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The Failure of Family Medicine – a short story by Michael Fine

by Michael Fine

© 2020 by Michael Fine

This is a work of fiction. Names, characters, businesses, places, events, locales, and incidents are either the products of the author’s imagination or used in a fictitious manner. Any resemblance to actual persons, living or dead, or actual events is purely coincidental

3/17/2016

Progress Note:

New to Establish.

Chief Complaint: “tired and hunger pains x 3 days”

History of Present Illness: 36-year-old English speaking Hispanic female with fatigue and abdominal pain of three days duration. The fatigue is so severe that the patient wasn’t able to get out of bed two days in a row – very unusual for her – and her two girls, ages five and seven, had to wake her in the morning so they could get to school on time. Usually, it’s the other way around. The patient works in an office as a receptionist and never misses work but she did have to work an eleven-hour day on Monday, which was okay for her – she likes the overtime and her girls go to her mother in Pawtucket after work. The abdominal pain actually started last June and keeps her up at night. It’s burning and boring, comes and goes, but when it comes on it’s there for weeks at a time and is associated with burping and belching. It is worse when she lays down, better when she stands or walks; the same feeling she gets when she is hungry, only ten times worse. No nausea, vomiting, or diarrhea. No blood in the stool or black tarry stools. No fever or chills. Not emotionally stressed. She lives with her girls who she says are her whole world. Sleeps ok except for the discomfort. Poor appetite. No medications. Doesn’t smoke. Drinks occasionally. Needs a note for work – reports that her boss is a good person but very precise and says she needs a doctor’s note if she’s out more than a day or two, but she likes her boss who she says is fair but strict. She was seen at an urgent care center two weeks prior for the same abdominal pain but without the fatigue, when the pain was keeping her up at night and the clinic wasn’t open. They ordered an ultrasound which she is going to have tomorrow. Her boss knows about that already and understands she will be in late, so the out of work note she needs is only for yesterday and today.

Review of Systems: No trouble swallowing. No cough or wheezing.  No chest pain or pressure.  Exercises regularly. Regular periods but very heavy flow. No back pain or muscle pain. Nerves and emotions ok. Mood good, but worries about her girls from time to time. Doesn’t see or hear things that might not be there. No thoughts of hurting herself or anyone else. Had diabetes with her pregnancies that resolved after her children were born.

Physical Examination: is remarkable only for epigastric tenderness. No masses, spasm or rebound. No Murphy’s sign. Normal bowel sounds.

Laboratory Studies: blood sugar 146 (elevated but she just ate).  Hemoglobin A1c 6.1.

Assessment and Plan:

#1. Fatigue and hunger pains. Likely recurrent diabetes. Will refer to nutrition for diabetic diet and teaching. Start metformin 500 mg twice a day. Consider and test for Lyme disease (fatigue), anemia from blood loss (heavy periods), gall bladder inflammation (fat, forty, and fecund).

#2. Abdominal pain. Possible gall bladder. For sonogram elsewhere. Will ask patient to have the radiologist send us the results.

Recheck 3 months.

_______________

When I met Julio, it felt like the world had flipped over, turned itself inside out and righted itself again. After I threw the girls’ father out, that two timing son of a bitch, I thought I was done with men and that my girls would be enough for me forever. Sure, I went out on Friday nights. You have to get dressed up, put a little makeup on, drink a little and dance a little once in a while otherwise you don’t feel like you are alive. My mother would come over to be with the girls. Mostly it was girl talk and girls dancing with each other.  The men would come sniffing around, pretty ghetto, lots of bling and baseball hats, thinking themselves so hot but there was nothing there, no one to take seriously.

But Julio, now there was a different kind of man — serious, smart and adult, dark and quiet and really good looking like one of those men in the newspaper who model men’s suits. We met at the wedding of my boss’s daughter, who was marrying a guy from Boston. Very smart people. Smart and successful. I didn’t think there were going to be any Spanish people at the wedding, which was at a very pretty place in Bristol overlooking the ocean. Me and the other girls from the office, we were on our best behavior, and I was thinking, pretty night, pretty bride, the girls and I would sit together and talk and then we’d dance like we do at the office Christmas party when only the girls dance and the men, they just sit there and drink beer.

