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Primary and Preventative Care for the Underserved | NEWS-Line for Physician Assistants

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FEATURE STORY 11/01/2008
Author: Rebecca Bryan  
Primary and Preventative Care for the Underserved
"I have always felt a need to work with an urban, underserved population," says Lisa Benish, PA-C. "I chose the physician assistant profession because I felt that PAs were increasingly in need and I felt that it was a career that would enable me to provide cost effective care in a team with others in an underserved setting." As a PA for West Side Community Health Services (WSCHS) in St. Paul, Minnesota, Benish is killing two birds with one stone, fulfilling both her need to work in an urban environment, as well as the country's need for PAs within that setting. And what's more, she takes pleasure in doing it.

"I think it really has to do with the fact that I like being around a highly diverse population," says Benish of her decision to become a PA in an underserved environment. "And it's interesting, to me, to be around people that speak different languages and come from different cultures, and to learn from them about their different cultures and languages."

Benish has been working at WSCHS, a federally qualified health center (FQHC), since 2005. "FQHCs are organizations that serve populations with limited access to healthcare," she explains. "FQHCs provide comprehensive, culturally competent, quality primary healthcare services to medically underserved communities and provide healthcare with fees based on ability to pay." WSCHS is the largest FQHC in Minnesota, she adds, with several clinics throughout the Twin Cities metro area.

When she first began at WSCHS, Benish practiced in two small clinics located within public housing complexes. After one of the clinics closed in 2006 and combined with a larger clinic who's goal was to "expand healthcare access on the east side of St. Paul," Benish followed and has been working at the larger clinic, East Side Family Clinic, ever since. "Our organization, WSCHS, serves and urban population that is multicultural and multilingual," she states. "The patients are diverse racially and ethnically with a high percentage that are African American, Asian (primarily Hmong), or Latino." She notes that a lot of her patients are either uninsured or underinsured and many patients have incomes 100-200% below poverty level.

Whether or not a patient has the funds for healthcare is essentially a non-issue throughout the WSCHS clinics, Benish explains. "[Our] focus is to provide high quality, culturally competent and affordable healthcare to all, regardless of background or ability to pay." WSCHS also offers diabetes, asthma, prenatal, and adolescent care, as well as mental health care and nutrition services.

As a PA, Benish's main focus at East Side Family Clinic is providing both primary and preventative healthcare. From newborns to geriatrics, she sees a wide variety of patients, approximately half of which are pediatric. She says that her appointments in the pediatric arena include anything from well child checkups to teen contraception and management and treatment of STIs. As far as her adult patients are concerned, she treats those dealing with diabetes, mental illness and kidney, liver and cardiovascular disease, among other chronic diagnoses. "Additionally, our clinic serves a lot of immigrants and refugees," she adds. "These patients have a higher incidence of various infectious diseases like chronic hepatitis B, TB and parasitic diseases."

According to Benish, on a daily basis, she can see any number of these issues come through the door of the clinic, although certain parts of her day may be dedicated to specific appointments. For example, she only sees well child checkups on Friday mornings. "So, I have some specialized days in that sense, but typically it can be anything." She explains that while she does everything in her power to provide the best treatment for her patients in the office, making sure that they follow through at home is an entirely different story. Because many of her patients are not able to take care of themselves outside of the office, Benish is always brainstorming ways to help them work around this problem.

"Over the years, I've learned a lot of tricks in trying to help people who don't really have the resources available to get the care that they always needed," she elaborates. "Some ways that I work around their needs [are]: I help people apply for assistance programs with pharmaceutical companies; I know a lot about the cost of different medications and where to get them for less of a cost; and I also work with a social worker who is very helpful in [providing] different services and letting me know of transportation services or community resources to help people follow through with different things." She adds that she also encourages her patients to take advantage of free services offered each year by the state, for example free pap smears and mammograms for the female population.

However, while she may be able to offer her patients ways to keep up with their healthcare, it is ultimately up to them to really commit to taking care of themselves 24/7, Benish explains. She says that though some patients really work to keep themselves healthy, others simply do not respond to her assistance, which can be frustrating. "I find that if I find the right combination of things to work [for] the person—resources or education, whatnot—then I do get some good response," she says. "I have a lot of diabetics who are successfully treated [and] might not otherwise be if they didn't have our services, but it does depend on the person, too, for sure." And when that person does not want (or cannot afford) to do what they need to do in order stay healthy, Benish does whatever she can to accommodate them. "Sometimes they'll just simply refuse to see a specialist, and I do my best to try to consult with them on the phone to see if there is a way that I can help manage them outside of specialty care."

