Which of these medications will work better for this patient? Probably the one they can actually pay for . . .
Lessons like these are infused into my daily learning at the Federally Qualified Health Center (FQHC) that I have called home throughout my family medicine residency. When looking for a residency program, I was intentional about finding a program where my knowledge base would extend beyond clinical competencies and into the multitude of other issues that impact the lives of our patients. Every day, community health centers (CHCs) provide me and other residents across the country key patient-centered competencies.
At Erie Family Health Centers, a FQHC on the West Side of Chicago in Humboldt Park, I am challenged daily to meet the health care needs of a diverse, underserved patient population. From navigating referrals for those without insurance to collaborating with case managers for complex panel management, I am learning what it really takes to improve health outcomes for those who are traditionally excluded from our health care system.
In this issue of the Journal of Graduate Medical Education, the authors of “Community Health Center Engagement and Training During Obstetrics and Gynecology Residency” reveal important gaps in the education of the majority of obstetrics and gynecology (OB-GYN) residents.1 Their results show that, across the United States, OB-GYN residency programs generally do not provide sufficient experience in community health for residents. The authors also point out that only 1 in 10 OB-GYN residents plans to work in a CHC after graduation—a statistic that is likely related to the lack of training they receive.
Family medicine residents are on the front lines in providing care to patients in under-resourced communities. Serving vulnerable patient populations continues to be central to the mission of our specialty,2 and, as a result, we train in CHCs across the country, in places of high need and low resources. We are proud to be leading this work, yet recognize that our OB-GYN colleagues are critical members of the community health care team. We need more of them.
The evidence appears clear—residents who train in a community health setting are far more likely to continue working in a CHC or similar setting when they graduate. The CHC patient population is both clinically and socially challenging; patients face a number of barriers to health care that may not be commonly encountered in academic or private practice settings. Without experience handling these issues during training, when mentors and teachers are readily available, starting as a new CHC attending may be daunting.
At Erie Family Health Centers, my colleagues and I aren't just learning medicine—we are learning to accompany patients as they navigate a complicated health care system. We also learn how to advocate for change. We refer patients to local exercise programs, figure out which medications are on the 340B Drug Discount Program list, and help patients design an insulin regimen that aligns with their factory night shift job. We are trained to be aware of existing community resources and how to connect patients to services that are desperately needed but unaffordable. A key part of our job description is to consider the social determinants of health at play for each patient. As we progress in training we become more adept at using resources judiciously and providing culturally competent health care for diverse and vulnerable populations.
OB-GYN residents and attendings have so much to offer in these settings. While family medicine physicians are well equipped to manage many pregnancies and gynecological problems, we need the expertise of OB-GYN colleagues for patients with more complex problems. Many of my patients have complicated social situations and find it stressful when we refer them away from the FQHC to specialists “en el centro.” Our patients benefit greatly from having access to services, like loop electrosurgical excision procedures (LEEPs) and pregnancy dating ultrasounds, from OB-GYN team members at their own FQHC health care home.
The article by Cheng and colleagues is timely, in that it highlights workforce shifts that could positively affect US maternal morbidity and mortality. The United States has the worst maternal mortality rate in the industrialized world.3 These devastating statistics do not affect all communities equally, but rather fall along racial and socioeconomic divides, such that women of color are up to 4 times more likely to suffer a pregnancy-related death than white women.4
Improving these disparities does not require more specialized research or advanced procedures. One important way forward is to focus on the basics of pregnancy care. Reducing the death tide of our mothers and babies requires that physicians with training in obstetrics put down roots in underserved communities and provide outstanding prenatal, antepartum, and postpartum care. When more residents (OB-GYN, family medicine, and others) are adequately trained to serve the complex needs of vulnerable groups, and then include this population in their subsequent careers, we will see an improvement in outcomes. This applies to CHCs in both rural obstetrical deserts as well as urban underserved communities, which both fall short in their attempts to fill OB-GYN positions.
Indeed, working at a community health center is challenging and can lead to burnout. Residents and attending physicians can feel stretched to their limits as they work to care for patients who are both medically and socially complex. At the same time, this work is extremely rewarding. Through my residency experiences I am continually motivated by the mission to provide health care to those who are most in need, regardless of whether they can pay for it, are legally documented, or hold any particular identity that may have excluded them from society.
CHCs open their doors wide and as a result, clinicians are pushed to grow clinically and personally. In a city like Chicago, where life expectancy drops 16 years across a handful of train stops, it is inspiring to work at chipping away health disparities. CHCs can also be highly stimulating, as residents and attendings are often pushed to the edge of their practice scope. It may be months before my uninsured patients are able to see a specialist, thus, we are constantly pressed to read and collaborate with colleagues to manage problems in the interim.
Finally, community health settings provide opportunities to be a part of team-based care. I am privileged to work within a high-functioning obstetrical team that includes OB-GYN attendings, but unfortunately no OB-GYN residents. Graduating more OB-GYN residents with experience in CHCs could prepare them to play leadership roles in similar teams. At my CHC we also work alongside passionate team members who are behavioral health specialists, medical assistants, case managers, nurses, health educators, and more. Sharing in this team effort is an important aspect of my resident learning, as no physician can do this work alone.
My residency program is one of the original 11 teaching health centers (THCs),6 a program in which residents make a CHC their home base for training, as opposed to a hospital. Currently, there are 2 OB-GYN residencies participating in the THC program: Oklahoma State University Houston Center Women's Primary Care Clinic and Community Health of South Florida. These THCs provide excellent care for some of the most socially and medically complex patients in our country while simultaneously educating the next generation of physicians.
The THC program is just one innovative approach to medical education and it has yielded success—early evidence suggests 3 out of 4 THC graduates practice in an underserved community.7 OB-GYN residency programs will face unique challenges in expanding CHC exposure, as the specialty, due to increased surgical focus, is inherently different than family medicine. Nonetheless, Cheng et al bring to light an important gap in OB-GYN training that can be addressed if leaders consider creative ways to increase CHC experience during training. CHCs are an important place for residents to get into the trenches, and I look forward to seeing more OB-GYN residents there.