Linah Lubin Colgrove, IQ Solutions, Inc.
We all know someone who has been frustrated with some aspect of the health care system. A physician learning that a patient is not adhering to his prescribed medication; a patient feeling a lack of empathy from her doctor; the shared frustration of navigating the complexities of health insurance – none of these scenarios is unfamiliar to many of you.
But what if a person who is gravely ill does not speak English and has to rely on a non-medical bystander to interpret the doctor’s orders? What happens if someone doesn’t qualify for insurance or can’t afford his medications? What if fear of stigma is keeping him from making a necessary visit to the emergency room? Unfortunately, these “what if” circumstances create a common reality for many underserved and immigrant populations, particularly in Latino communities. And this reality exists for Latinos in cities and neighborhoods all across the country – even in the shadows of some of the nation’s best medical and academic centers.
While many individuals and institutions including the Robert Wood Johnson Foundation (RWJF) are making efforts to reduce barriers to quality health care, there is still much work to be done on the research level, community level, and in building the pipeline that directs Latinos to medical school and careers in medicine.
Clinical Scholars and alumni are tackling these issues every day – through research and community-based work – to raise the bar for the quality of care that’s provided to underserved populations. Since 2005, community-based participatory research (CBPR) and community-partnered research training and practice have been integral to the Clinical Scholars program. As a result, Scholars get valuable hands-on experience working with community partners to create new programs or improve existing ones that change people’s lives – including their own.
“It was my opportunity to learn from the community,” says Clinical Scholar alumna Rosette Chakkalakal, MD (‘10-’12), of the community-based participatory research she engaged in while in the program at Yale. Having immigrant parents herself, Chakkalakal knew that immigrant health was what she wanted to pursue as soon as she got into medicine. She met with a community partner from a federally qualified health center in Fair Haven – located in New Haven, CT – during an interview for the Clinical Scholars program at Yale and learned right away about the opportunities she would have to collaborate with Fair Haven’s large Latino population consisting mainly of Mexican, Central American, and Puerto Rican immigrants and their families. Chakkalakal started as an observer of two diabetes prevention programs held at a nearby middle school – one for adults taught mainly in Spanish, and one for children that incorporated more English. While both programs focused on the importance of exercise and healthy eating, Chakkalakal couldn’t help but wonder if there might be benefits to integrating the two programs so that parents and their kids could learn about diabetes prevention together. With input from the community, she and her team developed a quality improvement program that combined the adult and child programs into one family-centric program – a move that honored the culture of the participants while maintaining the integrity of both programs (Rosette Chakkalakal, et al. “Preventing Diabetes among Fair Haven Families: A Community-based Approach to Quality Improvement.” Journal of Health Care for the Poor and Underserved 23, 2012). Of the experience, Chakkalakal says she learned that community-based participatory research is an “essential skill-set for helping immigrants in any population.”
A native Spanish speaker who grew up in a migrant farm community and was the first in his family to attend college, Clinical Scholar alumnus Gerardo Moreno, MD, MSHS (’07-’10), knew that it took more than simply being able to translate a language to communicate effectively in a clinical setting. Moreno and his colleagues – including current Clinical Scholars – recently completed a study on how the quality of interpreters for Spanish-speaking patients affects self-reported outcomes for quality of communication between a doctor and a patient. “A lot of barriers these patients were facing are related to language, but there is more to it than that,” says Moreno. Patients have to be able to communicate with their doctor, but in some cases there isn’t a family member who speaks English or a clinician who speaks Spanish, and the only option is to ask a janitor or other bystander who is not invested in the patient’s care and may not interpret everything accurately. Moreno and his colleagues looked at other measures, including listening time, how easy or difficult the words were, and how long doctors spent with their patients using an interpreter. His work stems from an existing RWJF grant initiative, Hablamos Juntos (Together We Speak), meant to improve communication between health care providers and their patients with limited English proficiency.
Clinical Scholar alumna Lisa DeCamp, MD (’08-’11), found that breaking down the barriers to quality care was made simpler by building up a new role for Latino community members invested in their children’s care. DeCamp, who participated in CBPR during her time as a Clinical Scholar in Michigan, is now a pediatrician at Johns Hopkins Medical Center in Baltimore. Roughly half the population is immigrant Latino families. With the help of a grant, DeCamp has helped create the Latino Family Advisory Board for the pediatric unit at Hopkins. Participants generally speak little English and are low-income, but they keep coming to meetings to be a part of clinic improvement. These board members weigh in on decisions being made, and lend a hand designing brochures that help others with low literacy. At a recent meeting, Board members gave input about how Spanish-language signage would work most effectively in the design of an upgraded emergency department. DeCamp finds that because this group has been so involved in providing opinions and making decisions, they want to have a stake in the outcome. “This work is a great example of the medical system interfacing with the community,” says DeCamp. Even a large academic hospital center such as Johns Hopkins values the role of these community members, who are now advocates for their families, neighborhoods, and the entire community.
