Patient dedication

Atlanta’s Good Samaritan Health Center sits on a hill in a modern, $2.3 million white building that’s wildly different from the run-down tire shops and soul food joints surrounding it. The road leading here is narrow and lined with weeds and construction cones.

Inside, full-time staff physician David Derrer moves through one of his typical days, with 14 scheduled appointments before noon. “I’ll probably work through lunch,” he says, while making notes on a patient’s file. He steps into a room and greets Kirk, a young African-American man who recently lost his job and home. Kirk lives at a local homeless shelter until things get better. With high blood pressure, he can’t get work as a truck driver.

“Are you still smoking?” Derrer asks. Kirk nods: “You got any meds for that? You know, to quit?” Derrer looks at him: “Are you ready to quit?” Kirk chuckles and looks down, shaking his head. Derrer pats his arm. “I’ll give you medicine when you’re ready.” Then he prays with him: for the blood pressure, for the need to quit smoking, and for work.

Sharon, a middle-aged African-American woman, is one of the patients who has changed. She carries a quart-sized plastic juice bottle full of water wherever she goes, but she didn’t used to. Six years ago she first came to the clinic with unmanaged diabetes. She had been caring for her daughter with cerebral palsy, leaving no time to take care of herself. Without insurance, she had no way to pay for her regular medical care.

Doctors at Good Samaritan taught her the importance of exercise, nutrition, and drinking plenty of water. Sharon now exercises more and eats better. Since her daughter’s recent death, she has let some of her new habits go, but she plans to go back to them. During her daughter’s final days, Sharon says she found comfort and help from her doctors at Good Samaritan. She still seems surprised that one doctor took her hands and prayed with her: “How many doctors you know take a personal stand with you?”

Changing patient behavior: That’s a crucial challenge for clinics serving poor and uninsured patients. Many are overweight and suffer from chronic diseases like hypertension, diabetes, and heart disease brought on by stress and bad habits—smoking, drug and alcohol abuse, and poor diets. These patients frequent hospital emergency rooms, which aren’t designed to treat chronic disease.

Charity clinics have increasingly stepped into that gap. Shepherds Clinic in Baltimore offers relationship-emphasizing wellness programs, focusing on long-term rather than short-term change. Shepherds, which sits on a knoll surrounded by bright pink rose bushes, has walls painted in variations of yellow, blue, and green. Jessica, the brown-haired receptionist, greets patients as they walk in, calling some of them by name as they approach the desk.

Located in a rough section of Baltimore, Shepherds serves “a stressed-out population.” The surrounding neighborhood has record high rates of homicide and hypertension, statistics that form a powerful contrast with Shepherds’ bulletin boards that advertise the clinic gardening club, yoga classes, and healthy eating and cooking workshops.

The clinic’s working poor patients don’t have insurance. They make too much money for Medicaid, so if they didn’t come to Shepherds, they’d be using the local emergency room. Executive director Jack VandenHengel says the clinic’s patients are focused on paying rent, avoiding eviction, and keeping utilities on: “People come here at their wit’s end. Their world is falling apart. … They need a primary care physician who will pay attention to them over time.”

The clinic’s staff confronts a fatalistic mentality that asks, “Why would you do anything different if you’re just going to be dead?” That’s where classes about cooking healthy foods, gardening, and exercising fit in: They encourage patients to take off bad habits and put on better ones. Even with all the offerings, the clinic staff can’t force patients to take advantage of the free resources. It often takes months before a patient ventures beyond the examining room to see what else the clinic offers.

Patient counselor Susan Hildebrant is deep in conversation with a man who wandered into Zarephath Health Clinic in Zarephath, N.J. He didn’t have an actual appointment: He just needed to talk. Hildebrant says part of her job involves talking to people who don’t have friends, family, or other support networks. Sometimes those random conversations open up opportunities to discuss spiritual things.

The clinic serves mostly low-income Hispanic families, but it also sees students and anyone unemployed and without insurance. Sometimes patients see the doctor. Sometimes they see both counselor and doctor. Hildebrant explains to patients basic stuff: why it is important to eat healthier food, how to budget, and what to cook. She says her patients see fast food as a better meal than banana and peanut butter, which costs about the same but is healthier. Hildebrant says many Hispanic diabetics find it hard to limit their intake of rice, a cultural staple.

The process of behavioral change can be painfully slow. It requires cultural understanding. Wayne Aoki, mental health director at Los Angeles Christian Health Center, says the responsibility for change belongs to patients, not doctors. Attempts to badger patients into compliance never work: “In some ways it’s like you are laying out a cost-benefit analysis for your patients.”

For many impoverished people, healthcare isn’t a priority. They aren’t in the habit of making and keeping appointments. That can be a problem when specialists agree to see a patient for free. No-shows waste specialists’ time, making the doctors less likely to offer charity care in the future.