You sometimes don’t really see the person who sits next to you at a table because you have to turn to look and that’s not polite if you don’t know the person. I was talking to the girls when Julio came to the table. He was alone but he went around the table, from person to person, introducing himself and saying, “Julio Mendez, party of the groom. Julio Mendez, party of the groom. Julio Mendez, party of the groom.” Very formal and polite, like he was the principal of a school or the captain of a ship. Dark suit, dark thinning hair, dark smart eyes that kept to themselves, but he looked at you, just for a moment, and his eyes didn’t go right from your face to your chest, the way half the men in the world behave. Big shoulders but not tall, maybe a little taller than me but not much, and a strong grip when he shook your hand, strong and warm like he was learning you with his grip and really wanted to know what made you tick from the way you squeezed his hand.

He was wearing a pink almost purple silk tie that stood out, that was different from how the rest of him looked. That said, there is something different about this man, something alive inside – some kind of courage, or pride, or passion, that said how he looks and acts might not be all of who he is. Anyway, he sits down next to me and I don’t look at him and he sits there, quiet for a few minutes. He knows I’m Spanish and I know he’s Spanish but neither of us are saying anything and I’m waiting for him to turn to me, or for me to turn to him, and for one of us to make a little joke in Spanish about being Spanish at a place where there weren’t any others; about waiters or something, the kind of thing Spanish people say to ourselves about each other when no one else is looking, but he doesn’t do that at all. He turns to me and says, “I’d like to know you better. Tell me about your life,” which is not what you expect to hear from a man you are sitting next to at a table at a wedding, and he says it in English, this beautiful clear formal English he speaks as if he’s Castilian and is speaking English Castilian, and I talk to him in English.  I tell him about my life and my girls. He’s listening, asking questions, and he really gets me, like he knows something about what I had to live through with the girls’ father, like there are things he’s had to live through himself, but he doesn’t talk about those things. I’m liking the strength in this man who has feelings and a good brain, who has a heart but doesn’t wear his heart on his sleeve. That’s what strength is. We talk English to each other always. Except later, when we talk Spanish to each other in bed.

_______________

5/1/2016 

Progress Note:

Same day acute.  36-year-old Hispanic female with abdominal pain and trouble sleeping. Still uncomfortable and did not want to wait for scheduled follow-up.  Lots of burning in the chest which keeps her up at night. The chest pain is midline, not on the left. Does not travel to the left arm or shoulder. Worse when she lies down. Not worse with walking or climbing stairs – and walks four to six blocks a day to the bus which she uses to travel to work, but no regular exercise program. Not short of breath with walking. Work is busy but not stressful. Does not eat a low cholesterol or limited calorie diet. Drinks two to three cups of coffee a day, and a glass of wine or two each night to relax after her children are in bed. Not a smoker. Pain is still like a hunger pain. Did not take the metformin.

Physical Examination: reveals no chest tenderness, no pleural or pericardial rub, normal heart sounds with no murmur, good breath sounds equal on both sides. Abdomen soft, not tender, without rebound or spasm, and normal bowel sounds. Extremities without swelling or edema. Patient appears anxious.

Laboratory Studies: Lyme Titers negative. Hemoglobin 12. Low normal. Normal Hemoglobin A1c 6.0 today. Ultrasound elsewhere reported by patient to be normal.

Assessment and Plan:

#1. Chest pain. Rule out heart disease. Check cholesterol and stress echo. Might consider reflux gastritis if normal.

#2. Diabetes controlled by diet and exercise. Ok to wait on metformin. Reinforced nutrition consult which is booked for two months hence – diabetes teaching has a big backlog.