A short car or train ride away from Baltimore, Clinical Scholar alumnus Matt O’Brien MD, MSc. (’04-’06), currently serves as the medical director for a south Philadelphia health center he co-founded called Puentes de Salud (Bridges to Health) that serves a largely Latino population. O’Brien began doing health advocacy work in the Latino community during his residency and came to Philadelphia with an interest in providing direct services. What differentiates Puentes de Salud from other community health centers? “We target acute medical needs, but we also tackle the social determinants of health,” says O’Brien. Several of the center’s programs have active education components that indirectly affect patients’ health. For example, they started a tutoring program three years ago that now has around 50 children enrolled and a full waiting list. Kids get homework help, do art projects with a local Mexican American artist, and hear talks from medical students about the importance of getting a flu shot. But it didn’t fall into place overnight. O’Brien began building relationships within the community – attending the same church and community events for three years before coming in to build a clinic. By the time the center was in business, he and his staff had become part of the neighborhood. The community became a part of the health center too, with Latinos represented on the board of directors and partnerships forged with local businesses and services. Now O’Brien has a largely volunteer physician staff, two nurse practitioners, a nurse, a psychologist, and a thriving community health worker program where the focus of research intersects with work in the clinic. He attributes his success to his training as a Clinical Scholar. “It’s the only program that offers such unique training,” says O’Brien. “It’s one-stop shopping – research, clinical work, leadership and advocacy skills – it’s all in the [Clinical Scholars] program.”
Beyond CBPR and making inroads within a community, an important way to reduce barriers to quality care is to grow the workforce of medical professionals caring for Latinos. Speaking the language and understanding the culture can be a critical asset when it comes to gaining patients’ trust and helping them with decision-making. And it all starts with the pipeline.
For Clinical Scholar Efrain Talamantes, MD (VA Scholar ’12-’14), whose research focuses on migration and health, the most important part of working with the Latino population is being a mentor to high schoolers near where he grew up in Southern California. These kids – many of them Latino – get a glimpse into future possibilities when they “see people who look like them be successful.” As part of an initiative called Alliance in Mentorship (AIM), Talamantes worked with a team of mostly Latino residents and physicians to develop a toolkit for mentors to help Latino high school students build skills and examine opportunities for pursuing medicine. AIM is a community of healthcare professionals and students throughout the country committed to mentoring aspiring health professionals, and much of their work is done using online videos and in-person meetings with students.
To Talamantes, “paying forward” his experience by mentoring others is his passion. “I can influence new generations of physicians who are underrepresented in the field,” he says.
As a board member for The Latino Coalition for a Healthy California and an advisor for the Latino Medical Student Association, Clinical Scholar alumnus Michael Rodriguez, MD, MPH (’92-94), knows how critical mentoring and training are to building the pipeline for Latinos in medicine. Rodriguez, who holds several positions at UCLA – including Director of the Blum Center at UCLA addressing Poverty and Health in Latin America – has advised and mentored trainees for nearly thirty years.
“As the son of immigrants from Mexico and El Salvador who did not graduate from high school, my work is partially guided by the principle of working with and giving back to my community, which includes helping colleagues early in their careers – just as I was helped” says Rodriguez. “I am inspired by and learn from this process that provides me with new perspectives on how to promote health equity, social justice and keep the [United Farm Workers of America] UFW ‘Si se puede!’ [Yes, it is possible] mentality.”
There’s no doubt that this small group of Clinical Scholars and alumni has had an enormous and long-lasting impact on individuals and entire communities –and these are only a few highlights of the many examples of great work being done to help the underserved. As the Latino population in this country continues to grow and as the health care system changes, there’s also no doubt that more attention needs to be paid to prevention efforts, community-based participatory research, and reducing barriers to health care. But let’s not forget the importance of building up the health care workforce.
There’s a pipeline that runs from neighborhoods and communities to colleges, medical schools, and medical practices. Together, we can keep building the pipeline and help guide the future of health and health care in all communities. How will you help?
Learn about RWJF programs that provide opportunities for scholars from underserved, economically or educationally disadvantaged backgrounds including the Summer Medical and Dental Education Program, the Harold Amos Medical Faculty Development Program. Learn more about RWJF’s commitment to diversity in the scholar, fellow and leadership programs within the Robert Wood Johnson Foundation Human Capital Portfolio.