Judith Chamberlain, M.D. '77: All in the family
Never lose your sense of the absurd. It will do you well in medicine." That graduation-day advice from then-DMS dean Dr. James Strickler served Dr. Judith Chamberlain well when she was practicing family medicine in Dexter, Maine—population 4,000. Her first office was on the second floor of 13-bed Plummer Memorial Hospital, "an old barn of a building," Chamberlain recalls. "The ghost of Mr. Plummer was there at night, running up and down in the elevator, and the attic was full of bats," she recalls. "Our night nurse used to catch them and let them go outside."
During her 16 years in Dexter, Chamberlain did everything from treating sore throats and skin rashes to assisting with surgeries and delivering babies.
"If we had an ambulance come in with someone in cardiac arrest," she remembers, "the R.N. and the doc on call—me or my partner—would run the code; the EMTs would do the CPR; and the maintenance person or whoever we could find would be the scribe. We actually saved our fair share of people, too!"
In her first year of practice, she learned ten times what she had in residency, she often says. With about half of her patients on Medicare or Medicaid, she also learned firsthand about the realities of providing health care to Maine's poorest and, often, sickest residents.
"We talk in medicine all the time now about cultural competence," says Chamberlain, referring to the growing push for doctors to be able to work effectively with patients of various ethnic and racial backgrounds. "But we forget that we also need to be culturally competent about poor people." When medical students or residents were working in her practice—which was most of the time—Chamberlain would make them do house calls with a home health nurse to see the situations in which many of her patients lived, "what they're up against," she says. "It's a real eye-opener."
Jennifer Durgin is the associate editor of Dartmouth Medicine magazine.
That kind of firsthand knowledge comes in handy in her current role as medical director for Schaller Anderson, the company that manages Medicaid for the state of Maine.
"Whoever thought I would spend my days reading the Medicaid benefits manual?" she asks, laughing. Probably not her DMS classmates. Chamberlain and a few other DMS '77s were known for knitting and doing crossword puzzles during class lectures. "You might as well multitask," she says in her own defense. "It keeps you awake . . . especially if you've been studying late the night before." During her Hanover days, Chamberlain was also active in the local Quaker community; today, she belongs to a Unitarian-Universalist church, where she sings in the chorus and teaches Sunday school.
She entered medical school planning to go into family medicine and never wavered from that course—no matter how many people tried to dissuade her. She recalls some physicians telling her, " 'You're too smart for that.' Then," she continues, "they'd say, 'And nobody can know all that stuff.' And I'd say, 'Well, which one is it? You're too smart or you're too stupid to learn it all?' "
Chamberlain's own doctor growing up was her uncle, a family physician. Her grandfather was a family doctor, too. His office was on the other side of his kitchen pantry, and when he died, her uncle took over the practice.
Grew up: Suburban New Jersey
Education: SanStanford University '74 (B.A. with honors in biology; minor in French); Dartmouth Medical School '77 (M.D. with honors)
Training: Eastern Maine Medical Center (residency in family medicine)
Why family medicine?: "Because it's the most fun in the world!"
Family: Life partner (and former practice partner) Karen Marlin, a physician's assistant, and teenage daughter Nena, whom the couple adopted from Russia when she was 2½
Pets: Six horses—Dusty, Rosie, Tickle, Kassi, Shaq, and B.G.; two dogs—Murphy Brown and Jake; and four cats—Oreo, Oliver, Tinkerbell, and Dodger
For 30 years, Chamberlain followed in their footsteps as a family doctor—first in her own practice in Dexter, which she ran for several years with her life partner, Karen Marlin, a physician's assistant, and then in a larger practice in Brunswick, Maine. During that time, she also served as president and a member of the board of directors of the Maine Academy of Family Physicians. In 2007, she was running for president-elect of the American Academy of Family Physicians when she was invited to apply for the job of medical director at Schaller Anderson.
