Where I'm Coming From

(This article originally appeared on Progress Notes on February 9, 2012.)

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When I entered medical school in Richmond, Virginia, I was certain I wanted to be in primary care but I was not yet sure what specialty.  Once I had decided to work in a medically underserved community I chose family medicine because in a rural site, where resources are limited, there is added value in the breadth and scope of family medicine training. I would be able to see all patients, regardless of age, gender, or initial symptoms. This training served me well when I took my first job after residency, in the small town of Keysville, Virginia.  In Keysville, I worked for four years providing care to patients in town and in the surrounding counties.

While in Keysville, I helped launch an international medical service and community development in the Dominican Republic in partnership with the College of William and Mary in Williamsburg, Virginia.  Working with this project in close partnership with the community of Paraíso, just outside the capital city of Santo Domingo, I have become more aware of the concept of community-oriented primary care. At its heart is the idea that primary care is most effective and most responsive when it is provided in the context of the community.  Interventions and care should take into account—and make use of—community resources in order to have the greatest effect. There is little value in a doctor’s recommendation that a patient does not have the resources to follow.

After four years in Keysville, I returned to Richmond to provide care to the Hispanic community and to work more with medical students.  Through our department’s International/Inner City/Rural Preceptorship (I₂CRP) program, I further developed my understanding of community-oriented primary care and of the importance of social determinants of health – the wide-ranging community and environmental factors that affect health, such as local schools and education, environment and pollution, access to affordable and nutritious foods, and safe public space for exercise.  Robust evidence supports social determinants and the need to address them if we wish to improve health (and, perhaps, reduce costs).

Knowing this, I have noticed my perspective changing both on my specialty and on my medical practice.  It is increasingly clear that social determinants wield tremendous influence on individual health and that to be effective in primary care we must advocate for change that targets social determinants, but change that is focused on communities’ needs as the community itself identifies them. For example, diet might be difficult to address in a community where the cheapest food is calorie-dense fast food. Exercise might be impractical if patients work late hours and lack safe places to exercise.  I believe that we must both keep social determinants in mind as we work with patients and push for reforms that will address (and improve) them. 

One-on-one primary care provides notable benefits for the individual, but there is great value in advocating for socially responsible change that will benefit the community at large and, as a result, benefit the individuals we care for.  It is not appropriate or sufficient for those outside a community to define what a community’s priorities should be.  These priorities should be mutually agreed-upon with the community and should target its key needs.

It is with this combination of motivations and interests that I practice and teach day-to-day.  At the heart of all medical care is the one-on-one care provided for the individual patient.  This is the core of what we do and what we believe as clinicians, and this relationship and responsibility still carry critical importance.  However, we must provide this care with an understanding of the social determinants of health.  We must recognize the limits of some of our standard recommendations. Finally, we must begin to connect with our communities.  Much of medical education occurs in the sheltered and protected environment of tertiary care centers and classrooms.  Students must begin to learn how to look outside of that environment, work with and understand communities, and help build coalitions and partnerships that stand to improve conditions within the communities we serve but to do so on the communities’ own terms.

This is an exciting and challenging time to be in primary care.  With our national workforce shortage in primary care, we are both in high demand and heavily worked.  For these reasons, we need to train medical students with broad vision, individual focus, and community orientation to provide the medical care that our community and our nation need.  I hope to be a part of this solution.  It is an important step in making our medical care more efficient and more effective.