Many of us can recall a time we felt nervous about seeing a doctor. Maybe it was because we were wary about how much the visit would cost, or what a diagnosis would mean for our health. Now, imagine how much more stress you would feel if you had experienced trauma — from domestic violence or human trafficking, for example.

Trauma survivors are the people family medicine physician Anita Ravi, M.D., cares for. On the latest episode of The Dose podcast, Ravi and Keisha Walcott, one of her former patients, talk about how to design health systems for women and girls who have experienced gender-based violence. Ravi and Walcott explain how health, poverty, and trauma are interlinked and why providers must address all three.

Transcript

ANITA RAVI: A lot of my training had been in our community health centers. That’s where I did all of my residency training. And you start to see ridiculous situations. Like our board exam questions will be like, “Which one of these medications is best for pulmonary embolism?” But nothing ever asks you, “If a patient can only afford a diabetes medication or a pulmonary medication, which one should they get?”

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. I’m Shanoor Seervai, and you just heard from Anita Ravi, a family medicine physician. Anita’s patients are women and girls who have survived trauma, like being trafficked to the United States or living in an abusive home. Many of them are too afraid to seek medical care and even if they do, they can’t afford to pay the bills. On today’s show, she’s going to talk about how to design health systems that break through these barriers. She’s joining me with Keisha Walcott, one of her former patients and a trauma survivor herself. Anita, Keisha, welcome to the show.

ANITA RAVI: Thank you so much.

KEISHA WALCOTT: Thank you.

SHANOOR SEERVAI: So Keisha, could you just start by telling us a little bit about how you first met Anita?

KEISHA WALCOTT: About six years ago, I was in a very bad place. I was going through a really bad relationship. I was in the shelter. I was just really distraught. I am an immigrant. I was brought here as a child and I didn’t have any kind of immigration status at the time. So I didn’t have health insurance, so I couldn’t work in the U.S. legally. And I had two small children at the time. So I was just in a relationship that I was being taken advantage of. And it was so hard to just get simple things like food. I had been going through like an eviction and I met with a lawyer and was trying to get some assistance for rent. And she just started going through my situation and she was like, “What is your most immediate need?” And at the time I had had a pulmonary embolism.

I had underlying issues like sickle cell disease, and I was not getting follow-up care at all. I was existing, but I wasn’t living. And she was like, “Well, there’s a doctor that she started this program in NYC. Do you think that you’ll be able to reach her to go to the doctor appointments?” I was like, “Well, sometimes I can’t get there or sometimes I can’t even get to our appointments.” And she was like, “Well, I’ll send you measure cards to get to your doctor’s appointments.” And on a little yellow sticky note she gave me Dr. Anita Ravi’s telephone number, which was surprising to me because doctors don’t usually give you their personal telephone. I didn’t know it was her personal telephone number at the time. I got home and I called the number and she answered — the doctor herself answered the phone. So that was surprising to me. So that was how I met Anita.

SHANOOR SEERVAI: And Keisha, thinking back to that first appointment and other appointments that you had with her, how are these different from previous times that you’d gone to see a doctor?

KEISHA WALCOTT: Even if I’ve gotten care immediately to address whatever the situation was, it never ended up where I would follow up or I could get the proper medications because I didn’t have any insurance. I remember one instance when I was on a certain medication for an embolism and it wasn’t working for me at all. It was just not stabilizing, it wasn’t working. And Anita sent me to a specialist and they advocated and got me this very, very expensive medication for $2. So it was just like, “Wow, I don’t have to settle for less. I don’t have to be at the bottom of the barrel scrimmaging for the leftovers. I can actually get quality care. I can get decent medication that’s actually going to help me.” And that medication led me to become well and not have to take the medication anymore. So these are the things, it was just a completely different experience.

SHANOOR SEERVAI: Mm-hmm. And Anita, you mentioned that Keisha was one of your first patients at this clinic you started for trauma survivors. So tell me about the clinic and what motivated you to start it in the first place?

