Teaching culturally humble primary care

For a doctor to care for a patient in the most effective way possible, the two must have open lines of communication. Some might call it a shared language.

In many instances, that statement can be metaphorical. In watching her trainees grow from medical students to primary care physicians working on the front lines with the underserved populations in Northern California, Tonya Fancher, MD, MPH, has a different vantage point.

“It’s just so beautiful to witness the care between doctors-in-training and patients,” says Dr. Fancher, the associate dean for workforce innovation and community engagement at the University of California, Davis School of Medicine (UC Davis). “The way the students humbly seek and share information, and when they also share a common language, background or culture, there’s just nothing more beautiful to me.”

A recent interaction stands out.

A Spanish-speaking woman came into one of UC Davis’ community clinics. She was wrapped in a Cookie Monster blanket—it read “galletas,” Spanish for cookies. She was ill and upset and unable to understand what was happening around her. Her demeanor changed when the resident physician spoke to her in Spanish, their shared language, and talked about their shared immigration experience.

“The way she transformed in those few minutes was amazing,” Dr. Fancher says. “The power of sitting down and talking with someone—when you can speak their language or share an interest or experience, that immediately puts them at ease in a way that most of us could not—is amazing.”

Fifteen years ago, an interaction like the one Fancher described was harder to find, particularly in the underserved communities surrounding UC Davis.

When she arrived at UC Davis for a health services fellowship, she was struck by the lack of continuity of care some patients received. It differed from what she had seen as a medical student and resident at New York University School of Medicine, where Bellevue Hospital and the school’s community clinic operated as a single entity.

“When I first started at UC Davis, I remember seeing a patient whom we diagnosed with cancer, that really needed coordinated care and follow-up but we were unable to see them in our clinic,” says Dr. Fancher. “They left the hospital and we worried and worried about them. As a primary care doc, and as an educator of future physicians, that just broke me. So, I went back to NYU to ask how they did it.”

Dr. Fancher’s inquiries planted the seed for a concept that has shaped UC Davis’ approach to training the next generation of physicians: Improving access to care for all requires an intentional effort to recruit and train physicians who will provide culturally humble primary care where it is needed most.

A decade and a half later, UC Davis’ TEACH Program—where care to the underserved is provided at the Sacramento County Health Center the school staffs with medical students, residents and faculty—has served the diverse needs of Sacramento and the surrounding community.

“With incredibly supportive and visionary leadership, we have made great strides.  But we continue to see patients who come to the emergency room because they don’t have primary care where they live,” Dr. Fancher says. “That just seems like a solvable problem.” 

When Dr. Fancher entered medical school, she felt disconnected from her purpose.

“As I sat in the lecture hall, I thought, when do we get to start taking care of patients?” Dr. Fancher says. “That’s really not how it worked. The coursework was really difficult for me and I needed to find a place to give me purpose and remind me why I need to master anatomy and biochemistry, so early on I started to volunteer in the adolescent clinic to teach about safe sex.”

She uses that experience—the disconnect and difficulty—to inform how she interacts with students.

Melody Le Tran, MD, was one of the first students to enter the Transforming Education and Community Health for Medical Students (TEACH-MS) program.

Dr. Tran considers Dr. Fancher a mentor and crucial figure in her medical training. The day before a pharmacology final as a second-year medical student, she turned to Dr. Fancher for help.

“I was really struggling to connect to the material, and I couldn’t study,” Dr. Tran says. “I reached out to Dr. Fancher who suggested we meet, even though it was a Sunday. She took me to the hospital where I met a patient who was on 10 different medications and didn’t have a good understanding of why each was important. The woman also did not have a primary care doctor. Dr. Fancher asked me to sit down with the patient to review each of the medications, explaining what they were for and how they worked. In that moment, she helped me reconnect with why I came to medical school.”

Dr. Fancher believes that it’s vital to foster connections between students, their patients and their communities—and the impact their work will have throughout their training.

“Students come to medical school passionate about equity and social justice,” she says. “The experience of training is so hard that they sometimes develop this hardened shell that can suffocate the social justice mission that they came in with. That’s heartbreaking to me.”

The Association of American Medical Colleges predicts the nation could see a shortage of up to 120,000 physicians by 2030. The shortage of primary care physicians alone could be as high as 49,300. That shortage is also expected to be dire in the Golden State where, according to a study by the California Future Health Workforce Commission, the primary care physician shortage could exceed 4,000 physicians in the next decade.

Much of Dr. Fancher’s work—such as the Accelerated Competency-based Education in Primary Care program, which aims to create primary care doctors quicker—is aimed at meeting that need.

“Students who are applying to medical school recognize that primary care is a dire need,” she says. “But primary care is a really hard job and is not for everybody. What we’re trying to figure out is who are the people who are committed to primary care and what can we do to best train them for residency and for practice.”

In the search for students who stick, UC Davis is in the midst of what Dr. Fancher is calling the “admissions revolution.” When a medical student applies to UC Davis, weight is given to factors beyond test scores and undergraduate GPAs. Those factors include a student’s experiences, background, the community from which they come and where they intend to practice. Enrollment at the medical school echoes California’s diverse cultures and geography.

“There are lots of patients and communities north of us that don’t have enough doctors,” Dr. Fancher says. “We are working with the community health centers in those regions, and supporting pathway programs there, to identify local students and train them in place, thereby preparing them for practice in that community.”

That approach will contribute to reducing disparities in care.

“We know that the more primary care physicians there are in a region, the longer people live,” Dr. Fancher says. “And we know that when a black patient is seen by a black physician that they also fare better.”

Now a faculty member at UC Davis, Dr. Tran fits the bill for the type of medical students the institution is looking to recruit.

“Davis strengthened my desire to train in primary care,” Dr. Tran said. “The reason I came to medical school wanting to be a primary care doctor is because of my family’s background as refugees from Vietnam. I often think about how people, like my family, come here to try to build a better life and they have such a difficult time accessing basic medical care.”

That physicians who train at UC Davis seem to keep the most vulnerable patients top of mind offers an indication that the work the institution and Dr. Fancher are engaged in is paying off.

“I am proud to be a part of a team that aligns a medical school with regional health systems to provide (specialty and primary) care and to intentionally recruit and train the next generation to continue the mission.” Dr. Fancher says. “It’s about creating all types of doctors who will take care of patients in the places that need them.”

UC Davis, a member of the AMA Accelerating Change in Medical Education consortium, has a number of projects that aim to train residents and students to meet the needs of the population. Among them:

• The Transforming Education and Community Health for Medical Students (TEACH-MS) program, directed by Dr. Fancher, has expanded medical student training opportunities in community-oriented care for urban populations.
   
• Rural Program in Medical Education (Rural-PRIME) and Reimagining Education to Advance central California Health (REACH-PRIME)  provide students experience working with patients and families from culturally diverse backgrounds in California’s rural and Central Valley regions.
   
• The Accelerated Competency-based Education in Primary Care (ACE-PC) program is a collaboration with Kaiser Permanente Northern California that enables students to graduate in three years and enter primary care residency. Founded by Dr. Fancher, ACE-PC earned a $1 million AMA grant.
   
• California Oregon Medical Partnership to Address Disparities in Rural Education and Health (COMPADRE). This collaboration between Oregon Health & Science University and UC Davis, 10 health systems, 10 institutional sponsors and federally qualified health centers will address workforce shortages in disadvantaged communities between Sacramento and Portland. Dr. Fancher serves as one of primary investigators of the program, which was awarded a substantial AMA Reimagining Residency initiative grant.