Position: Medical Director, Southwest Georgia Community Health Institute
No doctor wanted to come to this poor community. We couldn't get no one to come here to serve these poor folks. Then they scraped Dr. Hotz up from someplace and he came. I remember before, I would wake up at six in the morning and sit all day in Albany to get care. Wouldn't get home till five at night. Dr. Hotz is so nice and patient with the poor folks around here. How he treat an old lady like me with respect! He saved my life.—104-Year-Old Patient
Dr. Hotz has turned down inquiry after inquiry from other agencies, and from the upper echelons of organized public health, in order to stay the course with his chosen avenue of service.—Georgia State Representative
Our commitments to our patients are for better or for worse, for richer or for poorer, in sickness and in health, till death do us part. It is a vow that physicians should take and be able to do. If we can't work with an institution to honor that commitment, then we shouldn't work there.—James Hotz, MD
In "Doc Hollywood," a 1991 movie, Michael J. Fox starred as Otis Stone, a young doctor driving from Miami to Beverly Hills, who envisions the glamour and fortune that will come to him as a plastic surgeon to the stars. Stone's car breaks down in Grady, a small town in southwest Georgia whose only physician is retiring. The local residents conspire to turn Stone's car trouble into their good fortune. They succeed. Thanks to their ingenuity and subterfuge, Stone stays on in Grady as a family physician.
The movie is modeled, roughly, on the experience of James Hotz, MD. Although he is a far cry from the celluloid Dr. Stone, Dr. Hotz did find himself in rural southwest Georgia somewhat unexpectedly. He stayed there because it was what he was looking for.
James Hotz had always wanted to help people. However, as a bright young medical student at Ohio State Medical School, he had become disillusioned with medicine. "People weren't taking a global view of medicine. In medical school, you're taught that when people come in the door, you take care of them. But what about people who can't get in the door? I knew there were communities that just didn't have access."
In 1974, during his third year of medical school, his advisor suggested that if Hotz was interested in the "big picture," he take a month off and contribute to the "big picture" in Washington, D.C. Mr. Hotz did, helping Congressman William Roy of Kansas craft legislation creating the National Service Corps. This program matches needy communities with physicians and other health care workers who want to serve these communities, under the auspices of the federal Public Health Service. Mr. Hotz returned to school determined that, as soon as he finished his residency, he would join the Corps. He recruited his wife (a nurse), his sister (a social worker), and his brother-in-law (a fellow internist), to join him and volunteer as a group.
Dr. Hotz completed his residency in internal medicine in 1978. To his astonishment, when he and his team volunteered, the National Service Corps could not find a placement for the four of them together. It was a devastating disappointment. "Just five years earlier, I'd worked on lists where there were literally thousands of communities without physicians," he recalls. "In Washington, we were designing programs, but then you hand the program over to a bureaucracy to handle, and they handled it just like a bunch of bureaucrats. They could not find a spot for us—and we were willing to work for $32,500 a year!"
Dr. Hotz found work, this time under Neil Shulman, MD, who was at that time serving as Georgia's rural health advisor. Dr. Shulman assigned Dr. Hotz to the state's Improved Pregnancy Outlook Program, offering Dr. Hotz the chance to work either in the inner city of Athens, Ga., or in the rural southwestern part of the state. Dr. Hotz chose Athens, but Shulman instead had Dr. Hotz and his wife driven to the little town of Leesburg in southwest Georgia. "He didn't have to trick me," he says. "That movie made it sound like I didn't want to go there. My wife, sister, brother-in-law, and I all wanted to go to an underserved area. We were looking for a frontier, a place that didn't have a doctor, a place where we could come in and make a difference, and we found it. There are too few doctors here because there are too few amenities—but this creates the real opportunity to make a difference in health care." Years later, Dr. Shulman wrote the story of how he tricked Dr. Hotz, and sold it to the movies—the rest, as they say, is Hollywood.
Reality was somewhat less dramatic, but equally difficult. Within two months' time, Dr. Hotz and his team began a nonprofit primary care service nearby—Albany Primary Health Care—using four trailers joined together on land donated by the county. The enterprise grew from there. Today, Albany Primary Health Care features four primary care centers staffed by 11 internists, 3 pediatricians, a pulmonologist, 10 physician assistants, plus secretarial and administrative staff. The staff at these geographically separate centers serve 25,000 patients spread over a 14-county area half the size of Massachusetts with a total population of 350,000—most of whom are African American. As they have done from the first day, the centers see all residents regardless of their ability to pay.
True to the movie, Dr. Hotz and his team had barely begun seeing patients when they ran up against smoldering resistance to their presence in town. It came mostly from a vocal minority of established physicians in the greater Albany, Ga., area. As Dr. Hotz remembers it, "When young idealists from the North come down, the first thing that these docs think is that they're a bunch of damn federal doctors. That's putting it kindly. At the first medical society meeting we had, they said, 'We don't need a bunch of goddamn communists down here,' and they told us to go away."
Despite the near-brawl that resulted, Dr. Hotz and his team persisted, because they were needed: they saw people standing in the mud and rain to see them. "You get plopped down into a community that needs a fully trained generalist who can take out appendices, deliver babies, suture folks up, take care of fractures and strains, blood pressure complications, and all that. You see people coming in who can't afford medication," he says. "Kids that are being abused. Tuberculosis that in med school you learned doesn't exist any more. Or the first person you see in this little town is a 35-year-old woman dying of cervical cancer because she hadn't had a PAP smear. And you realize how inadequately trained our physicians are to take care of a whole community's needs." The underserved population needed access to basic care, and Dr. Hotz was determined to provide it. But he now realized that in order to effect change, he would have to avoid 90 percent of potential conflicts, preserving his energy for the really important battles.
