Nonprofit Health Center a Success : San Ysidro Clinic Draws Top Doctors
Doctors graduating from major American medical schools usually don’t choose to work at community clinics such as the San Ysidro Health Center, where the patients are often poor and many know only a little English.
So Dr. Luis A. La Luz, a 1979 Harvard Medical School alumnus, might be considered unusual; he is one of three or four physicians from his 100-plus graduating class who opted for primary family medicine at such a clinic.
“Physicians think about money and, having devoted a lot of time and effort into becoming a doctor, they want something rewarding,” La Luz says. “But no matter what you do as a doctor, you can be comfortable. The question is: how comfortable do you want to be?”
La Luz is well paid at San Ysidro and--more important to him--enjoys the work.
“I’m not selfless, I’m not noble,” he said. “I just felt this would be a lot more interesting medicine. The patients are wonderful and I can help and identify with their problems.”
Not all doctors who start at the clinic are as committed to such work as La Luz. Over a period of years, the emotional toll of caring for people with social as well as medical problems can become too great.
But even those who leave see the San Ysidro center as one nonprofit clinic that belies the common perceptions of inadequate care and poorly trained doctors at such facilities.
“I like it, actually,” said Dr. Daniel Bressler, a 1981 Harvard graduate, one of several San Ysidro physicians who came to the clinic initially as repayment to the federal government for having paid their medical school bills. “But ultimately, five years from now, I think I would burn out, because emotionally it can be very draining. You have to have a real strong Mother Theresa streak to take care only of patients who are poor.”
The doctors are part of the National Health Service Corps, a 12-year-old federal program--now being cut back by the Reagan Administration--which awards scholarships to students in return for a commitment to practice in medically underserved areas after they graduate. The commitment is one year for each year of a scholarship.
While these doctors might have chosen other practices had the scholarship program not existed, the prospect of practicing in a clinic as repayment was agreeable to them. And their San Ysidro experiences have convinced them that medicine for the poor can be done efficiently and well.
“The idea of serving areas that can’t easily solicit doctors on their own appealed to me,” Dr. Jeffrey Humbarger, a University of Cincinnati medical school graduate, said. “I didn’t sign up just for the scholarship.
“And I knew that this clinic was one of the best places in the West, if not the country, to fulfill the obligation. The hours are pretty good, it’s not slave labor, and the range of illnesses you see is fantastic.”
The Ohio native now is debating whether to remain at the clinic for a while after completion of his obligation.
“The patients here get as good care as they would at a for-profit clinic,” Humbarger, an internist, said. “This clinic is giving poor people comprehensive care almost like an HMO (health maintenance organization) such as Kaiser gives.
“And my wife and I like living in Chula Vista, even though people in North County may thumb their noses at us.”
The 18-year-old San Ysidro Medical Center offers complete medical and dental services with 14 full-time physicians and dentists under a community board of directors. Family medicine students from the UC San Diego Medical School also spend time at the center.
The nonprofit center qualifies for a variety of government grants to care for many patients who are able to pay only a small portion of their bills--if anything. In addition, the center has been aggressively establishing prepaid flat rate plans to compete under new government cost-containment proposals.
The addition of doctors such as La Luz and those from the National Health Corps has helped transform the clinic from a small medical office dependent on semi-retired physicians, as is sometimes the case with such facilities. The clinic today is often pointed out as a showpiece of the often-maligned San Ysidro border area, burdened with the image--partly correct and partly myth--of a depressed, high-crime area.
In the view of La Luz, most medical school students are directed away from family practice, particularly in lower-income areas, and into research and specialty fields.
“Medical schools in general are run by people who are academics and who are into doing the latest research,” said La Luz, who ran errands for clinics in inner-city Chicago areas before entering medical school. “At Harvard, the types of research being done are overwhelming, and most students cannot imagine doing something mundane, as they imagine family medicine to be.
“But I find that treating patients, talking to people, is as stimulating as research and I wanted to do family medicine. You have to know about the mental and social aspects of dealing with a patient as well.”
Dr. Antonio P. Linares, another health corps member, said a decision to remain at the clinic indefinitely, as in the case of La Luz, depends on individual interests. “Dr. La Luz has developed significant ties to the community,” said Linares, who is in his third year of commitment.
Linares sought to fulfill his commitment at San Ysidro after visiting it while still a 4th-year medical student at Case Western Reserve University in Cleveland. “The track record of San Ysidro under county reviews consistently shows it is much more effective in its treatment, and cost of treatment, than elsewhere,” he said.
