This paper will address how should family physicians do the work of caring for the patient in the context of family and community. We hope the paper and our discussion today will stimulate reconsideration of what we mean by the words care and context. Our paper is the only one of the Keystone III papers to address what actually goes on in the exam room between doctor and patient; it is the only one to address the nature of the relationship. Whether the relationship be with the individual patient or with an entire family, this relationship occurs in multiple overlapping contexts that are subject to the forces of the larger society. Family medicine likewise exists within multiple contexts that other participants will discuss. Howard Stein talks about the long-term tension in family medicine between being a reform movement and wanting to be mainstream. One solution to this dilemma is to become a leader of all the fields in medicine exactly by being a reform movement, with the goal of changing medicine for the better. We will be leaders in infomatics, leaders in collaboration with behavioral scientists, leaders in integrating research into practice through EBM, etc. The drawback of this strategy, also a point made by Howard, is that the tensions within family medicine represent and reflect the tensions within North American, or U.S. society in general. We ARE the problems out there; or the problems OUT THERE are IN HERE. In the spirit of that understanding, we will talk about caring for the patient within the context of family and community, with a persistent effort to show that the difficulties of caring in context have to do with the presence within family medicine, the doctor-patient relationship, the family, and medical institutions, exactly the problems that face American society. Insofar as we have not addressed those as a society, they remain problematic within our work. These problems are not the political concerns of a small group of leftists or feminists within family medicine; they are the political problems of our country. And insofar as we, as citizens, disagree on how best to address them, we will not find consensus within family medicine on what the problems are nor how to work on them.

Personal contexts

With that opening, it is important to put ourselves in context, to begin with who we are so that our work makes sense to you at both the personal and professional level, and so that you can see clearly how our work is centered squarely within our values. Lucy, with Lillian’s editing has written the first portion of this paper; Lillian, with Lucy’s editing, has written the second portion. We believe they fit together in addressing the interlocking contexts of family and community.

Lillian: I am a family physician, residency-trained, and a health services researcher and former RWJ Clinical Scholar. My research covers the area of vulnerable populations, including homeless, immigrant, and other impoverished communities, with a focus on their health status, access to care, and quality of care. So, how did I choose to focus my work on these areas? My parents were born in Eastern Europe and survived the concentration camps of the Holocaust, and this had a major impact on my desire to help immigrants and other vulnerable populations. We were raised with the importance of education, and with the goal of becoming a professional who would “make the world a better place.” As such, we would often go to rallies to help the downtrodden, such as to free Soviet Jews. I chose Montefiore as my residency, because of its goal of not only training good family doctors, but also of learning about the impact of culture and poverty on health, and about how to work within public health and health policy to make change. During my residency, I walked to our South Bronx clinic and very much felt a part of my community, with patients calling down from their tenements to say hello to Dr. Lillian. But I felt like I was climbing up a greased pole with my patients, by relying on the medical model to treat them. We would work together to get their hypertension under control, but then a job loss would propel them into problem drinking, and we were back at ground zero with the blood pressure control. Or, a poor mother whom I taught about breast-feeding and health prevention, brought her child in for injuries from falling out of a tenement window that did not have grates. I felt that I had to work to improve the social conditions of our poor populations to create longer lasting improvements in their health.

Lucy: I am a 54 year old family physician, residency-trained. I regard myself as a metaphorical grandchild of Lynn Carmichael as John Frey graduated from the Miami program in 1973 and came to Worcester to start the residency there which I completed in 1976. John passed Lynn’s legacy directly to me and others and added his own. Insofar as we are children of our teachers, I am part of their progeny. I am also a child of general practice. My father was a GP in Brooklyn where he, like so many of our forebears, ran his office out of a portion of our home. I am also a child of immigrants and conflicts and woes: my father was born in Russia, as were all my grandparents who fled pogroms at the turn of the last century. They came to a better place, learned the new language, struggled against discrimination and poverty to gain their children an education. But education did not make it all better. My father became addicted to morphine in residency and abruptly terminated my parents’ honeymoon to return to New York City to get a fix. My mother attempted to hide his addiction for years and to run his practice despite his increasing depression and disability. I experienced at first hand in my family both the dream of general practice, and the failure of the vision and the marriage that was linked to it. Like my father I have chosen to do generalist practice with poor people as a lifetime commitment but unlike him I have chosen to surround myself with supportive colleagues to share the enormity of this burden and to limit the claims of medicine on my ability to be a whole person with a need to take care of myself and my family. Like my mother I have gained many skills to function under adversity, but unlike her I have chosen to be open about how personal suffering affects what we can and must do in our work. As the child of an addict, I am always finding myself pointing out the elephant in the living room--this elephant has included the undeclared war against the people of Vietnam and now Colombia, the multifaceted discrimination against poor people and people of color in our society, and the abuse of girls and women in families and the larger society. I have been committed to addressing issues of abuses of power wherever I find them, and family medicine has offered me multiple levels both within and outside medicine to address these injustices. Within this value framework, we offer you this work:

Contexts

Care involves relationships. To talk about caring in context, we need to address the various relationships involved when we engage in caring: between doctor and patient, between patient and family; between patients and the broader social context. As well, we need to look at how we as physicians engage with that broader context. We will focus on the ways that these relational contexts are NOT working compared to the images of them and preferences we have for them as ideal. For instance, in the doctor-patient relationship many of us have idealized the long-term cradle-to-grave relationship with 4 generations of families over a lifetime of practice, yet increasingly neither we nor our trainees are able to approach that ideal. Likewise, we have idealized the vision of family life in which confident and loving adults maintain a long term relationship, raise children and care for the older generation in close connection, yet so many of the families we care for are fractured by drugs, alcohol, abuse, violence and irreconcilable conflict. At the community level, we share an ideal of civic and community life in which patients and families have adequate resources to feed, clothe, house, and educate their members as well as obtain available affordable health care and medications, yet we live in a society where, unbelievably, millions of families do not have access to food, shelter, and health care. At least one of these problems could be addressed by a single payer universal health care system, but we will not address this directly in this limited space. Let’s first talk about how each of these ideals--of the doctor-patient relationship, the patient in the family, and the patient in the community-- is currently constrained, limited, or made impossible because of huge forces at work in the society, forces which are based on inequality and its sister, abuses of power.

