Proceedings of the First National Conference on Community Health Center – Primary Care Residency Program Linkages, "Community-Oriented Primary Care and the Role of Community Health Centers" (Part 1, Babitz)

Marc Babitz, MD (United States Public Health Servoce, Region VIII, Denver, Colorado) [Dr Babitz is a Senior Fellow of the Coastal Research Group]:  Thank you, Terry.  It’s a pleasure to be here, I am thrilled that the first topic is Community Oriented Primary Care [COPC], because I think it has a philosophy of care that is very important for our CHCs.

I want to spend a fair amount of time helping you all understand the expectations of the United States Public Health Service [USPHS].  Much of my time is spent talking about COPC to varous audiences:  to training programs, residency programs, medical and dental students.  But primarily, I talk to our health centers to help them understand our federal expectations of how they conduct their primary care programs.

Just a little background, I am a family physician.  I trained in the Community Hospital family practice residency prgram in Santa Rosa, California.  I went to Guerneville, a rural community West of Santa Rosa and spent nine years as a National Health Service Corps [NHSC] family physician as part of the USPHS.

I think USPHS physicians were doing some degree of COPC even then, although I hadn’t heard of the term at that time.  I spent three years in my “hardship” assignment – the NHSC headquarters in Rockville, Maryland – before I was able to get to Denver, where I have been for about six and a half years.

I want to give you the quick version of how we teach COPC and try to make sure you and I all are on the same wave length.

Let me ask you a question first.  How many of you know the topic of COPC pretty well?

[Many audience members raise their hands]

That’s great, because three years ago I would ask that question of other groups,but there would not be many hands raised.  How many of you know it well enough to teach it? How many really understand the elements and the perspectives?

[Several audience members raise their hands]

When I give talks on the subject, I begin with a 1987 quotation of Dr. Paul A. Nutting from the preface of the book Community-Oriented Primary Care:  From Principle to Practice, which he edited, who calls COPC a “marriage of the principles of epidemiology and the practice of primary care.”  I make fun of his definition when I talk to medical students because most of them, like me, hate epidemiology.

I prefer a 1982 quote by Dr. Fitzhugh Mullan, who is presently the head of the Bureau of Health Professions.  Dr. Mullan called COPC the “reunion of the traditions of Public Health and Personal Clinical Health Services” – that is, public health merged with primary care.  That’s pretty much true, but there is much more that needs to be said on that topic.

I like graphs, so when I talk to our providers and to student groups, at one point I would show them a graph in which two circles overlap each other.  Once circle is labeled public health, the other primary health care.  The area where the circles overlap is COPC, and that area of overlap represents, as far as I am concerned, the best aspect of public health and primary health care.

The next time I revised my slides, I had three circles made, the third circle being the community.  Thus, the community, public health and primary health care, all are essential elements of COPC.  All three parts are critical for our CHCs.

I’d like to spend a little bit more time on how we teach this and what we mean by these things. When we talk about COPC, we talk about the three elements of community, primary health care and public health.

• One’s practice is surrounded by a community.  To define a community, you have to understand some concepts.  A Public Health Service practice is designed to be a primary care practice.  The USPHS may apply some different definitions of primary care practice to the CHCs it subsidizes, than you might be using right now.  But it does incorporate the following qualities of personal health care:  that such care is accessible, acceptable, accountable, comprehensive, coordinated and continuous.

I want to talk about these qualities to some degree.  I think, historically speaking, that attempts to define the concepts we now call COPC first appeared in the medical literature about 1948.  A physician, named Sidney Kark at Johns Hopkins University, received a grant to go to South Africa – I believe to establish and head an emergency room.

Recall that in 1948 in US cities, like Baltimore, victims of heart attacks, strokes, and automobile accidents were treated in shiny glass emergency rooms. So, Dr. Kark went to South Africa to build an emergency room in rural South Africa.  Dr. Kark said, “Wait a minute!  They do not have any cars here.  I do not think they’ll have accident victims. Wait a minute!  People do not live long enough here to have heart attacks or strokes.  So what are we doing here?”

In fact, he ignored the provisions of the grant.  He did not build an emergency room.  Instead, he decided to spend the money on the community’s most urgent needs and set up a system to combat diarrhea and infectious diseases, parasites and malnutrition.  When he came back to Johns Hopkins, he wrote an article and used the term “community-oriented primary care.”