Having worked in an underserved, urban setting for several years now, Benish is certainly dedicated to ensuring that this often forgotten population receives quality care. Therefore, the notion of "Pay for Performance" is one of her main concerns within the PA profession. Her fear is that if PAs are now practicing or begin to practice based on this idea, many patients who are not able to control their diseases due to their environment or financial situation will not get the care that they need and deserve, which could "potentially increase healthcare disparities." She elaborates, "I work with many patients with healthcare disparities and poorly controlled chronic conditions, and I fear that many providers will refuse to care for these individuals in the future for financial reasons. It is not beneficial financially to care for those who have poorly controlled chronic conditions. Many patients who have poorly controlled chronic diseases have barriers to reaching control, or they are simply not motivated to get involved in their own health. Who will be there for these patients if ‘Pay for Performance' is the future?"

While she does have several concerns about this issue, Benish explains that, for both herself and her fellow PAs, "it may [push] us to focus more on chronic care management than what we're already doing, and that could be a good thing." She feels that in order to avoid the possible negative repercussions of "Pay for Performance," PAs need to work on motivating their patients to keep up with their own care as best they can. "I think it is difficult because patients aren't always going to do what we recommend, but if we can learn to motivate them better, that may help the situation," she notes. "I'm hoping that patients will be held accountable a little bit, too."

Though she does go above and beyond for her patients, Benish also recognizes the importance of leaving her work in the workplace and not letting it take over her own life. "It can be difficult," she admits. "I guess I've tried to learn, over the years, how to leave every day and not think about patients at home; as far as trying to always have a plan with a patient, so that when I get home I'm not thinking, ‘Oh, what if this happens? Or what if that happens?' But it is a challenging population and the stress is there."

Beyond the actual population itself posing certain obstacles for Benish on a regular basis, another significant challenge she faces is the little time she has in which to see them. Because each appointment is only approximately 15 minutes long, Benish finds it can be difficult to accomplish everything she would like within that time. She acknowledges that can be an issue for anyone who practices in family practice and explains that "a very effective team" can make all the difference in the world. "I definitely think I wouldn't be able to do all I do in 15 minutes if I didn't have a medical assistant [who gets] all the vital signs and…[has] everything I need before I even go in the room, or a staff at the front desk who checks people in and gets everything flowing, [or] the laboratory people there to help with questions and accessing reports." She notes that having colleagues in specialty areas, such as social work, nutrition and mental health, on hand also certainly makes her job easier "because a lot of [the patients] have psychosocial needs that really are difficult to address in a small amount of time, too." Additionally, Benish explains that interpreters are very helpful when it comes to speaking with non-English speaking patients, though she adds that she is hoping to take some Spanish classes in the future in order to better communicate with them.

Challenging as working with an underserved population may be, Benish finds it to be extremely gratifying. "I like the ability to be challenged," she shares, "and it's interesting to me to be the one to reverse certain conditions and deal with [them]. So, [overcoming] the challenge itself, that's a reward for me."

Seeing how appreciative patients and their families are of the specialized care she provides is also a great feeling, she says, recalling a specific little boy that she recently worked closely with. Benish diagnosed the boy with renal tubular acidosis and worked to set him up with a specialist to help manage the disease. "They didn't have appointments for quite a few months, so while waiting for him to get through to the specialist, I contacted [the specialist] and asked [her], ‘How should I manage this patient?' She gave me specifics on what to do and so I started to manage the patient. [He] eventually went to specialty care, but [he and his family] came back to me saying, ‘You know, I just want to him to follow you. I just want to see you. You've done everything. That specialist only just talked to me and sent me out the door. Can you just monitor him now?'"

It is situations such as this that have allowed Benish to realize that not every patient can be treated with the same techniques and protocol. Not everything is by the book and every case needs to be treated in a way that works well for the patient. "I've learned that there is such an art to medicine," she states. "If you only try to work with the cookbook kind of solution to treating patients, then it doesn't necessarily work. You have to try to think about the patient and their situation and how to help them with their health with who they are. So, that's where the art comes in, I think."

Looking to possibly go back to school for her master's in public health down the line, it seems as though Benish was certainly correct in following her initial feelings when choosing this career path. She stresses that PAs are definitely essential in any underserved community and hopes that more PAs will think about taking a position where they can serve this population. "There are so many community health centers across the country in need of physician assistants," she says. "I encourage other PAs to consider filling primary care needs that will improve healthcare quality, accessibility and affordability to all."

Lisa Benish, PA-C, earned her BS in cell and molecular biology from Winona State University in 1996 and her PA certificate from Ausburg College in 2001. She also has been NCCPA certified since 2001 and has been a PA at West Side Community Health Services in St. Paul, Minnesota since 2005. Benish is active in the Minnesota Academy of PAs and encourages others to become involved in their state and national associations.

Rebecca Bryan is the associate editor of NEWS-Line for Physician Assistants.

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