Time constraints on the doctor-patient relationship

Our residents are not being trained to stay in one place nor to have long term connections. If they do after they graduate it is a blessing, but not one that we taught them. Faculty tend not to have long-term commitments to one location; and in academic family medicine, moving to a better position is almost de riguer. Although McWhinney admonished us in 1975 not to let the demands of academic life--teaching, research and administration--conflict with the task of being a family doctor, we have done just that; we have “raised a generation of academic physicians who [are] superb teachers and scholarly writers but [have] ceased to be family doctors in any genuine sense.” As he recognized so early on, “Primacy of the person may be incompatible with the primacy of publication.”^{1 p.180}

Secondly , and more importantly, our health care system is increasingly set to destroy continuity of care. For the some 40 million uninsured patients, no continuous source of care is guaranteed. For insured patients, we and our patients are prevented from maintaining long-term relationships by so called “market forces” meaning that employers change insurance systems to get a cheaper “product” and thousands of families have to change physicians. By 1995, in northeastern Ohio about 25% of patients with IPA or PPO coverage had undergone forced discontinuity during the previous two years.² This could only have gotten worse in the subsequent years. This is an enormously duplicative and disruptive rupture for anyone who is doing anything of value in their doctor-patient relationship, from the child whose growth and development is concerning, to the teenager who needs a trustworthy figure to discuss birth control, to the woman with multiple symptoms whose family doctor has provided limited workups but extensive listening, to the older adult who faces retirement and now has a doctor the age of his grandchild, to the elderly woman who has outlived her last ten doctors and who would like someone to really understand what it means for HER to be 85. Patients forced to change physicians report poorer interpersonal communication, less physician knowledge of them and their family, less coordination of care, decreased continuity with the new provider, and less preference to see their regular physician.² Studies of continuity of care show that older patients with ties of more than 10 years with their physician are less likely to be hospitalized and incur lower Medicare costs than patients with a tie of one year or less.³ For Medicaid patients, greater continuity with one provider over the course of one year is associated with decreased hospitalization during the second year. ⁴ For patients, long term relationships are characterized by patient familiarity with the physician, physician knowledge of the patient, patient satisfaction with care, and patient confidence in the physician.⁵ For family physicians, we develop an extensive knowledge base about patients either through long term relationships or through relationships with greater intensity (more visits per year) and this intensity of care enhances our sense of responsibility toward the patients.⁶ When we know patients better we are less likely to use diagnostic tests and more likely to use expectant management.⁷ When our relationships with these individuals are “traded” in the “marketplace” we and our patients are the losers, though some stockholders are the beneficiaries. We and our patients are unable to control whether we will maintain these relationships; the relationship has no power to maintain itself, given the costs of health care. Instead, remote hierarchical bureaucracies whose phones are answered only by machines, faceless to us and to our patients, determine whether we will be this family’s family doctor. Of course the “bureaucracy” itself does not make the decision, it is made in board rooms, by corporate officers who make $800,000 per year, plus stock options. Power is not shared equally in the society, and its reflection here is our inability to affect these decisions.

Patients of course also move away to make a better life for themselves, but that is part of normal growth and development and not what I am talking about here. While patients’ mobility may affect their continuity with their family physician, as Ian pointed out⁸, many of these moves are within the same community, and most occur to young families. By the time patients start to enter the years of chronic illness, many are quite stable residentially. However, those patients fortunate enough to leave Medicaid and obtain a job with insurance benefits often find they must change their health insurance. The family doctor who (took Medicaid) and helped empower a woman to finish school and get occupational training, as well as delivering her children and supporting her through various family crises, is now left in the dust as she moves on to “real insurance.” For some, such success means choosing the supposed superiority of going to the more prestigious specialist rather than the lowly family doctor. In this instance “making it” results in leaving behind many of the essential sources of support and connection, like the family, community, or family doctor, in pursuit of status or prestige. Priorities at work in the larger society affect even so personal a choice as one’s physician.

Problems of power: the doctor-patient relationship

Within the doctor-patient relationship itself, we also find internal inequalities and both potential and real abuses of power. By virtue of class, often race, often gender, as well as income, education, and technical expertise, the doctor has more formal power than the patient. In the mechanics of the relationship, the doctor is in control of the timing, location, length, and conditions of doctor-patient interactions and remains clothed, sometimes standing, and definitely in charge of the conversation⁹. Medical students and young trainees who have not yet been socialized to dominate interactions with patients may find themselves uncomfortable with these power relations and may choose a more egalitarian style, at least until the pressures of training force them into controlling the interactions. It is not surprising that many of our patients appreciate our trainees not only for their youthful enthusiasm but also for their willingness to allow the patients to participate more as equals.

Given the power imbalances between doctors and patients, it would seem that our charge to ourselves would be to be extremely cautious and protective to offset this inequality and to conduct a relation between equals or one that empowers the less powerful. Such a goal is congruent with our reform spirit, in which a personal relationship takes priority over a technical one, and matches our ideal of a democratic society. Instead, we are exhorted to better “manage” time with the patient, in an effort to maximize efficiency and income. An industrial model of the doctor-patient exchange as a “product” to be manufactured with minimal inefficiency has superseded the concept of a relationship where growth and connection are to be fostered. No wonder that both we and patients feel out of control. The corporate model has taken over the personal model: another conflict in the society writ large in family medicine.

As individuals in family medicine, we are, of course, not immune to abuses of power. Regardless of how we think we practice medicine, as a system, we continue to treat patients in ways that are perceived as racist. These prejudices come out not only in our interactions with patients but in how we allow patients access to resources at the individual and societal level. HIV treatment,¹⁰ cardiac reperfusion,¹¹ and access to pain medication for cancer¹² and fracture¹³are a few examples of how people of color have less access to the quality medicine that we think we impartially practice. Abuses of power, of course, also go on at a personal level: a small percentage of physicians actively take advantage of patients’ vulnerability to abuse them sexually ^{14, 15} or do them active harm (for example the recent case of the trusted GP in England who systematically killed off his elderly patients over a period of years until the community became aware of the pattern).¹⁶ Indeed, it IS our responsibility to safeguard patients from our power, but we are so uncomfortable with the fact of that power that we pretend it is not there, and the result is that some of us are frankly abusive. The tension between the ideology of equality yet the practice of oppressive power dates back in this country at least to the Declaration of Independence, where the statement of men’s equality was belied by the brutal fact of slavery and the denial of the vote to women. Historically, Americans have not chosen to address the conflict between our rhetoric and our practice--as in “freedom and justice for all.” Within family medicine, caring for the patient requires attention to power in the relationship including scrutinizing our own allegiances and prejudices and potential for abuse of that power. We have not systematically addressed this any more than the society has systematically addressed abuses of power by trusted authority figures from the President on down. Family medicine mirrors our society.

