Complexity and Compassion Inspire Medical Director in Washington State

When one of his favorite patients died young from viral cardiomyopathy, Malcolm Butler, M.D., was moved to write down his thoughts in an essay.

“Jose was a friend of mine. Not the type you go out after work with, but the type that brought a smile to your face when you walked into the room,” Butler wrote. “But he had gone. It was his time. His baby had just turned two, and he had made it into the new millennium, and his 27th year.”

Butler, an NHSC alumnus—now medical director for Columbia Valley Community Health in Wenatchee, Washington—cites “Jose” (not his real name) as an example of the kinds of “social complexity” that must be dealt with on a daily basis by clinicians dedicated to helping the indigent and medically underserved.

Butler and his staff struggled for several years to get the young Mexican migrant worker the treatment he needed for his life-threatening illness, including a heart transplant. At each stage, some factor in the patient’s often desperate life—or from the legal system for dealing with unregistered aliens—conspired to thwart those efforts, leaving Butler only the bittersweet memory of his patient’s unfailing humor and smile.

Health professional schools do a great job of preparing clinicians for “medical complexity,” Butler believes, but usually don’t prepare them for all of the nonmedical issues that affect care for the underserved. The frequent commotion, even in a well-run clinic such as Columbia Valley’s, can come as a shock to new providers, he says. “There are 50 kids running around—the waiting room is packed—it’s just chaotic! And that’s because our patients have brought their lives with them into our practice.”

Nonetheless, it is a challenge that Butler relishes. He believes that the “mission-focused” career he pursued, with support from the NHSC, has helped make him “immune to a lot of the heartbreak that has occurred among many of my peers from medical school” who pursued more conventional careers in private medicine. “At the end of the day, they are worried about how many patients they saw, what their income is going to be.” Not so, for Butler and the health care team at Columbia Valley. “We can take a lot of joy home from our job even in this very difficult time for the American health care system.”

Butler grew up in the suburbs of Seattle where his father was a professor of medicine at the University of Washington. He earned a B.A. in philosophy at Cornell University, but hedged his bets with pre-med courses as well. “During my undergraduate studies, I realized that medicine was the thing I wanted to do more than anything else.” That led him back to attend medical school at the University of Washington where “I had the chance for a semester to be one of my father’s students in pulmonology and critical care, which was great.”

He received his medical degree in 1989. Butler considered several specialty options, including otolaryngology (ear, nose, and throat) and surgery, but “I realized I enjoyed obstetrics and other things too much” to be pigeonholed into one narrow practice area. His clinical training in medical school was mostly at the Harborview Medical Center, a public clinic in Seattle.

Upon graduation, Butler opted for a family practice residency at the Ventura County Medical Center in California. “I wanted to be a small town doc and Ventura had a good program for training people for rural practice,” he explains. As at Harborview, most of the patients Butler saw at Ventura were medically indigent and underserved.

After completing his residency in 1993, Butler chose to practice at Columbia Valley Community Health, a migrant health center in Wenatchee, located in the scenic, central region of Washington State. Butler received an NHSC Loan Repayment award and that financial assistance made Columbia Valley Community Health competitive with other sites he had considered that offered higher salaries.

The town of Wenatchee and surrounding areas are home to around 70,000 residents. About 70 percent of Columbia Valley’s patients speak only Spanish, Butler notes. Roughly one third have no insurance, with most of the rest on Medicaid. Only 10 percent have other types of insurance, whether Medicare or private insurance. The health center had around 40,000 medical patient visits last year, with an active patient base of nearly 12,000.

“It’s basically a young family type of practice,” he explains, “with lots of pediatrics and obstetrics.”

According to Butler, most adult patients at the center work at the local fruit orchards set amid the foothills of the Cascade Mountain range. And he has seen an evolution in the migrant worker population in recent years. “True migrants are more rare now. Farm workers tend to settle here for 9 months out of the year and then go home to Mexico for 3 months. They consider themselves to be ‘immigrants’.”

Butler’s original intention was to serve 3 years at Columbia Valley and then reassess his career plans. After his second year, he was appointed medical director, which solidified his commitment to the health center “because it seemed like there were so many opportunities for me to make a contribution to the clinic and to the community.”

