Emory Medicine, Spring 1995 - Alumnus Profile

Off the Beaten Path

by Susan Carini

The elegant Spanish moss draped almost everywhere cannot hide a host of social ills: drug use, grinding poverty, illiteracy, the still-palpable divide between rich and poor, black and white. A different variety of ills, however, have improved in Albany, Georgia, since the arrival of a reluctant dinner guest 17 years ago.

The dinner guest was former Emory resident James Hotz. He is the force behind establishment of three primary care clinics and an AIDS clinic in the area, and his plate is full - far fuller, in fact, than at that surprise dinner in 1978.

This part of Dr. Hotz's story is known to a wide audience, since he was the model for the physician in the movie Doc Hollywood, based on the novel by Emory faculty member Neil Shulman. (In the movie, a young doctor poised to begin a practice in plastic surgery finds his road trip to West Coast wealth and prestige stalled out in a small southern town, where the people convince him, through artful coercion, to stay on as their physician.)

Dr. Shulman himself artfully coerced "Doc" Hotz into giving two years to treating patients in an underserved area. The site was supposed to be in Athens, in northeastern Georgia, and was to involve work at a community health center. But when the time came to go, Dr. Hotz and his wife were shanghaied instead to Leesburg, near Albany. Local leaders got together and made a pitch to him, serving up a chicken dinner to make their offer more palatable.

The inspired health care project that Dr. Hotz still heads thus began with the words, "Pass the fried chicken." The cardiology practice he had planned to pursue in two years' time promptly vanished. Instead, he launched a career as a primary care physician, with a subspecialty in coalition building.

During his Emory years, Dr. Hotz learned a lot from Dr. Shulman. "He warned us that what works in Atlanta will not work everywhere. A medical system must meet the needs of its community." Dr. Shulman spurred Dr. Hotz to look beyond the potential glamour of the medical profession in order to ask some basic questions. "Most people," Dr. Hotz notes, "come to their doctors a few times a year. Looked at on a per-patient basis, why can't the health care system function better?"

When Dr. Hotz was growing up, it did. Raised in Fremont, Ohio (outside Toledo), he was the son of a factory worker in a family with five children. The doctor who treated him from birth was also the attending physician at his father's death. That continuity in the provider-patient relationship impressed Dr. Hotz.

Asked why he wanted to become a doctor, he recalled having just closed out a stellar academic performance in first grade. He stood by as his father reviewed his report card. "Very good, son," his father said. "I think you're smart enough to be either a doctor or an engineer." The younger Hotz thought that engineer could mean only one thing: train engineer. So he decided to become a doctor. He received his MD from Ohio State in 1975 and finished his residency at Emory in 1978.

Originally intending to pursue a cardiology practice, Dr. James Hotz somehow found himself practicing family medicine in southwest Georgia instead. Background: one of the first sites of a clinic he helped establish, which is now a $1-million facility in its third expansion.

In the rural community in which he found himself after completing his residency, Dr. Hotz set to work. Believing that health care works best when it is supported locally, he found an ally in the late Robert Woodruff, whose Ichauway plantation site is located between Dr. Hotz's Albany clinic and his Baker County facility. (The third clinic is in Leesburg.) When Mr. Woodruff heard about Dr. Hotz's success in improving health care for the poor in the area, he contacted him.

According to Dr. Hotz, "The Woodruffs have always been interested in health care, going back to the days when their workers were suffering from blackwater fever, or what we know as malaria." With people lying prostrate by the side of the road due to failure to take their medicine, Mr. Woodruff suggested a system whereby anyone entering the community store would be encouraged to take a sip of quinine. "This moxie or American know-how is the kind of insight we need in health care," says Dr. Hotz.

The Baker County clinic - a $1-million facility - is now in its third expansion, thanks to the generosity of the Woodruffs. The trailer in which operations first began is now only a humbling memory.

As Mr. Woodruff knew, however, facilities and medications only go so far. To have impact, patients have to use them.

"In this area," says Dr. Hotz, "it is not just a matter of treating the people who come through the door, but of finding the people who won't come through the door." Indigence is a factor in keeping people away, along with illiteracy, social mores, and pure stubbornness. As Dr. Hotz sees it, "Having the right medicine on the shelf is only half the battle - we must create a user-friendly environment for initiating lifestyle changes."