Problems of power within the family

Let us turn now to issues of power within the family. Historically in family medicine, when we have talked about caring for the patient within the family context, we have referred to where the family was at within the family life cycle. Power and vulnerability were not the central metaphors for looking at what was going on. A more feminist vision requires that we balance our contextual understanding of the family life cycle with the recognition that families are both nurturing and also dangerous places for the vulnerable. In this paper we will focus on the vulnerability rather than the strengths offered by the family context, knowing our predisposition for identifying the strengths of families. Unfortunately, our own romantic vision of the family as the safe haven, the source of love and comfort, protection from the rough and tumble of the world outside, is belied for many by the realities of family life. Powerful adults abuse vulnerable children within families in physical, psychological and sexual ways. While we all abhor child abuse and want removal and punishment of hideous offenders, we are not looking closely at our own experience. Fully a third of girls experience some kind of sexual abuse within their families of origin, and most never reveal it until adulthood. The vast majority of this abuse of power is perpetrated by men and older boys on vulnerable girls and some boys who lack a strong maternal figure to protect them. Stepfathers, mothers’ boyfriends, uncles, older cousins, grandfathers, and at time biological fathers, all may be perpetrators.¹⁷ For many girls, the family is not a safe place to live. Family medicine, like the wider society, has a historical reluctance to recognize and address the consistent abuse of girls, and some boys, because it would mean taking on the nature of male power in families.⁹ At times it means accusing powerful male figures within communities who will use all their resources to protect themselves and discredit the victims. Sexual abuse within families is not limited to low income families; poll any audience of middle class women and you will find that more than a quarter were sexually abused by the men in their families.¹⁸

Sexual abuse of girls is not only a catastrophe in itself; it also leaves a legacy of symptoms that family physicians confront every day yet may never recognize. Disproportionately, women who were sexually abused as children fill the ranks of the patients who carry diagnoses of somatization¹⁹ psychiatric illness,²⁰ irritable bowel disorder,²¹ chronic pelvic pain,²² fibromyalgia,²³ and any illness with a substantial functional component.²⁴ Beginning in adolescence, teens who acknowledge having been sexually abused engage in riskier behaviors than controls ²⁵ Sexual abuse survivors are less able to take care of themselves as adults and are more likely to smoke, drink, and overeat and less likely to get pap smears and mammograms, or to use seatbelts and condoms.^{24, 26, 27} Thus they are more at risk for a variety of later diseases like HIV, chronic lung disease, and they are more likely to have diseases detected later. Their inability to protect themselves and take care of their bodies may result from not valuing themselves, not recognizing danger, feeling disempowered and afraid. As Russell said about incest survivors, “Their self-esteem may be so damaged they don’t feel they deserve their own loving self-protection.” ^{17 p. 190} So abuse of power in families creates symptoms, and ultimately diseases, among our patients, but we often find ourselves blaming the patient and not the power abuses that shaped her childhood and her self-esteem. Caring for these patients in the context of their families requires recognizing that the family of origin may be toxic for its members. We need to learn to be critical of the harms that happen in families and familiar with identifying the resulting scars and injuries that affect their victims for decades. When we fail to recognize the origins of powerlessness over their own bodies that these patients experienced as girls and young women, then we turn only to strategies of “managing” them, as we are advised to do with patients with somatization, and we never address the issues based in abuses of power that shaped them. The result is that we are likely to recapitulate such abuses when we initiate invasive procedures and exams that repeat and restimulate their pain, helplessness, or sense of vulnerability.

Work with survivors of abuse in the family requires that we actually conduct the doctor-patient relationship in a different way. We need to be highly attuned to issues of shame that surround the experiences of physical and sexual abuse and change the way we conduct the physical examination. Because being touched by an authority figure is a “loaded” event for the patient, the dynamic of the physical exam needs to be a full partnership. Understanding what kind of abuse she experienced will clarify what parts of the examination will be the most difficult.²⁸ Whoever abused them as children, whatever violence they witnessed, whoever hit or controlled them as adults, never were they asked permission. The language of the clinician needs to put the patient back in control of the proceedings: “Is it ok for me to look in your mouth?” This seems like a silly question, but if a person had been forced to engage in oral sex, it would be an essential step for the patient to regain some sense of safety around opening her mouth and having an object poked into it. Likewise patients need preparation before considering an invasive procedure with the opportunity to refuse it if will be too traumatic. Consultants likewise require education about how to conduct a procedure with a patient who has previously been abused. Appropriate treatment of the abuse survivor moves the meaning of collaboration to another level: the family physician, mental health specialist, and medical specialist need to have clearly shared understandings about the absolute need for the patient to be in control before consultation can be effective and not harmful.²⁹ This strategy of giving control back to the patient, step by step, rarely practiced by physicians, recognizes that the patient should be the one to decide when her body is touched, probed, manipulated. The patient needs to know that she can stop the process at any time.

Families are also physically dangerous for women. Women are vulnerable to physical violence within the dating relationship, the cohabiting couple, and within the marriage union. Although our discipline has amply documented the high rates of current and lifetime violence against women and the severe adverse health consequences, and although we have participated in developing various screening tools to detect it, we have not yet committed ourselves to detecting it or preventing it.³⁰ At the community level, a Robert Wood Johnson study of five different communities revealed that in no case did the health care system systematically address the problem of violence in families, but instead “champions” in the community were the ones responsible for any change. Frank prejudice--class elitism, racism, sexism, homophobia--toward both perpetrators and victims dominated the attitudes of individual providers and impeded progress. Health care workers who focused on this work felt marginalized by their colleagues.³¹ Just as our society is torn about whether women should be treated as respected equals or maintained through force and threat and tradition in submissive roles, family medicine has not taken a clear stance. Care for the patient in the context of family and community must recognize our vulnerability to physical violence at the hands of intimates and must pledge to learn how to prevent it.

Violence in our world has deep and confusing roots. Our society is clearly ambivalent about violence and its relation to the definition of what it is to be male. On one level we would like to think that it is manly to turn the other cheek, yet on the other hand, we believe at both a personal and national level that it is honorable to arm and defend oneself against real and perceived threats. On the one hand, we believe in the idea that individuals should be safe in their homes and on the streets--i.e., that this should be a safe society--yet on the other hand, major forces in the population believe that this safety can only be maintained through the right of individuals to bear weapons. On one side we try to teach our children to be “good sports” (meaning to play fairly and to respect each other in the context of a competitive game) and on the other, we have one father killing another father in a boys’ ice hockey game in Massachusetts over how he called a play. With definitions of masculinity so tightly wrapped up in the need to fight, it is not surprising that 28.6% of male high school students carried a weapon within a 30-day period in 1999.³²

Where do boys learn to fight? Clearly the family is the crucible in which manhood is tempered. In a somewhat different way from how families are dangerous for women, families are harmful to men. Boys learn not to cry, not to acknowledge pain, not to talk about feelings, not to take care of their bodies, not to go to the doctor; they learn that to be “like a girl” is second worst to being a homosexual. The resulting misogyny and homophobia, tightly linked to definitions of manhood, cut men off from closeness with other men and from the tender parts of themselves. As they grow up, men lose out in the family of procreation; they recognize the loss of a relationship with their own fathers, yet cannot attain the closeness they would like with their own children. Thus while women may be victims of family violence, men are victims of the masculine ideology promoted by “family values.” Family medicine is ambivalent about our role in preventing this violence done to both men and women: while we advocate detecting it once the damage is done, we are hesitant to consider discussion of what it means to be a man within our usual anticipatory guidance.³⁰

