Why Community Health Matters to Laura Miller, MD

Community Health Center Network Chief Medical Officer Laura Miller, MD recently shared why she  chose a career in community health and what keeps her committed to providers and patients. Our interview follows:

For me, primary care has always been about social justice, about bringing high quality health care to people who haven’t had access.

After my studies in Ecuador in a small indigenous community, I returned to the US, completed pre-med studies and attended medical school.  In medical school I applied for and received a National Health Service Corps Scholarship.  The government pays for “x” number of years of school and the recipient, in turn, does “x” years of service.  So, I had a two-year service debt when I left medical school. I did my residency in Internal Medicine Primary Care and then when I finished my residency I had a very short list of places in the US that would fulfill the requirement for the scholarship I had received.

I ended up on a (Native American) reservation in Humboldt County, and really loved that work.  When I came back to the East Bay, I was actually debt-free which was awesome! I wanted to continue serving the community, so I reached out and ultimately found  LifeLong Medical Care, one of our clinics in the Community Health Center Network.  I started working at LifeLong East Oakland in 1999, and I’ve been there ever since.

Team Work for Wellness

I’ve seen my patients at the community clinic since 1999, so I have a very stable panel of people I have taken care of for a long time.  I see elders I have known for 17 years; they remember when I was pregnant with my now 15 year old!  For some patients, there’s a long history together.  Office visits can be like sitting down with an old friend, catching up and trying to make sure everything is still going well medically and socially.

Clinic is fast-paced.  In the morning, we do a “huddle”.  The huddle is amazing and sets the tone for the day.  In the huddle is myself, (the Primary Care Provider), and the medical assistant.   The MA knows our patients; we have a relationship and that works really well.  At the huddle are also a team nurse, front office person and medical records person.  We all sit together for 15 minutes and talk about the patients coming in.  I feel lucky that at East Oakland that I have lots of support.  We have behavioral health in house, we have a Wellness Center downstairs.  If patients have back pain, I can get them to Yoga, I can get them to back pain class.  If they’re smoking, we have a whole smoking cessation group downstairs.  We have built a very robust system to hold our patients well.

I’ll always remember one patient that came to us with congestive heart failure, and early diabetes; she kept going to the ER.  I told her “you don’t have to do that; we can take care of issues here.”

Clinic Operations – Cookin’ with Gas!

My favorite topic!  I love clinic operations and trying to create a clinic that is really, really smooth, and functions well for patients and providers and staff.  It really is about team based care, the “huddle” I described earlier, that’s my team, and when we’re cooking with gas, it’s totally fun.  There’s a lot of work that goes into that and I think it takes all hands to make a clinic work.  It’s not just about the doctor, not just about the medical assistant; there really has to be a sense of common mission about building a safe and healthy environment for patients.  There are a lot of tools out there.  Patient Centered Medical Home is a really important concept.  There are many tools out there, but I think also there are a lot of intangibles in this work. .  You really have to work hard on building an environment that is for all staff.  Yes, medicine is hierarchical, and the provider is sometimes at the top of the heap, but when building a clinic culture, you really have to know that everybody plays an important role.  Some staff members may be better than the provider at communicating with the patient.  Sometimes the medical assistant knows much more than the provider and can really build a trusting relationship with that patient, which in turn enables them to improve their health.

Trauma-Informed Care

We deal with a lot of high blood pressure; high blood pressure leads to heart attack and stroke, which disproportionately affect our communities.  Diabetes is big problem; in part, it stems from lack of access to quality food.  Obesity is very hard one to combat; it has many roots.   Social determinants of health, like access to food and transportation are deeply involved.

The other really difficult issue we face is trauma.  Our patients have suffered trauma in many different ways.  The neighborhoods in which our patients live can be dangerous.  There can be violence within the family, or in the neighborhood.  I learned early on to be very careful of saying, “Walk around the block for exercise.”  That could be really bad advice if walking around the block is going to put you in the way of a drive-by.  I try to be really aware of those issues with patients.  I’m glad that the Wellness Center is a safe space for exercise.  We’re learning more and more about trauma, about environmental trauma and injustice, and the devastating effect on patients.

In clinic, we took care of patients without insurance for many years and it took tremendous effort to build a system to just be able to get medication to patients.  Now, after the Affordable Care Act, things are much smoother, for our patients.

There are still a whole group of patients who remain on HealthPAC, the program of Alameda County for the uninsured.  There’s a lot of work to be done, but yes, absolutely we have made a difference.  For many patients, it’s very hard to focus on health.  When housing, food and transportation take their every waking moment, personal health can take a backseat.  It all goes back to social justice; we have to recognize and address all the factors that affect the health of our patients and our communities.