Part 3: A Caring Community
Erin Tracy, M.D., M.P.H.
March 31, 2011
Morning
North End Community Health Center
Caring for patients at MGH, Dr. Tracy has adequate space and computers in each exam room enabling a high-level of patient volume and efficiency. Nurses and medical assistants are available to help Dr. Tracy with many of the administrative tasks so she can move on to her next patient. Seeing patients at the community health center is a very different experience for Dr. Tracy. Here, the lack of space, staff and overall resources makes patient care a bit more challenging. For example, none of the exam rooms are equipped with an OB EMR. While the patients' perception is that Dr. Tracy is running late, she is actually in her office down the hall reviewing the patient's record to be better informed for the visit.
At the health center, Dr. Tracy has only one nurse assisting her. The nurse stops into the office throughout the day to tell Dr. Tracy about phone calls that are coming in and to let her know when her patients are ready to be seen but many of the administrative tasks completed by other staff at MGH falls to Dr. Tracy.
Ordering tests, filling out forms, looking up test results are all done by the doctors at this health center given the lack of resources and staff. As we discuss the lack of resources in the health center, Dr. Tracy's printer jams as she tries to print out materials for a patient. Crawling under her desk, she tries to fix the problem and eventually calls in her nurse for help. The incident highlights the of lack of resources readily available here at the health center where even technology problems are tackled by the doctor (although later that day a computer support person arrives to fix the printer..
The following is a summary of her interactions with her patients:
A postmenopausal woman is the first patient of the day. She is here to get her annual check-up. Dr. Tracy discusses the importance of continuing these annual check-ups to screen for cancer even though the patient has had a partial hysterectomy.
Dr. Tracy's second patient of the morning is a young mother who is hoping to have a vaginal birth after Cesarian section (VBAC). Dr. Tracy detects the baby's heartbeat using a Fetal Doppler and discusses birth control options with the woman.
The third patient of the day is a young pregnant woman in her late twenties with a positive tuberculosis (TB) test in her chart. Dr. Tracy ordered a chest x-ray for her but there is nothing in the record to suggest she has had the test done.
Dr. Tracy is very concerned that if she does not have the test and she develops a cough around the time of delivery, the young woman may not be allowed to care for her baby for fear of infecting the newborn with TB. But Dr. Tracy needs to balance these fears with the possibility that the mother will refuse the x-ray out of concern that it will expose her unborn child to radiation, despite the very low radiation exposure with a chest x-ray.
The young mother informs Dr. Tracy that she has had the chest x-ray at a hospital other than MGH. However, the results are not in the patient's chart meaning Dr. Tracy will have to track down the x-ray results by contacting staff at the other hospital.
Patient number four is a perimenopausal woman Dr. Tracy spends a significant amount of time patiently asking the woman about pain she has been having "in her ovaries." Dr. Tracy suggests that the woman have an ultrasound to rule out a medical problem.
Ordering the ultrasound is something that would have been done by support staff at MGH but here at the health center Dr. Tracy will need to make sure the ultrasound is ordered and follow-up on the results. Later Dr. Tracy tells me how grateful she is to have so much support staff at MGH. She would love to see more patients at the health center but logistical challenges make this impossible.
During the visit, the woman mentions having a procedure that does not exist. After the patient is examined and leaves, Dr. Tracy and I discuss the importance of health literacy, one of Dr. Tracy's advocacy interests.
The fifth patient of the day is a pre-operative patient complaining of pain with a history of endometriosis and post-menopausal bleeding. The patient has a polyp in her uterus that needs to be removed and wants to go under anesthesia for the procedure although Dr. Tracy has also offered to perform the procedure in the office at the hospital instead. Dr. Tracy will need to follow and keep track of any of the lab tests prior to surgery. After I step out of the room, Dr. Tracy gives the patient a pelvic exam and writes an order for her to be seen at MGH for pre-operative anesthesia testing.
The next patient does not show up for her appointment. This was not too surprising given the morning was snowy and the city had declared a snow emergency. The patient is a forty-eight year-old woman with an abnormal pap smear so Dr. Tracy is anxious to have her come in for a follow-up appointment in case she has cancer. Dr. Tracy's nurse called to reschedule the patient for the next available opening.
The seventh patient of the day is a young woman in her twenties who is 19 weeks pregnant. The doctor checks to see how she is feeling and whether or not she has had any cramping on bleeding. They discuss the pregnancy thus far and the woman's testing Rh negative prior to her current visit. Dr. Tracy checks for the baby's heartbeat with the Fetal Doppler machine and the look on the young woman's face when she hears the whooshing sound that the baby's heart makes is pure joy.
Dr. Tracy ends her day making a final phone call to a patient who is receiving good news. Although the patient has fibroids, she does not have cancer: a happy outcome that Dr. Tracy is anxious to share with her patient as soon as possible.
Despite the logistical challenges of providing care in often underfunded neighborhood health centers, these centers provide excellent care across a myriad of specialties in locations that enhance access for patients to services in their own communities. Dr. Tracy acknowledges and is grateful for the dedication and expertise of the many staff members with whom she works at the health center, and finds the work incredibly important and rewarding.
Conclusion
Dr. Tracy credits her outside life as a wife and mother as crucial to finding the balance that helps her deal with the stress of her job. "It's how I survive," she said simply. She is careful to compartmentalize her life into work and home and strives for quality and efficiency. She acknowledges the love and support of her husband, Robin, and of her 3 children: 9 year old twin daughters, Shannon and Bridget and her 6 year old son, Kevin, as being instrumental in her being able to find happiness and fulfillment in her many roles.
Dr. Tracy credits her father, a cardiologist, as a role model in finding this essential work-life balance. "With my father it was quality, not quantity," Dr. Tracy said. "I remember him as very present throughout my childhood even if he didn't make it to every sporting event or activity."
Dr. Tracy is very fulfilled by the balance she has achieved, professionally and personally, in her many roles: surgeon, obstetrician, gynecologist, scholar, author, teacher, mentor, activist, wife, and mother. Still, challenges remain. For Dr. Tracy those include increasing volumes of cases with less resources available to deliver care, a broken professional liability system, limited and often flawed performance measurements related to payer tiering, a shortage of primary care physicians, and the public's mistrust of the medical establishment. Despite these issues, Dr. Tracy remains fulfilled by the diversity and complexity of her many roles and by the profession of medicine. She epitomizes the balance working mothers and physicians can achieve.
Therese Fitzgerald, PhD
Part 1: Standing By ››
Part 2: Achieving Balance ››
