Healing the Gaps

IT’S A TYPICAL Friday morning at Eskenazi Health's Thomas & Arlene Grande Campus, a federally qualified health center on Indianapolis’ northeast side, and Alyssa Cooke, MD, an Indiana University School of Medicine graduate, is coasting through the day’s lineup of checkup exams.

Cooke, who specializes in internal medicine, gives clean bills of health to a pair of infants. She passes along good news to a 23-year-old patient with diabetes whose medication has brought her blood sugar under control. Even the mundane task of Cooke’s chart notes passes quickly. Yet her last patient before lunch poses a concern — a 2½-year-old girl whose chart shares a potential diagnosis: autism.

Cooke takes a seat on a rolling stool, and the anxiety of the girl's mother streams forth. When she calls her daughter's name, the toddler doesn't respond. The child tends to shake her head or flap her hands in front of her face — a form of self-stimulation and calming behavior common with autism. She only plays with a handful of toys. Only a select playlist of YouTube videos holds her attention. The mother concludes: "I'm maybe thinking something is really wrong.”

Cooke takes a breath, scoots her stool forward and unspools some slow words of reassurance. "She can hear you," Cooke says. "Her ears work, but her brain isn't processing it normally."

The mother nods, but fidgets with a Bic pen between her fingers. She talks about getting her daughter into a new daycare that may offer more social engagement. She acknowledges missing several calls from a Grande social worker who works with the families of children with autism. "I'm very scared right now," she says. "I want to know if there's a solution."

Cooke explains that autism exists on a spectrum — and that it is a lifelong condition. Some children, she says, grow into productive adults who work and live independently. She gave the mother information for the social worker and promised to get them connected.

Above all, Cooke dispenses encouragement. "The biggest thing is giving her as many resources as possible," she says. "But we also want to continue loving her and supporting her. You're doing that. You're doing a great job."

Cooke, a 2019 graduate of IU School of Medicine, practices internal medicine at Grande, where she works alongside colleagues who share her values and strongly advocate for their patients.

OPENED A YEAR ago, the Grande Campus — at the corner of 38th and North Arlington streets — is the nexus of care for this medically underserved area of Indianapolis.

With the help of a $4 million federal grant for the Indiana Primary Care Advancement in Clinical Training program, known as PRIME, IU School of Medicine hopes to recruit and train more physicians to work in similar clinics and in underserved areas across Indiana. And the need cannot be understated. In a nation with a shortage of primary care physicians, Indiana is among the states where the shortage is most acute. The School of Medicine is trying to close the gaps.

The federal Health Resources and Services Administration designates areas as medically underserved based on poverty rates, elderly populations, infant mortality rates and health care provider ratios. It gives geographic areas a score. Anything below 62 is medically underserved.

In Indiana, eight areas have a score of zero. They exist in urban areas such as Indy’s east side and in rural communities like Seymour, Waterloo and Gibson City.

The rural shortage areas are a product of the erosion of community-based health systems and the withering of local tax bases which might support them, prompting the disappearance of hospitals from some communities. In urban areas, where there are hospitals, the factors that keep people from accessing medical care are more complicated and related to social and environmental factors.

As Bradley Allen, MD, PhD, the School of Medicine’s interim executive associate dean for educational affairs, who oversees the grant, puts it: "We have these deserts of primary care and obstetrics care throughout the state of Indiana that are preventing people from accessing needed care.”

The impact is visible in lifespans. Within the boundaries of underserved areas, researchers from the Fairbanks School of Public Health reported that average life expectancy ranges between 68 and 75 years. That's 17 years less than the longest-living pockets in greater Indianapolis. These chasms in life expectancy stubbornly persist across all age groups — a grim tally that’s the final manifestation of gaps in education, home ownership, working conditions, transportation and health care.

"When we start talking about health care access, there has to be an understanding that we are just talking about a slice of all the things that impact one’s health," said Tess Weathers, MPH, a research associate at the School of Public Health, who has studied determinants of health for the Northeast community. "People in the medical community can’t fix everything that is influencing a patient’s health, but they are in a unique position to see that bigger picture and connect patients to others who can help."
Many of the staff untangling those knots at Grande are younger physicians — and IU alums — like Cooke, Elijah Huang and Christopher Hyppolite. Each sought Grande for its "value-based" approach that fuses advocacy and shared decision-making with patients. "We come alongside patients," said Huang, MD, a pediatrician, "and help make problems not as impactful in their daily lives."

Hyppolite, who graduated from IU in 2019, saw an opportunity to establish a standard of care and create access to child psychiatry where it had never existed before.

HUANG'S PATH TO Grande started in a lab just outside West Lafayette.

A Carmel native and biomedical engineering major at Purdue University, he spent a summer interning at Cook Medical's device development lab.

"Everything we did was so far down the road," Huang said. "I needed that personal connection to feel like I accomplished something in my everyday life." So, he opted for medical school.

Like Huang, the path Hyppolite, MD, followed to become a child psychiatrist involved a detour. From a family of doctors, he veered into accounting and worked at a hedge fund. His path changed after a battle with a rare form of bone cancer. He returned to school, earning a master's in medical science before arriving at IU School of Medicine.

