October 18, 2022, 1:00 p.m. David Mitchell — Keith Nokes, M.D., M.P.H., knew as a teenager that he was destined to work in an underserved community. He also knew he wanted to do it the right way.
“There’s a long history of people coming into communities and offering up answers, like, ‘I’m the person who’s going to come in and fix these problems,’” said Nokes, a family physician and faculty member at the Greater Lawrence Family Health Center and Lawrence Family Medicine Residency in Lawrence, Mass. “I think about things like, ‘How do you work in communities, and how do you bring a focus on service?’ For me, it was an idea of melding my interest in medicine with ideas of social change, community engagement and community leadership. That pushed me in my career path.”
Nokes, the son of a lawyer from a predominantly white Connecticut suburb, might seem an unlikely champion of health equity for the predominantly Latino community where he is a physician and mentor. But Nokes’ passion for serving underserved communities developed early.
As a teen, Nokes and other youth from his church traveled to the Lakota reservation in Pine Ridge, S.D., each summer to volunteer at a camp. That area ranks among the poorest in the nation, and its residents have the country’s shortest average life expectancy.
“I remember visiting the hospital on the reservation,” he said, “and that’s where I started to think about these things coming together. I looked at the history of genocide, and economic and social marginalization within this particular community, and also the history of initiatives and outside forces that continued to impact that community. I started to ask myself how could I work in a community like Pine Ridge without bringing in that additional imposition of, ‘I know what’s best.’ How do you work in a place that has that particular history in a way that is respectful and focuses on community empowerment rather than my personal vision?”
Nokes found his chance to address those questions in Lawrence, which has drawn large influxes of immigrants dating back to the 1840s. In the 1960s, immigrants began arriving from the Dominican Republic. Today, the town’s population is more than 80% Latino, and more than a third of its residents live below the poverty line.
Since 2019, Nokes has served as director of the Sam W. Ho Health Justice Scholars Program, which he helped start in 2012. The program recruits 15 first-year Tufts University School of Medicine students each year for a four-year process that prepares them to practice in underserved settings through a two-year curriculum, required clinical experiences and a longitudinal project that can focus on community-based research, a clinical intervention or advocacy.
One of the required clinical experiences is a third-year rotation in family medicine.
“The reason we do that is not because we feel family medicine is the only way to do this work,” Nokes said. “We feel that these ideas of community-oriented care, individualized and family-focused attention to the social determinants of health all come together in family medicine in a way that is not always the case in some other rotations.”
The health justice scholars program is based in the Department of Family Medicine and run by family physicians. Nokes said 57% of the program’s participants match in primary care specialties, including 30% in family medicine.
“We talk a lot about family medicine,” Nokes said, “but we want people in every specialty to be thinking about the concepts and skills that we work on as a group. If I have people who are doing critical care, I want them to think about the social circumstances surrounding a patient and how we are going to keep that patient from coming back to the hospital. What are the policy implications and factors that we can be doing advocacy around to support the community? What’s exciting is that they’re going to be able to take this forward into those specialties and act as leaders in this work wherever they are.”
The decade-old program is producing residency graduates who are working with underserved communities and trainees as attendings in community health centers and academic settings. That includes graduates who have come back to serve as faculty at Tufts.
“That’s really exciting to see that cycle and to see how former students are coming back to get involved,” Nokes said.
When Nokes finished his own residency training in 2001, he was a National Health Service Corps scholar looking specifically for a job in a community health center. He started practice at the Greater Lawrence Family Health Center that year and has filled a variety of roles in more than two decades there.
“As a new attending at the health center, I was able to do full-scope, in-patient work — including obstetrics, adult medicine and pediatrics in the hospital — and all of my outpatient work,” he said. “I also had this nice benefit of being able to work with residents both as an outpatient preceptor and as the attending physician for our resident teams in the hospital.”
Nokes is the inpatient pediatrics curriculum coordinator, director of medical student education and a longitudinal preceptor. He was a clinical instructor for Tufts for six years before becoming an assistant professor in 2013. He also serves as an assistant professor for Dartmouth Medical School and an adjunct assistant professor for the University of Massachusetts Medical School.
Nokes likely is a familiar name for many who have attended the AAFP’s National Conference of Family Medicine Residents and Medical Students where he has been a regular presenter for several years on topics related to caring for underserved communities and residency interviewing.
The popular Do’s and Don’ts of Residency Interviewing session has become a staple of the summer event in Kansas City, Mo. With medical students preparing to dive into this interview season, a recorded version of the session from the 2022 National Conference as well as a session focused more broadly on what to do (and what not to do) before and after an interview are available to AAFP members online. (Student membership in the Academy is free.)
Nokes hopes the interviewing session will give students a sense of comfort with the process and help them understand it’s a two-way street.
“It’s really about finding a place that fits right for you,” he said. “You are interviewing a program as much as a program is interviewing you. You are not powerless in the process. You’re an active participant and have agency through all of it.”
The interviewing session also aims to help applicants navigate difficult questions and give them insights about questions to ask.
“I tell medical students that I think interviewing can be a really enjoyable experience,” he said. “Certainly there’s a stress level, and there’s a lot that goes into it. But getting to meet great family doctors who are doing work you are passionate about, who may have shared interests, and who you can learn from and develop contacts — whether you end up in that particular program or not — it’s a nice opportunity to meet people and learn about what they’re doing because often they’re doing things that get you excited and interested.”