Lombard on DUMC's challenges with local care

Frank Lombard, associate director of the Health Inequalities Program at Duke's Global Health Institute, discussed the challenges Duke University Medical Center faces in providing care to local and rural North Carolina in an e-mail correspondence with The Chronicle's Shuchi Parikh.

The Chronicle: Is there a difference between Duke's national reputation and its reputation among local or rural community members, or do those two go hand in hand?

Frank Lombard: I think the national and local reputations are based on different things, and yes they diverge. Nationally Duke is clearly a leader in research and innovation, with some of the world's leaders in the treatment of a wide range of medical conditions. Sen. [Edward] Kennedy came to Duke because of the high quality treatment Duke provides, the innovations in treatments and the great expertise of providers which translate into improvements in treatment outcome. Presumably he had the resources to access the highest quality care for the treatment of his condition, and Duke had access to some of the world's leading experts in the field.

Locally, much of the community are looking at distinctly different issues upon which it forms an opinion. The local community looks at issues like accessibility, cost\billing of services etc. What I hear from people in and around Durham is that Duke is elite-provides amazing expertise-but is a huge behemoth with unfriendly structures around billing, etc.

I remember attending a meeting with a rural based community health center and having one of their leadership tell me that they only work with UNC, that some of the experiences they had with Duke's clinical research practices were disturbing, the words she used were "reminiscent of Tuskegee." I do not believe this was based in reality, but in this world sometimes perception is as important as reality. Having worked with Duke, UNC, Wake Forest and ECU, I think they are all really fine ethical institutions; however, it appears to me WFU and Duke shoulder some additional burdens in terms of local community relationship being such dominant forces in their community and being private to boot.

TC: Do you believe local residents would tend to choose Duke over other hospitals for specialty care, but may differentiate less when it comes to everyday care? Do locals sometimes feel they are lost within the Duke system-is that a valid concern?

FL: I have been told several times by members of the Durham community that Duke is a great place to be as long as you have a disease that is interesting enough to get adequate attention.

The loss of Durham Regional Hospital to Duke still to this day seems to generate high emotion for many residents of this community. Many feel like the community lost a valuable resource, one that I have been told was important for those who just did not want to attend Duke, but now have only one viable choice, Lincoln.

People have told me they feel intimidated coming to Duke because of the size and the feel of things, and feel Duke is highly driven by the research component. I have been told that all Duke cares about is researching the people who come in and that sometimes people feel like guinea pigs. Again this is anecdotal, but I have heard this more than once.

TC: How do you believe the Medical Center has exceeded other health systems in serving Durham and North Carolina, and how do you believe it can improve its community care?

FL: I think Duke provides excellent care, and actually does a great deal more care for the community in terms of care to the indigent than it gets, or takes, credit for. The tension between caring for the community and maintaining a viable operating plan has appeared to be deeply conflicting to many within the health system based on my observations- in many ways Duke is the only show in town and that creates a challenging dynamic for Duke to balance.

What I think Duke tries to do, and should continue to do, is to find ways to really partner with the local community-including always looking for ways to power share with members of the community in ways that cedes power from Duke to the community in really meaningful ways. An enthusiastic commitment to partner with the new Project Access in Durham will be an opportunity to leverage and focus the expertise, resources and leadership Duke has to the ultimate benefit of the Durham community as well as the population of uninsured adults in Durham.

Duke also has a remarkable resource in terms of capable, creative and compassionate faculty, staff and students in all areas-law, business, arts and sciences, engineering, etc.-many of whom are interested in helping to invest time and energy to be of service to the community. The DukeEngage program is a wonderful commitment by Duke to facilitate this

TC: I would appreciate any other thoughts you may have about how locals view the Medical Center and how Duke serves this community.

FL: I really think the "town-gown" relationship between Durham and Duke will be challenging for years to come, as it is with other communities across the country. To the greatest degree we can find ways to interface with Durham in ways that meet the expressed needs of the community-with a humble and open attitude of service-I believe we will find success.

Understanding the ways in which a medical model approach to health care facilitates the expanded access to very high quality health care to those for whom it is currently out of reach is crucial. At the same time we must continue to look for ways to create space to others to meet other wellness needs of the community-safety, nutrition, quality of life, access to mental health and substance abuse treatment, etc. This allows a full range of response more in the form of stewardship-nurturing the community that hosts us, supporting the community through increased resources and increased understanding of the community in which many at Duke find themselves for such a brief time.

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