IJJ Fellow Takes Us Behind the Scenes: ’The Story Behind My Story’
      Where Have All the Doctors Gone?

By Peggy Townsend
The Santa Cruz Sentinel

Click here to see the series.
http://www.santacruzsentinel.com/specialprojects/health/index.html

Peggy Townsend: The IJJ discussions “made me wonder what sort of ‘invisible’ barriers existed in our own communities."

Like all good story ideas, this one came when I least expected it. A few months before I applied for the Institute for Justice and Journalism Racial Justice Fellowship, I had interviewed an ob/gyn who was leaving town. He mentioned that it was hard for a physician to make a living in Santa Cruz County. With Santa Cruz County's housing costs among the highest in the nation, I knew that people like teachers and police officers had a hard time living here, but I hadn't considered it would be a problem for physicians.

The doctor said there were only five obstetricians left to deliver about 1,700 babies in the agricultural, mostly Latino town of Watsonville, which lies in the southern end of our county. No doctors wanted to work there because of the large number of uninsured and under-insured patients, he said. Interestingly, there were 24 doctors and midwives to deliver babies in the nearby, more prosperous city of Santa Cruz.

It was a story I wanted to pursue but because of time constraints, I had pushed the story onto a back burner. When I discovered the IJJ fellowship, I thought it might be the spark I needed to write a story that should be told.

I thought the story would be straight-forward and easy to cover. I was wrong.

The proposal

The story I proposed to both my newspaper and the IJJ would examine the reason for, and the consequences of, the doctor shortage in Watsonville. I had read reports about disparities in health care for people of color but somehow had not connected that situation to our affluent, liberal county with its university, ocean views and proximity to Silicon Valley. I wondered why there were so few doctors in Watsonville and whether people were more likely to die of diseases like cancer and heart attacks there than in the mostly Anglo town of Santa Cruz , 14 miles to the north. I wondered about the health consequences for women who were assisted in childbirth by overworked doctors and whether they got good pain relief like women in Santa Cruz. I was also curious about the reasons behind the doctor shortage. It had to be more than expensive housing. And I wanted to look at the town's lone hospital, which was reported to be in financial trouble.

My story proposal was refined even further by the first week-long IJJ seminar at Harvard University. Surrounded by old brick, huge leafy trees and a real sense of history, I listened while experts discussed the kind of health disparities that occur every day between blacks and whites, and whites and Latinos across the country. And I wrestled with issues about race and class that I hadn't considered. I was especially struck, for instance, by a discussion about how banks were able to red-line minority neighborhoods so African Americans could not get mortgages, thus hamstringing them in their efforts to advance economically. It made me wonder what sort of "invisible" barriers existed in our own communities. Even more importantly, I made connections with IJJ Senior Fellows in the program who had the hands-on advice and experience that I could use when I returned to my newspaper

Reporting
Even with all my new information, it didn't take long to realize the difficulty of this assignment. As a longtime reporter in the area, I thought I’d have no difficulty talking to doctors about the health-care situation but, early on, I came face to face with a circle-the-wagons mentality that was hard to break. While doctors would talk about the business end of having a practice in the Watsonville area, they tended to tap-dance around issues of medical quality and access. Several assured me that everything was fine, even though I had heard persistent rumors about lack of pain relief in the hospital for women in labor and instances of cancers not being detected because those without private insurance could not make appointments with specialists.

I have been a reporter long enough to know that if you can't get a story head-on; you need to circle your sources. So I began to talk to people on the periphery of health care (those in support groups and advocates) and then to ask them for references to another source, which led me to yet another source. I finally found a physician who was willing to be my "headlights" on the story. He did not want to be quoted, but he was able to lay out the situation and point out the problem spots. I also began scouring the Internet for information. The California's Health Department has a huge amount of information about causes of deaths (categorized down to zip codes), hospital budget statistics and birth statistics. There are also plenty of reports from advocacy groups about access to care for Latinos. I'm sure other states have similar statistical breakdowns available.

I felt like I was climbing Everest… Thankfully, the fellowship was one of the things that kept driving me forward.

Health care statistics, however, are difficult to interpret.A higher reported rate of heart attack deaths at a certain hospital could have as much to do with the demographics of the area it serves as it does with lack of access to health care or information. A low rate of infant mortality may simply mean women with high-risk pregnancies are sent elsewhere to have their babies.Numbers also can't be relied on to tell the whole story. For instance, I spent hours breaking down deaths from cancers and heart attacks for each county area only to find that little statistical differences existed between causes of death for those in Watsonville and those in Santa Cruz. But people in advocacy groups referred me to those whose late diagnosis had led to more serious disease. For instance, I interviewed a woman who did not have insurance and thus did not have a routine colonoscopy at age 50, which would have discovered the colon cancer that was ravaging her body by the time she was 55. Statistics didn't tell her story of not having access to a specialist who might have caught her symptoms earlier by performing a colonoscopy.

Statistics were good backups for what I found, but I spent too much time on them early on. Unfortunately, I also had to spend weeks just learning about the intricacies of the health-care system in the U.S., the state and our county in particular. I interviewed experts, read reports, and then had to re-interview experts because something one person said did not match what another person said. There were questions for which even the experts had to seek answers.

I felt like I was climbing Everest. Each laborious step forward often
resulted in two steps backward. Thankfully, the fellowship was one of the things that kept driving me forward. Even as I considered quitting, I remembered my feelings at the Harvard seminar and how important it was to tell these kinds of stories.