It’s been used off and on over the years.  Yet I never heard the term until about 1984-85 when I met Dr. Mullan, back in the central office, and I did not really begin to use it myself until about 1986-87.  But I ultimately became convinced that it was an appropriate term to describe what CHCs have been doing for a long time anyway.

When considering the COPC perspective of public health one might identify four factors:  (1) the application of epidemiological knowledge, (2) the incorporation of a population-based perspective, (3) the use of strategies of prevention, and (4) the use of patient education.

• First, is the idea of applied epidemiology.  Parenthetically, the University of Colorado Medical School now has a required primary care clerkship for all the predoctoral students. The primary care clerkship is a COPC clerkship, which is fine, since I am asked to talk to the students.

As I mentioned earlier, I tell medical students that epidemiology is a a topic I did not like very much. However, I did learn that epidemiology, or the study of the rates of various health status indicators occur in populations, was indeed relevant to what I was doing.  Some epidemiological knowledge proved valuable, such as the variations among populations as to their infant mortality rate, their teenage pregnancy rate, and the chief causes of mortality among their aged.  That kind of knowledge actually helped my as a family physician understand more about the patients I was serving.

• Second, the COPC approach to public health is population-based, unlike so much of what I call “the room to room to room” philosophy of patient care that is the basis of so much of medical training.

To have a sense of the health care needs of many patients, the physician must have a sense not only of the individual’s health status, but of the general health of the population of which he or she is a part.

Even so, I have found that population-based health care is something the students do not understand, the residents do not understand, and sometimes the staff doesn’t understand.

Third, public health in a COPC context emphasizes prevention (and the preventive approach subsequently has become a cornerstone of primary health care).  From the discipline of public health we learned you get a lot more for your dollar if you can prevent illness or injury, rather than treating its consequences.

• Fourth, invest in health education – provide your patient population with the information they need to maintain or improve their health status.

I want to spend a little more time on the concept of primary care itself, because this is a subject with which most of us are familiar, although COPC has features that differ from primary care in general. The first thing, obviously – from both a public health point and a CHC point of view – is access to services.  And to us, you are not doing primary care if you do not address access failures.

So primary care is not simply opening up an office and seeing those patients who come to you. Primary care is having a practice that makes sure people do not have artificial barriers to care. Obviously, financial barriers are the biggest ones.  But there are also transportation barriers and those are found both in urban and rural areas, as you well know.

There are a lot of situations where the urban bus lines do not run from the side of town where the health center is to where the people live whom they should be serving.  Transportation can be our biggest barrier in a rural area, where you have to drive 120 miles one way to find prenatal care.

But we can also talk about culture and language.  We link culture and language together all the time, but being fluent in a language has little or nothing to do with being culturally competent.  I took French in high school, although I should have taken Spanish.  But the kids I went to school with who learned high school or college Spanish, did not know anything about the culture of the numerous Hispanic populations that I, as a primary care health professional, would see in California.

Even so, we need to talk about the two together.  Culture and language are really a combined entity and we must recognize the access barrier that this combined entity presents.

In  Denver, when I talk to the medical students, I am always surprised that they do not know that Denver has the largest Korean population in the Midwest.  They do not know that Denver has a large newly arrived Russian immigration population.  They do not know that Denver has a considerable H’mong population.

Those from California are familiar with these population groups now.   But in Denver, it’s a shock to people to know that these different groups live there.  They do know that there are some people who speak Spanish, although they think most of them are Mexican, which is not true.  So I talk to the students about that, and point out that these access barriers in a primary care setting should not exist.

My definition of primary care includes its having to be “acceptable.”  “Acceptable” is the one word I unfortunately never see in other definitions of primary care.  But primary care has to be acceptable care, because, unless primary care is given in a way that a patient can use it, it has no value.  I will share with you the experience taht taught me this lesson.

When I was a family practice resident in Santa Rosa, I volunteered at a migrant clinic in Healdsburg, California.  It was an evening clinic that the residency program sponsored.  I saw a little boy with an ear infection.  Well, I was relieved, because that was an easy diagnosis.  I prescribed liquid amoxicillin, wrote the prescription and sent the family on their way.  But a few minutes later the famliy came back in the tow of the community outreach worker, who was a Hispanic woman and a former farmworker.

