“Esta Es Mi Clínica”

All Lucía Jimenez* wanted that cold, late February afternoon was to go home. For months she had held down three jobs that left her only a few hours of sleep between shifts. Those jobs, at a factory and two restaurants, paid rent and utilities for her part of a small apartment that she and her two children shared with two other Latino families in Midvale, Utah.

But sleep would have to wait. Jimenez had an appointment at the one-story Community Building Community (CBC) medical clinic, where volunteer medical students from the University of Utah saw uninsured and indigent patients. She was desperate to dispel the long shadow of uncertainty her health had cast over her life.

After experiencing bouts of intestinal pain two years before, Jimenez had gone to several other free clinics in the Salt Lake valley in search of help. Language barriers between her and the providers made communication difficult.

The first doctor who reviewed her bloodwork diagnosed failing kidneys and put her on medication she couldn’t afford. Relatives supported her with fresh food and encouraged her to drink lots of water.

At a follow-up, a different doctor’s brief explanation of the second round of tests left her confused.

Finally, a friend suggested the CBC clinic.

In the waiting room, an interpreter called her name. She led Jimenez into a consulting room and introduced her to a 23-year-old white-coated Annie Li.

Li had begun medical school just four months earlier. As a clinic volunteer, she gathered information from patients to present to the attending physician, former Utah Department of Health chief and longtime clinic volunteer, David Sundwall, MD. It was a little nerve-wracking. Occasionally, Li froze in front of patients and forgot what to ask.

Li listened to Jimenez through the interpreter. She could see the strain in her features.

Something else struck Li: how close Jimenez’s story was to her own mother’s.

Li, her twin sister, and their parents had emigrated to the United States. They had left China for their father’s new job in electrical engineering in Utah’s Salt Lake valley when the twins were only one.

When Li was seven, her mother was diagnosed with lupus. Like Jimenez, Li’s mother had struggled to navigate the complexities of the U.S. health care system. What had proven particularly difficult for her was understanding lab test results. While she was conversationally fluent in English, the laboratory terminology was impenetrable.

Jimenez showed Li a sheaf of lab paperwork going back more than two years.

“No one explained to me what these tests mean,” she said in Spanish.

Would she eventually need a kidney transplant or dialysis? Not knowing weighed on Jimenez. Not that the Mexican national believed she could ever afford such medical miracles.

Jimenez’s predicament brought back Li’s memories of her mother huddled over lab results at the kitchen table. She recalled the worry etched on her mother’s face, lips moving silently, trying to pronounce words she didn’t know.

INVISIBLE NEED

Lucía Jimenez is one of 3,000 to 5,000 people who annually depend on the CBC for dental and medical services. The majority, but far from all, are Hispanic.

“Over the years, what I’ve tried to do is to let medical students and people-in-training feel how great it is to do the right thing for the right reason.”

The need for such services is underscored by the extensive list of socio-economic, health, and other issues that dog Midvale’s minority communities. Midvale’s population is 24.5% Hispanic and 11.7% other racial minorities. In comparison with Salt Lake County and the state of Utah, Midvale claims the highest percentage of households with single mothers and the highest percentage of poverty. At $60,000, its median household income is one quarter less than Salt Lake County’s at $80,000. Midvale’s rates of suicide, cancer, stroke, heart disease, and drug-related deaths are all higher than county and state averages.

But how to help such a beleaguered community, especially when many live in the shadows because they are undocumented? The answer the CBC found, says current Midvale mayor Marcus Stevenson, was to build trust.

That began with developing a panoply of services— from classes on parent and child communication within conflicting cultures, teen pregnancy, emotional therapy, and legal support to vaccines, a food bank, and violin classes for children.

Today, the CBC is best thought of as a support system for underprivileged and often otherwise invisible Latino families on the margins of Utah life. But building trust with a long-marginalized community wasn’t achieved overnight.

THE VALUE OF PREVENTIVE CARE

Mauricio Agramont is the CBC’s tireless executive director. He deploys ingenuity and humor in the face of constant resource and funding challenges to achieve his vision of improving life for underprivileged Latinos in Utah.

By providing basic services at the beginning, Agramont and his small team sought to build bridges with the community that would allow them to encourage people to also get preventive health care.

“If you have to choose between paying the rent or getting your kids clothes for school, expensive nutritious food or the dollar menu, it’s clear what you’re going to do,” Agramont says. And among those choices is putting off seeking health care until a life-threatening condition leaves no choice but to go to the ER.

“You can prevent those emergencies with good care,” says Wayne Samuelson, MD ’80, recently retired dean of medical education for the Spencer Fox Eccles School of Medicine (SFESOM). “When somebody dies of complications from diabetes, they’re usually blind, have kidney failure, heart attacks. They’re feeling like they can lose limbs. Preventing that is straightforward. It’s something we can do with people that are learning how to be doctors.”

Samuelson’s passion for the CBC’s core mission led him to become its first long-term volunteer medical provider. He paved the way for med students who have been volunteering at the clinic since 2015.

Each year, students build upon the innovations and successes of their predecessors. In the clinic, students learn what theory and classwork can never teach them: the stresses, challenges, and rewards of serving those most in need.