Problems of vulnerability in the society

Although rape is most common by an intimate partner, fear of stranger rape dominates social thinking about women’s vulnerability. Fear of rape constrains women’s activities in ways that men are unaware of³³, and vulnerability to rape puts men into more powerful positions: either as those who might take advantage, or those who benefit by being protectors.⁹ In community samples, past experiences of sexual assault both by spouses and by strangers are associated with poorer subjective health and a variety of chronic illnesses and somatic symptoms.^{34, 35} Women who have been sexually victimized make more office visits and consume more medical care in the subsequent year than they did previously.³⁶ Some subgroups of women are particularly vulnerable to rape. Women who have been previously victimized in childhood are more at risk of rape in adolescence or adulthood.^{17, 37} In ways that are not well understood, prior victimization seems to predispose women to subsequent victimization. Broader social conditions such as lack of affordable housing have a direct impact on women fleeing violent relationships: they are more likely to become homeless. Homelessness itself is associated with more severe physical and sexual assault.^38-40 Thus the power inequities in the society, such as low income, homelessness, and male domination, multiply with personal vulnerabilities, such as being a sexual abuse survivor or a battered woman, to create very high risk conditions. Even though we know these facts, and we are aware that upwards of one third of women will experience sexual assault during their lifetime, these facts have not shaped how we conduct health care of women in the context of their family nor their community. Not only are we not asking about rape, we are not working on changing the factors that lead up to it. Prevention would mean working with children, teenagers, young men and women, around issues of control and domination. ^{41, 42} Addressing these discrepancies of power would require that we confront the prevailing ideology about what it means to be a man and a woman and to face our own ambivalence about violence as a definitional aspect of manhood. Really addressing family violence would mean challenging the meaning of the word family --and this would strike at our own definition in family medicine. We have not even begun this work.

Vulnerable populations

Vulnerable populations are at risk of poor physical, psychological, and/or social health. Underlying this definition of vulnerability is the epidemiological concept of risk, in that there is a probability that an individual could become ill within a given period of time. --LuAnn Aday

Vulnerable populations experience more problems emanating from social problems such as mental illness, substance abuse, violence and victimization (physical, sexual, emotional abuse), social isolation, competing needs (e.g., for food, clothing, shelter, child care, elder care), and inadequate or overcrowded housing. These social problems may exacerbate their health care needs and limit their ability to obtain care. Aday further states, “To be vulnerable to others is to be in a position of being hurt or ignored, as well as helped by them.” In this latter spirit we hope that future generations of family physicians will find a role for themselves in improving the health of the communities in which our patients live.

Vulnerable populations include many segments of our population. Their health is affected by their vulnerability. In our country, African American males (in Harlem, for example) are dying at very high rates. The rates of suicide, homicide, and other forms of violence are decimating this population. We know that ethnic minorities are less likely to seek medical care and that their health is compromised by lack of attention to their cultural diversity. Study after study has found that professionals do not treat them equitably in giving them the same timely, high quality, and appropriate care that we give to the majority population. Immigrants and refugees likewise have unique childhood experiences and cultural backgrounds that impact their access to care and the quality of care that they receive.

Persons with mental illness, disabilities, and substance abuse have unique health problems and experience major obstacles in our system to providing for their multiple and complex health problems. While insured populations with such problems are treated in private psychiatry offices and residential rehabilitation programs, poor populations are “treated” for these problems in under-funded state mental hospitals, jails or prisons, or they become homeless.^(43)(1) Further, there is a gap in care for persons with the dual disorders of mental illness and substance abuse, in that persons with mental illness who are on psychotropic medications, might not be eligible for entry into a drug rehabilitation program, and vice versa.

Impoverished populations are at great risk for high-risk health behaviors and their consequent diseases. However, growing research suggests that a person’s socioeconomic status has a greater impact upon an individual and community’s health status than health behaviors or use of health services.(44-51) For example, asthma rates are highly correlated with living in school districts close to pollution centers. Further, the accumulated life stressors of African American women as well as homeless women have a greater impact upon adverse birth outcomes than does the prenatal care that we provide.(52) The impact of lack of housing on health is a pervasive issue among all homeless persons, whether they are newly homeless, long-term homeless, formerly homeless or episodically homeless. Even relatively short bouts of homelessness expose individuals to severe deprivations (i.e. hunger, lack of adequate hygiene) and victimization (i.e. physical assault, robbery, rape).(53) Consequently, the homeless, adults and children, have a very high prevalence of untreated acute and chronic medical, mental health, and substance abuse problems. Research has found that unstable housing--such as extreme overcrowding, substandard housing (e.g. lack of heat) or loss of housing altogether-- contributes significantly to poor health outcomes, and that stable housing plays a critical role in improving these health conditions.(54) Children born into homelessness result in a second generation that is at risk for homelessness and poverty.

Cause of Vulnerability

The cause of vulnerable populations’ vulnerability is often rooted in our families and communities. Our society over time has put fewer and fewer material and non-material resources, social and human capital, into our communities, such as into our schools, jobs, family incomes, and housing. Further, there are fewer and fewer ties between people that could help them in times of need, as evidenced by the declining numbers of people who live together in the same household (one quarter of the U.S. population lives alone), and the growing number of single parent families. There is evidence that mental illness, substance abuse, and violence is affected by social ties, and that persons who come from family or social environments which are abuse and disruptive are more likely to have these problems.(43) Economic and social disadvantage continues to plague our minority communities, with resultant racial and ethnic disparities in health.

Obstacles to Care

Vulnerable populations face numerous problems in obtaining appropriate health care. These include cost, transportation, competing needs, education and literacy, mental illness, lifestyle, personal barriers, lack of availability of health services, medical provider bias, and insufficient discharge planning from hospitals.

1. Financial barriers and problems in satisfying eligibility requirements for health insurance prevent access to care. Today, not only are many doctors refusing to treat persons who do not have money, but also some are refusing to accept patients with certain less desirable forms of insurance.

2. Accessible transportation to medical facilities is often unavailable to these populations.

3. Vulnerable populations have competing needs. They may place a greater priority on fulfilling their basic needs for food, shelter, and income than on obtaining needed health services or following through with a prescribed treatment plan. A patient who is hungry may decide that buying food for their family must take priority over purchasing medicine for their diabetes.^(55,56)

4. Education, illiteracy, and language have a direct effect on health and health care. For example, patients may not be able to read their pill bottles and may be too proud to tell their doctors about this limitation; a physician may not realize that a patient cannot read the detailed instructions the physician has provided, even if they were written in the patient’s language. Lack of translators is a common barrier for patients who do not speak English.