Initially dead set on surgery, Hyppolite found his talent rested in working with children and his passion for mental health. While shadowing a consult psychiatrist at Riley Hospital for Children, he was blown away by how a short visit set the stage for a successful stay.

"It's emotionally challenging," Hyppolite said. "But if you see the benefit, you are like, I want to do that."

Cooke found her niche as a resident during rotations at another of Eskenazi's east side clinics. Each week, she worked with veteran peers whose approach to medicine matched her own. "These are the people I would want to have as my colleagues every day," she said.

Grande's patient population requires providers to embrace adaptability and flexibility. Two patients might share a diagnosis, such as diabetes, but their treatment plans differ vastly. Barriers that come up during care can be complicated.

Take filling prescriptions. Grande serves a robust group of Spanish- and Creole-speaking patients, some of whom are learning to navigate the health system. Sometimes, they don’t know prescription refills are an option — or necessary. When they return to see Cooke, they tell her they finished their treatment — and then things worsened again. "I didn't realize that was something we needed to discuss," Cooke said.

There's also a disconnect when Cooke explains her concerns to a patient with a chronic condition like diabetes or heart disease. If patients aren't experiencing symptoms, they may assume all is well. Then there are simple logistics. If a patient's job involves overnight work, they might miss an appointment. Struggles with childcare mean patients bring children to their own exam. "That's not always ideal," Cooke said. "Like for a pap smear."

Another reality is interrupted care. In recent years, about 16% to 20% of Indy’s northeast residents say they needed to see a doctor but couldn’t because of cost, according to a community survey conducted by Weathers and colleagues in the School of Public Health. Another 17% reported experiencing homelessness or being at risk of it. "If keeping a roof over your head is a worry, you can't attend to your health care," Weathers said. "It's just the reality of a different day-to-day life."

Hyppolite frequently sees children with undiagnosed autism and related conditions. Often, his sessions are a form of root-cause analysis for families. “But isn’t that what medicine is?” he said. We’re trying to understand and modify behaviors.”

TACKLING ENTRENCHED DISPARITIES has presented opportunities.

Grande's initiative offered access to mental health services for children, allowing Hyppolite to establish a standard of care from the ground up. That’s significant in a state where every county has a shortage of mental health professionals.

Over the past year, Hyppolite has spent ample time working with children with undiagnosed autism, which often comes with conditions like anxiety and ADHD. Many families don't understand their child's behavior. Recently, Hyppolite saw an 8-year-old autism patient whose parents moved up his appointment after an outburst. The boy had become agitated after soccer practice, hitting his stepbrother with a cleat.

During the visit, Hyppolite asks the boy about his feelings – but he doesn't know what’s driving them. From the parents, Hyppolite gathers details. The father said it might be due to watching The Simpsons. The mother said it may be late nights watching siblings play sports. "I'm just worried we're regressing," she said.

Hyppolite suspects the cause might be the increased dosage of an anxiety drug. "Maybe we're at too much medication," he says. "I'm not so foolish as to think I'm infallible."

The boy's father experienced issues with side effects from mood medication. But his wife worries that reducing the child’s dose would lead to more anger and aggression. Hyppolite explains: "The way I see it, medication is a cast. It's there to help with healing and get him in a frame of mind where therapy matters and helps. When that happens, we remove the cast."

Hyppolite's conversations often involve root-cause analysis. "But isn't that what medicine is?” he said later. “We're trying to understand what happened and modify behaviors."

During his fellowship at Eskenazi's Midtown Mental Health Center, Hyppolite was inspired by the staff's work with patients, including children. "I really wanted to build something here (at Grande)," he said. "They felt the same way."

Hyppolite values time with his young patients, sometimes spending 45 minutes to understand their behavior and barriers. "They're not little adults," he said. "We cannot impose expectations on somebody who doesn't know what they don't know."

In a later session, a 16-year-old girl who had anxiety and suicidal ideations is showing progress. She’s been getting outside more, exercising, and she’s changed her diet. Hyppolite asks if she had thoughts of self-harm. She smiles and says, “no.” Hyppolite seems to know that already. "What I see in front of me is someone who's made changes for the better," he says. "I can see it on your face. I can see it on mom's face. You've put in the work, and that's not easy. I'm so proud of you both.”

The School of Medicine’s push to encourage more physicians to enter underserved areas through the PRIME grant coincides with a related effort, known as INPACT, that aims to entice more students to enter primary care with scholarship aid. In fact, the two initiatives overlap: There is a shortage of doctors in many areas, and the need is particularly sharp in primary care.

For Cooke, Huang and Hyppolite, exposing students to environments like Grande is as vital as scholarship dollars in coaxing more primary care doctors to underserved areas.

Hyppolite said it comes down to a fundamental question: What do you want out of your day? It can be challenging to work in an underserved area, but with rewards beyond scholarship incentives. "We shouldn't have to fight or lobby for people to be here," he said. "There are plenty of people who already want it and have it in their heart to be at this place.”