Return to clinic one month, after stress test done. To call if more chest pain. To call 911 and go to the Emergency Room for chest pain that lasts more than three minutes, that feels like someone is standing on your chest or that you feel in the left arm or shoulder.

_______________

I thought Julio would call me, but he didn’t call me and for a while I forget about him. You know how it is. You meet someone and I don’t know, they make you pay attention in a different sort of way and you think, maybe, cool, maybe more, and then they don’t call you and the girls need this and that and then you forget about that person you met.

So, a few weeks later I see my cousin, Yvette, at La Casona and she says, “I heard you met my husband’s brother Julio and that he thought you were very hot,” and I say, “Who?” and then I remember, and I guess I start to turn colors or something so she pushes me a little, kind of like a love tap, and she says, “Oh, oh, I see the way it is,” and I say, “It’s not nothing. I met the guy and never hear another word from him so what good is that?” and she says, “He’s a very good man and he’s been through a lot” and then she gives me the lowdown: he has a wife and three kids but the wife is more than a little crazy; in and out of the loony-bin, so he takes care of the kids who are now teenagers and he takes care of the wife when she is good enough to be home but that he is mostly alone. So, he doesn’t call me. Because he can’t call me.

And then it’s the summer and Yvette calls up and says bring the girls to the Colombian Festival, which is Sunday, so I bring the girls and my mother and we are standing in the middle of that field looking at the exhibits and so forth and listening to a band that is playing Colombian music, but way too loud, and then it starts to rain. The girls are running around somewhere so I find them and go to the big T-Mobile tent to get out of the rain and I’m standing there with the girls and a man comes in; he’s holding a program book over his head to keep the rain off, and it’s Julio. “Hey,” I say. “Hey,” he says. And then I introduce the girls and my mother.

_______________

6/1/2016  

Progress Note

Follow-up. 36-year-old Hispanic female with abdominal pain and trouble sleeping. Much more burping and belching. Pain still present, worse at night. Radiates to left shoulder. Not present with walking or climbing stairs. Nausea, no vomiting. Anxious but no feelings of impending dread when the pain is present. Pain lasts for hours. No shortness of breath. Everything at home and work ok. Stress echo pending; was rescheduled by patient. Hemoglobin A1c 5.8 today. No diabetic teaching yet. Did not start metformin. Watching calories and walking everyday (to the bus).

Physical Examination: Clear lungs. Heart, regular rate and rhythm. Abdomen soft not tender.  No Murphy’s sign. ? epigastric tenderness.  Extremities without edema.

Assessment and Plan:            

#1. Rule out heart disease. Needs to be careful with exertion until stress echo done – is walking to the bus every day — but is to call 911 for crushing chest pain.

#2. Diabetes.  Controlled by diet and exercise. Watching calories and exercising.

_______________

Soon Julio starts to come around. He’s shy about it. Very proper. “I have a question about my kids,” he says. “Could I buy you lunch and pick your brain,” he says on the phone.

“I only get half hour for lunch,” I say.

“Okay how about dinner?”

We meet.

“The girls are with my mother-in-law after school and she spoils them,” he says. “I make them wash the dishes and do their homework. They are thrilled to stay with their grandmother – she lets them watch TV and eat junk food all the time.”

His kids are 18, 17, and 15. He doesn’t want them sitting on the computer all night or watching TV, but that’s all they do, watch TV on the computer in their rooms. They need the computer for homework. Is he wrong? Or just old fashioned?

“No,” I say. “They need to sleep, and they need to read. Make a rule. No computer after nine PM. And then turn the router off every night at nine.”

“They’ll watch on their smart-phones,” he says.

“Take their smart-phones every night at nine,” I say. “Give the phones back at breakfast. That way they’ll eat breakfast.”

“They need to talk to their friends,” he says.

“It’s after nine. They need to sleep,” I say.”

“But they say it’s not cool,” he says.

“You have a landline?” I say. “If they need to talk, let them use the landline. You can watch that.”

