Poverty Doctor

KoreAm Journal/March 2005
Story & Photos by Bill Stephens

Even though it's early Thursday, Dr. Emily Dow moves quickly down the long narrow hallway of Clinic B at UCI Family Health Center--Santa Ana.

The mostly Latino patients are starting to fill up the adjacent waiting room, hallway, and small exam rooms.

The 47-year-old South Korean-born Dow wears the white lab coat of her trade with a silver and black stethoscope around her neck. Dow is 5'2," slim, with short black hair. Dow calls the medically underserved Santa Ana community the clinic serves the "third world of Orange County." Set in a lively neighborhood dotted with small Latino businesses, the clinic provides low cost quality medical care for the poor. Seventy percent of its patients are Latino, mostly Spanish-speaking immigrants. Some 40 percent are without medical insurance and most are below federal poverty levels.

Dow puts in 10 hour days, doing patient care, administration, and teaching medical students and residents. Today she's seeing patients back-to-back all day, 15 minutes per visit.

"It's hectic," says Dow, who is medical director of the family medicine clinic at UCI Family Health Center--Santa Ana, where she's assistant director of the center. "Patients flock here. Often very sick, they want to be seen right away."

The clinic sees a lot of diabetes, high blood pressure, high cholesterol, obesity, so-called "lifestyle" diseases. Patients often acknowledge risky behaviors like smoking, poor diet, sedentary lifestyles. Dow sees a lot of hepatitis C and liver disease from drug use or drinking.

Dow's 9:45 patient is an uninsured Latino woman with high blood pressure and low back pain that prevents working. Dow talks to the woman in fluent Spanish in a concerned, professional manner.

From previous visits, Dow knows the woman can't afford expensive tests and medicine, physical therapist, or orthopedic surgeon. Instead, Dow orders a plain x-ray, arranges for free medication, shows the woman back exercises, and encourages diet improvements.

Poor patients are unique, Dow says. "You often deal with not only health problems, but psycho-social issues. They are often depressed or stressed because of finances and family conflict, because they can't find a job or pay rent."

They can't afford all the tests she'd like to do, and are often sicker than average, with multiple problems exacerbated by lack of medical care.

"Our patients are not well-informed medically, often lacking middle class competency skills," Dow says, adding that because poor patients focus on daily survival, they often don't keep appointments and ignore doctors' instructions.

"It can be frustrating. But most patients are grateful, delightful people who remind you daily you are filling a need."

Earlier, Dow says, a new Latina patient proclaimed: "You are a woman! You speak Spanish! Can you be my doctor forever?"
Recently, Dow says, a pregnant teen patient stopped smoking. "It made my day."

"My next patient is another example," Dow says, emerging from her small, windowless shared office.

He's a nearly blind Spanish-speaking man who needs eye surgery. He doesn't have insurance, but found a doctor who will operate free. But blood pressure and diabetes out-of-control recently forced Dow to postpone the surgery. "He was disappointed, but remains cheerful, and keeps coming back."

The man can't afford expensive diabetes and blood pressure medications, but Dow arranges for free medications, and reminds him about health habits. The man's son says they like Dow because she's nice, is a good doctor, and speaks Spanish.

En route to her next appointment, Dow says knowing Spanish "helps me get closer to patients and learn their personal history."

Dow's next patient speaks English. "My hair is falling out," the woman says. "I thought I better come right away."

Dow examines the woman's scalp, identifies a skin rash, and prescribes medication that will solve the problem. The woman leaves happy.

Retreating to the nurses' station to chart, Dow is also happy. "Usually, I'm treating many problems in the same visit," she says.

Working with poor patients requires creativity.

"We can prescribe all the medications in the world. But if our patients can't pay for them, what will they do? We negotiate what we can do within their confines.

"I use patient assistance programs for medications, plus free pap smear and mammogram programs. Community agencies offer education and emotional support for patients.

"I tell patients where they can get help for psychological and financial problems. We have a clinical social worker here who provides free counseling. I often encourage patients to finish school."

When it comes to keeping appointments and following instructions, she's tolerant but not patronizing. "We shouldn't lower our expectations. Poor patients can learn to function better in this society.

"I encourage them to take responsibility for their health and lives, to solve their problems in an assertive manner. They tend to be fatalistic and just let things happen to them.

"Practically every visit, I encourage patients to improve lifestyle habits, negotiating small steps rather than overnight change."

Dow also guards her own health. "I get drained because patient problems are multi-faceted. It takes all you have to gather up the resources to help them."

"Because there's a lot of burn-out among physicians practicing poverty medicine, you have to realize you can't solve all their medical and personal problems. Talking with colleagues in the same line of work helps, and I try not to take myself too seriously."

As a child in Seoul, Dow enjoyed a middle class life because both her parents worked--her father as a seminary teacher and her mother as a nurse. But when Emily came to America in 1968 as a 10 year old, her family suffered downward mobility. Her father struggled to find work and her mother tried to master English to hold down nursing jobs to support the family of five. They moved from city to city, settling in Los Angeles, where they moved from apartment to apartment. The family lived in a one bedroom apartment south of L.A.'s Koreatown in a neighborhood so rough that her father pretended he was armed when he met his wife's bus each night.