Project Access NW, a program that matches needy patients with specialists in Seattle and its environs, helps people become good patients. “Teaching responsibility is integral to our success,” executive director Sallie Neillie says. Among Medicaid patients, the missed appointment rate is over 30 percent—but at Project Access it is 5 percent, because mentors counsel patients repeatedly before they ever see a doctor. The program kicks out patients who miss more than two appointments: “We want them to make us part of their team. To help them, they have to play by the rules.”

Some patient populations are more difficult to reach and teach. Shelter Health Services, a clinic on the grounds of a Charlotte women’s shelter, deals with many homeless women. One patient, Theresa, came to Shelter Health Services to get a glucose meter to help her manage her diabetes. Lisa Bishop, clinic manager and R.N., warns Theresa that her diabetes demands careful behavior such as not walking around barefoot and having a doctor clip her toenails to prevent infection.

“Did they go over dietary guidelines with you?” Bishop asks. Theresa shakes her head no, so Bishop proceeds to tell her the foods she needs to avoid. Most people think of cookies and desserts, she says, but watch the potatoes, corn, and bread. Bishop then grabs a meter out of her desk and scoots her chair over until she is inches from Theresa. She counts out test strips, places them in a small black bottle, and says, “This will last you for 10 days. Let me show you how to use it.”

As Theresa watches, Bishop clicks a small needle into the device and demonstrates the process step by step. Then she hands the device to Theresa: “Now you try it.” Theresa holds it tentatively between her fingers. She has a hard time getting the needle to click. “It’s OK,” Bishop says. “It takes practice.” Theresa whispers, “I used to watch my mom do this when I was growing up.”

About a third of the people staying at the women’s shelter suffer from a chronic disease. Brochures in the diagnostic room cover the most common: diabetes, high blood pressure, HIV-AIDS, and TB. Since the clinic works with such a transient group of patients, staff members focus on education, jumping on teachable moments. “Repetition is the key,” Bishop says.

The clinic hosts biweekly educational workshops and makes sure they are interactive and use familiar terms. “At the end, we offer HIV testing and get the results in 20 minutes,” Bishop explained. At the clinic’s open forums, women sometimes ask questions like, “Why is weed a bad drug?” and “Why do my feet always stink?”

Clinics like Shelter Health Services rely on teachable moments, but others feature a calendar of classes. Charlotte Community Health Clinic (CCHC) has an education room furnished with 15 black chairs facing a whiteboard and television at the front of the room. CCHC offers classes including exercise for people with arthritis, introduction to diabetes, and how to read nutrition labels. Patients with chronic diseases come to the clinic every three months for disease management and lab work—services that emergency rooms can’t provide.

Angela Williams, 50, a heavyset woman dressed in a sparkly purple halter top and black leggings, walks across the grassy area behind CCHC. Peering into the seven raised garden beds, she searches for signs of buds, but the young plants aren’t producing blueberries or peppers yet. Williams first came to the clinic five years ago because she had a cold. She was grieving her mother’s death and handling her grief by eating.

Nurses at the clinic told her she was at risk of developing diabetes and high blood pressure because of her weight. It took years for Williams to change her behavior: “It’s very hard. … If it weren’t for this program, I could be dead.”

She finally went to the diabetes class, the hypertension class, the diet class, and the exercise class: “Whatever they had, I would take an early lunch and go!” She lost 85 pounds over the past year and credits the clinic. She learned from a nutritionist the size of a proper portion—and holds up an open hand to demonstrate. As Williams learned about nutrition, her family benefited: “My family knows we are going to have salad three times a week. We have turkey and baked chicken. If we have fried, it will be once a month.”

Jill Lipson, a patient education coordinator, set up the clinic’s well-organized calendar of events, including supermarket tours—Spanish-speaking patients tour Compare Foods, and English-speaking patients tour Food Lion. Some of the education programs are limited to specific patients who need special attention, Lipson says: “We have to do it hands-on to really get it.”

Clinics often woo patients through cooking classes. Alene H. is one of a dozen people gathered inside a large class-style kitchen at Church Health Center Wellness in Memphis. Today they’re learning how to make stuffed vinaigrette chicken and a cucumber salad.

Alene has attended every cooking class offered over the past year: “I’ve learned to like things I didn’t think I would like.” Squash and artichokes for example: “Now I bake a lot of food instead of frying. Catfish, chicken … you know. I bake it now.” She moves the food around in the skillet. “I use less salt. Sometimes you don’t have to use salt at all.”

Linda Stewart, 52, has lost 20 pounds since coming to the cooking classes. She’s lowered her A1C level, which measures blood sugar, from 11 to 7: “I’ve learned how to cook with in-season vegetables.” She bakes instead of frying and uses more herbs.