“They say that is so awkward,” he says. “They say that makes them different.”   

“You are the father,” I say. “You love them and want them to succeed. They need to be different. There is plenty of time for them to be cool, when they are twenty-two and on their own. Enough kids go ghetto already.”

“You are so smart,” he says. “Way smarter than me.”

He never says a word about the mother of these kids. He drops me at my house, thanks me, and shakes my hand, like we are in a business meeting or something.

Then he calls the next week.

Every week he needs advice. About his mother, who is living in Baltimore.  About his business. He owns a little company that makes electrical things, circuit boards and switches, that he started fifteen years ago in his basement because he has a good head for math, and a good head for engineering which is what he went to college for in Colombia. He has twenty-seven employees who always fight with each other, and endless drama. All of a sudden I am an expert at kids, at families, at labor relations; and all of a sudden he needs my advice about all these things.

Some weeks I don’t hear from him.  I’m guessing then his wife is home or acting up. Julio never complains.

But one night at dinner I say, “tell me how your wife is this week,” and his eyes get dark and he starts with a whisper.

“She’s stable,” he says. “She’s home and everything is under control.”

That night his handshake turns into an embrace. I kiss him on the cheek, and he holds me to him, hard and close, as if he is holding on for dear life.

_______________

7/12/2016 

Progress Note

Did not keep appointment.

_______________

We go to Slater Park on Sundays. We do the Carousel, which the girls love, but mostly we sit in the park and the girls run free. They do the playground and they run down to the lake pretending to be this and that, and sometimes they meet other kids in the playground and they create a whole little telenovela that unfolds on the banks of the lake and has them running in and out of the trees and hiding behind the kiosks and the out-buildings, while Julio and I sit in the sunlight and talk.

He is an attentive man, that Julio, but tense. One day as we get ready to leave I see him stop and fall back and then try to stand again, and then stop again, his face set and serious, and then he struggles slowly to his knees and from his knees to his feet.

“What is it?” I say.

“It’s nothing,” he says. “Just my back. A little pain. A little spasm.”

“I can fix the back,” I say, laughing, because it is beautiful out, and he is a beautiful man, and I feel like I can fix anything and everything, and that life it is so good. And when he stands I come behind him and put my hands on his shoulders and start to give him just a small massage. The muscles in his shoulders and neck are big and stronger than I ever imagined, and they are tight like the steel cables that hold bridges up. His tight back muscles do not loosen much when I try to knead them as if they were dough, but Julio says, “Bueno,” which is the first Spanish word he ever says to me, and then he turns quickly away from me, as if I have hurt him.

Suddenly his face is very dark.

“It is good,” I say. “It is okay. Come to my house after 9:30 when the girls are in bed. It is okay Julio.”

“I cannot go to your house,” he says. “It is not proper.”

“It is okay,” I say.

And he turns and walks stiffly away. I can see the pain in his back, how he feels a jolt with each step, in his back and neck, which are locked in spasm, like a cable being wound by a winch.

That night he comes to my house after 9:30, after the girls are in bed and he stays only until midnight.

Later I learn that he is parking his car around the corner and down the block so no one can tell.

After that he comes to my house many nights between 9:30 and midnight, and I give him a key, and sometimes he comes between 4 am and 6 am so he’s gone when the girls get up, and nobody knows, and everybody knows at once, and I am loving him and I am not ashamed.

_______________

9/20/2016  

Progress Note

Open Access/ Same Day Acute.  36-year-old Hispanic female with abdominal pain and trouble sleeping. DNKA last visit because she was feeling better. Now pain and trouble sleeping again. Had stress-echo which was normal. Still has chest pain and abdominal pain, suddenly worse at night, keeping her from sleeping. Sleeping less – only a few hours a night now. Not exercising. Drives to work. No new stresses. Family status unchanged. Single mother of two young daughters. Doesn’t smoke or drink. Not concerned about her personal safety because of any relationship issues – no intra-partner violence. No change in diet – eats fruits and vegetables – some but not too much citrus or other acidy foods. Has been drinking milk and taking Tums at night, and that helps her to sleep.

