Cardiology, With Heart
Tuesday, May 24, 2005
"This is a mess," cardiologist Nancy J. Davenport declares as she examines the hugely swollen legs of Jerone Browner-El, who sits slumped on a stool in an office at Washington Hospital Center looking miserable and angry.
"You're like the popping fresh doughboy, baby," Davenport adds gently, scanning the list of medicines the 56-year-old Northeast Washington resident is supposed to be taking. The drugs are supposed to control his blood pressure, rein in his diabetes and shore up his badly enlarged heart. Because his kidneys are failing, his feet are so swollen he can barely stuff them into soft shoes that resemble bedroom slippers. His blood pressure is dangerously high.
Davenport zeroes in on that first, asking Browner-El whether he is taking the hypertension medicines she gave him. Sometimes, he replies, scowling. His wife quickly interjects, assuring Davenport, who has been her doctor for several years, that her husband is mad at her for making him go to the doctor.
"We are a mess," she says to Davenport. "You're the reason, along with God's grace, that I'm here today," she adds. This time, she tells Davenport, it is her husband who needs help.
So do a growing number of low-income Washington area residents who are facing an acute shortage of doctors, particularly specialists, willing to treat them.
In the District, an estimated 15 percent of the population has no health insurance and one in three residents receives health benefits from a patchwork of government programs. Those covered by Medicaid, the government program for the poor and disabled, are increasingly unable to find doctors willing to care for them because of the program's low reimbursement rate. The same problem affects the thousands enrolled in the D.C. Healthcare Alliance, a network of doctors and hospitals launched six years ago, two years before the city's only public hospital, D.C. General, was closed.
"It's really hard for people without adequate health insurance to get cardiovascular care," said Paul Ginsburg, an economist who directs the Center for Studying Health System Change, a nonprofit Washington think tank.
"Doctors who offer pro bono [services] or discounted fees are few and far between," said Carolyn Gardner, director of the Washington Free Clinic. Finding specialists remains a huge challenge for her staff, she said. For patients with heart problems, the clinic relies on the services of a lone cardiologist who comes to the Mount Pleasant clinic once a month. Frequently, she said, her staff has to "get on the phone and beg, borrow and steal" to obtain appointments for patients with other specialists.
Follow-up care is essential for cardiac patients because heart problems tend to be chronic and often occur in conjunction with diabetes, hypertension and lung ailments. Numerous studies have found that people who receive only episodic treatment for these problems tend to suffer from needless disability and premature death.
Because patients often wait months to see a specialist, many wind up in crisis in swamped emergency rooms. Doctors there are required to take care of them during a crisis, but not to provide the continuing care that might prevent a recurrence.
Davenport, one of the Washington area's few female interventional cardiologists -- heart specialists with advanced training who perform angioplasty and other invasive procedures -- is an exception. Although she sees about 100 patients per week in her own office in upper Northwest, two Saturdays a month she holds a cardiology clinic for less affluent patients, many of whom who live in medically under-served areas of the District.
Using an office borrowed from another cardiologist and with assistance from medical students from Georgetown, where Davenport teaches, she dispenses advice and encouragement and gives away large quantities of free drug samples in plastic shopping bags she brings from home. She arranges for tests and follow-up care for her growing roster of established patients, as well as a steady stream of new ones, some referred by other doctors or hospitals or their friends or relatives. A minority of patients are homeless; others live as far away as Calvert County.
A few patients arrive without an appointment and are seen anyway. The majority are enrolled in Medicaid or the D.C. Healthcare Alliance, which covers poor people who don't qualify for Medicaid.
Many of the 20 or so patients who typically show up for the Saturday clinic -- taxi drivers, recovering drug addicts, hotel workers, former prisoners and the elderly -- would be unlikely to see a heart specialist outside an emergency room. Most have a serious cardiovascular problem, sometimes several of them. A surprising number are in their forties and have survived at least one major stroke or heart attack.
Unlike most heart specialists, "Nancy has an open-door policy," said Tom Norin, the administrator of her large practice, which follows about 3,000 patients.
While many physicians decry paltry insurance reimbursements and complain they must work harder to compensate for rising malpractice insurance costs, Davenport, who is board-certified in internal medicine, cardiovascular diseases and interventional cardiology, shows no interest in the financial aspects of medicine.
"The truth is that she's the least interested of any physician I've ever met in making money," Norin added. "I have to literally chase her down to get her to talk about it."
Norin said the clinic, at which he sometimes volunteers, was started more than a decade ago by a former partner of Davenport's; her new associate Getu Assefa sometimes helps out. Echocardiography technician John Galvin also donates his time on a few Saturdays during the year, performing tests that cost about $600 each on clinic patients.
Davenport, who adores talking about cardiology, is much less forthcoming about herself. She looks surprised when asked why she continues to operate a clinic that adds to her prodigious workload. In exchange for borrowing the hospital center office of cardiologist H. Brandis Marsh and dispensing his large stash of samples to her patients, Davenport makes rounds for him every weekend.
"I feel responsible," she says simply. When asked to elaborate, she observes that many clinic patients would be unable or unwilling to travel to her office.
A Full Schedule
Davenport has a tart sense of humor, boundless energy and a direct, unflappable manner that befits a nurse, which was the first of her three careers. Now 59 and a grandmother, she left a tenured professorship in nursing at American University to enter George Washington University School of Medicine at 35. She'd already earned a doctorate in cardiac physiology at GWU and worked for two years as a postdoctoral fellow in a lab at the National Institutes of Health (NIH).
