCMH recognition and to be part of a safety net for their patients; our clinic is not unique in that respect. But there are times when the degree of disparity between my patients and the affluent patients who can access the "best" care in the nation clearly weighs on my patients. They are deeply aware of what they do not have and what they cannot access. And they are often resentful of the discrimination they have faced because of these disparities.
Working within this community has enabled me to witness firsthand what I learned while pursing my master of public health degree -- that a community's resources and environment can have an enormous impact on the health of its residents. It has been exciting to be part of my local AFP chapter and to contribute to the enactment of bills that can make a real difference in the health of New Yorkers, such as a lower speed limit to reduce pedestrian deaths and expansion of health coverage for pregnant women.
In a few months I'll be moving back to the West Coast, primarily for family reasons. It was a difficult decision, and there are many things about New York -- particularly the people I've come to know -- that I will truly miss. As is true with any major change, my upcoming relocation has given me the opportunity to reflect on my time as a family physician in New York. This is the only environment I've worked in as a practicing physician, and although I have encountered the occasional frustration when dealing with a subspecialist here and there, the overwhelming experience has been better than I even imagined when I applied during medical school.
Family physicians are a diverse group with a diverse set of skills to treat the communities we work (and often live) in. My work during the past several years has taught me a great deal about caring for communities that are in need of creative, evidence-based, compassionate primary care. I have built a foundation that will influence my practice of medicine wherever I go, and for that, I will always be grateful to New York and its patients.
Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.