The Primary Problem

Drs. Jennifer McLean and Amy Brown—who live in Denver and Glenwood Springs, respectively—practice in medically underserved areas of our state. It's not what most doctors would call a choice position. They do it because they love it. But their jobs come with a fringe benefit that might make other would-be docs reconsider the waning career of general practitioner.

Three-and-a-half hours away, at Glenwood Springs–based Mountain Family Health Centers, Dr. Amy Brown is complaining about colonoscopies. “The hardest part of medicine is that you’re responsible no matter how well—or not—someone is taking care of his own health,” she says, explaining the difficulties she has in getting her patients to undergo procedures like colonoscopies, ultrasounds, and CT scans.

Of course, it’s just a momentary gripe. Brown, 43, knows all too well the people she serves often don’t have the money, time, language skills, medical insurance, education, or citizenship to access health care beyond what she offers in her community clinic. She knows that if she can’t ameliorate a patient’s medical issue in her office on the one day that patient makes it in to see her, it’s likely that the patient simply won’t get help at all.

It’s a predicament, because although family practice physicians like Dr. Brown have a wide breadth of knowledge, there is a natural limit to what they can offer. In a setting where patients have access to insurance, Brown would quickly send a patient to a specialist when the situation exceeded her knowledge base. But the tomes on Brown’s office bookshelf—Human Labor & Birth, Primary Orthopedic Care, Rapid Interpretation of EKGs, and Color Atlas and Synopsis of Clinical Dermatology—illustrate that she must be all things to her patients. This is not only because her patient base is either uninsured or underinsured, but also because there simply aren’t all that many specialists practicing in Glenwood Springs.

Brown’s typical day, much like McLean’s in Denver, includes a roster of 20 or more patients. They have similar complaints and familiar medical conditions: diabetes, hypertension, pregnancies, mental-health issues, viruses, and chronic back pain. Unlike McLean, whose patient base is about 60 percent Spanish-speaking only, Brown’s practice skews as high as 80 percent Spanish speaking. Brown learned the language while living abroad in Chile as a child, and except for a noticeable lack of accent she’s clearly comfortable with the language. As we head toward an exam room, a smile spreads across Brown’s face as she reads the electronic medical record on her laptop. “This is one of my very favorite patients,” she says. “She’s a delight.”

“Cómo está usted?” Brown says as she walks into the room, her short blond bob tucked behind her ears. The patient, an elderly woman with borderline diabetes and a nagging pain in her side, smiles and points proudly to two small packages on the counter.

“Dos regalos. Uno para ti y uno para su niñita,” the patient says.

Brown grins, her blue eyes lighting up, and opens the small regalos—gifts—including the one the patient had brought for Brown’s four-year-old daughter.

“Qué bonito—how beautiful. Muchas gracias,” Brown says, turning the small, inexpensive jewelry boxes in her hands. The look on Brown’s face says it all: This is why she spends her days in a rural community clinic making tens of thousands of dollars less than she might at a private practice in a bigger city. Her patients obviously appreciate her.

McLean’s desk in Denver is spare, save a few sticky notes, an Obama “Change” badge, and a pin that reads, “I work at a community health center and I vote.” McLean exudes a confidence that comes from knowing what she does is important. “I always wanted to work in an underserved urban area,” McLean says. “I feel like an advocate for those who don’t always have a voice.”

It’s a job that should demand respect, yet across the United States, primary care physicians, working in community health centers or in private practice, are vanishing. America has 352,908 primary care docs today, and the Association of American Medical Colleges estimates that 45,000 more will be needed by 2020. Unfortunately, the number of medical students choosing family medicine dropped by more than a quarter between 2002 and 2007.

The decline isn’t a surprise to anyone in the medical field. According to the American Medical Association, the average educational debt of indebted graduates in the class of 2010 was $157,944. McLean, who trained at St. Anthony North, was saddled with $105,000 worth of debt; Brown, who did her residency at Rose Medical Center, shouldered about $230,000. These high debt burdens force many medical students to choose specialties other than primary care, which can pay 50 percent less than a career in, say, cardiology.

That discrepancy in dollar signs results in disturbing statistics: Just 30 percent of U.S. doctors practice primary care, while 66.7 million Americans live in places that are federally designated as having a shortage of primary care physicians, like Glenwood Springs. In fact, 53 of Colorado’s 64 counties are designated as Primary Health Professional Shortage Areas, and the Colorado Department of Public Health and Environment says that the Centennial State requires approximately 180 full-time primary care docs to meet the health needs of its underserved regions. This scenario makes McLean and Brown part of an even rarer breed: primary care docs who practice in medically underserved areas. While both say they would work where they work no matter what, McLean and Brown acknowledge that they’ve found a way to reconcile the financial downsides of primary care medicine.