Physical Examination:  Mucus membranes pink. Clear lungs. Cardiac regular rate and rhythm. Abdomen soft with moderate epigastric tenderness – replicates pain!  No mass or other tenderness. No rebound. Extremities not tender, without edema.

Assessment and Plan:            

#1. Reflux gastritis rule out H Pylori. Check H Pylori titers. Start Prilosec 20mg daily for 30 days. Recheck one month.

_______________

And then Julio’s wife improves. And then she is awake and alert and making dinner. Cleaning the house. Paying the bills like she used to do, once upon a time. Asking about his day.

Maybe it is the medicine. Maybe her brain was injured and has healed. Maybe it is an act of God.  I wonder if it isn’t me, if they aren’t bad for each other, and when Julio is with me his wife has the space she needs to live. Maybe she knows about me, and makes herself recover to get him back, as if her illness was just the way she talked to him, the way for her to get his attention away from his kids and his work. It doesn’t matter. She is better. She is awake and alert and she knows that something is going on. That I am going on.

I know that Julio never thought this was possible. That he came to me in sadness and loneliness, mourning his wife, his family, and his marriage, but now he is torn in two. I know he loves me and that he respects his wife, but he doesn’t love her. I know that he now likes his wife again, but he doesn’t love her. I know he loves me, that he loves my girls, and everything that is false about the world becomes true for him when he talks to me, when I lie in his arms.

I stop sleeping. He comes now once a week and doesn’t stay long. He looks dark, the way he looked when we met.

I am glad for him. I am glad for his wife. My girls are sad. They think about him, and they are sad. They think about me, and they are sad. His children brighten and do better in school.

I am not sleeping. There is an ache in my chest where my heart should be. An ache, not a pain. There is a burning. I am sitting up all night. A part of me is always listening for his key in the door. He is a good man, an honest man, a man of principle and tremendous integrity.

It was not like this with the father of the girls. The father of the girls, he just used me, flattered me, and tricked me. I was nothing to him and when the time came I threw him out because I always knew he was no good. This is different. I love Julio.

So, I end it.

Then it feels like I will never sleep again.

_______________

10/20/2016 

Progress Note

Follow-up. H. Pylori gastritis. 36-year-old Hispanic female with abdominal pain and trouble sleeping. Some improvement with Prilosec but still not sleeping. Burping and gas much less. Burning and chest pain less. Some nausea, no vomiting or diarrhea. No appetite. Not bloated. Hunger pain gone, but still left with an empty feeling. Mood down. Sad but not hopeless. Not sexually active. No suicidal or homicidal ideation. Doesn’t like the short days, or the winter.

Physical Examination: Lungs’ clear. Heart regular rate and rhythm. Abdomen soft, not tender, normal bowel sounds, no mass. Extremities without edema.

Laboratory: H. pylori was positive

Assessment/Plan:       

#1. Pylori Gastritis. Add Lansoprazole 30mg twice daily for 14 days. Amoxicillin 500mg twice daily for 14 days and Clarithromicin 500mg twice daily for 2 weeks. Possible side effects – diarrhea and a metallic taste in the mouth. The importance of taking all the medicine reviewed in detail.

#2. Depression versus Seasonal Affective Disorder. Trial of bright light 30 minutes twice daily for one month. Recheck then. If no improvement, consider behavioral health referral.

Recheck 4 to 6 weeks.

_______________

At 4:30 in the morning I think I hear a key in the lock. I have not forgotten Julio, but I have put him out of my mind. Ancient history. Sadness. Don’t go there. You live and you learn. But now I am thinking about the girls’ father who I haven’t seen or heard from in two years but who still has a key, and it is like him to come sneaking around when he’s in trouble or when his girl of the moment has thrown him out. Sneaking around or worse. He has done me worse. I thought once to buy a gun so I would be ready for him when he comes around again, but I don’t have the stomach for that and I don’t want it in the house for the girls to see, or the girls to find. But I do have a baseball bat. A metal bat from softball. Once when I was a girl I played.

