Devon Blackwell has a history of attention deficit disorder, but things have improved so much that he isn't sure why he even needs to be here at the East Baltimore Medical Center.
The 17-year-old from Baltimore has improved at school, developing a love of physics. He's getting along well with his guardian. He's looking forward to attending trade school next fall.
Yet here he sits, in a paper robe on an exam table near Johns Hopkins Hospital, speaking with his new physician. And Dr. Deanna Wilson wants to talk.
"Do you have friends?" she asks. (Yes.) "How about best friends?" (Not exactly.) "What do you eat on a given day?" (Cereal with O.J., some meat at dinnertime.) She weaves her way through queries on his TV watching habits, household chore schedule, milk consumption, even the tattoo on his forearm.
Clearly, to her, Devon's health involves more than the size of his Adderall dose.
"Health isn't just a biological or medical issue," Wilson says later. She's one of four physicians in a groundbreaking new residency program at Johns Hopkins Medicine that concentrates on urban health care. "Is your goal to heal the population? Well, what ails it? Stress, psychological factors, depression: [many] issues play into biological problems. We need to become conversant in other languages. We're interested in a little paradigm shifting," she says.
A 28-year-old graduate of the Yale School of Medicine, Wilson wants to help redefine medical care in Baltimore and other American cities. In addition to clinical training in pediatrics and internal medicine, she and her fellow interns (that is, first-year residents) will gain experience in prisons and with police. They'll also earn master's degrees in public health or a related field, clearing the way for policymaking careers.
"We're training people who will end up coordinating health centers, creating more programs like the one we've created, working on Capitol Hill or becoming the future health commissioner," says Dr. Rosalyn Stewart, who helped design the six-year Hopkins residency.
In the clinic, Wilson writes a prescription refill, advising Devon to eat a good breakfast each day and avoid drinking too much soda. That will help him concentrate, she says. Big sister, mentor and scientist, she's becoming the hybrid that Hopkins aims to develop.
The need for doctors
It was two years ago that Myron Weisfeldt, chairman of internal medicine at the Hopkins School of Medicine, took a hard look at health trends in Baltimore. The picture was not encouraging.
Those who live in the city's low-income neighborhoods suffer disproportionately from many ailments, including hypertension, obesity and HIV/AIDS. Residents of relatively affluent Roland Park live an average 20 years longer than their counterparts in the Hollins Market area five miles away, according to the city Health Department. A 2008 RAND Corp. study found that Baltimoreans would have to make 150,000 more visits to medical clinics per year just to attain a moderate level of health.
None of that came as news to Weisfeldt, a man whose job description includes working closely with the university's Urban Health Institute. But to him, things had reached the point of crisis. "We should have been training career [physicians] to serve underserved communities, and we weren't," he says.
There are reasons the U.S. health care system has evolved in a way that shortchanges the urban poor. In the days before researchers discovered such treatment staples as antibiotics and penicillin, the medical world focused on curing maladies that threatened the population.
That emphasis gave rise to a system favoring treatment of acute illness over continuing or general care ("primary care," in modern parlance), and medical training kept the trend in place. As recently as 2005, the Department of Health and Human Services found that nearly two-thirds of new physicians were moving on to careers in subspecialties.
Weisfeldt, a cardiologist, decided to take action. He asked two of his public health experts -- Stewart and fellow pediatrician-internist, Lenny Feldman -- to dream up a program that could change urban medicine. Hopkins, he said, would find a way to fund it.
Feldman became director, Stewart his assistant director. From the start, they looked beyond the usual definitions of health.
Asthma, hypertension, drug abuse, HIV and mental illness -- these were significant urban health problems, they agreed. But what about the social factors that make them worse: the unsanitary housing that triggers asthma, the scarcity of safe parks that keeps kids and grownups indoors and sedentary? In the standard model, doctors leave such matters to others. Feldman and Stewart included them.