She said:  “Dr. Babitz, excuse me, you can’t prescribe this to that family.”  And inside my mind, I am thinking:  “Whoa!  I am the doctor, right?”  I did not say that, fortunately, but I did ask, “Why not?”  There is, of course, an answer to that question.  You do not prescribe liquid amoxicillin to migrant farmworker children in most cases, because one has to keep liquid amoxicillin in a refrigerator or it will go bad in three days.  (Now, most brands of amoxicilliin are more stable.)

But this child and his family lived in their car and worked in the fields.  So, had I given this child amoxicillin, that child would have taken his medicine three times a day for ten days.  I know migrant workers, and know how they feel about their children; I know how they care for them.  The family would have made sure that the child would have taken all of the medicine as directed, but when the child was brought back to the clinic ten days to two weeks later, a doctor would look into the child’s ear and find a rip-roaring ear infection.

And what is liekly to have been the doctor’s first response to the reason for the ear infection still being present?  Non-compliance!  We like to blame the patients for not getting well, do we not?  Medical students and residents do it all the time.

It could not be that Dr. Babitz prescribed an unacceptable treatment, given this child’s social, cultural and economic background.  That’s not possible, is it?  It could not be that I wrote the prescription in English and they only read Spanish.  That could not be be the problem, could it?  It could not be that I gave them directions in my 2th grade education while they only got to third grade.

It could not be that, could it?  It wold be the patient’s fault.  I spend a lot of time talking to the residents and students about acceptability of care to point out that if care is not given in a manner that the patient can use it, it’s worthless.  It’s a waste of time, so do not do it!  It should be a tenet of primary care, that if you can’t do it acceptably, do not do it.

“Accountable” is a term with a dual meaning.  I am a Federal official, so I must deal with a meaning that refers to whether federal fund are used correctly and our bureau’s rules are followed.  But the term also refers to quality of care.  Does a CHC have quality improvement systems in place?  Does your center have established goals for care, and does it strive to meet them?  Do you meet the standards of care your clinic has established?

Do you meet your own standards as to, say, what percentage of women should have pap smears who are over 40, mammograms for over 50?  Do you have a standard for what percentage of your children should be immunized fully by age five or six?  And then do you measure that?

Are you accountable to yourself?  When you teach others about the standards they should adopt, and tell them that they should do this and that, do you ever measure to see if yo’re really doing it or not?  A lot of health centers need to do that, need to be accountable, not to me, but to themselves and therefore to their clients – their patients – who deserve nothing but the best.

A standard definition of primary care, which I hate, is that “primary care is first point of contact care.”  The Public Health Services’ Bureau of Health Professions has it in their brochures.  That’s bunk as far as I am concerned.  First point of contact has nothing to do with primary care.  When the emergency room doctor sees you, that is your first point of contact, but it is not primary care.

Nor can you define care as primary care based on the specialty of the physicians who provide that care.  My definition does not list physician specialties at all.  Today, everyone in health care, including Pas and nurse practitioners, is a specialist.  Once cannot get anywhere in health care without being a specialist of some kind.  But the specialties are in two  broad categories – generalists and partialists.

When I talk with third and fourth year University of Colorado medical students, most of whom have already planned their careers, I point out that most of them are going to be partialists, not generalists.  I believe it helps shift the paradigm to use the term partialist in place of subspecialist.  It feels different.

We cananot use the term “partialist” around the hospital much (laughter), but patients understand what it means.  When a lady goes in for a pap smear and she has a rash and says, doctor, I have this rash on my arm and the partialist says, excuse me, I do not do skin, go to a dermatologist.  So she makes an appointment, visit, trip, and goes to the dermatologist for her rash, but she also has palpitations, and tells the dermatologist that she has a funny feeling in her chest and doest not know if she is having a heart attack.

The dermatologist says, excuse me, I do not have expertise in heart problems.  Howe many remember those stories?  There are two kinds of specialists in  America these days, partialists and generalists.  The fact is, as you know, that only about 30 percent of the doctors in America are generalists and 70 percent are partialists, even though in the rest of the world, it’s the other way around.  The lack of generalists is an access barrier in itself that we’re all familiar with.

