Michigan effort puts new doctors in front of poor, underserved patients

• Michigan is short about 400 primary care doctors, according to federal data
• A new residency program rotates new doctors in primary care clinics, a public health department, and a mobile van serving homeless patients
• The program is supported by $960,000 a year in federal tax dollars, in addition to $1 million from Oakland County

PONTIAC — Michigan has too few family doctors, limiting access to medical care in a state where residents tend to be older, unhealthier, and where not everyone can get the care they need. 

Now a solution might be taking shape — not in sprawling hospitals often associated with medical training, but in a nondescript conference room this gray November morning with a table loaded with papers and laptops.

On most weekdays, it’s here at Honor Community Health that six doctors-to-be meet to discuss patient care.

They are the first six doctors of 18 that will be trained here over the next few years through an unusual residency program that rotates doctors through Honor Community Health’s network of 21 primary health clinics, 11 school health centers, and a specially-outfitted Ford Transit van that travels around treating homeless patients. The residents also spend time in Oakland County’s busy public health clinic across the hallway from the conference room.

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It’s a dramatically different approach to training doctors. Residencies, where doctors train after graduating from medical school, often take place in hospitals, where young doctors typically see patients for only a short time, said Dr. Beena Nagappala, president of the Michigan Association of Family Physicians.

“In a hospital, you treat a patient and it’s ‘Bye-bye. Follow up with somebody else,’” said Dr. Oluwabusayo Alade, one of six inaugural residents in the Oakland County program. 

“Here you get to know the patient, their community, and the resources to help them. You help the patient get back to the clinic. You help them to find the supports they need. It’s not ‘bye-bye.’” he said.

As Bridge has documented this year, worker shortages exist “across the board,” in the healthcare industry, said Scott Stewart, director of strategic initiatives at Honor. 

But training doctors in hospitals encourages them toward specialty care — orthopedics, for example. Training doctors in the community as primary care offers a chance, he said, to “show them the excitement of the change you can make in lives.”

“These aren’t just patients on Medicaid or who are uninsured or underserved, but they are people who are worth serving just as much as anyone else,” he said.

The three-year residency program is the first doctor training program in Michigan to take place in Federally Qualified Health Centers — a network of more than 370 community health centers throughout Michigan that are open to all patients, but whose focus is on patients who are un- or underinsured.

The U.S. Health Resources & Services Administration estimates that Michigan had 1,450 primary care physicians in 2021 — nearly 400 fewer than what was needed. 

The program’s aim goes beyond simply training doctors. It’s about increasing the odds they choose careers in community health centers that provide care in underserved communities — those most at risk for going without care in a state with too few doctors.

The Honor program began Oct. 1. 

Dr. Eduardwil Hernandez-Vegas, who got his medical degree in Venezuela, said one of  the first patients he saw when he started last month, was a Venezuelan man who hadn’t been to a doctor for more than a decade. In the meantime, he’d developed diabetes that had gone undiagnosed.

The patient was appreciative. Word spread. His sister-in-law came by, then her friends and then more family members. Some told him they did not have a regular doctor or routine care, he said.

“We have new patients — 10 or more,” Vegas said. “They didn’t feel comfortable before.”

Connections through shared language and culture can be critical in care. Knowing the importance of a patient’s traditional diet — what foods mean to them — can help doctors formulate realistic medical advice, for example, Dr. Lizmar Rivera-Nuñez said.

She, too, had been on her laptop this morning, readying for a patient who speaks only Spanish. 

Paid interpreters or interpretive technology can feel impersonal and nuances of conversation can be lost, said Rivera-Nuñez, originally from Puerto Rico.

Today, it will be just doctor and patient.

“You can see them relax,” she said of her patients.

The doctors reflect much of Honor’s 17,000 patients each year, about 3,200 of whom — 18 percent — speak English as a second language or not at all.

Nearly three in four patients identify themselves as members of a racial or ethnic minority group, including 40 percent who described themselves as Black and 30 percent who said they are Hispanic. Roughly 80 percent reported incomes at or below the federal poverty level meaning they earned less than $30,000 for a family of four. Nearly 1 in 10 described themselves as homeless.

In short, they are patients who often see a doctor only after disease has spiraled out of control and sent them to a hospital, said Nagappala, at the state’s association of family doctors.

She lauded the Honor program, part of the larger, federally-funded Teaching Health Center Graduate Medical Education.

“A lot of the social determinants of health play into the picture” at community health centers, she said.

While residency programs at larger health systems may include rotations through community health centers, the rotations are usually short stints — almost an afterthought, said Stewart, Honor’s strategic initiatives director. The new program puts the Honor center in control, shifting doctors’ training from big hospitals to smaller facilities such as dental clinics.

Some doctors-in-training in Oakland also will work in mental health clinics, learning about trauma-informed care and gaining an understanding of how adverse childhood experiences, or ACES, can significantly affect a patient’s mental and physical health throughout their lives.

Honor will train 18 residents each year across the three-year program, with six residents in each class. 

Core funding — $960,000 a year — is part of $175 million in federal funds for 81 community-based residency programs throughout the nation. 

Additionally, Oakland County will contribute $1 million this first year to help pay for salaries for new staff, including a program coordinator and additional preceptors or physicians who train.