Vol. 14, No. 2, Winter 2000/01

An Inside View on the Indian Health Service: Reflections on Changes in a California Clinic

Gary Coomber, M.D.

"Haven’t you paid off those loans yet?" "Are you thinking of staying in this place, like, forever?" These are a couple of questions that I heard early in my career. Nowadays, they don’t ask me outright, but I know that some friends still wonder about my choice to work for the Indian Health Service (IHS). There is still a mentality in the culture of contemporary Western medicine that the IHS doctor is somehow "not ready for prime time," or is perhaps even still a trainee. Patients and colleagues suspect the doctor is filling some kind of payback obligation before getting permission to clear out and go into private practice. An example of this attitude occurred seven years after I had graduated from my three-year residency and received American Board of Family Practice certification as a family physician. An Emergency Room physician working with one of my patients concluded that it was time to call on me, the "Indian Health resident," to come in and admit my patient to the hospital.

Why would a medical student choose the lifestyle of an IHS doctor? This career choice does not mean sacrificing income, prestige, and or career opportunities. In fact, working for the IHS may offer welcome security and stability. In California, the medical profession is in a tumultuous state. Medical offices are facing unexpected economic pressures and hardships. This is the decade of the "employee physician." The private doctor has to hustle to generate enough income to pay all the overhead: rent on the office, staff salaries and benefits, taxes, supplies, and Worker’s Compensation and malpractice insurance coverage. Private practice, once the benchmark of success and autonomy in the culture of the medical professions, is now burdensome and expensive. It is perhaps unattainable for the family physician who wants to do a good job of listening to and caring for patients, and still claim a little time away from medicine for his or her own mental, physical, and family health.

How, then, can one enjoy and concentrate on working as a doctor these days? One way, available to a select few, is the way that I chose in 1986 when I joined the staff of the Sonoma County Indian Health Project in Santa Rosa. The benefits are considerable. I receive a generous package of health, dental, and vision coverage, vacation and sick time, and a retirement plan. The Federal Government provides malpractice coverage, a must in our litigious society. (Enough, though, about my good fortune in finding a steady job in a tough market in a beautiful area of the country. Someone might construe this as boasting and consequently, my next night on call could be a humdinger.)

What is it like working in Indian health? Those not so familiar with the Native American community in Northern California continually ask whether the patients I treat are in some way "different" from society at large. In health, as in any area of society, the answer is both "no" and "yes." IHS doctors encounter and treat a little bit of everything. We have a wide variety of what enthusiastic young doctors call "good pathology." (They miss the irony of that term. Pathology is the science of disease.)

We treat a lot of diseases of lifestyle. We routinely see elderly smokers who have lived over half of their years before the Surgeon General first reported the links of smoking to lung cancer and heart disease. We regularly see middle-aged people who were brought up to believe that a daily bacon-and-egg breakfast is a habit of healthy, prosperous people. We encounter new parents who subscribe to their grandparents’ view that the fatter a baby is, the healthier he must be. These habits and notions do not promote good health in this new age where lifestyle has changed drastically. Much of our entertainment is electronic and many jobs no longer require hard physical labor.

Additionally, we are now seeing an increase of certain adult diseases. A time-traveling visitor from the 1950’s would be shocked to see the incidences of cancer, congestive heart failure, strokes, kidney failure and diabetic complications that we have in these modern times. It is easy to blame all of this on the toxic aspects of modern life, diet, chemical food additives and pollution. These factors should not be discounted and indeed are important considerations when planning for good health. But we are also the victims of our own medical success. For instance, many more patients survive heart attacks than used to, and those who have strokes these days can be expected to live for years afterward. Only a generation or two ago, infectious diseases such as pneumonia exacted a huge toll in human lives, particularly in the poorer and rural communities. Now, the challenge is to put limits on the usage of antibiotics in order to prevent allergic reactions and the breeding of resistant bacteria.

Our patients have become smarter consumers of health care over the past ten to twenty-five years. They know that physicians have a lot more to offer for diabetes than "the needle." Patients know that gallbladder surgery is less hazardous and uncomfortable than it used to be, due to new surgery techniques. Gallstone-dissolving pills may be given to patients who are not candidates for surgery.

In our facility and in the state at large, we see some patients with disorders due to general societal affluence or well being. We also see patients with conditions that are linked to demoralizing poverty. We live in an unusual time and place. Try to imagine a setting in history other than modern, Western post-industrial society where the poorest citizens are the ones who suffer the most often from obesity, gout, and the consequences of insufficient exercise.

Doctors see life in all stages. Health services are offered to teen mothers, as well as women seeking assistance to become pregnant for the first time in their late 30’s. We provide assistance to healthy women with normal pregnancies and to expectant mothers who are considered high risk due to infections, lifestyle problems, family dynamics and nutritional problems.

My share of the practice has evolved over the last fourteen years. When I was the only physician in the office, and fresh out of residency training, I functioned as "all things to all patients." I kept track of ten prenatal patients at once and attended about as many births annually. I assisted on major surgical operations, performed in-office procedures and collected and processed blood and urine samples. I dispensed medication out of our "pharmacy" – a collection of drug samples and bulk purchases of medicine that we dispensed free of charge.

This year, I have not had more than a dozen clinic visits with expectant mothers. The medical science of childbirth and care of women related to childbirth is known as obstetrics, or, O.B. In 1994, I let obstetrics go as I had two associates enthusiastic about this work. The result has been fewer sleepless nights and no loss of satisfaction on my part or that of the patients. Through the demands of the schedule, and the force of familiarity, and perhaps reflecting the interests of my partners, I have become the consultant on the care of the "incurable." I see patients with chronic pain and rheumatologic disorders such as Lupus and Rheumatoid Arthritis. I also see patients who have been traumatized as children and ended up in maladaptive behaviors such as substance abuse or troubled relationships. My schedule tends to fill up with those who need a good listener: the patients whose needs overrun their appointment times and demonstrate what a work of fiction a clinic schedule can be.

After fourteen years of working as an IHS doctor, I have a few stories ripe for the telling, some triumphant, some humiliating. Others are of frustration and failure. The vast majority, I am thankful to say, are stories of how energizing it can be to practice medicine. Did you ever find something that you could do for sixteen hours a day without getting tired of it? I have. Most days.

Gary Coomber has worked at the Sonoma County Indian Health Project in Santa Rosa for fourteen years. Raised in Southern California, this American-British-Canadian physician enjoys his work with the Native community in Northern California. Dr. Coomber will be writing about the point of contact between the two societies of Native Americans and Western medicine.