Primary care should be “comprehensive.”  When one considers that our CHC clientele is comprised of people who have the least economic means, the greatest problems culturally accessing care and the greatest transportation problems, why do we force them to go across town for the x-ray, then over here to the lab and over there for the referral and then back here for Medicaid eligibility services and over there for the WIC program?  Why would anyone want to do something like that? We try to have as much as we can on-site, especially for those who are less fortunate in many ways.

Primary care should be “coordinated” and provided with “continuity.”  If you as a primary care provider are not staffed to provide all health care on site, I understand that, but you should know where the health services your patients need are located.  And those other services you are referring your patients to need to coordinated with the care you are providing them.  We all know about the value of continuity of care, in contrast to episodic care.

In summary, the Marc Babitz/U.S. Public Health Service version of what primary care means is a different definition than most of you hear anywhere else.  But, I would encourage you to take this definition to heart and would encourage you to teach it.

When, then, does “primary care” become “community-oriented primary care”?  “Primary care” is a set of behavious that are incorporated into one’s health care practice.  COPC is a process which augments that set of behaviors with some additional, formal activities.  I also would hope you find that this is the kind of primary care that you see in operation when you work with health centers, because this is what we expect of them.

“Defining the community” is a game in itself, which I am not going to go into.  But we have this federal term called “service area population” which is illustrated by a diagram that shows clinics and HMOs and other doctors and people in the hospital. But when we talk about where patients get care, that’s the part everybody understands.

The key to the slide is the upper right hand corner of the box.

And when I discuss this slide with CHC physicians or residents or medical students, I ask, what if in the “service area population” box there’s a pregnant teenager, what if there’s a gentleman with undiagnosed hypertension, and what if up here there’s a woman with a sub-clinical breast mass that you picked up on a mammogram, and what if in the “clinic” boxes there are adults with runny noses, sprained ankles and low back pain?

If all of our time is absorbed with taking care of these latter problems, while not caring for the pregnancy, the hypertension and the breast mass, then how is our practice taking care of the health of our community in the long run?

And do we not need to be concerned about those outside the health care system?  Not focusing on the wider population because we get so busy going from room to room to room, we may ignore the people for whom medical attention might make the biggest impact on the community’s health.

At some point with the students or the health center doctors, I ask, is not the reason we chose to by physicians to improve the health of our communities? Did not we want to be physicians to make people healthier?  Or do we just want to be busy and get paid for paching up people?

If it’s the former, then we need a different vision of how to do it.  When we guy into the room to room to room approach to health care, it doesn’t matter who sits in each room.  It doesn’t matter how the patients got there, whether it was simply because they had money, or could speak the language.

Do you think if you, the physician, are busy in the room, that you are doing your job?  Wrong!  The relevant questions you should ask are:  Who is in the room?  Should they be in the room?  Are the people who ought to be in the room in there?  That’s the challenge of American health today.

Why do we spend so much money on health care and have such lousy health status indicators?  The Denver Broncos can get MRIs of their knees every other day if they want, but many people cna’t get immunizations or pregnancy care.  Yet, where is the blip for MRIs on the graph tracing improvements in American health status?  It doesn’t exist.

In 1984, the Institute of Medicine, that august group that studies fascinating things like lymphomas, realized that the biggest problem facing health care at that time was how we delivered care.  It wasn’t that we needed new medicines or fancy treatments or new protocols.  It was our system that was wrong eleven years ago.

And this is where Paul Nutting comes into the picture.  Paul was the director of the study for the Institute of Medicine on Ways to Approach Health Care Delivery.  Well, in 1984 they reported on some places that did COPC, both private practices and public practices like CHCs.  They studied how these practices differed from traditional practices and why, in fact, they were more effective in improving the health of their communities.

They concluded  that the practices were successful because:  (1) the kind of care their practices provided met the broad definition of primary care described earlier – comprehensive, continuous, accessible, appropriate; (2) they served a target population within a defined community; (3) they made specific efforts to identify major health problems of the community; and (4) they addressed those problems by changing how they delivered care or how they interacted with community groups.  And that’s COPC, as officially defined by the Institute of Medicine.

The part of the U.S. Public Health Service most directly concerned with CHCs about three years ago changed its name from the Bureau of Health Care Delivery and Assistance to the Bureau of Primary Health Care.  That bureau’s emphasis is on the CHCs.

CHCs should have a focus on their  community.  They’re not just concerned with the patients that they see in the rooms.  They are looking out with a little broader vision.  I think that sometimes that’s the difference between residency programs and training institutions, on the one hand, and CHCs on the other.

