Primary Care in the West 7th Community—Tradition and Evolution

The Twin Cities is fortunate to have many strong Family Medicine residencies, and United Family Practice Residency (UFPR) is no exception. This 27-year-old residency program is steeped in rich St. Paul history, staffed by a faculty, about half of whom have been with the program for over 20 years, inspired by residents who are drawn to the program from all over the country, and housed in a Federally Qualified Health Center (FQHC). The unique local nature of UFPR is evident from the moment residency applicants set foot into the clinic. They are taken on a tour of the West 7th neighborhood and given a history lesson, because both the community we serve and the roots of our clinic define us. We descended from the Wilder Infirmary, which began providing free and low cost care in the 1930s at Miller Hospital. When Miller Hospital merged with St. Luke’s Hospital, the Wilder Infirmary became the Miller Outpatient (MOD) Clinic. United Family Practice Health Center evolved from MOD Clinic and Helping Hand Health Center, which was started by St. Luke’s Hospital and West 7th residents. Four of the physicians from the time of this merger continue to practice medicine at United Family Practice Health Center. Dr. Tim Rumsey could boast (but does not—we do) that he has in his panel patients he has seen for 40 years and he has also provided continuity of care to some of the most transient of patients—our homeless population. The clinic operated under United Hospital,

within the Allina Health System, but has since become a FQHC, maintaining the 90-year commitment to promote access to comprehensive patient-centered primary health care for low income and medically underserved St. Paul residents. In keeping with the theme of continuity and longevity, the residency is led by its original director, Dr. Kathleen Macken. It is not unusual for a resident to attend a delivery with Dr. Macken and discover that she had been at the delivery of the laboring mother, as well as the father, multiple aunts, uncles and cousins. The strength of the relationships she has developed with her patients was illustrated when the residents asked her to see one of her patients in the ICU at United Hospital. She found a very tense situation as she approached the room. A couple of security guards and the chaplain were standing outside a patient room. Dr. Macken had been the patient’s physician through her pregnancies, attended her deliveries and provided primary care up until this admission. The patient’s children were now large men in their thirties and staff felt threatened by them as discussions of their mother’s poor prognosis were not well received. There was visible relief on the faces of these men, when they saw her approach and they asked her if there was truly nothing more that could be done for their mother. She gently told them she agreed with the ICU staff. The patient’s sons were immediately satisfied and agreed to transition their mother to comfort cares. Due in large part to the strength of family practice physicians in providing prenatal care, Dr. Macken was asked to take over the directorship of a prenatal clinic, which had been started by a perinatologist, at Face to Face Clinic on the East Side in 1992. Faculty and residents care for pregnant and postpartum women here between the ages of 12 and 25 years of age. For many of the young mothers seen there, relationships forged with residents and staff are the first profound experiences with primary care. UFPR’s commitment to the community extends beyond providers providing excellent care. From its inception in 1992, UFPR has been committed to Community Oriented Primary Care (COPC) and each resident participates in a longitudinal project that partners with community members to assess and respond to the community’s needs. Projects have included community gardens, project coordination in local homeless running groups, establishment of a multi-disciplinary geriatric assessment clinic, engagement with Reach Out and Read, a national early literacy program, and electronic mapping of neighborhood assets.

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As a result of one of these resident COPC projects, the clinic began to provide CenteringPregnancy, a group prenatal care program, which has been shown to decrease the rate of preterm births, low birth rate babies, and increase breastfeeding rates by combining risk assessment, prenatal education and support into one entity. One teenage mother told me that her Centering group gave her the courage to face labor. Point of care ultrasound made its way into the curriculum thanks to the efforts of a recent graduate of the program who joined the faculty. Hand held ultrasounds are now well utilized by residents, as well as senior faculty. The clinic has implemented a medication-assisted treatment program for opioid addiction, partnering clinicians with behavioral health staff. Residents have been quick to adopt the Integrative Behavioral Health into their continuity clinic flow, pulling in dedicated behavioral health staff to see patients in real time, who may be interested in behavioral change to adopt healthier habits, who may be actively experiencing grief, or whose anxiety creates barriers to improving their health. I am grateful to be able to drop into our dental clinic for curbside consults and to refer more urgent patients quickly. We have also forged a medical legal partnership with the Mitchell Hamline School of Law, which has been instrumental in relieving the stress of many of our patients. The faculty are extremely well-rounded. We are all practicing physicians with busy patient panels and work in both the inpatient and outpatient settings. Fewer opportunities exist that allow physicians to practice in both settings. The continuity of care has been rewarding for the faculty, whose patients appreciate seeing a familiar face when their health deteriorates or when they are experiencing labor. Residents witness the entire spectrum of disease processes and learn from core faculty the role primary care plays in managing much of what walks in the clinic or the emergency room. The opportunity to speak directly with consultants at the hospital has been invaluable, particularly when many of our patients are uninsured or under insured and we can coordinate care in creative ways. One essential component to the UFPR is the quality of care provided to every patient, regardless of income or background. One room can find a homeless man and the next room could be occupied by a local TV celebrity. Sixty percent of the patients are covered by medical assistance, 20% are uninsured, and 20% have commercial insurance. Residents have a panel of patients that range from fetal to geriatric, from mentally resilient to psychotic, from pleasant to combative. A major sustaining force for the providers at our clinic model is the engagement and opportunity to work alongside highly motivated residents; the newest generation of physicians maintains the curiosity and optimism to provide exemplary primary care to the culturally rich and diverse population of the West 7th neighborhood and beyond. It is truly a privilege “To Serve and To Teach” in a clinic that began 90 years ago with the Wilder Infirmary and provide compassionate, respectful health care for the urban underserved here in the West 7th neighborhood of St. Paul.

Sue Inoue, MD has been a faculty member in the United Family Medicine Residency for 19 years. She attended the University of MN Medical School after graduating from the University of Chicago, followed by a Residency at St. Paul Ramsey Medical Center and Maternal Child Health Fellowship from West Suburban Hospital in Oak Park, IL. She is a member of the Board of Directors of the MAFP Foundation. Dr. Inoue is a soccer mom with a minivan, insisting all children sharing her residence study music. Favorite decompression activity—knitting. Least favorite, running, but can’t give it up.