At the time she entered medical school, Davenport and her husband had four young sons, and her husband was establishing his career as a Washington litigator specializing in complex product liability cases. Their daughter, now 17, was born during Davenport's residency at Georgetown.
Davenport grew up in a medical family: Her mother was a nurse and her father was a prominent Chicago surgeon. She said she decided to go to medical school because she was irked that a physician's signature was required for routine blood draws at NIH. "I decided I wasn't going to be the bottom person on the totem pole," she said.
Her practice is located in the upscale Foxhall Square medical building on New Mexico Avenue NW. She routinely works 90-hour weeks, shuttling among Sibley Hospital, Suburban Hospital and Washington Hospital Center, sometimes staying up until 4 a.m. performing cardiac catheterizations on patients who've had heart attacks.
Davenport displays none of the status consciousness common among high-powered specialists: She tidies up the exam rooms and empties the trash after her clinic is over and recently walked out to the waiting room to apologize to a patient who had been waiting 30 minutes to see her. She doesn't own a cell phone or PDA or use e-mail.
"Nancy is a first-rate person in all respects," said Marsh, the cardiologist whose office she borrows. "She knows her cardiology, she pays attention, she follows up and she seems to enjoy the kind of personal relationship with her patients that was the neat thing about medicine when I started. Nancy is never too busy to do something for someone else."
Open Door, Free Admission
Before she met Davenport in the emergency room of Washington Hospital Center six years ago, Carolyn Browner-El said doctors elsewhere had minimized her complaints of chest pains and sent her home with nitroglycerin.
Davenport, she said, was different. She performed several tests and then did a cardiac catheterization, determining that Browner-El had a weak heart because of cardiomyopathy, a condition that affects the heart's pumping ability. Now 49, she became one of Davenport's patients and her heart problem improved.
"Dr. Davenport gave me a regimen of medicines that stabilized my heart, and now I see her once a year," said Browner-El, who said her family income is about $1,200 per month. She is now struggling with a more serious problem: Her liver is failing and she needs a transplant. But when she and her husband came to the clinic last month, Davenport was more worried about Jerone.
Davenport tells the couple she will call another kidney specialist--the fourth she has contacted on his behalf-- to ask if he will see Browner-El. She gives him a follow-up appointment, reminds him to take his blood pressure medicine and asks if he needs a coupon for a free home blood pressure cuff.
As she heads for the next patient, one of two pagers clipped to her white coat emits a piercing beep. The emergency room at Georgetown has a 40-year-old woman who may need a cardiac catheterization. Davenport tells Georgetown to send the patient to the hospital center and she'll see the woman after her clinic closes around 2 p.m. -- and before she heads to Suburban Hospital to make rounds there.
Two Saturdays later, Davenport is in the clinic by 9 a.m. Usually her daughter, Gina, serves as the receptionist, but this time it is her husband, Jim, who is wearing jeans, a T-shirt and running shoes.
Robert Dent, the first of the day's 20 patients, arrives 15 minutes early for his appointment. At 56, he has survived a near-fatal heart attack and a less serious one, as well as a blood clot. He has artificial hips and knee replacements, wears a pacemaker and has undergone surgery on his shoulder. Retired on total disability, he takes medicine for high blood pressure, elevated cholesterol, and heart and lung problems.
He met Davenport in 2003, when he was taken by medevac to Washington Hospital Center from Fort Washington Hospital near his home in Prince George's County. She performed angioplasty, but the artery later closed up and last year he had his second heart attack. Davenport performed a second angioplasty, this time combined with low-dose radiation to keep the artery open. So far, it seems to be working, and Dent says he is faithfully taking his medications.
"That's my girl right there," Dent says, grinning broadly as Davenport greets him with her customarily cheery "Hi, sweetie."
Dent, who is dependent on Medicaid, said he particularly appreciates the samples of the seven drugs Davenport gives him. Once he had to pay for them, and he recalled "I couldn't get them all, because they would have eaten up all my [$500] monthly check."
Davenport congratulates her next patient, a 47-year-old former hotel laundry worker, on his normal blood pressure and abstinence from drugs. Davenport met the man a year earlier while he was spending three months in the hospital recovering from a stroke he said was induced by his crack cocaine habit. The man is so pleased about his blood pressure that he asks "Miss Davenport" to write the numbers on a piece of paper so he can show his mother.
She declines to give a D.C. cab driver, who has shown up without an appointment, more Viagra samples along with his other medications because she suspects he may be selling them. "One a day for personal use, okay, but 10? Come on," she says later. "He's not getting any more."
Davenport says that while smoking, drug use, high-fat diets, alcoholism and other bad habits are common among her patients, she doesn't lecture them, believing it would be counterproductive.
But she admits to occasional frustration. A few months ago she had a talk with a patient whose lengthy list of life-threatening medical problems is exacerbated by her morbid obesity. Davenport felt she'd gotten through until she walked by the Blimpie restaurant in the hospital lobby an hour later and spotted the woman tucking into an order of french fries.
One Step Forward . . .
Jerone Browner-El is back, looking much more chipper than two weeks earlier. He tells Davenport that the nephrologist she found for him tweaked his medicines in the hope of avoiding dialysis and draining the 30 pounds of fluid that have accumulated in his legs.
Davenport tells him she is glad to see that his blood pressure is lower than last time, and he replies, looking somewhat sheepish, that he is taking his pills.
When the doctor asks about his wife, Browner-El tells Davenport that doctors at another hospital have told Carolyn there is nothing more they can do to treat her failing liver.
"They may not be able to get her a [new] liver, but someone can take care of her," Davenport says. "And if they won't, you give me a call and I'll poll some of my GI [gastroenterology] buddies and see if they'll take her." ·