On Los Angeles' Skid Row, getting into a homeless shelter often requires a negative test for tuberculosis. Homeless people are considered a high-risk group for TB in Los Angeles County, which has the largest estimated rate of homelessness in the country.
The JWCH Institute's Center for Community Health—a Skid Row free clinic for primary, recuperative and women's health care to the poor and underserved—provides chest X-rays that test for TB in patients who already have had a positive skin test. But because the center lacks a radiologist, the staff used to send suspect TB X-rays to a private radiology group that charged $25 to $35 a film.
It was far from an ideal arrangement. JWCH shipped out X-rays on the day they were taken, but "it would take several weeks to get the results back," says Paul Gregerson, M.D., JWCH's chief medical officer. The long lag time meant more time on the streets for people in dire need of a place to stay.
Desperate for another option, Gregerson approached Jimmy Hara, a Kaiser Permanente family practice physician who volunteered at JWCH. He recommended two colleagues who might be able to help: Ronald Saul and Keith Terasaki, radiologists at Kaiser Permanente Sunset Los Angeles Medical Center. The pair were already reading X-rays on a volunteer basis at two smaller clinics, the Hollywood Free Clinic and Melrose Free Clinic.
That was about five years ago. Since then, Saul and Terasaki have read about 15 X-rays each day for JWCH. All told, they each spend about a half-hour a day—essentially, their lunch hour—reading JWCH X-rays.
Gregerson estimates the doctors' time saves the clinic between $75,000 and $100,000 a year, freeing up funds for JWCH to see several hundred more patients annually.
Besides checking for TB, Saul and Terasaki also read bone and spine films to check for a bevy of other conditions among patients at the clinic, including pneumonia, cancer and bone fractures.
"If a patient comes in with a chronic cough or a questionable nodule, having to wait three or four weeks for an X-ray to come back is definitely a problem," says Gregerson. "Now we get them back so much faster," usually within two to three days.
Terasaki says the process will speed up even more in a few weeks, when JWCH completes a system upgrade that will allow it to transmit scans digitally—saving the time it takes to wait for a driver to transport scans from the clinic to Kaiser Sunset.
Saul, who spent two years after medical school working for the Indian Health Service, says working with the clinic has given him a sense of community—a feeling that's sometimes lacking when he's simply reading scans all day. "Doing it makes you feel like you're a little more in touch, and that's gratifying," he says. "It's that team approach that's gratifying in this setting."
Like JWCH, the small clinic on a Montana reservation where Saul worked had little in the way of subspecialty care. "That's when I first became interested in radiology," he says. "During the week we worked with radiologists, but on weekends we took our own X-rays."
At first, Terasaki says, he was reluctant to commit to the clinic because of the time involved, but a visit there changed his mind. "It's around the worst area of Los Angeles," he says. "There were homeless people all over. Even parking there, we were a little leery. But we met the doctors, and we really began to appreciate the work they did."
Last year, JWCH leaders asked Terasaki to join the clinic's board. Terasaki says he's grateful for the opportunity. "Before, I spent all my energies on just my work here at Kaiser," he says. "But it's essentially a different world out there. Now I spend a little bit of my time in that world," learning about a whole new set of issues. For instance, many of JWCH's patients lack citizenship or legal status, so even with health care reform, the center will continue to serve a deluge of people who lack health insurance.
Gregerson is just glad to have the expertise at hand. "To have the perspective of somebody who does medical care and is so giving of his time—and has a passion for people who have been underserved—has been great for us," he says. "And it's been great for the safety net as a whole."