The noise goes away.

I open the door. There are flowers between the front door and the storm door. From Julio. It’s four-thirty in the morning. I am looking for him but all I see are the red taillights of a car driving away. Julio is gone. He was here. And he is gone again.

_______________

12/1/2016

Progress Note

Follow-up. 36-year-old Hispanic female with abdominal pain and trouble sleeping. Abdominal pain resolved. No burping. No belching. No bloating. Mood improved. Not sleeping well though.  Often wakes at 4 A.M. but then able to go back to sleep, so often gets 7 hours of sleep a night in total. Using a light with daylight spectrum an hour or two a day as instructed. Appetite fair. Not stressed. No suicidal or homicidal ideation. Not seeing or hearing things that aren’t there. No chest pain.

Physical Examination:  Lungs’ clear. Heart regular rate and rhythm. Abdomen soft without masses. No Murphy’s sign or rebound. Extremities without swelling or edema.

Assessment and Plan:            

#1. Reflux gastritis. Resolved.

#2. Seasonal Affective Disorder.  Effectively treated with light therapy.

#3. Sleep Disorder – early awakening. Sleep hygiene reviewed. On awakening patient is to get out of bed and read for at least twenty minutes or until she feels sleepy and then return to bed.  No TV in bed.  Use bed only for sleep or sex.

Return to clinic in 3 to 4 months for regular health maintenance examination.  Will recheck hemoglobin then and consider iron for heavy periods.

_______________

We work it out.  It is hard but we stay with it. One day I call him up at his place during the day.

“Stop bringing flowers,” I say. “I love the flowers, but it isn’t flowers I want. I can’t sleep Julio. I want you back, but all of you not just flowers in the middle of the night.”

“I am sorry,” he says. “I thought you would be pleased. I still think about you. All the time.”

“Thinking about me doesn’t do anybody any good,” I say. “It’s very nice that you like me. It’s even very nice that you love me. But loving and liking aren’t the same thing as two people being together. I need someone for me, or no one. And I need someone for my girls.”

Then I don’t hear from him for two weeks.  

“I gave my word,” he says, when he calls me. “This is not your problem; it is my problem. I promised I would take care of her in sickness and in health. She is better now and that is good. But what is inside me isn’t better.”

“I don’t care anymore what is inside you,” I say. “You are ripping me to pieces. Love me or let me alone.”

He knocks on the door one night after the girls are in bed. He is looking dark like he is angry at me.

“I’m going to stay married to her,” he says.

“Why are you here,” I say. “You are making it worse for me, not better.”

“I am going to stay married to her, but I want to live here with you.”

“Nice,” I say, “very nice. You get your cake and eat it. What about my girls? Don’t you think they need a real father? And what about your kids? They need a father too.”

“I thought you’d be happy to see me,” he said. “Maybe I shouldn’t have come.”

“Shit or get off the pot,” I say. “I do love you, but you are tearing me apart.”

“What I came to say is that I am going to stay married to her, but we will make this work. I found a clean three family on Transit Street. A beautiful old house. Four bedrooms in the upstairs apartment. Three bedrooms in the downstairs. It has a big yard and a carriage house.”

“And you want us all to live together? Are you crazy? You want me to live in a triple-decker?” I say. “How very convenient. What about your wife?”

“It’s not a triple-decker,” he says. “It’s a real house. My wife knows all about you,” he says.

“You were her shock therapy. She got better. But we didn’t. She and I didn’t get better. She knows it is you and me now. And it sucks, but this is the best I can do. Maybe someday she finds someone else and we divorce. But not now. Now I am with the kids, and I am with you, and we find a way to make a family out of the terrible mess I have made.”

