Back home at Hopkins following their Native American experience, (l to r), pediatric residents Amena Smith, Laura Scott, Kristal Prathe and Helen Hughes.
Facing residents and faculty filling Johns Hopkins Chevy Chase auditorium last fall, pediatric resident Amena Weston Smith discussed the health care needs of Native American children in this country. In her talk, entitled “The New Morbidity of Native Americans,” she noted that these children face an overwhelming burden of disease with higher rates of depression and mental health disorders, drug and alcohol abuse, adolescent pregnancy and youth suicide, chronic illnesses like diabetes, and a higher incidence of obesity than their non-Native American counterparts.
She added, “One thing that stuck out was the high child mortality from injury, which is three times higher compared with other ethnicities.”
Smith’s presentation was prompted by more than an interest in researching the health status of Native American children. She had just completed a one-month rotation at Tuba City in northeast Arizona, where Johns Hopkins pediatric residents face these health disparities first-hand. Why did she go?
“I wanted to understand why we go there, the health care needs of Native American children in this country, and how we help meet them through our elective,” Smith said at a recent Johns Hopkins Children’s Center Grand Rounds.
That’s a commonly heard motivation, says Johns Hopkins Pediatrics Residency Director Janet Serwint, noting that the Indian Health Service Elective has been offered to residents since 1992. In total, some 240 pediatricians in training have gone through the program, caring for children from 8 a.m. to 5 p.m. each day in Tuba City’s Indian Health Service Hospital, its pediatric ambulatory clinic and emergency department, and twice monthly in the local high school clinic. Living in an apartment adjacent to the hospital and clinic, they are “deeply integrated” in the community, which, Serwint adds, helps them understand the patient in the context of their daily lives.
“They run into people in the grocery store, see them on the street, interact in meaningful ways to better understand their environmental, lifestyle and medical issues,” Serwint says. “It’s a very powerful experience.”
Part of the elective’s allure is also prac-ticing in an extremely rural environment and treating a homogenous patient popu-lation with chronic conditions, as well as some exotic ones. “Scorpion bites have not been on my differential diagnoses here in Baltimore,” says Serwint, “but they were in Tuba City.”
Practicing in a different culture is an-other attraction, adds Serwint, noting that the experience helps the pediatrician understand the medical, social and emo-tional issues important to patients and their families.
“How does the culture guide you, how do customs and the family’s health care beliefs guide your negotiation with the patient?” Serwint says. “This experience helps inform their future decision making. It’s certainly good preparation for community practice.”
Pediatric resident Kristal Prather agrees, citing the community commit-ment and cultural sensitivity of Tuba City pediatricians she worked with.
“Families do come with a certain set of beliefs and practices, which helps you achieve the health goals for the family,” says Prather. “Practitioners in Tuba City feel it’s very important to integrate your-self into the community.”
Among the challenges, Prather adds, is managing patients living in very rural areas. Navajo Nation is sparsely populated with some 150,000 people scattered across an area about the size of West Virginia. Many residents live miles from town in dilapidated trailers or small ramshackle homes on dirt roads with little or no access to electricity and running water. Consequently, the emphasis is on community outreach and ambulatory care.
“Pediatricians work hard with families to avoid an admission if possible because it’s so hard on families,” says Prather. “They do whatever they can to manage the child as an outpatient, which is a refreshing way to work with patients.”
Such remote and impoverished conditions— 80 percent of children in the region live under the federal poverty line—also invite difficult-to-manage health problems like diabetes, diarrhea, influenza, obesity, pneumonia, and mental health issues like depression and alcohol/ substance abuse.
“It’s a different set of illnesses in a different setting,” says Steve Holve, pediatricianin-chief of the Tuba City Regional Health Care Corporation. “No one in Baltimore doesn’t have water and electricity and lives 80 miles from the nearest hospital.”
A significant shortage of pediatric subspecialists in the area, observes Holve, adds both another obstacle and opportunity for the pediatric residents. For specialty care, patients rely on telemedicine consults and quarterly visits from Phoenix-based pediatric cardiologists, neurologists and orthopedists, and what the attendings and residents have picked up.
“It can be quite challenging to know a little about everything in making decisions,” Holve says. “You use all the things you learn and a lot more.”
Pediatric resident Helen Hughes concurs: “Primary care providers there, by necessity, become a little more comfortable with specialist management.”
Hughes notes that her Tuba City comfort level was raised by what she was learning there as well as by her experience in Baltimore treating urban poor children with chronic conditions like diabetes. She also found Hopkins in another way in Tuba City, pointing to its public health initiative “Together on Diabetes,” in which children and families receive nutrition and physical education. The value of the Tuba City elective for her, Hughes adds, was learning how to do more with less.
“The experience makes you think more and to be open to different ways to treat patients because Tuba City doesn’t have as many resources as we have here,” says Hughes. “You have to be more thoughtful about the care you’re providing, about ordering tests and imaging, what you’re putting your patient through, which we should be thinking about anyway.”
Tuba City veteran Laura Scott agrees, citing Tuba City’s all-paper outpatient clinic: “There’s no computer charting, no EPIC.”
But what Scott liked was the intimacy of the small clinic where, unlike the expansive Harriet Lane Clinic at Johns Hopkins, nursing and physicians work together in one place.
“They know their families really well and the patients and families see the same faces every visit,” says Scott. “It’s very much about the continuity of care. It’s a really neat dynamic.”
That dynamic has helped improve outcomes for patients, too, Smith noted in her Grand Rounds presentation. Disparities in vaccination coverage in the area have been eliminated, post-neonatal mortality has declined 90 percent between 1965 and 2009, and child mortality rates have stabilized during that time, as well. Infectious causes of death other than pneumonia are now responsible for less than 1 percent of childhood deaths, compared with 22 percent in the 1960s.
How about outcomes for the residents who rotate through Tuba City? Has the experience shaped and influenced their careers in pediatric medicine? Serwint hasn’t tracked their paths but one telling outcome, she says, is the number of residents—currently 11—who end up practicing in Tuba City following their rotation.
“People are drawn to the practice and the community,” says Serwint. “The environment offers a balanced way to live, a more solitary kind of place where you can reflect on your career.”
So, how would the residents sum up their experience?
“It’s cool to be able to go somewhere and train for a month in a totally different environment. It’s such a different patient population and a different approach to treating those patients,” says Scott. “I learned a lot about primary care there.”
“The highlight for me was incredibly supportive pediatricians who integrate you with the community as much as they can,” says Prather. “And there’s so much land to explore.”
“You leave understanding so much more about Native American culture, what it’s like to live on a reservation and deliver health care in an extremely rural environment,” says Hughes. “And the most beautiful sunsets I’ve ever seen.”
“I loved being in Tuba, living in the southwest, working with the people, experiencing a whole other part of the country,” says Smith “This is a treasure for residents.