5. Those vulnerable individuals who experience psychological distress as well as disabling mental illness may be in the greatest need of health services and yet may be the least able to obtain them. This inaccessibility may be due to the mental ill health itself, as paranoia, disorientation, unconventional health beliefs, lack of social supports, lack of organizational skills to gain access to needed services, or fear of authority figures and institutions as a result of previous institutionalization. Further, the homeless mentally ill often require integrated services, largely unavailable today, able to handle their multifaceted problems including mental illness, substance abuse, physical illness, criminality, and such social service-related problems as housing and employment.

6. The social conditions of the marginally housed or homeless affect compliance with medical care. These social conditions include lack of proper sanitation; lack of a stable place to keep medications safe, intact, and refrigerated; and an inability to obtain the proper food for a medically indicated diet such as diabetes mellitus or hypertension.^(55,56) Lacking social support, some vulnerable population groups often do not have anyone who can transport them to a clinic or care for them if needed after giving birth or experiencing a major illness. While most marginally housed persons are long-term residents of their community, many are quite mobile within a city in their search for subsistence resources. This mobility makes continuity of care difficult.

7. Vulnerability itself at times present barriers to care. Because an exhibition of toughness is necessary to survive, disadvantaged populations may at times deny that they have health problems in an attempt to maintain a sense of their own endurance and to maintain a sense of control, however fragile. Yet while attempting to present a tough façade, they actually may be afraid, because of neighborhood violence, to venture out of the immediate geographical area to which they have become somewhat acclimated and thus cannot seek medical services in another area. They may be too embarrassed to have medical professionals see them in a condition of poor personal hygiene or poor health. They may fear that their meager financial resources will be taken away to pay for the medical care they receive. Fear of authority figures can result in failure to seek medical care. For example, undocumented immigrants have reason to fear that medical providers will call in Immigration and Naturalization authorities; runaway teenagers and homeless women with children may fear child protective service workers; and drug abusers or ex-cons may fear the police.

8. There is a desperate lack of facilities that can adequately treat vulnerable populations. As a result, national health care reform and universal coverage are necessary, but may not be sufficient, to solve all of the access problems of special populations. For example, availability and accessibility of primary care for many homeless persons in Great Britain is quite limited despite the elimination of hospital and medication charges.⁽⁵⁷⁾ Because of their great personal demands and lack of resources, many vulnerable populations end up seeking care in emergency rooms, but emergency rooms cannot provide the continuous comprehensive medical care that their complex problems require. At the same time, many primary care settings that were designed for the housed poor are not set up to treat the multiple complex problems of vulnerable populations and address the unique cultures of various ethnic groups as well as of the homeless.

Public health systems for the poor tend to targeted specific programs such as family planning, prenatal care, tuberculosis testing and treatment, mental health and substance abuse treatment, or immunization, yet the multiple medical and social problems of vulnerable populations do not neatly fit into such types of services Furthermore, integration of mental health and substance abuse services with other service settings is infrequent and has been declining.⁽⁵⁸⁾ Thus, many vulnerable populations end up seeking medical care late in the course of their diseases or for traumatic or life-threatening conditions.

9. Homeless and other vulnerable populations may find the medical profession itself a barrier to obtaining needed medical care. For example, medical providers may consider homeless persons to be undesirable patients because of their poor hygiene, their mental illness, or because of assumptions that they come to hospitals for shelter and not for a medical problem.⁽⁵⁹⁾ Providers may not understand how the priorities of disadvantaged patients differ from their own in adhering to schedules and keeping appointments, setting up the possibility of conflict and failure. Treatment plans are often automatically based on the assumption that the patient has a reliable source of food, social support, and a home.⁽⁶⁰⁾ Availability of clinicians may itself be an issue: physician recruitment for clinics that serve the underserved may be hampered by poor working conditions, inadequate salaries, physician biases against working with such populations, and the lack of respect this work receives from the medical profession.⁽⁶¹⁾ Further, providers may be afraid to care for vulnerable populations, because of fears of malpractice suits or of contracting AIDS.⁽⁴³⁾ Some HMOs today actually prevent pro bono work; physicians who previously gave of themselves freely to provide care to the uninsured, are no longer able, under their contract, to give away medical services.

Model for Understanding Use of Health Services and Health Outcomes

As we think of the role that the family physician can play in community, it is important to understand how vulnerability affects access to care and health outcomes. The Behavioral Model for Vulnerable Populations ⁽⁶²⁾ can help structure our thinking around the various aspects of health in which family physicians can become involved. In this model, health services use and outcomes are explained in terms of three groups of factors.

Predisposing -> Enabling -> Need -> Health Behaviors -> Health Outcomes

Predisposing factors, such as demographic characteristics and health beliefs, explain people’s predisposition to use health services. For vulnerable populations, we would include mental health, substance abuse, criminal behavior, housing status, victimization, immigration status, and acculturation in this domain. Enabling factors, such as income and health insurance, measure the available social, economic, and health care resources that could encourage or inhibit health care use. For vulnerable populations, we would also consider receipt of public benefits, competing needs, and access to information resources. Community level enabling factors include the structuring of care at medical facilities to provide for the unique needs of our communities (e.g., are there providers trained to care for the unique needs of vulnerable populations, and are the clinics set up to do so), community crime rates, and the level of social services in the community. Recently, the “human capital” and “social capital” of the surrounding communities (e.g., civic participation and voting rates) have also been found to affect access to care for vulnerable populations. Further, the overall socioeconomic status of our vulnerable populations affects their health outcomes, perhaps to an even greater degree than the medical care that we provide. For example, the “Weathering Hypothesis” has found that the accumulated life stressors experienced by vulnerable populations affect their health regardless of use of health services. African American women are more likely to have adverse birth outcomes regardless of their level of prenatal care.(53) Clinicians’ evaluation of patients may be affected by the patients’ vulnerable status, and patients’ perceptions of their health may be related to their vulnerable status. In addition, particular conditions are more common among vulnerable populations: mental illness, substance abuse, tuberculosis, HIV, hepatitis C, asthma, sexually transmitted infections, violence, and premature and low birth weight newborns. Health behaviors include personal health practices such as diet, tobacco use, exercise, hygiene, contraception, and sexual practices. This domain also includes health services utilization and the process of care provided in health care facilities (is it appropriate to the needs of vulnerable populations). Thus this model shows how multiple factors besides the medical care that we provide in our office settings affect the health outcomes for vulnerable populations in our communities.

The role of the family physician in community

Never doubt that a small group of thoughtful committed citizens can change the world. Indeed it’s the only thing that ever has. ⁽⁶³⁾ --Margaret Mead

The health problems of individual patients result from communal level problems such as socioeconomic status, violence, pollution, and lack of housing. Further, many health problems are related to national health policies, including housing, illegal drug, substance abuse treatment, welfare, mental health, and prison policies. Family physicians have a key role in improving the health of our communities.(64) In the course of providing continuous comprehensive care to individuals and families we will find that our patients will guide us in the community issues that are salient to our population. Our involvement in the health of the community can take place at different levels: as a clinician, educator, researcher, and community change agent. We call this the “activated family physician.” We are in a unique position to help our communities, not only because of our expertise in medicine, but because, despite recent issues of breakdown in trust and communication between patients and doctors, we are still in an honored place in society. Our words and actions are carefully listened to and observed.

