Take-Home Messages

In time, we hit our stride. For many years, we remained a small, stable staff: one doctor, two nurse practitioners, one patient care coordinator, and one medical assistant. In the 17 years that I was part of the CMC microcosm, I learned a number of lessons that may prove useful to others who share my interest in decent, affordable, and personalized healthcare for those we call underserved. I call these lessons my take-home messages.

1. The mom-and-pop convenience stores that dot most inner-city neighborhoods provide a good model for primary healthcare. CMC was small, personal, located in a residential area, and offered a familiar array of what you might call "the main things." In place of diapers, detergent, sandwiches, sodas, and beer, we offered shots, pills, check-ups, cures for garden-variety illnesses, and help with the more complex ones. Most striking of all, we had the complementary roles of nurse as mom and physician as pop which, although stereotypical, are useful in describing the blend of nurturing and problem solving required for holistic healthcare. The best nurses know something about doctoring – and the best doctors know a thing or two about nursing. Both understand that there will always be a large, shifting, gray area between nursing and medicine.

2. Small is beautiful and personality is essential in serving people who have trouble navigating the massive, complex, and dysfunctional organizations that constitute the US healthcare system. Too many people get lost in the aisles of our medical warehouse stores. They don't know how to ask for what they want, how to use the goods they are sold, or how to return what doesn't work. They can't afford to shop in advance of need. They are ill-served by institutions that crank out health services as if they were products and regard patients as customers.

3. More is not better except when it comes to spending time with patients in order to understand their big picture. Too often, a person who has had no prior healthcare is catapulted into a complicated course of treatment that is financially, culturally, and personally unsustainable. I think of Ruby, recently diagnosed with diabetes. During a hyperglycemic episode, she had gone to the nearest emergency room, from which she'd been admitted to the hospital. She was discharged on tight diabetic control, with a weigh-and-measure diet and a complex schedule for insulin injections and glucometer testing. She couldn't (or wouldn't) prepare the prescribed foods, handle the multiple daily injections of two different types of insulin, or purchase the supplies needed to operate the glucometer. Her expensive hospitalization in the care of highly skilled professionals had not served her well. At CMC, we were able to stabilize her condition reasonably well on one injection a day, a rule-of-thumb diet, and frequent contacts to bolster her resolve. We became expert at giving first-class second-class healthcare.

4. Good healthcare, by itself, will never result in healthier communities. The environment, adequate food and shelter, meaningful human relationships, and healthy lifestyles are vastly more important in determining the well-being of a population. I also like what Washington Post columnist Courtland Milloy wrote during the crisis provoked by the recent closing of DC's public hospital: "... scars on the souls of black folk cannot be treated in hospital emergency rooms, but removed only with spiritual scalpels wielded by a community of people who care." In my experience, that applies not just to "black folk," but to all those who suffer.

5. Except in a crisis, healthcare is never the most important thing. For those sitting on what we call the "wino bench" down the street, the most important thing is the next taste of booze. For many of our families, it's getting through one more day – pay the rent; put food on the table; make sure the children go to school; survive. For school kids, at any given moment, it's not learning to say no to drugs or sex or dropping out of school, it's social security (not the kind you get from the government), friends, and fun. For my patient, Sheila, her high blood pressure and diabetes were never a priority, but flagging down a taxi to take her to CMC ("not the emergency room, no, not there!") as she began slipping into shock after a bee sting, was.

6. You can't separate preventive and curative services. People respond best to health counseling when they are sick or scared. A young man, Derrick, comes in with a stomachache. I find out that his girlfriend has just gotten pregnant. He's lost his job and, along with it, his health insurance. His mother has kicked him out of the house. Is this the time to talk about safe sex and pregnancy prevention? One thing is sure: it's the only possible time, because once Derrick feels better and leaves the office, I won't see him again.

7. To be effective, health workers in rough-and-tumble neighborhoods must expect to experience, and work amidst, the same chaos that reigns in the lives of their patients. There's Darlene in her motorized wheelchair outside the clinic, parked at the bottom of the steps. She sends her grandson, Joey, in to tell us she's out of all her medications – has been for "awhile." Between patients, I go out on the sidewalk for an impromptu consultation with blood pressure cuff, stethoscope, and prescription pad in hand. And I schedule a home visit. At CMC, on any given day, we were faced with countless missed appointments, walk-ins, and "failures to comply." We coped with exam rooms full of out-of-control kids ("Sorry, I don't have a babysitter") and adults ("Snooky, you really can't lie there on the waiting room floor all morning. We promise to see you as soon as we can."). This is life. You learn to deal with it.

8. Sometimes it's not that people are underserved, but that services are under-received. I think of the Clinton administration's push to make more vaccines available to clinics like ours. It didn't address the real problem that, for us, was getting children to the clinic to receive the vaccines. Our refrigerator was well stocked. But even their favorite nurse, Teresa, standing outside the front door of one of her large, extended families, offering door-to-door vaccinations, couldn't always get an answer to her knock.

9. The underserved are not just the poor or uninsured, but include all those who get only pills and procedures instead of time and attention; all who are treated only in parts and exist in the mind of the clinician without a face or name; all who are talked at, but not listened to; all who are denied nursing care (not nursing services – nursing care); and all who are discharged cured, but not healed.

Is CMC a model I can recommend? Probably not. For us, the bottom line was a call to serve, not to earn. We wanted to keep our patients – not a group of shareholders – happy. We focused our efforts on a few thousand souls in a neglected section of the city. Even so, we did not turn a sick neighborhood into a healthy one. True, some found healing at CMC. One of the most important lessons I learned was that physicians and nurses, working together with a clear sense of their individual and professional strengths and limitations, have potential for healing the whole person unequaled by either healer alone.

Veneta Masson, RN, MA, was one of the co-founders of Community Medical Care (CMC) in inner-city Washington, DC. Masson is the author of Ninth Street Notebook: Voice of a Nurse in the City, which contains lessons and reflections from her years at CMC. CMC opened in September 1978 and the clinic has survived the departure of the founders and (so far) the exigencies of managed care and increased regulation. CMC, with an expanded staff, recently relocated to a new, larger site in another part of the city.

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