Paying for lunch is really overrated. Thankfully, it is relatively easy to find free lunches around campus. On any given day, there are often several lunch discussions on a vast variety of topics, and it is a known fact that medical students are too busy to go to these talks… unless there is free food. I am beginning to think that there are very few things that medical students wouldn’t do for free food. I often overhear conversations similar to this:
“You went to the lunch talk on the phyla of athlete’s foot? How was that?”
“Well, I was a little disappointed because they ran out supreme, so I got stuck with pepperoni”
“Yeah, that’s why I went to the proctology talk, they had Jason’s Deli”
While the attendance of the meetings is often dependent on the type and quantity of food present, there are some that are packed despite the small quantity of cheap pizza present. This was definitely the case when I went to a talk with Dr. Ron Anderson, CEO of Parkland Health and Hospital System, Dallas County’s public hospital. The room was cramped with students, a few residents, and various other staff to hear what he had to say.
His aim was to discuss the concept of “Community Oriented Primary Care” (COPC). He took us through the history of the practice and discussed national health programs that dated back to the 1800’s. I will not get into the history and development of public health programs, as this could easily fill up an entire semester of material, but it is a surprisingly rich and interesting history. COPC was first defined by Sydney Kark based on five basic questions:
- What is the community’s current state of health?
- What are the factors that have contributed to this health state?
- What is being done about it?
- What more can be done and what is the expected outcome?
- What measures are needed to continue health surveillance of the community and to evaluate the effects of the existing programs?
Parkland’s venture into COPC primarily began with a dilemma which presented itself in the early 1980’s, one which draws many parallels to the dilemma of today: The recession caused increased the number of people seeking care at Parkland and caused a steep decline in local property values. Parkland was faced with a drastic increase in demand as people lost their jobs, but there was no increase in funding for the hospital. The solution was to move high-volume, low-cost community centered care into the community by purchasing clinic space and concentrate the low-volume, high-cost specialty care at the hospital itself. This model of decentralization and focus on community has now expanded into:
- 11 health centers
- 9 women’s clinics
- 11 youth/family centers
- Geriatric services
- 28 homeless shelters (plus 5 mobile vans and 2 dental vans)
- Refuge outreach
- Dallas County Jail & Juvenile Health Services
Personally, I was surprised that Parkland’s health services were so far-reaching. More shocking, however, is the manner in which they developed these services. One would think that they simply looked for places where they could obtain the cheapest property, and then implement a standard set of services, disregarding the location of the clinic (at least this is what I would assume). I could not have been more wrong in my assumption. Instead, Parkland started by traveling to the communities and practicing what they call “deep listening.”
Another point that was emphasized was that the communities were not divided by zip code or voting district, but by what the residents defined their community as. Dr. Anderson told an anecdote that there was a highly trafficked and successful clinic in south Dallas which had outgrown itself. Parkland moved the clinic to a larger facility about one mile away, on the other side of a major highway. Patient visits dropped dramatically. In his words, “Coverage does not create care.” Social workers and liaisons from the hospital went into the community and realized that the clinic was no longer considered to be within the confines of the community as defined by its residents, and they were forced to launch a large publicity campaign in order to encourage the residents to attend the clinic.
Parkland’s first order of business in many of the communities was not what most would think is directly health related. Hospital liaisons would talk to the communities, frequently by talking to church leaders, speaking during church services, or by holding town halls, and find out what the primary barriers to health were. Often, the hospital would go to the community with the goal of improving diabetes or children’s health but they would find out that the community could not be receptive to the help being offered until other issues were addressed first. Examples given of these issues were drug sales and living conditions. Parkland would involve the Dallas Police and Fire Departments in order to improve the living conditions within the community, so the focus could then be directed at more traditional methods of healthcare.
One slide in his presentation was from a 1990 study[i] estimating that social environment contributes to prevention of premature death about 50%, physical environment 20%, and the healthcare system only about 10%! (The other 20% was genetic endowment.)
By using this proactive, aggressive approach to community health, Parkland has been able to save money and increase good outcomes. Going out in the community and performing mammograms certainly has its costs, but treating a stage 1 cancer versus a stage 3 cancer means a savings of tens of thousands of dollars, and significantly better outcomes. Below are statistics adapted from Dr. Anderson’s talk that seem to show (at least in part) that this approach saves money and increases good outcomes:
Before this talk, I felt that prevention and community centered care were important and certainly worth investing in. After the talk and some research on my own, I realize how important these really are and that I needed to adjust my perspective regarding the most effective methods of delivery for community oriented primary care. Springing into action is excellent and we need more action in my opinion, but deep listening and honing in on the ways we can positively impact a community’s health in the most effective way is a critical step that cannot be overlooked. Programs like those implemented by Parkland will improve overall health and, if you believe the numbers, save us money in the process.
In the future, I will pay more attention to who is speaking and less to what type of food will be available… unless it’s a Jason’s Deli lunch box, because let’s face it, those things are just way better than pizza.
[i] Evans, R.G. AND G.L. Stoddart, Producing Health, Consuming Health Care. Coc Schi Med, 31(12), 1247-1363. 1990.
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