Treating the neighborhood: A family physician serves an underserved community

Michael Malone, DO, cares for residents of two inner-city Chicago areas, inside and outside the exam room.

By Tanya Albert amednews correspondent — Posted April 26, 2004

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More than a decade ago, then-accountant Michael Malone joined the ranks of future doctors who decide to subject themselves to academic rigor followed by exhausting on-the-job training because he wanted to take care of people.

He gave up his accounting job and took the undergraduate sciences courses needed to apply to medical school and then plowed through the MCAT.

After completing osteopathic school and residency, however, he shunned private practice, electing instead to practice someplace he was really needed -- an inner-city neighborhood.

After finishing his residency in a tough neighborhood on Chicago's West Side, Michael Malone, DO, took a job with Access Community Health Network, which operates 42 health centers in underserved Chicago neighborhoods and the suburbs. The network's mission statement: Services are available to all who need them without regard to age, race, ethnicity, gender, language, religion, education, sexual orientation, physical condition or ability to pay.

He was assigned to a clinic on Chicago's South Side where 38% of the residents are living below the poverty level. The Englewood and New City neighborhoods also are home to many working patients who don't have health insurance through their employers.

He's been there almost three years.

"I can't imagine doing it any other way," Dr. Malone said during a lunch break in the small office that he shares with the other physician assigned to the clinic. "I wanted to be where I was needed. Everybody deserves the right to have medical care."

Data in the Institute of Medicine 2003 report "Unequal Treatment, Confronting Racial and Ethnic Disparities in Health Care" shows that 47% of African-Americans and 53% of Hispanic adults younger than age 65 rely on urban safety net emergency departments, outpatient department or clinics for their health care. Only 30% of whites fell into that category.

Study after study shows that people living in poor urban neighborhoods, where residents are less likely to have health insurance and there are fewer doctors, have less access to care than those in more affluent areas.

Other studies have shown that minorities don't have as high of survival rates for cancer and other diseases, in part because they don't have the same access to health care as more affluent white patients.

Dr. Malone wants to help change those statistics. "When I walked in here, I felt like this is where I'm supposed to be," Dr. Malone said. "I consider myself blessed to be here."

In some ways, Dr. Malone's job is no different than that of any other family physician.

He gives children shots for school and helps patients manage their diabetes. He's also noticed an increase in the number of obese children he sees.

He has patients who don't take medication he's prescribed. Some don't come in for follow-up visits. Domestic violence, drug abuse and teen sexual activity are included in discussions he has with patients -- albeit more often than for many of his physician colleagues.

And Dr. Malone is likely to see a higher rate of patients who don't comply with doctor's orders or don't come back for follow-up visits than physicians practicing in more affluent communities. Patients often move and will receive care from a number of different physicians, so continuity of care is one of his biggest concerns.

"Too many cooks in the kitchen and something is going to happen," Dr. Malone said. "One doctor gives a beta blocker and one doctor gives the patient a different beta blocker, not knowing the other one was prescribed, and you can get in trouble."

To prevent something like that from happening, he asks patients to bring in all the medication they are taking.

Dr. Malone had to educate himself on the terminology his patients use so that he can understand what is going on in their lives.

For example, Dr. Malone discovered that when he asks patients whether they drink alcohol, they would answer no even if they drank a six-pack of beer a day because they didn't define "beer" as "alcohol." He also has picked up terms that describe how a patient might use cocaine or marijuana, for example "Do you lace the marijuana with anything?"

And while teen pregnancy has been declining nationally, the clinic's statistics show an increase in the number of pregnant teens visits. The clinic has an ob-gyn once a week.

"The prevalence of abnormal Pap smears in young teens is alarming," he said.

The most visible sign that Dr. Malone's practice isn't your typical family practice is the clinic's exterior. There are metal bars on the windows of the building at 53rd Street and Ashland Avenue. Patients need to be buzzed in through a locked door. There haven't been any serious incidents since Dr. Malone joined the two-doctor clinic, but a security guard stands outside the door throughout the day.

"Some people think I'm nuts for coming here," Dr. Malone said. "Something can happen, but I don't do anything foolish. I'm very comfortable where I am. If you're not, that's when something bad is going to happen."

In the office, the patients are linked to programs in the broader community.

Other members on the clinic team are able to help patients work though Medicaid or Medicare forms. They've also assisted some patients with senior housing.

And through Access Community Health Network, Dr. Malone is able to refer patients in his neighborhood clinic to programs in other parts of Chicago that can offer them services for mental health, HIV, substance abuse and other health concerns.

"It's a community-oriented network designed to reach out in every area," he said.

But Dr. Malone doesn't limit his practice to inside the clinic.

About once a month he makes home visits to patients who can't get out on their own.

He and his office partner, general physician Ming-Chung "Mike" Chen, MD, go to churches to talk about healthy living, covering topics such as how diet and exercise can prevent high cholesterol and heart disease. Diabetes is often a topic of conversation, too.

They do outreach to senior homes, and in the near future they plan to extend their outreach to schools to talk about sexually transmitted diseases and tobacco.

"I am in a true community setting," Dr. Malone said. "Getting health news out there is important."

What patients want

Patients say that Dr. Malone and Access Community Health Network are meeting the needs of inner-city residents that all too often go unmet.

The clinic is easy for many residents to get to, they're given help on how to maneuver through an often complicated health care system and they trust their physician.

Those are several factors that Chicago residents identified as barriers to health care in underserved inner-city neighborhoods in a 2000 Chicago Dept. of Public Health report "Chicago Plan for Public Health System Improvement."

For patients who have encountered doctors talking down to them and not performing as basic a task as pulling out a stethoscope and listening to their heart, Dr. Malone's bedside manner is a treat.

He takes the time to explain to them exactly how diabetes is affecting their bodies, even though they may not be "feeling bad."

He asks lots of questions and listens to the answers. He explains why he is prescribing a certain medication.

And he does it all with a smile.

"He looks out for me," said Englewood resident Wesley Durrell, who has been seeing Dr. Malone for about a year. "I wouldn't replace him for a million dollars."

Patients initially worried that Dr. Malone wouldn't stay long. They had seen other physicians come to their community for a year and then leave.

But Dr. Malone said he has no intention of going anywhere.

"I want to be here," he said. "They are going to have to drag me out kicking and screaming."

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Community snapshot

New City Englewood
Population 51,721 40,222
Living below the poverty level 34% 43%
Median household income $25,647 $18,955
Racial makeup 50% Hispanic or Latino,
36% black or African American, 13% white.
98% black or African American.

Source: Chicago Dept. of Health. Figures and racial classifications are from 2000 Census; underrepresented minorities are not included in totals.

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Perceived inequities

For the most part, patients more often than doctors believe the health care system treats people unfairly based on race, money, language or education. Below is the percentage of doctors and patients who believe a certain factor "very" or "somewhat often" leads to unfair treatment.

Doctors Public
Whether or not they have insurance 72% 70%
How much money they have 47% 71%
How well they speak English 43% 58%
How well educated they are 39% 48%
What their race or ethnic background is 29% 47%

Source: Kaiser Family Foundation, National Survey of Physicians, March 2002

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