Those rewards aren’t monetary, notes Samuelson. “Over the years, what I’ve tried to do is to let medical students and people-in-training feel how great it is to do the right thing for the right reason.”

AGENTS OF CHANGE

In 2023, the SFESOM revealed a new curriculum that scaled up Samuelson’s idea of compassion as its own reward. It includes working in clinics as a key component of all four years of medical training. Students work under the supervision of volunteer, board-certified attending physicians at five clinics: Midvale CBC, People’s Health Clinic in Park City, and three Salt Lake City clinics—Fourth Street Clinic, the Population Health Center in Rose Park, and U of U Health’s South Main Clinic.

Along with excitement, however, students, providers, and U of U Health administrators have had questions and concerns about the endeavor: Will it impact the special culture of the clinics? What happens when volunteering becomes mandatory in a curriculum?

“It’s uncharted territory,” says Sara Lamb, MD, vice dean for education at the medical school.

But it’s a journey she insists that the U, its students, and leadership have a moral obligation to pursue. The low-income, student-led clinic network is a first not only for the U, but for academic medical centers nationwide.

“Nobody has done this in medical schools that we can tell. While teaching hospitals have volunteer student-run clinics, no one has integrated experiences for students across the four years of medical school into the core of their program,” Lamb says. “It’s something that we do as a mission of the school. All our students are going to have a longitudinal relationship with all five clinics for the entirety of their medical school experience.”

Lamb hopes students will recognize barriers to access and become change agents on a global level.

“You should have a right to get the services you need to be healthy,” she says.

Every clinic sees medical issues unique to its patient population. In the CBC’s case, attending physician Sundwall knew Hispanics had a higher prevalence of metabolic syndrome, which includes conditions such as obesity, hypertension, diabetes, and hyperlipidemia. These conditions all raise the risk of heart disease and other serious health issues.

Initially the clinic was free, but after a modest co-pay was introduced, the number of patients seeking appointments at the clinic surprisingly went up.

“Patients wanted to have a little skin in the game,” Sundwall says.

Still, CBC patients couldn’t afford most drugs. Sundwall helped them find discounts. He emphasized to students the need to be sensitive to the impact of health care costs and to seek to provide care in the most affordable way possible.

PRESERVING THE VOLUNTEER SPIRIT

Lamb traces the seeds for the CBC clinic becoming a model for a first-of-its-kind medical school curriculum to a medical school town hall in spring 2018. Many med students had expressed frustration that their medical school experience offered little in the way of direct clinical work. Their frustration had even led some to question why they had decided to go into medicine in the first place. It set her thinking about how to balance medical education with real-life patient encounters.

During a 2021 call to Samuelson, Lamb asked, “What do you think about Midvale being part of clinical-skills experience and clinics like that becoming a core of what we do as a school? Not just for students who opted in, but for all students.”

As Lamb, Samuelson, and others fleshed out the initiative, faculty and students expressed concerns about taking advantage of patients and ensuring a high quality of care. The last thing Lamb wanted was for it to appear that the school was pushing medical students on vulnerable people, giving them less-than-optimal care.

There were other challenges, too: scaling clinical time so that it remains a meaningful experience and ties closely to the core of students’ education, maintaining student interest and investment, and convincing skeptical faculty that students taking longer with patients who are short on time doesn’t disadvantage them.

CBC staff and patients do not share those same preoccupations about the program, Lamb points out. Rather, they are excited and inspired by what’s happening.

THE BEARER OF GOOD NEWS

In a CBC exam room, Li reviewed Jimenez’s three sets of lab results and an X-ray of her kidneys.

Jimenez stared into the distance, glassy-eyed with exhaustion.

As Li reviewed pages of tests and results, she found that the first set of labs indeed had some alarming numbers. But Jimenez’s turning to a healthier diet and drinking a lot of water had borne fruit. The subsequent results showed that her kidneys were good—better than good, actually. The tests revealed a picture of overall health.

Li tried to convey to Jimenez that she did not think the results were as bad as Jimenez believed. She would consult with Sundwall, she said, and then he would be in to see her. The attending reviewed the results and agreed with Li’s assessment: Jimenez’s kidney function was improving.

“You should have a right to get the services you need to be healthy.”

Sundwall sat beside Jimenez and touched her hand reassuringly. While the tests weren’t completely normal, he explained through an interpreter, they weren’t bad enough to require seeing a specialist.

“We need to continue monitoring you to understand what is happening,” he explained. “Okay?”

“Thank you,” Jimenez said in faltering English.

Li smiled softly. Jimenez smiled back.

Outside, light from the setting sun broke through the clouds. It glazed pink-orange, illuminating the snow-capped Wasatch mountain peaks to the east. But all Jimenez could think about was that she had her future back—one unburdened by medical confusion. Relief smoothed away the lines of exhaustion on her face as she zipped her jacket and walked home to her children.

*Reporter Stephen Dark spent two weeks interviewing staff, patients, and providers at the CBC Midvale clinic. While there, Dark, who speaks Spanish, volunteered as an interpreter for patients and providers. Lucía Jimenez is a composite drawn from several patients he met at the clinic. Read the complete story: utah-health.shorthandstories.com/esta-es-mi-clinica