ANITA RAVI: Sure. So I’m a family medicine physician. And the reason that I highlight that is because I think it’s such an important part of our health care system. I can take care of adults, children, and people across the gender spectrum. And all of my work and training, the reason I became a family medicine physician was, I was particularly interested in working with women who are going in and out of the criminal court systems. And a lot of my training had been in our community health centers. That’s where I did all of my residency training. And you start to see ridiculous situations. Like our board exam questions will be like, “Which one of these medications is best for pulmonary embolism?” But nothing ever asks you, “If a patient can only afford a diabetes medication or a pulmonary medication, which one should they get?”

And those were the kind of real-life situations that were happening all the time in how we were practicing medicine. And when you start to overlay that with gender-based violence and trauma, which is what I was seeing with women who are going in and out of court. I did a lot of my work volunteering on Rikers Island, and you see such profound histories of ways in which people have experienced trauma and violence. And it keeps them from being able to access systems in the way that they need. So PurpLE Clinic came about because the issue of health and human trafficking actually was just emerging in the health care field. So there were more conferences talking about this intersection of health and human trafficking. And there were so much when I came across the field that intersected with the court systems with violence, trauma, and people not being able to access care.

So I started designing a project where I was going to interview survivors of trafficking who are incarcerated on Rikers Island to ask them about their health care experiences while they were being trafficked: where they were getting care, and what would make them feel more comfortable, actually connecting with long-term care. We don’t really have that information in the medical literature. So while I was doing this, I was collaborating with community-based organizations and it’s so awesome that things you can learn about health from people outside of the health care system. So there were social workers and people who were like, “Yeah, yeah, yeah. Research is great. That’ll come out in like five years and maybe impact something.”

But we are seeing clients now who cannot get care. And they’re not documented,  they may not have insurance, but also they’re afraid to go in. It’s one thing if we’re sitting here and we build a bunch of free clinics and we’re like, “Oh, we’re getting through all of these logistical reasons why people don’t get care.” But there is very, very little focus on building systems where people are comfortable accessing what you have designed. And I think that’s such a key part. And I really believe if we can ace that, then anybody can get care no matter what. So if you can optimize the health care system for survivors of gender-based violence, everybody will benefit.

SHANOOR SEERVAI: And you feel like the rest of the health care system isn’t designed for people who may be afraid to come in?

ANITA RAVI: Correct. Our team always says that the health care system is reactionary instead of being proactive in its design of how we can serve survivors. I feel like our health care system exploits resilience in the survivors. So they’re like, “Resilience, survivors can figure it out. They figured it out forever. So they’ll figure this out too.” Resilience should not be a reason why things can’t be designed better and more optimally.

SHANOOR SEERVAI: Anita, what have you learned about how to care for and how not to care for people who have experienced trauma at the PurpLE Health Clinic.

ANITA RAVI: I think you start to reflect on, sometimes designers call it pain points in the system. What are the things that aren’t working and how can we do a quick little fix, rapid innovation, rapid cycle and come back and fix it and see if it works? There’s all these steps, you start to celebrate these victories. If someone makes an appointment, it is a victory. Then if someone comes in all of the way, one of the worst diagnoses that exists I think in our medical system is something called “left without being seen.” It’s like a formal diagnosis code. And it is somebody who checked in, was waiting in the waiting room, at some point they left before the doctor saw them. So they’ll be sitting on my schedule, I have to close the chart and now I put this diagnosis code, “left without being seen.”

And I can’t think of something worse than someone taking the chance, taking time off childcare, doing all these things, making the effort, and then they weren’t seen. So I was constantly trying to figure out, “Okay, once you do design something where someone feels comfortable getting in, how do you keep them engaged?” And then the next part became, “How do you do it so people just don’t end up coming for one visit?” I always ask people what their dream job is at my first visit. I’ve been doing that since I was a medical student because I kind of want to understand what are people aspiring to? What do they care about?

Because my job is to help people get to where they want to go. So the more I understand that the more I can act on it and build around it. So I would stay up at night because maybe I would see one person once and I would never see them again. And I’m like, “Okay, what did we do? What do we need to do differently? Is it transportation? Is it that they don’t have a phone anymore? What are the things that I could do to make someone feel comfortable not just engaging, but staying engaged?” There’s “left without being seen,” but there’s also “engaged without being seen.” Like someone comes in and they engage, but they aren’t seen for who they are, or getting the care that they need. And that also is a silent diagnosis you don’t want to happen either. You want someone to feel comfortable coming back by seeing them and listening.