Family Physician-Clinician Role in Community: Medical organizations are thinking about how their work can be enhanced by focusing on community.^{(65, 66)} Greenlick states, “The traditional one-to-one physician-patient role obligations should be expanded to include a set of ‘one-to-n’ physician-population obligations. The latter include at least 3 components: (1) a resource allocation component, (2) a component focusing on the epidemiologic nature of clinical practice, and (3) a component focusing on members of the population who are not regularly attended to within the normal context of physician care.”(67) Toward the third obligation, outside of our paid work as clinicians, we can volunteering to serve populations that do not have access to quality medical care. For example, we can take care of patients at community health fairs, community heath centers, immigrant/refugee clinics, or shelter-based clinics. We can meet with students and families in schools to talk about prevention of injury and violence, substance abuse, behavioral problems and school drop out, sexually transmitted diseases, and unplanned pregnancies.⁽⁶⁸⁾

Family Physician-Educator Role in Community: As educators, we can teach our students about caring for our communities at all levels. But first, we need revise our admissions policies to recruit students who have a concern about communities and a passion for this work. Once they are in our medical schools, we will find them teaching us about how to provide service to our communities! We can help them learn about the communities and encourage them to document the assets and problems of the community. We can help them to get to know the resources of the community and to strengthen those resources for solving the community problems. We encourage them to ask questions about the community. What is the status of its schools, religious institutions, and outdoor areas and other gathering places? Where the poverty areas located, and what are the greatest needs of the poverty areas? What health interventions are already ongoing at the community level, and who are the community leaders? What does it mean to be a part of a community? What does it mean to advocate for the health of our communities?^(69,70) The education begins with medical students, but includes residents, fellows, faculty, and practitioners, so that they have a hands-on perspective of what it takes to be an activated clinician and to effect social change. Through direct patient care of vulnerable populations, we can break down stereotypes and stimulate the satisfaction and excitement that results from working to help impoverished persons. In fact, medical students are clamoring for such experience, shown by their heroic efforts to set up shelter based clinics, clinics in churches, and health fairs.

At the residency level, RRC requirements for community medicine, compared to those for surgery rotations, for example, are unstructured and not well defined. The last fresh look at the RRC requirements was taken ten years ago in the 1990 report, “A residency curriculum for the future.”(71) We suggest a task force to set clear requirements for our curriculum in community medicine, a rotation that would focus on improving the health status, access to care, and quality of care within communities and in community-based settings and organizations. Some options to consider would be a full month rotation, or perhaps one-half day per week longitudinally for the second and third years of residency. This education may not be easy for many faculty to support and implement, since they did not experience it. Therefore, a community medicine curriculum task force could establish a standardized curriculum, educational materials, and faculty development training materials to actualize such a curriculum. The curriculum committee would include community clinicians and community members as full members of our “clinical” faculty forging with key organizations and legislators within our communities. These community members will ensure that we focus on the current issues of our communities in a way that is relevant and acceptable. Their role will be invaluable for building and maintaining trusting relationships with our community and its leaders, and for enhancing the likelihood that our initiatives will be adopted and sustained.(69)A model curriculum of this type was developed by Ellen Beck during her fellowship at UCSD, “Making a Difference in the Community, Addressing the Health Needs of the Underserved: A Faculty Development Program for Family Physicians.”(72) The educational program would educate residents and raise the levels of our faculty knowledge base at the same time by including them in the educational process. The curriculum would include sessions and experiences on homelessness, community based medical care, occupational medicine, methods of conducting needs assessments of our communities, and research skills unique to community based medicine. The curriculum would also include skills in how to be an activated clinician, how to be a community change agent, and how to implement community-based change in health and health services.

Training programs can also adapt elements from the program on “Understanding and Changing Communities” developed by the UCLA Clinical Scholars Program.⁽⁷³⁾ In this model, residents learn how to create coalitions and partnerships with community organizations, how to “play well with others”, how to develop a community-based project, how to prepare and deliver a “20 second sound bite”, how to present to a legislative or governmental entity, cross-cultural skills, community data collection skills, and how to translate clinical experiences and research into changes in policy. Leaders of community-based interventions will review their projects, and local and national community activists will be invited to participate including public health officials, advocacy groups, and community service groups. The skill sets involve conducting focus groups to identify community members’ ideas, beliefs, values, and expectations; conducting needs assessments; conducting population-based surveys, incorporating population data into practice; identifying, interacting, and negotiating with community leaders; establishing a community-based network of advisors; creating and working in multi-disciplinary teams; conducting interventions in our communities; working with the community to disseminate the information generated from the family physician-community partnership; and most of all, implementing changes that will continue after the initial project is completed.

Family practice residents should be encouraged to conduct a community-based project. “Key elements for a successful resident-community project include a long-term commitment, supportive faculty, didactic sessions on community health issues, close contact and good communication with community members, [working in pairs or teams], and discussion and reflection…[We] might better address important social determinants of health…than more traditional approaches to health promotion.”⁽⁷⁴⁾ In one year, the residents could be encouraged to do a community based needs assessment of the zip code in their community that has the highest poverty rates. (Enubuzor, Harriet. San Diego: UCSD, unpublished data, 1998). Upon getting to know their community, they could then identify a malleable problem, and propose a solution and implement it. The next cohort of residents could develop and implement an intervention based on the needs assessment. Thus, this longitudinal approach builds upon the work of generations of residents to solve a community problem, and makes it seem feasible, rather than unattainable. In this way, the residency will gain a deep understanding of its community, will develop relationships within the community, and the community will begin to gain trust in the residency program.

However, this type of residency and medical student educational program on communities requires resources. It cannot depend on one dedicated faculty-researcher. It requires enough faculty with expertise in medical and social sciences and protected time to implement such a curriculum. This work cannot be limited to classroom didactic sessions, but must be experiential in community settings.

Family Physician as Change Agent. Family physician researchers and research fellowship directors can choose to focus on studies and interventions that will directly improve the health of our communities, and as clinician activists we can do the same. For example, if we are carefully listening to and observing our patients, we might notice the high prevalence of rape. One physician, Deborah Cohen noticed just that, and she worked with the community to uncover the source of the problem and then worked to solve it: she got the city to put good lighting in the darkened corners of her community, with a subsequent drop in the rate of rape. Or a family physician might help a community to make the connection between the escalating rates of asthma and local air pollution due to heavy motor vehicle traffic and to effect changes that have a greater impact on the health than working individually with patients around the use of their inhalers.

