Filling the Void : Science File / An exploration of issues and trends affecting science, medicine and the environment : Compassion Led Dr. Carol Jennings to the Inner City, but Few Colleagues Choose to Follow in Her Footsteps
Practicing medicine anywhere these days can be a big challenge. But for the relatively rare physician who works in the inner city, such as Dr. Carol Jennings, the challenges go off the charts.
A 60-year-old man who recently walked into her clinic, the South Central Family Health Center at 45th and Main streets, illustrates one dimension of the problem.
He had not seen a doctor for years and told Jennings he wanted a checkup. But after some probing questions by Jennings, the patient explained that he had been feeling faint and was having trouble walking.
Jennings ordered a brain scan. A cancerous tumor was found. “He should have been in treatment months ago,” Jennings said.
On another occasion, a patient called Jennings late in the day, reserved and apologetic that she had no money to pay for her treatment.
The woman, 6 1/2 months pregnant, explained that she had begun having contractions and felt feverish. Jennings heard enough to order her straight to the emergency room of the closest hospital.
Jennings met her there and watched as her fever rose to 107 degrees before doctors brought it down. As it turned out, the young woman was able to deliver a healthy baby. The cause of the problem was a relatively common bacterial infection that had gotten out of control.
“She was one of the sickest women I’ve ever had,” Jennings said. “Like a lot of our patients, she was not very sophisticated medically. She did not come in immediately when the problem started and waited until it was almost too late.”
The South Central Family Health Center, a nonprofit community clinic, is 45 blocks from Los Angeles City Hall. It is in a neighborhood that by almost any yardstick is one of the most medically underserved communities in the state.
Jennings has seen cancers go untreated until the sufferers are immobilized. Patients have come into the clinic with diabetes so advanced that they are experiencing blindness or have partially destroyed kidneys. Small medical problems, like bacterial infections, become life threatening.
Confronted with such problems, relatively few family practitioners are willing to work in an inner-city practice, a fact underscored by a study from UC San Francisco.
The study identified medically underserved areas as those with fewer than 30 primary care physicians per 100,000 population. Jennings’ district has one of the worst doctor-patient ratios in the state: only eight primary care physicians for every 100,000 residents.
Counting all physicians, including other specialists, there were only 11 doctors for every 100,000 residents in the clinic’s statistical area--bounded roughly by the Santa Monica Freeway on the north, Firestone Boulevard on the south, Broadway on the west and Alameda Street on the east.
By contrast, the city of Santa Monica had 229 primary care doctors and 704 physicians of all kinds for every 100,000 residents, said the study, which used 1990 hospital and census data.
As a result of the doctor shortage, residents of Jennings’ district were at least three times more likely to be hospitalized for conditions such as asthma and diabetes than residents of such doctor-rich communities as Rancho Palos Verdes, Beverly Hills or Arcadia, the study found.
Though a shortage of primary care doctors was found in nearly one-third of California’s communities, the shortages were most severe in areas with large African American or Latino populations.
The statistical portrait constitutes a near-perfect profile of Jennings’ area and confirms a host of problems that have been of long-time concern to health experts. Chief among them is how to get more doctors into low-income areas.
“There are plenty of physicians out there, but they are not located where they are needed the most,” said Dr. Kevin Grumbach, the lead author of the study. “It’s a very serious problem for cities.”
Grumbach said that threatened budget cuts in state and federal health programs may make the problems faced by small clinics like Jennings’ even worse.
“It’s not a great era for programs designed to care for the politically disenfranchised,” he said. “The programs that are there in underserved communities . . . are all at risk.”
Dr. Reed V. Tuckson, president of Drew University of Medicine and Science in Los Angeles, the largest African American-oriented medical school west of the Mississippi, said doctors are reluctant to work among the poor because the patients often are uninsured and unable to pay.
He said physicians also like to work close to research centers and in practices in which there is a strong infrastructure of laboratory and other services and a chance for a significant amount of peer contact.
Perhaps an even bigger problem, Tuckson said, is the relatively low number of black and Latino physicians, the men and women most likely to practice in minority neighborhoods. “People who are not from inner city neighborhoods are not as naturally inclined to locate their practices there,” he said.
(According to the Assn. of American Medical Colleges, only 1,205 black and Latino physicians graduated from U.S. medical schools in 1994--11.7% of the total graduates and roughly half their proportionate share of the general population.)
In most respects, the study’s findings and the concerns expressed by Grumbach and Tuckson mirror the problems faced by the South Central Family Health Center.
About 95% of the clinic’s clients are Spanish-speaking and about 70% are without any health insurance. Almost all the rest receive state-supported Medi-Cal benefits. Only about 1% of the patients have private health insurance. Those without insurance are charged on a sliding scale based on ability to pay.
Jennings knew about the shortage of physicians in the inner city, the lack of insurance by most of the patients, and the often life-threatening health conditions when she took the job at the South Central Family Health Center. She said these challenges were actually part of the attraction.
Raised in Thousand Oaks, she said she was in junior high when she began thinking about becoming a physician. During training at UC San Diego Medical School, she began working at a shelter for homeless women and realized that she wanted to practice medicine in the inner city. During her residency at the California Medical Center in Downtown Los Angeles, Jennings began working at South Central.
“I was drawn to the area because it was one of the most needy areas around, and I really wanted to be in a place near underserved people,” said the 32-year-old Jennings.
At times the work is exhausting, in part because so few other physicians or health care administrators want to work in the inner city.
In addition to her clinical duties, which include delivering about 60 babies a year, Jennings is the clinic’s medical director, supervising a staff of five full-time health workers, plus the volunteer and part-time physicians who work at the clinic. She also runs the clinic’s on-site pharmacy, and has been acting as the clinic’s executive director since the director left in March. As acting executive director, she is responsible for fund raising, writing grants, making personnel decisions and involvement with the community.
In 1993, the clinic had 25,000 visits, but last year it lost two physicians and was forced to stop taking new patients for a while, so the number of visits declined to 18,000.
It took more than a year to fill one of the vacant physician slots.
“The [doctors] we pursued ended up in other places, for better pay or fewer responsibilities,” she said.
Jennings tries to tone down the public’s tendency to over-romantize practicing medicine in the inner city.
“It’s work,” she said. “It’s beautiful work, but it’s work, and you get to go home. . . . I like to think of [the clinic] as ‘stuff’ that needs to be done. I don’t want anyone to feel like they have to be special or Mother Teresa or something.”
Bolstered by part-time physicians, the clinic lifted its moratorium on new patients two months ago and was flooded with applicants.
“It doesn’t take long for word to get out,” Jennings said. “We have a very loyal following.”
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The Toll of Physician Shortages
A new study has shown a correlation between shortages of primary care physicians and higher rates of hospitalization for illnesses that could be treated on an outpatient basis if diagnosed early. The problem is more pronounced in Los Angeles County than in Orange County. Researchers say the trend is most noticeable among low-income patients, African Americans and Latinos.
Primary Care Admission Annual Household Physicians Rate* Income Under Community (per 100,000) (per 10,000) $15,000 Laguna Beach 97 14 8% Buena Park 48 42 12% Santa Ana 35 23 16% Anaheim 62 29 13% Costa Mesa 99 20 10% Central Los Angeles 8 57 43%
African Community American Latino Laguna Beach 1% 9% Buena Park 3% 21% Santa Ana 3% 65% Anaheim 2% 21% Costa Mesa 2% 18% Central Los Angeles 27% 71%
* Includes hospitalization for diabetes, asthma, high blood pressure, chronic obstructive pulmonary disease and congestive heart failure. Figures are from 1990 hospital records.
Source: UC San Francisco