Linares said that, in strict terms of providing the greatest public service, doctors fill a social gap much more at such a clinic than they would while practicing a private specialty such as plastic surgery or urology.
“Having had the experience here now, I would have done it (worked in a clinic) even without the health service obligation,” he said.
Dr. Jose J. Escarce will be leaving San Ysidro this summer and returning to the University of Pennsylvania on a fellowship following two years in internal medicine at the center.
“My dream has always been academic medicine, even though this has been an excellent experience,” Escarce said. In fact, the nature of his fellowship--geriatric medicine combined with health economic policy--grew out of his clinic work. “Certainly the policy aspect developed from here,” he said, “since we are on the front lines in San Ysidro in terms of how medicine is delivered.”
Doctors unfamiliar with community clinics fear at first that the clinic setting will make it impossible to deliver quality care, Escarce said. “But I’m proud both personally of the care that I have given and which the clinic delivers, and for relatively low cost,” he said.
“The best evidence of the quality here is that we enjoy tremendous respect among doctors elsewhere in San Diego. We have the pick of doctors from faraway places, with 30 to 40 people usually applying for two or three spots.”
And Escarce said that San Ysidro will become even more attractive given the growing oversupply of doctors for available positions nationwide.
While the clinic is well aware of the nationwide pressure from government agencies and insurance companies to cut costs, La Luz said, no one has ever told the doctors to cut a certain procedure or fix a set number of X-rays. “We don’t overutilize but we certainly don’t underutilize at the expense of any patient,” he said.
The work is not without its problems, however. La Luz said that doctors often work harder than they would in private practice because of the large number of patients.
The fact that many patients depend on government help to pay their medical needs means doctors have to spend a significant amount of time dealing with the bureaucracies that administer such assistance, La Luz said.
In addition, Linares said, the economic problems many patients face means that the doctors often are dealing with society’s knottier social issues.
“Not only are we dealing with, say, a patient’s foot ulcer, but perhaps where the patient might sleep tonight, what he or she is eating, and when, and the fact that if I don’t sign a certain paper, the patient is not going to get the $50 that he or she needs for food next month,” Linares said.
“Many of the patients that we admit tend to be sicker than they would in private practice elsewhere and we do a lot more social care,” La Luz said.
The clinic in some respects also competes with doctors across the border in Tijuana. “We see patients who go to Mexico for their health care first and don’t get nearly as good care, not sophisticated, and only come to us later,” La Luz said.
“Some who live here go to Mexico and don’t come to us because they don’t know that they can come without having to pay the full bill at the same time, and they don’t appreciate that there is a difference between the traditional (Mexican) general practitioner and a well-equipped medical center.”
Escarce said that many patients are not sophisticated in judging differences between types of medical care.
“At times they are not happy when we aren’t giving them the pills or the B-12 shots that they get from doctors in Tijuana,” he said, “and some come to us only reluctantly after they don’t get better in Tijuana.”
Bressler said that patients who may live in a bus or along the street--who have led a hard life--are difficult to take care of “in the sense that they aren’t nice because life hasn’t been nice to them.” Others provide wonderful moments of pleasure, such as older Mexicans who appreciate a doctor’s time the way elderly Eastern European Jews responded to Bressler when he trained at the Harvard-affiliated Beth Israel Hospital clinic in Boston.
“The fun of working here can differ from week to week, depending on the patient,” Bressler said.
Linares would like to see the patient mix expanded. “I have (South Bay) neighbors who want their kids to have physical examinations and they asked me where my office was and I said San Ysidro. They responded, ‘Oh, well, that’s far away.’ They really don’t want to mix. That’s reality.”
“Look,” Escarce said. “As long as some patients are paid for by the state and others are paid for by private insurance, the patient perception difference is going to be there.”
Humbarger added: “When we had a marketing consultant look at setting up an HMO here, she said that you can’t sell the name ‘San Ysidro’ to an Anglo working person.”
Humbarger said that some clinic patients are Caucasians who recently have lost their jobs and qualify for county assistance by coming to the center. “The first time they come in here, they are very negative,” he said, “they don’t like to mingle in the waiting room, but after the second and third visit, they find the care is the same they got at Kaiser or at their private insurance and express surprise.”
Although doctors such as La Luz who plan to remain indefinitely will probably continue to be the exception, all the physicians believe that the San Ysidro center can continue to attract quality doctors.
“It’s been true that if you come from a good medical school with good residency training, you go to fancy clinics and don’t come to a place like this,” Escarce said. “But things are changing, given the oversupply of doctors, and this place has a good reputation.
“I don’t think my departure will diminish the quality or quantity.”