- Building a Medical Home for the Underserved in New York City:Lessons Learned from a Private Practice
While there is much discussion about the importance of culturally competent care in serving poor and minority communities, all populations respond to a caring provider in a friendly, well-organized, and efficient organization. Over the past 25 years as a clinician, I have found that many of the same values that motivated my early practice among affluent suburbanites, where optimal conditions can be taken for granted, also served me well in serving disadvantaged populations, where they cannot be.
The Real World
Mesmerized by television icons such as Drs. Kildare and Casey, I decided to be a doctor when I was eight. Many years later, as a resident in a busy inner city hospital, I realized I had made the right choice. I loved the pace and challenges, but mostly the responsibility of caring for people who really needed help. Despite this sense, I was enticed to work in the so-called real world of private practice and, in the summer of 1982, I stepped into a Norman Rockwell painting set in the privileged hills of suburbia. Instead of the gentle landing promised by my professors, however, I soon realized that my schooling had prepared me poorly for this job. Quite capable of treating malnutrition and jittery babies born to addicts, I had never seen poison ivy, removed a fishhook, or been asked why an office visit was so expensive. Like most physicians trained in institutional programs, I had a lot to learn.
With an abundance of well-to-do families in the area, pediatrics was competitive and lucrative. Most of the over 50 local pediatricians understood well the importance of developing strong patient-doctor relationships; the most popular practices, including ours, excelled in this task.
Getting close to a patient is tricky. Physicians are taught to divorce personal feelings from professional duty, and to avoid emotional involvement.1 I remember a colleague, when I was a medical student, tearing up after obtaining a history from the frightened parents of a critically ill child. Taking her aside, our instructor informed the upset [End Page 343] trainee that there was no room for such behavior; if she had to cry, she would have to do it on her own time. My experience, throughout my career, has taught me otherwise. Rather than diminishing my authority and role, I have found that honest interaction allows, and fosters, open communication, arguably the most important instrument in a physician's medical bag.
The ABCs of Building a Practice
The first step in developing a practice is to be knowledgeable about whom you serve. Compared with the hospital where I had done my residency, where we cared for diverse, multi-ethnic populations with complex social burdens, my practice in a suburban community in New Jersey was easy, especially since my partners and I had grown up in similar places, with similar lifestyles. Complementing cultural familiarity is an understanding and alliance with the organization and dynamics of the region. We did our homework. Before I ever heard of the term community needs assessment, our practice had reached out, becoming involved with and responsive to the towns in the area. We viewed this as necessary in order to know how to prioritize our services and build our business. Serving on the Board of Health, facilitating workshops (at civic and faith-based centers) and Lamaze classes, and acting as consultants for local schools and summer camps, we ensured that each and every school nurse, coach, and principal knew us. In these ways, we met community needs and helped build an ongoing source of patient referrals.
The practice grew exponentially, soon adding a second office and hiring more staff. Yet, in my role as managing partner, and after nearly fourteen years and the trappings of success—a huge house, Golden Retriever, and shiny Jeep—I began to feel something was missing. The thrill was gone. My independence as a practitioner, once embraced, felt professionally and academically isolating. I began to compare my trade with my image of so-called Medicaid mills (although I had never actually seen one) at...