Getting to the heart of health care for the poor

Stanford cardiologists help low-income residents through monthly program at Arbor Free Clinic

Credit: Mike Goodkind

Resident Alexander Ungewickell, MD, (left) talks with patient Cresencio Martinez while medical student Patrick Lin takes notes. Martinez came to the Arbor Free Clinic recently for the new services being offered at the student-run clinic in Menlo Park.

Crescencio Martinez was waking up at 2 a.m. every night with heart palpitations. He felt lightheaded and started getting numbness in his fingers, but he put off going to see a doctor because he didn't have any medical insurance.

'I heard about this clinic at my church,' said the 52-year-old Sunnyvale gardener, seated nervously on the edge of the patient's table at the Arbor Free Clinic in Menlo Park on a Sunday afternoon, discussing his symptoms with Stanford cardiologist Euan Ashley, MD. 'I was getting worried.'

Concentrating hard on the image of Martinez's heart on a donated sonogram machine, Ashley, an assistant professor of cardiovascular medicine, nodded his head, furrowed his brow. Martinez, a Mexican immigrant, was getting his heart checked for free at a new monthly specialty cardiology clinic recently added to the weekly clinical services offered at Arbor in donated space at the Menlo Park division of the Veterans Administration Palo Alto Health Care System each Sunday.

'People who don't have access to care don't tend to have their hearts checked,' explained Ashley, who heads up the cardiology clinic, volunteering to care for patients while teaching medical students who also volunteer at the clinic. The cardiology and mental health specialty clinics were added to a handful of other monthly specialty clinics available at Arbor that include dermatology, neurology, optometry, orthopedics and now mental health. Ashley is one of several physicians from Stanford Hospital & Clinics who volunteer their time at the Arbor Free Clinic.

'Mr. Martinez's heart function isn't quite normal actually,' Ashley continued, speaking through an interpreter to Martinez, a native Spanish speaker. 'Ask him to put his left arm above his head. Perfect. Let's see if we can see all four chambers at once … left ventricle,' Ashley murmured under his breath. Mouth dropped open a bit, eyes squinting, shirtsleeves rolled up, he said, 'His heart's not as strong as it should be.… Wait, wait, wait….'

Expanding programs

Under the supervision of School of Medicine faculty volunteers, medical students have been treating homeless and uninsured patients at the Arbor Free clinic for 15 years. A survey conducted three years ago by Lars Osterberg, MD, clinical associate professor of medicine and medical co-director of the Arbor Free Clinic, on the medical needs of the homeless in the Palo Alto area spurred the opening of the two newest specialty clinics. Among the medical ailments topping the list were high blood pressure and mental illness.

'The poor really have a lot of cardiovascular risk factors,' said Osterberg. 'Many smoke. Many don't have a balanced diet. Cheap food is high in fat and carbohydrates, contributing to their risk of diabetes. Many have hypertension. These factors put them at high risk for cardiovascular disease.'

The specialty clinics at Arbor have always been a unique part of its program, something other local clinics don't tend to offer and something Osterberg would like to see continue to grow both in the number of patients treated and the number of faculty volunteers.

'We have an abundance of talented specialists and a community that lacks access to them,' Osterberg said. 'This is a way Stanford can really partner with the community.'

Still, time and space at the clinic are limited and, for now, there are always patients turned away.

About 20 patients a week are treated in the main clinic while half a dozen or so are seen monthly at the individual specialty clinics. The clinic attracts a large Latino population and patients primarily from East Menlo Park and East Palo Alto.

'We turn away a handful every week, and many others will wait a long time to be seen,' Osterberg said. 'The patients never complain though. They know they would wait longer in the ER and we don't rush them through their appointments.'

Sometimes the line of patients weaves out the door and down the sidewalk of the VA-Menlo Park hospital, but by 2 p.m. on the Sunday when Martinez visited the clinic just a few scattered patients were still left waiting in the lobby of the clinic.

A Chinese immigrant from Mountain View with a swollen ankle and no health insurance had been waiting for two hours with his wife. A laid-off office worker from San Bruno had been waiting for three hours for a physical that would enable her to sign up for a new training course as a pharmacy technician.

Ashley saw about seven heart patients this particular Sunday, although he typically sees three to four patients during each clinic session. Since the opening of the cardiology clinic, he's seen patients with atrial fibrillation, vascular disease, heart murmurs and one patient, Martinez, with newly diagnosed heart failure.

'Poverty is one of the greatest predictor of heart disease,' said Ashley, explaining why he volunteers at the clinic. He hopes to increase the number of cardiology clinics to twice a month. He knows it's needed. 'People are falling through the cracks.'

Making the diagnosis

Dressed in slacks and a button-down shirt, Ashley leaned over the keyboard of the sonogram machine, long, slender fingers tap-tap-tapping on the keys. His patient, Martinez, waited patiently for the verdict, his hands, tanned from long hours working under the sun, held tightly in his lap.

'I'm screening the aortic valve for gross abnormalities,' Ashley explained, speaking to Martinez through the volunteer interpreter, Silvia Maria Fernandez Illescas, a graduate biology student.

'The heart looks sluggish. The valves look OK,' Ashley continued. Martinez doesn't smoke or drink, and tries to eat healthy food, he said. But his blood pressure is higher than normal at 142 over 85.

After about an hour of examining Martinez's heart, Ashley was ready to make his diagnosis.

'Your heart doesn't look normal,' Ashley said. 'I found it's a little bit weaker than it should be. It's not severe, but it's not normal. Probably the high blood pressure is responsible for the sluggishness. We need to get you some good medicine to help the muscle recover.'

Martinez nodded.

'What is high blood pressure due to?' he asked through the interpreter.

'Genetics, diet,' Ashley said.

'How long will I have to take the medicine?' Martinez said.

'Probably for life,' Ashley said. 'The hope is that this will make the heart muscle stronger. The good news is we caught this early on. It's only mild heart disease right now. The medicine should help you live longer. You should be OK.'