Because it wanted volunteer doctors serving as family practitioners full-time "in the field," the National Service Corps discouraged its volunteers from practicing the kind of medicine usually performed at a hospital. Nonetheless, in 1978 Dr. Hotz did precisely that, basing part of his practice within an Albany hospital. He knew it was an essential step in providing a continuum of first-class care for his patients. When his two-year stint in the National Service Corps ended, Dr. Hotz extended his commitment. After six years, Dr. Hotz's sister and brother-in-law left to enter private practice up north, but Dr. Hotz and his wife stayed on. He intensively recruited new professional staff, and stabilized finances by securing federal Community Health Center funding.
Having fought for acceptance and credibility, Dr. Hotz set about building coalitions of public and private providers—including competing hospitals, health professional educators, mental health practitioners, and others—to focus on community-oriented primary care. In joining these coalitions, providers agreed to assume responsibility for the health of the entire community, both the "haves" and "have-nots." This often meant offering services for a reduced or waived fee. The key was that participants gave to the coalition only what was in their expertise to give: urologists gave urological consultations, not primary care; health education specialists were asked only to educate on health matters, such as prevention of disease by changes in behavior (e.g., stopping smoking); hospitals admitted all patients—on a sliding fee basis.
These collaborations resulted in several new initiatives: an Area Health Education Center (AHEC) established in 1990 (AHECs, are organizations found throughout the United States, variously funded by the federal government and state governments, but all begun under a 1972 federal grant program, and intended to help bridge the gaps between primary health care services and medically underserved populations); a family practice residency program (1991); physician assistant and nurse practitioner training programs; cervical cancer screening; mobile outreach into rural areas; a support network for pregnant teens; housing for HIV-positive homeless; and case management programs for diabetes, hypertension, and perinatal patients, featuring a "Health Advocate" assigned to monitor each case and serve as an advocate when necessary.
In 1990, Dr. Hotz's focus on collaboration led to the creation of another nonprofit organization—Southwest Georgia Community Health Institute (SOWEGA-CHI)—designed to coordinate public and private health resources, improve community health status, and increase the local availability of health professionals. Dr. Hotz took on the additional job of SOWEGA-CHI's medical director. It received a financial kick-start from the Woodruff Foundation and a local hospital.
SOWEGA-CHI began serving as an independent planning body to keep track of health system performance, integrating area health resources to reduce overlap and turf issues. Its principal work is assessing health system data—a needed step in devising health care strategies and effective community health programs. As Dr. Hotz explains it, "What the Community Health Institute does is to say, 'Now that we have a system in place, how do we measure the impact of that system on a community, and how do we then look at developing service lines and outreach where that system is not addressing all the needs of the community?'" SOWEGA-CHI's efforts have resulted in the distribution of child car seats to 2,000 area residents; and creation of a rural HIV/AIDS clinic that provided patients with case management, pharmaceuticals, and counseling within easy reach. In addition to its many other achievements, SOWEGA-CHI coordinated health care delivery systems during the severe floods of 1994.
Even early on, Dr. James Hotz's work drew recognition. He won the National Service Corps Commissioned Officers' Award for Outstanding Community Service four times—in 1978, 1979, 1982, and 1983. He received the Georgia Association for Primary Care's Distinguished Provider of the Year Award in 1987. And in 1995, Dr. James Hotz won national recognition when he received the Robert Wood Johnson Community Health Leadership Award.
With the award came a $100,000 stipend to further Dr. Hotz's vision. With the help of Community Health Leadership Program (CHLP) staff, he used the money to create a new Survey Research Center within SOWEGA-CHI. "There are critical competencies that are not present in these rural areas," Dr. Hotz explains. "People who do planning, people who can actually measure, and do epidemiology. We needed to concentrate these competencies into a formal entity, and then make that available to health providers in the community."
Dr. Hotz also leveraged the award, using it to attract matching funds and top-notch people, and to help cover expenses for the Survey Research Center's first two years of operation. During that time, the center conducted real-time surveys of its health district, and produced a "report card" of each community's health status. Information from the survey was also used to inform providers, showing impacts and outcomes of present programs and highlighting problem areas.
By the end of the two-year period, the Survey Research Center had proven so useful that it was picked up by the regional hospital as a permanent new program, with a $250,000 annual budget. Someday, Dr. Hotz says, he would like to see its parent, SOWEGA-CHI, itself as a part of the regional hospital structure, insuring its long-term survival, institutionalizing its valuable focus on outcomes, and helping providers adjust responsively to community needs.
Winning the Community Health Leadership Award also gave Dr. Hotz the opportunity to interact with other CHLP award winners at the program's annual retreats. "One really tremendous benefit from this is to realize that there are a lot of people who have similar visions and ideas, who are 'thinking out of the box,' who are doing sometimes risky things. You get about 25 of them together, and it's very reassuring. You know you're not crazy." Dr. Hotz now works with the CHLP, helping to select the 10 new award winners each year.
Dr. James Hotz says that, to be a leader, "You have to be willing to measure and evaluate where your leadership has taken people who have followed you. You always have to keep questioning and trying new things, and not getting complacent. Leadership is a work in progress."
Dr. Hotz wrote a sequel to "Doc Hollywood," entitled "Where Remedies Lie." The title and the book's central idea comes from a Shakespearean quote, "Our remedies oft in ourselves do lie/Which we ascribe to heaven." As Dr. Hotz likes to tell students at Emory University, Morehouse Medical School, and Mercer University Medical School, where he serves as an associate professor and preceptor: "Health reform starts with you. It's one person at a time, and it's your commitment. If you can't do that, then you are not a leader. You can't bring somebody with you."