"It was hard for me to fit in," Dow says. "I didn't belong to either Korean or American culture. Plus, I was very shy. Ever since, I've empathized with underdogs."

But Dow was good enough in school to make UCLA, where she earned honors in linguistics. Today, she speaks Korean, English, Spanish, and some French, German, and Japanese. After a master's in Teaching English as a Second Language, Dow taught English for a year in Seoul. "I got in touch with my Korean identity, but found Korea too restrictive then for a career woman," says Dow, who describes herself as strong willed, independent, self reliant, hard working, idealistic.

After Korea, Dow enjoyed teaching English four years to immigrants at a community adult night school in North Hollywood. A friend suggested medical school.

"I laughed," she recalls. "But when I thought about it, it fit."

Dow wanted a career combining her love of languages, traveling, different cultures. "I wanted a portable skill helpful to the less fortunate which addressed universal health care needs."

While pondering medical school in 1984, Dow read an article about two women who started a clinic in South Los Angeles. "Wow!" she said to herself. "That's what I want to do."

Her growing desire to help the poor, Dow says, probably came from her mother's nursing profession, her immigrant identification with underdogs, teaching English to doctors in Korea, and the then much-reported Ethiopian famine.

So while teaching English at night, Dow took science classes during the day, and ultimately entered University of Cincinnati College of Medicine at age 30, keen on poverty medicine.

"I didn't want to do something any doctor could do in any suburban neighborhood. I wanted to contribute to more equitable distribution of resources."

After her residency in family medicine at Harbor-UCLA Medical Center, Dow became a staff physician and later medical director at South Central Family Health Center, the same clinic she'd earlier read about. "It was challenging and fulfilling, and I learned a lot."

After working with the impoverished Maya for six months in Chiapas, Mexico, Dow was hired by UCI in 2000. She worked as a staff physician at Family Health Center--Anaheim before coming to the UCI Family Health Center--Santa Ana.

At 12:30, Dow jumps into a lunch meeting with clinic residents, who along with medical students, see patients under the guidance of UCI Family Medicine faculty.

Dow reappears at 1:30 to work station three, where she greets third year UCI medical student Steven Smith, for whom she has been a preceptor-teacher for the last month. Dow has won awards at UC Irvine for her teaching.

"I've learned a lot from her," Smith says. "She cares about you learning the concepts." He says she helps him rethink his diagnoses, but with a smile.

After Dow dispatches Smith to a patient, she is again moving from room-to-room seeing patients.

In one exam room Dow sees the familiar face of a white man with multiple medical problems including heart disease. He has stopped drinking and curtailed smoking, but recently became dizzy.

"Did you pass out and then fall? Dow asks.

"No, I just became dizzy."

"Can you describe your dizzy feeling?"

"I just became disoriented."

"Still no drinking? she asks.

"Yes. And that's something, because I love beer."

"Well, keep it up. How about smoking? Still down to a pack a day?"

He nods.

Dow moves on to a young Latina who complains in English about debilitating headaches.

"They move across the whole side of my head," the woman says. Dow:

"Under more stress recently?"

Woman: "I don't think so."

Dow notices a soft drink can.

"We got you to cut back on soft drinks."

Woman: "I just had that one today."

Dow: "Reducing caffeine can cause headaches. But I think these are tension headaches."

Dow prescribes medication and reminds the woman to drink fewer soft drinks.

Dow says the only primary care doctors willing to work in poor neighbor-hoods are often people from underserved minority backgrounds, and foreign trained physicians.

"Medical students are idealistic. But then reality sets in. They have large loans to pay, and want to start families. Lifestyle is important to most physicians--nice office, good pay, and time for family. After the rigors of medical school and residency, who wants to go into the trenches?

"Also, many physicians don't want to work with patients who can't afford the medication and tests they are trained to prescribe."

She says poverty underlies many health problems, and doctors can't solve poverty. "But we can help poor people lead healthier lives and take charge of their health."

Dow favors a national health insurance system so everyone is taken care of. She favors more programs to encourage medical students to work with the poor, noting a government loan repayment program for doctors who go into underserved areas.

"We need to expose med students to the underserved," says Dow, who notes UCI School of Medicine has a new program for students wanting to work with Latino underserved, and that the residency program is recruiting residents committed to working with the poor.

The patient load at Dow's clinic doesn't let up. She sees a young Latina who complains of severe itching all over her body. Dow prescribes medicine and suggests dry skin care.

A Cuban lady Dow has been treating for acid reflux happily reports enough improvement that she wants to stop the medication.

More patients arrive. Dow will not leave for home until 6:30 in the evening.

Away from work, Dow enjoys reading, traveling, watching cooking programs.

She has traveled the globe, and continues to visit new countries.
However, she now spends a month of her annual vacation treating the indigenous poor in Chiapas, Mexico with Doctors of the World. "The patients are even sicker there, with malnutrition an underlying problem."

Someday, Dow would like to work with refugees, perhaps through the United Nations.

Dow has no career regrets, even though she could earn more elsewhere. "Money isn't a motivator for me. I'm just trying to do my part to make things more just.

"I'm no saint. My goal is to be a useful human being, and I gain a lot personally from what I do.

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