SHANOOR SEERVAI: Mm-hmm. And this point of transportation, Keisha, you brought this up, you talked about how initially your lawyer would give you MetroCards; in New York, that’s how you can get on the subway. Can you just talk a little bit about how it’s so important for the health care system, the doctor to address something like your transport, how you’re getting to the clinic?

KEISHA WALCOTT: So even like the lawyers that I’ve encountered, for her to realize that this was a problem to send me MetroCards and I realized at that point it can happen, right? You have these funds, these petty funds, it’s $2.50 to get on a train at the time. And if it’s worth $5 to help someone to get to the doctor, why can’t we do that? We throw away money on things that have no use all the time. So if you can take $5, allocate $5 to give to someone to get to the doctor that is such a great accomplishment.

SHANOOR SEERVAI: Keisha, once you started working at the PurpLE Clinic, what are some of the things you noticed about the needs of the people who came there, and what did you do to help them?

KEISHA WALCOTT: Sometimes in the winter, I would notice that patients were coming in without jackets, didn’t have socks on. It would be 32 degrees outside and they didn’t have socks. Sometimes they were hungry and they had to take labs and didn’t have anything to eat prior. So we designed where we’ve got a donation closet and I would ask staff, “Do you have anything that you’re not using or you want to donate to our closet?” And then it just caught on, we got socks donations, we got toiletry donations. We got all these things from staff members and from clinics and hospitals. They were doing drives for coats for PurpLE Clinic. We started having a separate room where we could keep the children if the moms had to have an examination or something.

SHANOOR SEERVAI: And hearing all these things that you’re saying, Keisha, I just can’t help wondering, the medical system traditionally doesn’t think that this is their responsibility. Doctors are supposed to provide a clinical diagnosis, they’re supposed to treat your medical condition, but they’re not necessarily looking to see whether you have good shoes or not. So Anita, what is it that you realized turning this traditional idea on its head, what a doctor really needs to be thinking about?

ANITA RAVI: When we think about what good we’re doing, if you work in a system long enough, you start to realize that what you thought was having impact was only making yourself feel better and maybe not the patient that you’re working with. So often, in primary care we’re taught to manage diabetes and hypertension, but what good is it if I’m going to tell you, “Oh yes, diet and exercise,” if you don’t feel safe walking around in your neighborhood, if you don’t have shoes for it. And then later you come back telling me that you have chronic back pain and I’m like, “Oh yes. It’s because you have bad shoes and maybe you should see a podiatrist,” but you can’t even get access to physical therapy or a specialist, that kind of thing. So you kind of create more problems and more interactions with the system the less you understand the root cause of what someone is telling you about and where you fall into that cycle of their health if you have to be so conscious of it.

SHANOOR SEERVAI: A lot of what you’re describing points towards the importance of considering a patient’s financial situation. How do poverty, health, and trauma, all taken together, impact a patient?

ANITA RAVI: There’s this concept called the health poverty trap. And we see it in practice all the time. I’m sure any physician who has worked in a community health center, a federally qualified health center, the VA, and in correctional settings, we see it where, again, for a variety of reasons, people may have poor health, but they may also not have access to health care, which means they may not have insurance, they may have documentation status. But that makes it hard for them to get employment, or to get a job, or to keep a job which might benefit their access to care.

So now they can’t get a job or they lost their job because of health. So now they have even less access to health care and it becomes this vicious cycle. And I think when we think about the health poverty trap, I think about it in terms of survivors too, because we always talk about violence as a cycle of violence and disrupting the cycle of violence.

And it doesn’t just impact an individual, it’s intergenerational. It will impact their children. I think about when I see someone and I’m like, “Oh, the guideline says they should get a Pap smear.” The Pap smear costs $30. To me that seems like a best practice and a guideline, but that $30 to my patient may have a higher chance of declaring bankruptcy than she does of getting cervical cancer. So now she has paid $30. So she couldn’t afford for this “best practice,” to screen for cervical cancer. She’s received a bill for $30. She can’t pay it. She might be in an abusive relationship or she might be trafficked.

