Residents at Signature Healthcare Brockton Hospital adapt to treating patients at ‘the clinic’ twice a week

   Guaciva Rivera shifted on the patient exam table, the white crepe-style paper crinkling beneath her.
   She looked eagerly to Dr. Justin Routhier as he slipped into the exam room and closed the door behind him, using one hand to flip through Rivera’s medical history and cupping a bottle of pills in the other.
   “It looks like from hospital records they prescribed you a different medicine,” Routhier said, holding up the bottle of pills Rivera was taking to treat her pneumonia.
   “My sister went to the pharmacy and she said, ‘Too much money,’” said Rivera, 47, of Stoughton.
   “That’s what I thought,” replied Routhier, who had suspected she couldn’t afford the pricier and more potent drug prescribed by the hospital.
   But since Rivera had been recovering without incident, Routhier encouraged her to finish the lower cost — but less powerful — drug she had brought in.
   It doesn’t take a doctor, though, to know Rivera’s inability to afford a higher-quality, more expensive medicine was symptomatic of a larger malady.
   “We can have a social worker talk to you on the way out,” Routhier told her.
   A prescription for social services isn’t a remedy usually issued by any of the residents completing their intern year at Signature Healthcare Brockton Hospital.
   But for two hours every Tuesday or Thursday afternoon, they abandon the fast-paced, high stakes world of the hospital to do check-ups and counsel patients about everything from flu vaccines to cancer screenings on the second floor of a brick building on Quincy Avenue — known to these residents simply as “the clinic.”
   It looks like any other nondescript family doctor’s office. Old magazines sit untouched on side tables in the whitewashed waiting room. The only splash of color comes from a heap of children’s toys in a corner.
   Around 1:30 p.m., a flock of four residents comes through the front door, passing by waiting patients slouched in chairs.
   A nurse pokes her head from behind a door near the receptionist and calls out a name.
   They lumber into an exam room, where the nurse checks their pulse and blood pressure before dropping their medical chart in a bin outside the door.
   That’s the signal. The doctor can see you now.
   Except these doctors are doctors in training — out of medical school for less than a year and working under the supervision of staff physicians at the hospital to offer primary care to patients who don’t have a doctor.
   Most patients don’t speak English fluently or at all, and the majority have little means to pay for basic or emergency care — let alone preventive care such as mammograms and colonoscopies.
   “When people come to the hospital, they’re acutely sick, so we don’t do a lot of health maintenance stuff,” said Dr. James Knutson, 31. “The clinic is sort of that setting where you can round out the big picture.”
   The Medical Continuity Clinic has been running for more than three decades — since the inception of the residency program at Signature, said hospital officials.
   The residents can see up to four patients per day each, but average two or three.
   On one recent day, Knutson listened to his patient’s lungs, nodding as the patient complained of a cough and night sweats.
   Was it the flu?
   Knutson looked at his patient’s chart again. The patient was a recent immigrant from Haiti — one of a “flurry” of Haitians he had seen come in this past month.
   A simple flu was off the table. He had to consider tuberculosis. Or even malaria.
   “Normally, you never think about tuberculosis as sort of the average American patient, unless they’re an HIV patient,” he said.
   Knutson took no chances. He consulted someone in the hospital who was well-versed in tropical diseases.
   There are only two requirements to be a patient at the clinic: You have to have been treated at the hospital, and you have to have no primary care physician.
   “These might be patients who, under other circumstances, have no access to medical care,” said Dr. Dale Ellenberg, the hospital’s medical education director who oversees the residency program.
   It’s also notable what isn’t required to be a patient at the clinic — health insurance. The residents, serving as primary care doctors, don’t receive any extra compensation for their time there. It’s part of their training.
   Hospital officials said they budget other overhead costs of running the clinic as they do for other community service offerings, such as free public health screenings.
   The appointments are usually scheduled as a follow-up about a week after the patient has left the hospital, Knutson said.
   “You send them home, and you don’t want to just say, ‘Good luck! Come back to the emergency room when everything fails ... again,’” he said.
   Though the initial reason for the visit — a follow-up for pneumonia, for example — is often only where the problems start.
   Rivera, the Stoughton woman seeing Routhier, had not been to a doctor in more than a decade. She couldn’t say when she had last seen a gynecologist, and at 47, has never had a mammogram.
   She had no primary care doctor, and her ability to pay for health care and medicine was limited.
   But she spoke English fluently, which made her an exception.
   Although interpreters are assigned to the clinic, residents agreed some messages get lost in translation.
   Dr. Leah Palifka recently had to page the interpreter to come to her exam room. Everything written and spoken was translated for the patient in his native tongue.
   But the patient took the medication wrong, didn’t fill out the right paperwork to receive aid and missed a later appointment.
   “The language barrier is significant,” Knutson said.
   Knutson strives to make his exam room a sanctuary, where he can tell a patient she’s needs to lose weight, stop smoking and drop an illicit drug habit.
   “In the doctor’s office, you have to really cut to the chase and you have to make it very plain to the patient that there’s absolutely no judgment,” he added. “Those answers are important, and you have to create this environment where, ‘Talk about your crack habit,’ is easily done.”