“You didn’t make a mess,” I say. “You got a mess. Now you are trying to make lemonade out of lemons. But I don’t know if I can do this.”

“I don’t expect you to,” he says.

“It’s too crazy. I don’t know what I will say to his wife, who I only feel sorry for. I don’t know what I will say to his kids or how they will look at me. How they will think about me. I don’t know how his wife will be able to stand it. Or me. Maybe it will make her crazy again. Or me. Or both of us together.  

But then I feel like I know his kids from all he has told me about them. He is twisting himself in knots for me. For my kids. For his kids. For us. What about the third apartment? I say. It’s in the carriage house. I want it for my mother, I say. That’s why a three-family, he says.

And then, as crazy as it is, I think I will do this thing. We will probably kill each other or him or we will fight, and it will wear us out, but it just could work. Suddenly I want to meet them all, his kids, even his wife, and make them feel as good about themselves as he makes me feel about living.

This is nuts but he is a good man.

So, I throw him out again, this time for good.

_______________

6/1/2017 

Progress Note

First Prenatal Visit. 37-year-old Hispanic Female. Last Menstrual Period 4/12/2017. Positive pregnancy test. Risk Factors: Advanced maternal age. Iron deficiency Anemia. History of Depression. Adult onset Diabetes Mellitus, diet controlled. Estimated Date of Delivery 1/16/2018.

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Dr. Michael Fine

Michael Fine, MD is currently Health Policy Advisor to Mayor James Diossa of Central Falls, Rhode Island and Senior Population Health and Clinical Services Officer at Blackstone Valley Health Care, Inc. He is facilitating a partnership between the City and Blackstone to create the Central Falls Neighborhood Health Station, the US first attempt to build a population based primary care and public health collaboration that serves the entire population of a place.

He has also recently been named Health Liaison to the City of Pawtucket. Dr. Fine served in the Cabinet of Governor Lincoln Chafee as Director of the Rhode Island Department of Health from February of 2011 until March of 2015, overseeing a broad range of public health programs and services, overseeing 450 public health professionals and managing a budget of $110 million a year.

Dr. Fine’s career as both a family physician and manager in the field of healthcare has been devoted to healthcare reform and the care of under-served populations. Before his confirmation as Director of Health, Dr. Fine was the Medical Program Director at the Rhode Island Department of Corrections, overseeing a healthcare unit servicing nearly 20,000 people a year, with a staff of over 85 physicians, psychiatrists, mental health workers, nurses, and other health professionals.

He was a founder and Managing Director of HealthAccessRI, the nation’s first statewide organization making prepaid, reduced fee-for-service primary care available to people without employer-provided health insurance. Dr. Fine practiced for 16 years in urban Pawtucket, Rhode Island and rural Scituate, Rhode Island. He is the former Physician Operating Officer of Hillside Avenue Family and Community Medicine, the largest family practice in Rhode Island, and the former Physician-in-Chief of the Rhode Island and Miriam Hospitals’ Departments of Family and Community Medicine. He was co-chair of the Allied Advocacy Group for Integrated Primary Care.

He convened and facilitated the Primary Care Leadership Council, a statewide organization that represented 75 percent of Rhode Island’s primary care physicians and practices. He currently serves on the Boards of Crossroads Rhode Island, the state’s largest service organization for the homeless, the Lown Institute, the George Wiley Center, and RICARES. Dr. Fine founded the Scituate Health Alliance, a community-based, population-focused non-profit organization, which made Scituate the first community in the United States to provide primary medical and dental care to all town residents.

Dr. Fine is a past President of the Rhode Island Academy of Family Physicians and was an Open Society Institute/George Soros Fellow in Medicine as a Profession from 2000 to2002. He has served on a number of legislative committees for the Rhode Island General Assembly, has chaired the Primary Care Advisory Committee for the Rhode Island Department of Health, and sat on both the Urban Family Medicine Task Force of the American Academy of Family Physicians and the National Advisory Council to the National Health Services Corps.