Eventually, I found the people with the best answers were hospital administrators. They seemed to have a good handle on the entire health-care system--from a business, medical and economic point of view. One of my best sources was an ex-hospital official who helped me interpret financial data on area hospitals and alerted me to figures that led me to discover that the hospital was among the 100 most expensive hospitals in the country when it came to cost-to-charge ratios. In other words, it was charging $582 for a $100 procedure. Those who were hit hardest were those who didn't have insurance or had high deductibles, although their charges affected private insurance costs too.

Finally, I had enough information to bore even the most interested health-care consumer and newspaper reader. So, I decided I had to narrow my focus for the stories. I picked topics I thought were most interesting and most crucial to the majority of our readers: Why were there too few doctors in Watsonville; why was the town's lone hospital among the most expensive in the country; why was there no place to get chemotherapy in Watsonville and why did women in Watsonville mostly get a different kind of pain relief during labor than their counterparts in Santa Cruz. I also wanted to write about how doctors in our county, because of a technicality, were reimbursed 25 percent less for their Medicare patients than doctors in the Silicon Valley a 30-minute drive away.

The best piece of writing advice I received was to write the story as if I were covering it in another state or miles away.  With that approach, I was able to add detail that brought the information home to people. I think it also helped me to lay out the problems more clearly in a readable, magazine style.

I struggled with the length of my report and eventually decided to write a three-part series, laying out the situation in easy-to-read, people-centered stories. I had three editor changes during the project (each was very supportive of the story), and also I relied on help from several Fellows from the Institute, especially Martha Mendoza of the Associated Press and Victor Merina, to smooth out the rough patches.

The series ran Sunday through Tuesday. My series was the second-most read story on our Web site the day it debuted.

Lessons
Here are a few lessons about writing on health care that I learned from the project:

1. Lies, damn lies and statistics: Before using any figures, make sure they mean what you think they mean. Low infant mortality may only indicate that high-risk moms and infants are transferred elsewhere for delivery, not that prenatal care is excellent. Ask local and state health experts about the meaning of the numbers you find.

2. Start outside and work in. The best tips for problems came from talking to advocates who put me in touch with patients. Once I had their stories, it was easier to get doctors to talk about problems with care and access. In other words, they did not want to tattle on their colleagues but if you already had the information, they would discuss it.

3. Don't underestimate the power of gossip in the health care community—and use it. Within a few weeks of interviewing I began to have doctors mention that they heard someone was doing a story on health care. I then told those people I wanted to speak to certain doctors who hadn't returned my calls. Lo and behold, a week later, those doctors suddenly began to return my calls.

4. Keep it simple. Nothing can put a reader to sleep faster than the terms “Medicare reimbursement” or “payer mix.” Use easy-to-understand language that makes a reader realize you are talking about them. Do not use jargon no matter how tempting.

5. There are lots of Web sites devoted to health care studies and reports, especially in California. I liked the California Medical Board at www.medbd.ca.gov; the Centers for Disease Control at www.cc.gov; U.S. Department of Health and Human Services Department www.hhs.gov; California Health Care Foundation at www.chcf.org; California Department of Health Services www.dhs.ca.gov and the Office of Statewide Health Planning and Development www.oshpd.cahwnet.gov. There are similar sites in other states, I'm sure.

6. Lots of reports are generated by universities and teaching hospitals. Look there for guidance and for experts who can help you interpret what you've found.

7. Know your stuff. Make sure you are prepared before any interview with a health professional. Asking the right questions will get you the right answers. Few people wanted to volunteer information you already didn't know. Nurses are wonderful sources for information.

8. Make health stories personal. Saying there are no chemotherapy clinics in a town is one thing. Telling the story of a 62-year-old woman who has to walk seven blocks to the bus on chemo-numbed feet or the woman who is embarrassed to ride the bus because chemotherapy gives her diarrhea makes a reader feel the lack of services. Health stories are made of politics, money and medicine, but people will make readers care. And telling readers why a situation exists is extremely important.

9. Always fact-check medical details. Nothing kills hard work like mixing up epidural anesthesia with spinal anesthesia.

The results
Sweeping health-care changes will never happen overnight. So writers who want instant results may be disappointed with a story on health care. But weeks after the series ran, I continue to get comments about how important it was. A group of women were inspired enough to band together to offer rides to women who need chemotherapy and have no way to get to their appointments except by riding the bus. Donations also poured in for one of the subjects I profiled.

These are small changes, but a larger change may lie ahead. Our area congressman, along with other members of Congress, are working to get disparities between Medicare payments for doctors here and those in other counties changed. An aide told me that articles like the ones I did make it easier to make their case for changing this inequity. Another effect of the series: I am much more in touch with health care in this county and have been able to not only be a resource to other reporters at the newspaper but have been able to localize health stories that come over the wire.

Thinking back, I also realize how proud I was to not only be associated with the Institute for Justice and Journalism but also with the reporters who were chosen for the fellowship with me. They inspired me as much as the experts and their insights into my series during the week-long follow-up seminar at the Poynter Institute were not only invaluable but spot-on. It was great to know I wasn't alone in my struggles and I left feeling like I was part of this smart, determined, talented kind of family.

The fellowship not only gave me the spark but also the fuel to write a story that needed to be told.

Click here to see the series.
http://www.santacruzsentinel.com/specialprojects/health/index.html