So she ends up back in that cycle. And now her kids are affected because they can’t get what they need, whether it’s for school or for housing or other things. She has to find a way to pay off the bill. She may never come back, or she has to compromise her health in other ways, in order to get the money to pay for this Pap smear. We can’t just be fixing one half of that system. I need to understand all parts in order to make sure I’m not inadvertently harming someone by what I believe to be a best practice in one domain.

SHANOOR SEERVAI: Mm-hmm. And with everything that you were doing at the PurpLE Clinic, you still had patients needing to pay sometimes for services, like you said, $30 for a Pap smear.

ANITA RAVI: Yeah. So what I started doing is I became very good friends with the pharmacist. I feel like too many people probably had access to my Discover card number because it was crazy. Even on a sliding scale, people could not pay a $1.99 copay. So they would come and say to me, “Yeah, I didn’t fill this hypertension med. Yeah, I didn’t fill this yeast infection medication because there was a copay and I couldn’t afford it.” Or they’d tell me about a favor that the pharmacist pulled that they took money out of their tip jar and they used that to cover the dollar.

So that is so, again, unacceptable. I think when we think about grand scale of sliding fees and of course, people can afford $1.99. We don’t understand ultra poverty, I think. And I think ultra poverty hits a lot with people who have experiences of violence and trauma. There’s evidence-based medicine, but then there’s practice-based evidence. And that’s how I think about saving receipts, and thinking that one day you can show like, “Hey, there’s a need for these things.” And if we can fund them, it will be a normalized part of care and then we can focus on the stuff that we need to as doctors and physicians in health care system.

SHANOOR SEERVAI: And what about just the element of listening to a patient coming in really just trying to understand what’s going on? And Keisha, you sort of alluded to this, when you met Anita you were in a dire situation, you really needed care, but you also really needed somebody who would listen to what was going on for you, for your body, in your specific case.

KEISHA WALCOTT: I appreciated that she was aware. She listened to me as well as looked at signals. If someone comes in and they’re hungry, they’re not going to say they’re hungry, you know? So you taking the initiative to say . . . because a lot has to do with pride, especially when it’s someone who is resilient. And if you can offer a Quaker Oat bar, that’s something simple. You’re helping someone not be hungry. If you’re hungry, you can’t focus. You can’t express the things that you need to express. You can’t talk about what you need to talk about. So now it’s going to turn into a mental health session because you’re going around in circles.

People will come in and they can’t tell you why they’re coming in because they can’t think straight. And this is things that I’ve bumped into numerous times where I’m sitting there for three hours and I don’t know why the patient is here because they can’t express to me what’s actually happening or what’s going on. So as practitioners we have to go above and beyond and initiate this, “Do you want something to drink? Do you need something to eat? You’re going to have to do labs, do you want to get something to hydrate?” If you give that initiative, they’ll be more appealed to accept.

SHANOOR SEERVAI: So PurpLE Clinic which you started, Anita, that was a pilot and you’re now working on something new, which is the PurpLE Health Foundation.

ANITA RAVI: I think one of the coolest things about PurpLE Health Foundation is I’m not the founder, I am the cofounder. And I think co anything is so exciting. So I took a lot of lessons learned from running and designing PurpLE Clinic for four years. But I got to meet this team of superhero women. So I felt like, almost like Professor X in X-Men. I went around and found five women who all had these special gifts. And we came together to design something that we believe in. So it’s two other family physicians, a social worker, Jessica, she just went out of her way whenever she would send patients to PurpLE Clinic. So you can tell those people, you can learn from your patients who it is they trust and who it is that sees what they need from a whole view.