Chamberlain did apply for the job and, when she didn't win the president-elect post, decided to accept the position with Schaller Anderson. (Though practicing medicine isn't part of her job now, she still sees patients as a volunteer doctor at a free clinic in Brunswick.) Chamberlain's role with Schaller Anderson is twofold: to accept or deny any out-of-the-ordinary charges to Medicaid, and to oversee a team of nurse managers who work to improve the health of a particular subset of Medicaid beneficiaries.
Using a system designed by the company, Chamberlain and her team track the 1,000 or so Mainers on Medicaid who are most likely to rack up big bills in the near future—mostly in the form of emergency room visits and hospitalizations. If someone is on kidney dialysis, for example, there's not much that can be done to curb costs and improve that person's health, Chamberlain explains. But if someone has poorly managed diabetes and is depressed and living alone, Chamberlain's team can help.
Patients are frequently suspicious when the nurse managers from Schaller Anderson first get in touch with them, explains Chamberlain. They will ask questions such as "Who are we?" she says. "Why are we calling them? Are they going to lose their Medicaid if they don't do this?" But once the patients figure out that the service is free, she continues, and that it's aimed at helping them, then "people are very engaged."
The nurse managers check in with this subset of patients on a regular basis, often helping them find transportation, heating assistance, or food stamps, in addition to assisting them with medication and disease management matters. It takes about six months of care management to see improvements in people's health and in individuals' perception of their own health, explains Chamberlain. "Their utilization of their primary-care doc does go up. But their utilization of the emergency room and hospital goes down." And that saves the state money, while improving people's health.
As for the other part of Chamberlain's job—being the gatekeeper of Maine's Medicaid dollars—she feels just as comfortable in that role. That's because she has "seen it from both sides," she says. As a primary-care doctor, she sometimes would find herself arguing with insurance companies to get them to cover a procedure. But, at other times, she'd find herself arguing with patients, trying to explain why they didn't need to see a particular specialist or have a certain procedure.
Chamberlain is warm, witty, and quick to laugh, but she can also be tough when she needs to be. "I find myself often in the position of calling up [doctors] I know and saying 'What are you thinking?' " she explains. She role-plays both sides of such an exchange to illustrate how these conversations go:
Chamberlain: "Why are you sending this person to Boston to see a neurosurgeon when we have perfectly great neurosurgeons in Portland and Bangor?"
Referring doctor: "Well, they asked me to, so I thought I'd help them out."
"Whoever thought I would spend my days reading the Medicaid manual?" laughs family physician Chamberlain.
Chamberlain: "Well, do you think it's medically necessary, because that's what your letter says? And if you don't, why did you write that? Do you want to take it back?"
Chamberlain doesn't seem to mind having such conversations. "If we want to take care of more people," she says, "then we can't spend money on things we don't need to spend it on"—like sending patients to see an out-of-state specialist when an equally qualified one practices in Maine.
At other times, Chamberlain finds herself in the position of approving very expensive but necessary claims. "There are times when I say, 'I don't care that this is costing $10,000 a month,' " she says. And sometimes, she'll deny a service but help the patient find another that is a better fit.
She and her team get their share of hate mail. One woman said she'd hired a private investigator to see that Chamberlain's medical license got pulled. Anyone can appeal a Medicaid coverage decision and request a hearing; that woman had had a hearing but lost.
It's not surprising that someone in charge of approving and denying medical claims would get angry letters. What is surprising is that Chamberlain and her team also get grateful letters. One mother of a severely disabled child thanked the team after they restructured when, how much, and what kind of in-home services her child received. Another man wrote one of the nurse managers thanking her for "saving his life."
Still, there are days "when I feel like I've fallen down the rabbit hole," says Chamberlain. "The rules are so crazy sometimes," she admits. "What they cover and what they don't. . . . Sometimes I just kind of go, 'Okay, it is what it is. . . . These are the rules. I didn't make them, but we have to play by them.' "
On those days, she remembers Dean Strickler's words of wisdom. Retaining the ability to recognize—and laugh at—the aspects of life that may sometimes seem crazy, or perhaps even absurd, is important. "He was right," Chamberlain says. "You do need that."
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