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.

After nine solid hours of seeing patients, Amy Brown is relishing a glass of organic Merlot while mixing a batch of salad dressing. Her four-year-old daughter, Olivia, plays in the living room; her husband, Dan, is firing up the grill on the back patio. The couple’s two-bedroom, new-build home looks like it could be in Denver’s Stapleton neighborhood. Instead it rests adjacent to the Grand Mesa National Forest, just a few miles outside downtown Glenwood Springs. It’s a modest but nice house. Brown shrugs when I tell her I like her home. “Real estate here in Glenwood is really expensive,” she says. “We can barely afford it. Without the loan repayment we wouldn’t be living here.”

Brown is referring to the Colorado Health Services Corps (CHSC), a program run by the Colorado Department of Public Health and Environment. The program, for which the Colorado Health Foundation is the leading funder, helps primary care physicians—as well as other primary care health professionals like nurses and dentists—defray their loan debt. But there’s a catch. To receive award money from CHSC—which doles out up to $35,000 per physician annually—a doctor must sign up to work in a Federally Qualified Health Center (FQHC), rural health clinic, or a safety-net facility in rural or underserved urban communities in Colorado. So far, the foundation has supported 104 awards totaling more than $7 million. Exactly $130,000 of that went to Amy Brown; another $88,000 went to Jennifer McLean.

“The money from the foundation helps,” Brown says. “It makes it easier for me to continue to do what I want to do, which is be an innovative healer in this community.” Brown’s affinity for the type of patient she sees no doubt helped her when she applied for the CHSC money. But that alone would not have garnered her the award. There are quantitative and qualitative criteria that each applicant—and each applicant’s current clinic—must meet to be considered.

“The demand for these awards is insatiable,” says Colleen Church, a program officer with the Colorado Health Foundation. “We have more applicants than available awards.” Brown, with her Spanish language skills (she’s also competent in Italian) and experience with different cultures (she’s lived in Chile, Brazil, and South Africa), had what the CHSC would see as an enhanced ability to accommodate an underserved population. Mountain Family, the clinic she’s worked at since 2004, is located in a federally designated medically underserved area, serves a patient base that has negligible access to medical insurance, and delivers high-quality primary care.

It was also likely Brown’s insistence that she would prefer not to work in private practice that helped her cause. The goal of programs like CHSC—there are other similar programs at the national level like the National Health Services Corps as well as in other states like Massachusetts, California, and Texas—is to give doctors and other health professionals enough financial support that they will want to continue to practice in these medically underserved areas for far longer than the three-year stint for which they signed up. “National data says that more than half of loan-repayment recipients stay for eight years,” Church says, “which means these grants are a significant tool for addressing our medically underserved populations.”

Church believes they are also a means to helping medical students and young doctors make choices without the psychological burden of huge loan debt. After all, by and large, American doctors say the reason they chose medicine as a career was to help people—not because of the money. Yet, reality has a way of changing even the most selfless intentions.

Yes, there’s the smaller salary to consider, but there are other elements to bear in mind. In rural communities, there’s less access to a network of other doctors who can be professional contacts or personal friends. In any underserved community, health-care providers have to take their patients’ finances into consideration—sometimes the necessary care isn’t a viable option when it comes to a patient’s economic status. On top of those things, these doctors have to be extremely culturally aware and incredibly flexible. “It’s not uncommon for a patient to schedule an appointment to, say, take out some stitches,” Brown explains, “and then bring in her entire family for me to look at during that appointment. It’s hard to tell someone that I can’t check her husband’s blood pressure and refill her kid’s meds because that’s not in my schedule. That’s bad customer service. It’s a challenge.”

Brown and McLean like to tout the positives of their work. Like many community clinics that receive federal funding and a steady influx of grants to treat the underserved, both doctors enjoy technologically advanced offices that use tablets or laptops and employ electronic medical records. Both Mountain Family and Clinica Pecos also use team-based models, which means the doctors aren’t the only ones delivering care. A well-choreographed effort between physicians, medical assistants, physician assistants, nurses, therapists, and other caregivers allows the doctors to focus on higher-level medicine instead of spending time administering vaccinations. “I was looking to work with people who know they can’t do it all alone,” McLean says. “Working here I feel like I can practice medicine and then go home at 6 p.m. and have a life.”

And that’s the crux of it: Primary care doctors in America need to be able to have a life without crushing debt and with the chance to choose to practice however—and wherever—they want. If America needs another 45,000 family medicine physicians in the next 10 years, someone might want to have a long chat with Amy Brown and Jennifer McLean.

For more information, visit www.cdphe.state.co.us/pp/primarycare/chsc.