Columbia Valley Community Health has grown tremendously since Butler’s arrival. Back then it consisted of 6 doctors, 2 nurse practitioners, and 1 certified physician assistant, squeezed together in a 7,000 square foot clinic, with 11 exam rooms. The dental practice and administrative offices were located in separate buildings. When he started, Butler was told of plans to consolidate all services under a new facility, but those plans never materialized. “There was such a huge demand for services and the facilities were so poor, that it seemed to me we had a long way to go,” he recalls.

Butler and his colleagues rose to the challenge. “We’re now in a 45,000 square-foot building, plus we have a second location now, for a total of 38 exam rooms,” which house 10 physicians, 2 certified physician assistants, and 2 nurse practitioners. The total number of employees has doubled during Butler’s tenure to 160. He’s especially gratified that Columbia Valley recently gained certification from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

When Butler started, he was one of several clinicians with the NHSC program, all of whom stayed at least 5 years. They continue to attract and retain NHSC clinicians to this day, he reports. Some of their clinicians also come through Washington State’s loan repayment program.

Columbia Valley has also risen to the challenge of offering competitive compensation to recruit and keep clinicians. “We had to come up with a mechanism to allow people an opportunity to earn just as much money here as they could in private practice. We’ve developed an in-depth and thoughtful incentive program so that if people are willing to work hard they can earn a much higher income than their base salary.”

Butler was prepared to practice with the underserved when he joined Columbia Valley, based on his clinical training experiences at Harborview and Ventura. Early on, he polished his Spanish skills and is now very fluent. “Not only do nearly all of our patients speak Spanish at the clinic, but also almost all the staff speak Spanish to me as well. It’s almost like living in a foreign country 10 hours a day.”

The quality of community health centers (CHCs), in general, has improved substantially in the past 10 years, Butler believes. “In the State of Washington, there has been an enormous emphasis on improving customer satisfaction and raising CHC facilities to a level where it’s not elegant, but at least it’s dignified. People can feel proud of the fact that we are their doctors, and the staff can feel proud to say this is where they work.”

He has also helped raise the visibility of the Columbia Valley center. “The center had been sort of unknown” in his early days there. “It was viewed as a place somewhere downtown and nobody quite knew what happened there or who practiced there,” Butler recalls. Because of the center’s success with retaining its providers nowadays, “everybody knows them and people recognize that we are a stable organization, able to deliver a good continuity of care,” Butler explains. “It’s a very enjoyable place to work.”

Columbia Valley Community Health—and the network of other clinicians in Wenatchee—together comprise a “regional hub for health care services,” Butler says. “That has made this a good place in which to practice, because there is a poly-specialty group right up the road with 130 specialists,” and a state-of-the-art 130-bed hospital is located nearby.

It also helps to work and live in one of the most beautiful recreational areas in the United States, Butler adds. “There’s a ski area 15 minutes outside of town, so there’s world class downhill and cross country skiing, as well as kayaking, fishing and hiking here.”

But the chief attraction remains the mission. “I came to this work out of a desire to serve such a population,” Butler reflects. “My father had been an academic doctor—salary and profit were not a large issue in his career—so I grew up in that atmosphere and did my training in areas that fostered the belief that there are some really needy people out there, especially in rural America, and there are great opportunities to make an impact.”

The old stereotype was of CHCs as a “training ground” for new physicians “to do your public service for 2 or 3 years and then you become a ‘real doctor’” in private practice. Butler sees signs of a changing attitude. “There are more people who are viewing indigent care as a career path, and NHSC has certainly helped that to happen.”

The CHC model also has lessons for general health care practice, Butler believes. “We’re proving that community-focused, primary care is a good model for health care delivery.” Community health centers are group practices, he points out. “In a group practice you forego complete autonomy. You are not allowed to be the egotistical physician. You need to be a team player—you need to be a model for that.”

Such group efforts “allow you to practice at a very high standard of care even in a rural setting,” Butler explains. The trade off, he continues, is that—although a community health doctor may not get a personal parking space or even a separate office— “what you do get is the teamwork and the camaraderie and a vision that the patient comes first and the clinician is a member of the team that is going to help that patient.”

Butler urges students and clinicians, who may be hesitant about whether such a career is right for them, to give it a try, as part of the NHSC. “My hope is they will be open to the possibility of making it a career, which is what happened to me. They should allow themselves to grow and expand and appreciate the experience.”

If you’d like to know more about community health centers, go to the Web page for the Bureau of Primary Health Care (BPHC) at http://bphc.hrsa.gov/bphc/related.htm and click on National Association of Community Health Centers.