The three user-friendly, walk-in clinics that Dr. Hotz has crafted are private and nonprofit, serve 20,000 people annually, and treat patients of all income levels. The centers are funded through patient revenue and the Public Health Service, which allocates money to about 600 clinics around the country that agree to provide indigent care. "I don't think about what patients pay when they come through the door, even though I have to be accountable at the end of the year," says Dr. Hotz, who juggles a $5-million annual budget. Payment for services is calculated on a sliding scale, depending on income, with Dr. Hotz's clinics collecting 58 cents on every dollar of services rendered. In the past year, the clinics provided a total of $2 million worth of services for indigent care.

All solutions are local

The three private, nonprofit, walk-in clinics that Dr. Hotz has crafted with funding from both private and public sources serve 20,000 people yearly, with payment calculated on a sliding scale, depending on income.

The success of these clinics depends in large part on a considerable amount of coalition building, which Dr. Hotz believes begins at home. Helping him pull the wishbone that first night in Leesburg was his wife, who has made a substantial contribution to community health care in her own right. With master's degrees in nursing and allied health from Emory, she initiated a paramedic training program at Darton College in Albany. And together, the Hotzes helped reestablish an emergency medical service in Baker County, needed because the 26-mile ride to Phoebe-Putney Hospital in Albany is too far for heart attack patients to travel without medical assistance.

Coalition building among local physicians also has been vital to the clinics' success. Most of the doctors in the area donate about 25% of their time, and they share the burden of covering on-call care of indigent patients in the emergency room. Local specialists often provide free bypass surgery or cancer therapy to those in need.

In 1990, Dr. Hotz helped form the Area Health Education Center (AHEC), through which local health care providers can get help in planning and developing a collaborative system of health care. AHEC's means to that end is to improve doctors' access to training facilities and personnel. The fact that medical training is usually done in metropolitan areas can pose a problem for smaller communities such as Albany. To strengthen this link between practicing physicians and training facilities, AHEC in essence "takes the gown to the town."

Another collaborative body important to Albany-area health services is the Community Health Institute, consisting of county health department and hospital staff, private physicians, and others who convene regularly to do needs assessment for the area. Their collective thinking and well-orchestrated effort resulted in formation of the community's AIDS clinic and several other collaborative services programs.

While James Hotz at age 7 did not want to become an engineer, he has engineered a virtual revolution of his own in delivery of health services to an extremely needy area. Likewise, the adult James Hotz wanted to be a cardiologist and is instead a primary care physician. In getting off the beaten path, he nonetheless found the right road for himself.

Engineering a better way

Dr. Hotz's Baker County clinic is located near Newton, Georgia, population 800. "One can escape from the town jail with a can opener," he divulges.

Health care has to reach people in the same way that electric lights do," Dr. Hotz has always insisted. On July 7, 1994, in Albany, the lights failed, but health care services did not. That day marked the arrival of the most devastating flood in Georgia history, as tropical storm Alberto stalled over the state, causing record rainfalls and swelling area rivers beyond their banks.

In Albany, the Flint River cut the community in half, leaving 45,000 people without access to a hospital. For 207 hours straight, Dr. Hotz and other health care providers ran a makeshift emergency room and saw more than 2,500 patients, determining who would go "up and over" - "over" being a helicopter ride to Phoebe-Putney Hospital.

On July 11, the floodwaters hit the town of Newton in nearby Baker County, and Dr. Hotz lost communication with his clinic there. Indeed, the last he heard from his office manager was that water was coming through the door of her house. He likened the situation to a military campaign: "Staff got isolated from their rest of their unit and had to fight their own battles."

With support from the National Guard - which supplied a helicopter, reliable radios, and all-terrain vehicles - Dr. Hotz and his team were able to set up a MASH tent to treat county residents. Working 120 hours a week, the physicians kept up the pace for three weeks straight in 100-degree weather, with nearly 100% humidity.

Help for the Baker County clinic itself came from the staff of the nearby Joseph W. Jones Ecological Research Center (formerly the site of the late Robert Woodruff's Ichauway plantation), who erected a dike around the building. The facility suffered $30,000 worth of damage, an amount that could easily have climbed to $750,000 without the dike.

While breathers have been taken all around, Dr. Hotz and his team are bringing equal dedication to the recovery phase now that the acute problems from the flood have dissipated. Perhaps nowhere more so than in this disaster did Dr. Hotz find evidence to support his claims about the mighty powers of collaboration.

Keeping the Lights On

Residents of southwest Georgia are still cleaning up from the flood of summer 1994.


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