“Act local, but think global.” Family physicians can work at the local and national levels to change policies on low-income housing, economics, family preservation, illegal drugs, tobacco, alcohol, and gun violence, the major causes of health problems in our country. We can work to build trust and communication between separate health and social sectors--schools, religious institutions, child welfare agencies, adult protective services, mental health treatment facilities, substance abuse treatment programs, and jail and prison systems-- to coordinate services for the multiple complex medical needs of our vulnerable populations. ⁽⁴³⁾ We can work toward national health reform so that our uninsured patients are cared for and our fragmented disjointed service delivery systems can come together. And, given that the overall social and economic health of our communities has been shown to have a major effect on health, independent of the medical care received, it is imperative that we invest in our communities and families to bolster up the developmental trajectories of our children, and thus to build the human potential of the next generations.^(75,76) Thus, the problems may present to us at the level of caring for a patient, but our response does not have to end at the level at the patient; it can and should proceed to the community level. We do not have to spearhead such efforts but we do need to be involved. In the words of Pirkei Avot, “We are not obligated to complete the task, but we are obligated to begin it.”

Conclusion

Care of the patient in the context of family and community requires that family medicine address the issues of power and vulnerability within the doctor-patient relationship, the family itself, and within our communities. As a society we have not been able to address squarely the inequities that abound in the areas of gender, race, class, education, and income, so it is not surprising that these same disparities frame the context in which we try to practice family medicine. We have shown how these same inequalities are detrimental to the health of individuals within families and communities as well as the health of families and communities themselves. To make a difference in the health and well-being of those most vulnerable and out of power, family medicine must address the same forces that maintain and benefit from the power inequalities. We must again take up our reform banner and join with individuals, families, and communities to change the context of our communities and our country. Indeed if family medicine fails to take a stand on changing the underlying power inequities and preventing further erosion of the health of the most vulnerable, we run the risk, by seeking the mainstream, of perpetuating the status quo. Hopefully it is not too late to choose.

Lillian Gelberg: I would like to acknowledge the guidance of Ellen Beck and Patrick Dowling in helping me to think “big” for this paper and in sharing with me their thoughts and experiences regarding community. And I am honored that the planning team of the Keystone Conference included me in this very important effort.

Lucy Candib: I would like to thank Richard Schmitt for editorial, technical and moral support, and the staff at the Family Health Center of Worcester and the Memorial Hospital Library for the time and resources to do this work.

