The following manuscript was submitted to the February 2017 Social Medicine Themed Writing Contest.
Ana sits on the exam table in front of me explaining how, in three short weeks, her mother will evict her from her childhood home. She is eight months pregnant and is studying night courses to become a paralegal. As her prenatal provider and primary care physician, I have been sending referrals to numerous community agencies in hopes of securing housing at the local YWCA.
Over the past few clinic visits, she has shared with me her desire to obtain long-acting birth control in the hospital after her delivery. She feels increasingly overwhelmed and wants to focus on her job, her schoolwork, and providing for her growing family. Despite the difficult circumstances, Ana is excited to attend the clinic’s weekly breastfeeding support groups, led by certified nursing lactation consultants, when the baby arrives.
Stories such as Ana’s are remarkable to hear, but these stories are also so common. At the Greater Lawrence Family Health Center in Lawrence, MA, this is just one example of how social challenges driven by poverty and institutional inequity directly affect our patient care. Community Health Centers such as ours have been proven to increase access to primary care and preventive health services to populations subjected to marked health disparities. In our family medicine residency program, we embrace social justice as a responsibility of being a primary care clinician.
The History of GLFHC in Lawrence, MA
However, available primary care or medical services in Lawrence have not always been accessible to most. Located approximately 30 miles north of Boston, the skyline of the city is dominated by now-repurposed mill buildings. These former textile factories echo the foundations of the municipality’s heritage as a city of immigrants. Following the first waves of Italian and Irish immigrants during the industrial revolution, the city then welcomed large numbers of Dominican and Puerto Rican migrants throughout the latter half of the 20th century. Today, the city of Lawrence is over 74 percent Hispanic and one of the largest concentrations of Dominican diaspora in the United States. For much of its history, the city was recognized by federal metrics as a primary care health shortage area.
One example of the dire need for doctors was the practice Dr. Nina Scarito, an accomplished obstetrician. One of the few obstetric providers in the city in the 1980s, she delivered over 20,000 babies at Lawrence General Hospital. Her former practice was located just blocks from the city park now named in honor, but due to the lack of other continuity OB/GYN or family medicine providers, she could not provide prenatal care to these women. For most of these families, their prenatal care consisted of a public health nurse who drove from Boston once a month to distribute prenatal vitamins.
Founded in 1980, the Greater Lawrence Family Health Center began its humble beginnings at 150 Park Street, building exam rooms in a converted elementary school. Speaking with experienced clinicians, it was clear that they endured a grueling call schedule. Despite a fully-scheduled clinic, the few physicians in town would leave over the lunch period to see sick patients in ED, return to clinic, and then report to the hospital to work on-call all night. Because the supply of providers was so scarce, it was difficult to address the great need for care. The health center was able to accept new patients once a month, which caused lines out the door and around the block waiting hours prior to registration.
Lawrence Family Medicine Residency Program
While there were some young physicians fulfilling their health service corps duties in the city, many would stay for a few years and then ultimately leave to begin private practices at the conclusion of their service obligation. In 1994, the founders of the Lawrence Family Medicine Residency began to form a radical idea to train resident physicians in community-oriented primary care, now known as patient-centered medical homes.
Since that time, the Lawrence Family Medicine Residency has become a national leader in primary care innovation and post-graduate medical education. The mission of the program, “to create and nurture learning environments where physicians are inspired to develop expertise in family medicine and to dedicate themselves to the care of individuals, families and communities, especially those who are underserved.”
Not only does the program emphasize clinical excellence, but almost equally important is the daily immersive education in social determinants of health. We learn to become the doctors our patients need, including medical Spanish, surgical obstetrics, women’s health, HIV and hepatitis C care, addiction medicine, and much more.
We strive to be an empowering presence in our community. As a program, we strongly value integrated collaborations with many community organizations. Partnering with the Mayor’s Health Task Force, our residents help organize community bike days, serve on the board for the local YMCA, and build a community doula program for low-income women. These initiatives and many others were highlighted when the City of Lawrence in 2015 was awarded the prestigious Robert Wood Johnson Foundation Culture of Health Prize.
Health Happens in Communities
Since its inception, our family medicine residency has graduated over 165 family medicine physicians working in underserved communities throughout country and the world. Similar to graduates of other teaching health centers, nearly 80 percent of the program’s graduates continue to work in underserved areas, compared to only 26 percent of their peers. Notably, roughly one-third of the graduates remain in Lawrence and surrounding communities following graduation.
Following ten years of service as a resident and then faculty at GLFHC, Dr. John Raser passed on sage advice “Lawrence really matters. It is not in the enclaves of privilege in this world where we will learn how to address the most pressing problems of our time. It is here in Lawrence, and places like it, where we will collectively figure out how to move towards honesty, understanding, and reconciliation across barriers of race and culture; and how with limited resources we all might live decent, connected, and healthy lives.”
Author’s note: All names and identifiers have been changed to respect patient privacy.
Resident Physician Contributing Writer
Melissa Palma is an Iowa-raised daughter of Filipino immigrants and aesculapian advocate. She trained in family medicine at safety-net community health centers and is a board-certified Preventive Medicine and Public Health physician in Chicago, IL. Her writing reflects on the privileges and responsibilities we have as physicians to advance health equity for our patients and our communities. When not in clinic, you can find her reading non-fiction while nursing a taro boba tea.