And same for Charina, for Keisha, Rebecca, Harika, the six of us, we want something different from the health care system. We want a new normal. I think all of us very firmly believe that survivors have the answers to a lot of the issues that we face, whether it’s racism, violence, poverty, all of those things. But that’s why when we designed PurpLE Health Foundation. In a key part of our mission it’s to improve the health of our communities by investing in the physical, mental, and financial health of women and girls who’ve experienced gender-based violence, because you can’t pretend that our normal systems already did that. And we need to pointedly invest in those things so that everyone thrives.

SHANOOR SEERVAI: Can you talk a little bit about how you’re financing the PurpLE Foundation?

ANITA RAVI: When we designed it we, again, wanted a system that we could design that we could take scalable best practices in health care delivery. So a big part of that, and in many of us having been in the system in a long time is, honestly, the restrictions that come with documentation and what we can and can’t prescribe because of insurance. So we looked into it and we decided that we were going to be a health care organization that was not going to be using insurance as a way for reimbursement for this clinic model.

So we piloted a system where we got funding — $1 million in funding over three years to work on getting our clinic off the ground — to demonstrate the model of care that we want to do that will be largely funded by other avenues, so that we have the flexibility of having longer appointments. So it’s largely from grants. And then we also do trainings. We want to disseminate a new culture of care. So it’s been amazing. We have been invited to give talks on trauma-informed care, on implicit bias, on so many things that are resonating so much with the health care system right now and beyond. And that has become an important way for us to be able to fund the work of the medical practice as well.

SHANOOR SEERVAI: Anita, one quick thing on my mind is that people probably ask you how you can scale this up. And most primary care physicians spend maybe 15–20 minutes with their patients and you spend a lot more time with your patients. So how can the model of care that you think should be provided be scaled up?

ANITA RAVI: There are so many best practices in communication that we can deploy no matter what a visit length is, or no matter who is running the system that we work in. So simple things like the language that we use. Sometimes people would be like, “Oh, your veins are so difficult to find,” when we do a blood draw. And sometimes when people have histories of substance use or other things, that is unintentionally shaming people or making people feel less comfortable with their existence and with their body. So again, that doesn’t take time to change how we talk about things. Or people would say, “If you have two blood pressure cuffs available,” because sometimes if the cuff is too small, the comment will be, “This is too small for your arm. Let me get a bigger one.”

And again, there’s so much interlap with trauma, and disordered eating, and body image issues, and other things, and for a simple thing like a vital sign you’re inadvertently causing trauma when you don’t need to. So these are things where we can have these in place, regardless of what patient we see we can just be like, “Oh wait, this didn’t work. Let me just try this other cuff.”

SHANOOR SEERVAI: And Keisha, you’ve helped to design PurpLE Health Foundation and the medical practice. Can you talk a little bit about some of the things that you felt we really have to do this so that we can make sure that we reach people?

KEISHA WALCOTT: I’ll probably share a personal experience. So talking about the intergenerational poverty trap and how it affects us. When I met Anita in 2015, my daughter was just graduating high school and she was on her way to college. And I had absolutely no idea how we were going to do this, but I knew that I wanted better for her. We knew that we wanted better. And through the PurpLE model of care and all the initiatives that the PurpLE Clinic had, it helped me to get back into school. We were both going to school at the same time. And these things are from the PurpLE Pilot.

So I was receiving mental health care services to help “clean out my closet.” It was like compartmentalizing all the things, all the shit that had happened throughout the years. And I was getting a stipend. It helped her to get a laptop for school. And we’ve come to the close of the PurpLE Clinic and we’re starting the PurpLE Health Foundation. And right now, she will be graduating as a social worker in two weeks. So it’s that cycle.

SHANOOR SEERVAI: Congratulations.

KEISHA WALCOTT: And the proof is in the pudding. It just works. When you have support in all these other areas, everything comes to fruition, right? And it’s happening live and direct. So we have to build a system that can support people to become their best. And I think that that is what PurpLE Health Foundation is all about. And that’s what we’re striving to do.

SHANOOR SEERVAI: Thank you both so much for joining me today.

ANITA RAVI: Thank you so much.

KEISHA WALCOTT: Thank you for having us.

SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show for the Commonwealth Fund, along with Andrea Muraskin, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.

Show Notes

Bios: Anita Ravi, M.D., and Keisha Walcott