References

1. McWhinney I. Family medicine in perspective. New England Journal of Medicine. 1975;293:176-181.
2. Flocke S, Stange K, Zyzanski S. The impact of insurance type and forced discontinuity on the delivery of primary care. Journal of Family Practice. 1997;45:129-135.
3. Weill L, Blustein J. Faithful patients: the effect of long-term physician-patient relationships on the costs and use of health care by older Americans. American Journal of Public Health. 1996;86:1742-1747.
4. Gill J, Mainous A. The role of provider continuity in preventing hospitalizations. Archives of Family Medicine. 1998;7:352-357.
5. Gabel L, Lucas J, Westbury R. Why do patients continue to see the same physician? Family Practice Research Journal. 1993;13:133-147.
6. Hjortdahl P. Continuity of care: general practitioners' knowledge about, and sense of responsibility toward their patients. Family Practice. 1992;9:3-8.
7. Hjortdahl P, Borchgrevink C. Continuity of care: influence of general practitioners' knowledge about their patients on use of resources in consultations. British Medical Journal. 1991;303:1181-1184.
8. McWhinney I. Continuity of care. Journal of Family Practice. 1982;15:847-848.
9. Candib L. Medicine and the Family: A Feminist Perspective. . New York: Basic Books; 1995.
10. Moore RD, Stanton D, Gopalan R, Chaisson RE. Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med. 1994;330:763-8.
11. Canto J, Allison J, Kiefe C, et al. Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction. NEJM. 2000;342:1094-1100.
12. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology [published erratum appears in JAMA 1999 Jan 13;281(2):136]. Jama. 1998;279:1877-82.
13. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. Jama. 1993;269:1537-9.
14. Kluft R. Incest and subsequent victimization: the case of therapist-patient sexual exploitation, with a description of the sitting duck syndrome. In: Kluft RP, ed. Incest-related syndromes of adult psychopathology. Washington, D.C.: American Psychiatric Press; 1990:263-287.
15. Enbom JA, Thomas CD. Evaluation of sexual misconduct complaints: the Oregon Board of Medical Examiners, 1991 to 1995. Am J Obstet Gynecol. 1997;176:1340-6; discussion 1346-8.
16. O'Neill B. Doctor as murderer. British Medical Journal. 2000;320:329-330.
17. Russell D. The secret trauma: incest in the lives of girls and women. . New York: Basic Books; 1986.
18. Elliott D, Briere J. Sexual abuse trauma among professional women: validating the trauma symptom checklist-40 (TSC-40). Child Abuse and Neglect. 1992;16:391-398.
19. Dickinson LM, deGruy FV, Dickinson WP, Candib LM. Health-Related Quality of Life and Symptom Profiles of Female Survivors of Sexual Abuse in Primary Care. Archives of Family Medicine. 1999;8:35-43.
20. Bryer J, Nelson B, Miller J, Krol P. Childhood physical and sexual abuse as factors in adult psychiatric illness. American Journal of Psychiatry. 1987;144:1426-1430.
21. Drossman DA, Lesserman J, Nachman G, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Annals of Internal Medicine. 1990;113:828-833.
22. Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am J Psychiatry. 1988;145:75-80.
23. Walker EA, Keegan D, Gardner G, Sullivan M, Bernstein D, Katon WJ. Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II. Sexual, physical, and emotional abuse and neglect. Psychosom Med. 1997a;59:572-7.
24. Laws A. Does a history of sexual abuse in childhood play a role in women's health problems? A review. Journal of Women's Health. 1993;2:165-172.
25. Nagy S, Adcock A, Nagy M. A comparison of risky health behaviors of sedually active, sexually abused and abstaining adolescents. Pediatrics. 1994;93:570-575.
26. Springs F, Friedrich W. Health risk behaviors and medical sequelae of childhood sexual abuse. May Clinic Proceedings. 1992;67:527-532.
27. Klein H, Chao B. Sexual abuse during childhood and adolescence as predictors of HIV-related sexual risk during adulthood among female sexual partners of injection drug users. Violence Against Women. 1995;1:55-76.
28. Roberts S. The sequelae of childhood sexual abuse: a primary care focus for adult female survivors. The Nurse Practitioner. 1996;21:42-52.
29. Ruddy N, with commentaries by Tillman Farley JN, and Kathy Hayden. Multiple personality disorder in primary care: a collaboration. Family Systems Medicine. 1994;12:327-338.
30. Candib L. Primary prevention: taking a deep look. Journal of Family Practice. 2000;VVV:in press.
31. Cohen S, De Vos E, Newberger E. Barriers to physician identification and treatment of family violence: lessons from five communities. Academic Medicine. 1997;72:S19-S25.
32. Kann L, Kinchen S, Williams B, et al. Youth risk behavior surveillance--United States, 1999. CDC Surveillance Summaries, June 9, 2000. MMWR. 2000;49(No.SS-5):1-94.
33. Furby L, Fischhoff B, Morgan M. Rape prevention and self-defense: at what price? Women's Studies International Forum. 1991;14:49-62.
34. Golding J. Sexual assault history and physical helath in randomly selected Los Angeles women. Health Psychology. 1994;13:130-138.
35. Golding J, Cooper M, George L. Sexual assault history and health perceptions: seven general population studies. Health Psychology. 1997;16:417-425.
36. Koss M, Koss P, Woodruff J. Deleterious effects of criminal victimization on women's health and medical utilization. Archives of Internal Medicine. 1991;151:342-347.
37. Gidycz C, Coble C, Latham L, Layman M. Sexual assault experience in adulthood and prior victimization experiences. Psychology of Women Quarterly. 1993;17:151-168.
38. Bassuk EL, Weinreb L, JC B, Browne A, A S, Bassuk S. The characteristics and needs of sheltered homeless and low-income housed mothers. JAMA. 1996;276:640-646.
39. Wenzel S, Koegel P, Leake B, Gelberg L. Antecedents of physical and sexual victimization among homeless women: a comparison to homeless men. American Journal of Community Psychology. 2000;28.
40. Wenzel S, Leake B, Gelberg L. Health of homeless women with recent experience of rape. Journal of General Internal Medicine. 2000;15:265-268.
41. Stringham P. Violence Anticipatory guidance. Pediatric Clinics of North America. 1998;45:439-448.
42. Stringham P. Domestic violence. Primary Care. 1999;26:373-384.
43. Aday L. At risk in America: the health and health care needs of vulnerable populations in the United States. San Francisco, CA : Jossey-Bass Publishers; 1993.
44. Race/ethnicity, gender, socioeconomic status-research exploring their effects on child health: a subject review. Pediatrics. 2000;105:1349-51.
45. Marmot M. Social determinants of health: from observation to policy. Medical Journal of Australia. 2000;172:379-382.
46. Lynch J, Kaplan G, Shema S. Cumulative impact of sustained economic hardship on physical cognitive, psychological, and social functioning. New England Journal of Medicine. 1997;337:1889-1895.
47. Wilkinson RG. Income, inequality, and social cohesion. American Journal of Public Health. 1997;87:1504-1506.
48. Kawachi I, Kennedy BP, Lochner K, Prothrow-Stith D. Social capital, income inequality, and mortality. American Journal of Public Health. 1997;87:1491-1498.
49. Williams RB. Lower socioeconomic status and increased mortality: early childhood roots and the potential for successful interventions . JAMA. 1998;279:1745-1746.
50. Fiscella K, Franks P, Gold M, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283:2579-2584.
51. Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality. JAMA. 1998;279:1703-1708.
52. Geronimus A. The weathering hypothesis and the health of African-American women and infants: evidence and speculations. Ethnicity and Disease. 1992;2:207-221.
53. Link B., Susser E., Stueve A., Phelan J., Moore R, Struening E. Lifetime and five-year prevalence of homelessness in the United States. American Journal of Public Health. 1994;84:1907-1912.
54. Bauman K. Shifting family definitions: the effect of cohabitation and other nonfamily household relationships on measures of poverty. Demography. 1999;36:315-325.
55. Kersey MA, Beran MS, McGovern PG, Biros MH, Lurie N. The prevalence and effects of hunger in an emergency department patient population. Academic Emergency Medicine. 1999;6:1109-1114.
56. Nelson K, Brown M, Lurie N. Hunger in an adult patient population. JAMA. 1998;279:1211-1214.
57. Reuler J. Health care for the homeless in a national health program. American Journal of Public Health. 1989;79:1033-1035.
58. Calloway M, Topping S, Morrissey J. Trends in linkage behavior among providers of homeless persons who are seriously and persistently mentally ill [abstract]. Association for Health Services 1998;15:54-55.
59. Baxter E, Hopper K. Private lives/public spaces: homeless adults on the streets of New York. New York: Institute for Social Welfare Research; 1981.
60. Koegel P, Gelberg L. Patient-oriented approach to providing care to homeless persons. In: D. Wood, Ed. Delivering health care to homeless persons: A guide to the diagnosis and management of medical and mental health conditions. New York: Springer Publishing Company; 1992:16-29.
61. Doblin B, Gelberg L, Freeman H. Patient care and professional staffing patterns in McKinney Act clinics providing primary care to the homeless. JAMA. 1992;267:698-701.
62. Gelberg L, Andersen R, Leake B . The behavioral model for vulnerable populations: application to medical care use and outcomes. Health Services Research. 2000;34:1273-1302.
63. Phillips P. Visionary medical and other leaders meet to plan healthier communities. JAMA. 1996;275:1529-1531.
64. Foreman S. Social responsibility and the academic medical center: building community-based systems for the nation's health. Academic Medicine. 1994;69:97-102.
65. Wright RA. Community-oriented primary care. JAMA. 1993;269:2544-2547.
66. Pathman DE, Steiner BD, Williams E, Riggins T. The four community dimensions of primary care practice. The Journal of Family Practice. 1998;46:293-303.
67. Greenlick MR. Educating physicians for population-based clinical practice. JAMA. 1992;267:1645-1648.
68. Haggerty R. Community pediatrics: can it be taught? can it be practiced? Pediatrics. 1999;104:111-112.
69. Charney E. Pediatric education in community settings: where do we go from here? Pediatrics. 1996;98:1293-1295.
70. Christoffel KK. Public health advocacy: process and product. American Journal of Public Health. 2000;90:722-726.
71. Merenstein JH, Schulte JJ. A residency curriculum for the future. Family Medicine. 1990;22:467-473.
72. Beck E. Addressing the health needs of the underserved. Bioethics Forum. 1999;15:31-35.
73. Brook R, Shapiro M, Wells K, Shekelle P. Renewal Application July 1, 2001-June 30, 2005. Los Angeles: Robert Wood Johnson Foundation Clinical Scholars Program, University of California at Los Angeles; 2000.
74. Miller FA, Melton WD, Waitzkin H. An innovative community medicine curriculum: the La Mesa housecleaning cooperative. Western Journal of Medicine. 2000;172:337-339.
75. Halfon N. Life course health development: an integrated model for measuring health and planning and paying for health intervention (unpublished paper). Los Angeles: University of California at Los Angeles; 1999.
76. McCain M, Mustard J. Reversing the real brain drain: early years study, final report. Toronto: Publications Ontario; 1999.