The residency programs are counting patients and families seen and procedures done.  The health center is concerned with the community’s health care needs and is seeking to bring in more kinds of people because they need care.

COPC has three elements:  community, public health and primary care issues.  But those elements are part of a five-step process:

The COPC Process

1. Define the Community:  “User” vs. “Community” (Provides the Denominator”)

2. Characterize the Community’s

            a.  Health Status

            b.  Special Health Needs

            c.  Cultural and Linguistic Makeup

            d. Available Resources

3. Identify Important Health Problems.

            a.  Define Own Criteria (volume, impact, morbidity)

            b.  Use Prioritization Process (nominate, characterize, select)

4. Develop “Emphasis Programs” to Address those Problems.

5. Monitor the Impact of the Programs.

The five-step process I talk about for COPC is what the University of Colorado (and I think I had some influence on this) uses for requird papers that medical students have to write after their clerkship.  The students must pick one or more of the COPC steps and write a paper on specific community health problem.

Denver Health and Hospitals is an institution which operates a large CHC system.  They are one of the training sites for this clerkship. I worked with them and we developed a full curriculum on how to teach COPC, with specific educational objectives, although four weeks is not much time to introduce this.

For step number one, the students define who is the community.  Communities are often defined geographically like a county, a half a county, city or census tract, and that’s fine.  They are also defined by people who are poor, such as people who are migrant farmworkers.  But the students have to know who they are.

Sometimes, especially when working with private doctors, we say that it is okay to define the community as one’s current patients.  There are a lot of things a physician could learn about his or her current patients, so as better to understand them and better improve their health.  Those physicians, however, need to look at that big box and see who’s in that upper right hand corner.

It is critical to now who is missing.  I think sometimes the doctors in private practice with whom we work who try to define the community as the patients in their current practice, are surprised at what they find when they get to the next step in  the COPC process.

The next step is to learn about the health status of  the defined community – how healthy they are, or the opposite, how unhealthy they are.  What percentage of women in the defined community (say, your practice) has had their pap smears on time, have met their mammogram schedules, are fully immunized?  So one looks for health status indicators.  Now a lot of such information can be gotten from public health programs – for example, infant mortality rates and teenage pregnancy rates.

The term special health needs is mentioned, because knowing some things about certain populations of people will define some needs for you.  If I tell you that you have migrant farmworkers in your community, right now you know about refrigeration, right?  You also know about pesticides, probably about poor sanitation, about hard work and occupational injuries.

Sometimes just by naming a population group (such as HIV infected) you can tell me a lot of the things they are going to need.  So there are groups where you can get information just by knowing who they are.

Culture and language, that is important to know as we categorize our community.

And we should not forget to find out who else is working in the community?  Is there a residency program whose residents care for indigent patients?  Can you collaborate some way with someone you currently work with?  What are they doing?  Does the Heart Association have programs in town?  Is there an adolescent clinic in town somewhere?  If so, what is it doing?

As a third step, we ask the students to keep track of the medical problems by different age groups.  Wse say identify your problems by categories of people – pregnant women, other adults, adolescents, children, and elderly, just to make it simple.  But then, try to rank them.  How do you rank them?  We’ll let you decide.  We so not care.  The literature suggests three different ways to rank problems.  Volume is one way.  I do not think seeing a lot of URIs is important, frankly.  It is important for the patient to get cured, but it is much less important than immunizing the kid.

I like to see the impact of the care discussed, because if you see people for prenatal care and you get them immunized, you’ll have a real impact on their health.  Or better yet – it may be particularly important if there has been a child drowning death in tghe community – to conduct or support a water safety program.  So infant mortality data may be really helpful to prioritize problems.  But it makes no difference how you prioritize.

This is a lifelong project you are embarking on.  You are going to take one program at a time, and try to work your way down the list.  You pick one of these problems that you’re going to work on.  Sometimes you skip number one, because it is too complicated or too expensive.  You try number two on for size.

You take COPC steps one, two and three, for the sole purpose of getting to step number four.  The only reason for knowing your community is because you want to make a difference.  You want to improve the health of the community.  And, you are going to develop specific programs to try and attack specific health problems.

You’re going to develop these programs in collaboration with other groups, using shared resources if possible.  They are going to have a specific purpose to try to change something in your community, such as the teen pregnancy rate, immunization rates, or anything else you (and your collaborators) might want to work on.