Many of the women come to the classes for fellowship. Helen, 69, isn’t as concerned with rapid weight loss as she is with keeping up with her friends. She walks regularly and wants to lower her blood pressure, but for now she’s here for conversation.

Julia Brown, 40, agrees: “The members here drag me to every class,” she says, laughing. She started coming to the Wellness Center after suffering from congestive heart failure. Her doctor said if she didn’t get her heart rate up, she wouldn’t see her daughter graduate from high school. Now, she comes to cooking classes, workout classes, and the gym upstairs where she says friendly trainers work with her to reach goals. So far she’s lost 10 pounds: “I look forward to getting up. I feel healthier.”

Barbara Golden, 63, suffered two heart attacks that initially left her paralyzed from the waist down. You can’t tell that by looking at her now: Thanks to years of therapy at the Wellness Center, she’s learning to cook. She takes recipes home to pass on to her grandson, breaking generational habits in the process.

Broken spirits

Nurse practitioner Takesha Leonard sits behind a desk at Jericho Road Family Practice on Genesee Street in Buffalo, N.Y. It’s a clinic with a mission “to demonstrate Jesus’ unconditional love to the whole person.” She wears a stethoscope around her neck, and a long skirt. She also wears very high heels: gray with white letters on them, and has an extra pair of heels, red, shoved under the desk.

The 4-foot-11-inch Leonard grew up in the Bronx and came to Jericho Road two years ago, where she serves African-Americans, Latinos, Vietnamese, Iraqis, and others. A sign on the front door lists office hours in 10 languages.

The Family Practice delivers babies and offers sick care, saving Buffalo residents from going to the ER every time they are sick. The staff also works to prevent chronic diseases like high blood pressure and diabetes. Leonard convinced Jimmy, an Iraqi client with a convenience store across the street, to sell fruits, vegetables, and grilled food instead of the greasy food that was helping to create more patients.

At first only about eight clients came to the practice daily, but then the employees “went door-knockin’.” They learned that neighbors couldn’t afford food, much less brand-name medication. Now Family Practice sees 20-35 patients daily.

The greatest thing about the work, for Leonard, has been including spiritual help in the practice. She created a form for patients to fill out asking them to comment on their personal health—and she left a box at the bottom asking about their spiritual well-being. She wasn’t prepared for the response she received to the “spiritual” box. Patients began to flood her with their spiritual concerns, and often with the simple request: “Pray for me.”

She had no plan for processing people’s spiritual needs. (Yvette, the secretary in the next room, said, “I told you not to make that form!”) Patients started coming for counseling instead of medical problems. Jericho Road CEO Dr. Glick isn’t going to pay her for being a spiritual adviser, but Leonard still endeavors to help the people spiritually. The worst part about it all is the feeling of helplessness and hopelessness: “I wish I coulda done more.”

The day I visited, Leonard took a call about a woman living in a shelter with her nine children, who had been bitten by rats. Leonard expects them to come in later this afternoon, although she really doesn’t have time to see them: “You cry, but you have to help them so you can go home and sleep at night.”

In the waiting room, the carpet is stained and the white top of the plastic play desk is scribbled all over with crayon. A pregnant mother comes in with two small children, a girl and a boy. She leans against the counter and commands, “Go play.” The girl has stringy blonde hair, wears a ruffled skirt with pink polka dots. She announces that her name is “Ladybug” and also Gabby, then waves three fingers, indicating her age, then says, “Mommy, my heart is breakin’.”

Wyatt, the boy, moans constantly. He obeys his mother and begins to scoot across the floor on a plastic bike, which he rides backward. “Come over here, I’ll give you a book,” says the secretary from behind the desk.

A slim black girl comes in, hair shorn, T-shirt torn (in a manner that indicates artistry rather than poverty). She wears an African wrap around the waist. She draws out an iPhone. She examines her fingernails. A Korean woman in the row of chairs on the left has a toddler boy on her lap. She looks at the point of tears. A slow-moving woman emerges from the hallway containing the exam rooms, and heads toward the bathroom in the waiting room. Finding it occupied, she sighs and takes out a wrinkled tissue.

While Wyatt learns to propel himself backward—the strings of his white hair fly up like spaghetti—no one watches. Then the pregnant mom slings Wyatt over her shoulder and tickles his stomach. She hangs him upside down from her lap and his hair falls like Einstein’s and his face looks like a little sun. He laughs.

Gabby stares at the black girl from a proximity too near for politeness. But the black girl just falls asleep against the wall. The Korean toddler begins to cry. His mother kisses and kisses and kisses him. In the hallway Takesha Leonard travels between exam rooms, still wearing her high heels.

On the walls in the hall: Chart holders, an eye chart, a map of the world, a poster featuring a pill bottle that says “Rx. Chastity. Take Once Daily Till Marriage. Waiting is Easier.”

Even in this waiting room.

With reporting by Tiffany Owens, Christina Darnell, and Kira Clark