And finally, the thing people hate to do – even our centers – you have to measure.  You have to monitor. You have to know if what you are doing is working or not.  Then why do you measure it?  Because you do not have time to waste.  I can’t afford to invest my time in a program that doesn’t work.  And I will tell you about my own experience.

When I was in  Guerneville, California, my very first health center, I loved making educational handouts.  I thought it was great to give patients things they could take home, that they could read about their illness.  Well, that’s all fine and dandy, except that I am a physician.  I’ve been to too much school.  I write with big words.  I used to type things, so that they were all on one line with no spaces.  I mimeographed on white paper.

So my handouts were single sheet, wordy, white handouts.  Because I had handouts on everything, I thought I was effective, until one day I accidentally noticed my program. I went out the front door of the clinic instead of the back door where the staff parking was.  There, I found that my porch and my lawn were decorated with white single sheet educational handouts.

They weren’t going to change anybody’s health out there.  I did not know things like the need for pictures, the need for writing at the appropriate reading level, about using big print or colored paper.  I did not know that stuff.  And I did not monitor my program.  That is when I learned about evaluating and that it’s important to evaluate, so that I am not wasting my time.  The other reason for evaluating is because we want to celebrate success.

Have you ever heard that phrase, a Continuous Quality Improvement (CQI) phrase, “we celebrate success”?  If it works, man, we’re going to have a party.  Hey guys, we just lowered the pregnancy rate in our community by whatever.  You know that we got 90 percent of our kids immunized this year?  Whoa, that’s neat!  That was a priority for us and we did it.  Let’s celebrate!  That’s part of COPC.

And the final part about COPC is that it’s a collaborative effort.  It’s the providers.  It’s the staff.  It’s the board of directors.  It’s the community.  It’s administrators.  It’s patients.  It’s everybody working together to try to improve the health of the community.  Nobody can do it by themselves.  Surely, doctors can’t do it.  I know that.  And patients can’t do it by themselves either.  Collaboration really makes a difference.

What I wanted to show you was how this relates to how the Bureau accidentally fell into the right thing.  CHCs, in their applications, almost since the beginning of time, havea had to do three things, from a clinical point of view, to get funded.  They have to do what is called the “Needs/Demand Assessment”.

They had to show the health needs and problems in their community, including the economic needs, the health needs, and so on.  They then had to take those needs and develop what used to be called health care plan, but now is called a clinical plan, which is a plan to address or attack some of those major problems the CHC found in the community.  The third major requirement from the clinical point of view, was that they had to have a quality assurance program to evaluate tghe quality of the program and how well they were meeting the needs and following thier plan.

All of these things fit in there, they’re integrated so that they are not independent entities.  They are probably integrated grant applications.  They have probabaly integrated public assistance.  Well, here’s what we left out.

If you look at COPC, and understand the steps, and look at what the  Bureau accidentally started doing twenty-five years ago, there is an incredible and fortunate amount of concurrence.  Because this defining and categorizing of the community is what we happen to call a Needs Demand Assessment.

And the ideal of COPC that seeks to identify important problems and develo0p programs for those problems, we called those Health Care Plans.  And the matter of monitoring and evaluating, we called Quality Assurance for many years, and now call Improvement Activities.  In fact, there has always been a concurrence between the COPC concept and what our Bureau expects of CHCs, migrant health centers, the homeless projects, and other projects that you might be working with.

With that I am going to stop.  Now that you have heard the philosophy, we’ll let the real world people talk and tell you how it really works at the house level.  It’s my pleasure to introduce you to Lil Anderson, who is from Region VIII, and is adminstrator of our Deering CHC, and she is also administrator for the Yellowstone Health Department.One more thing, by way of advertisement, the National Health Service Corps, for some reason, has put together a 56-minute video tape on these sermons.

If anybody is interested in this subject for teaching purposes, all Regional Offices are going to be getting a videotape of COPC by Marc Babitz, which is designed for students, residents, or new physicians, basically.  It will be available through the National Health Service Corps/United States Public Health Service Regional Offices.

This section is followed by: Proceedings of the First National Conference on Community Health Center – Primary Care Residency Program Linkages, “Community-Oriented Primary Care and the Role of Community Health Centers” (Part 2, Anderson)

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