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SAN FRANCISCO CHRONICLE
GENERAL, LIFE AND DEATH AT SAN FRANCISCO'S HOSPITAL OF LAST RESORT Hospital's Approach Makes Family's Care A Multigenerational Affair For Doctor

Mike Weiss, Chronicle Staff Writer
Wednesday, December 12, 2006


During her second year as a family health resident at San Francisco General, Dr. Teresa Villela began to treat Marcia Hernandez, who, like her, is a child of Latino immigrants. Marcia was recovering from drug addiction. Not long afterward, Marcia's father, Rafael Socarras, who usually accompanied his daughter to the clinic, suffered a heart attack.

Rafael was not Villela's patient. But because of the inclusive approach to family medicine pioneered at General in the 1970s, Villela soon became his doctor, too.

"We tell our patients we'll be their doctor over time, something most of our patients never had before," said Dr. Peter Sommers, who helped begin the family health clinic and still practices and teaches there. "Also, you say: 'I can see your family, too.' There's that continuity."

Before long, Villela was treating four generations of the Socarras family. That intergenerational approach is the essence of the care offered at the Family Health Center, the biggest primary care clinic in San Francisco. Last year, 10,000 patients were treated during 40,000 visits. This year, visits are up 25 percent as Baby Boomers age and more working poor find themselves without insurance.

After Rafael became Villela's patient, so did his wife, Laura, who was born in Nicaragua. Villela soon learned Laura was "exactly the opposite of her husband, who's a very, very tightly wound guy. He's Cuban. And she's very relaxed and calm and prefers natural remedies.

"It took six, eight months to have a sense of what was going on in the family," Villela said this summer. She was in her office in Building 80-90, an Italian Renaissance-style brick edifice that dates to 1938 and which is adorned with terra cotta gargoyles and has bronze trim on its elevator doors. Villela's office was overheated and cozy. There were Huichol Indian yarn paintings, and other artifacts that evoked her ancestry.

"Their narrative, as it evolved," Villela continued, "is that Marcia's husband is in prison." Jesse Hernandez is serving a life term for kidnapping and attempting to murder a cab driver with a knife in Modesto. "They never said it didn't happen, but that the consequences of it were unjust; he was overcharged."

Villela got to know Rafael and Marcia because of the "stress they were going through, their emotional emergency. Her response being drug use and suicide attempts, and his response to that being: You have to take care of your children. And a stress-induced heart attack.

"And then I started taking care of Marcia's children," Villela said. "Jesse Jr. at that time was a year and a half, and his two older sisters, Priscilla and Rita, through their teenage years and all the things they needed, such as contraception. And as time went on a lot of stuff happened." Villela, 47, laughed, deepening the lines at the corners of her eyes and mouth. Her natural expression is pensive -- she is always listening, never in a hurry.

"And to me," the doctor said, "the tell of how important all this is to the family was when Priscilla got pregnant and she decided to have the baby, she came to me. That's a lot of trust. Her boy is now 1 year old, Elijah. I got to deliver the great-grandson of my patient."

"It's very important to realize that this isn't a hospital just for people with AIDS, or trauma or psychiatric problems," said Dr. Alicia Fernandez, an internist at General who is Villela's partner of 27 years and the biological mother of their 5-year-old daughter, Emilia. "A lot of just plain folks are our patients, people who get cancer, diabetes, heart attacks, pneumonia, need shots, examinations. Teresa gets to see a lot of success. Kids who are healthy, parents who become better parents, people able to go on working."

And family narratives like the Socarrases' that keep evolving.

Rafael and Laura Socarras paid $18,000 for the bungalow they bought for themselves and their four kids in 1972 when he was a utility man for United Airlines. Their tidy three-bedroom home in the Mission District is only three blocks from General Hospital.

 

One morning as he and Laura prepared to take their first and only great-grandson, Elijah, to the doctor for the flu, Rafael railed against the airline where he worked for 15 years. "He is a big thief, United, stealing everything from the workers." Although he lost a portion of his pension after United filed for Chapter 11 bankruptcy in 2002, he did retain Blue Cross/Blue Shield as part of his retirement. He is also on Medicare.

"I tell you something," Rafael said. "San Francisco Hospital have good doctors. I go to private hospital, I pay lot of money, he do nothing. I have Blue Cross HMO, I want to go to San Francisco Hospital. It is close to my home. Dr. Villela sees my family."

Rafael and Laura look after Elijah every day while their granddaughter Priscilla works. On this day in mid-March, Rafael, who is 71, also had a scheduled appointment with Villela because his arthritic knee was painful and making him limp. He is a small, tidily put-together man, dressed, as usual, in a gray windbreaker and spit-shined black loafers.

At the registration desk, a problem developed. The hospital computer showed that he was insured with Blue Cross, but the hospital didn't have a contract with that insurer. Rafael explained, patiently at first, that his Medicare pays for his visits to Villela.

"The problem is," the clerk said, "you have to go wherever Blue Cross has providers."

Rafael produced all his many medical cards, and grew visibly agitated. Finally, a supervisor ironed out the problem. But on Rafael's subsequent two visits to the hospital he went through the same hassle, and each time was assured the problem was permanently solved. He learned to show up 45 minutes early because nothing ever changed.

By the time Rafael reached a clinic nurse, his blood pressure was 150/72, too high for a man with a heart condition. Villela entered the exam room dressed in a white smock over black slacks. She has a jaunty, balls-of-the-feet way of walking. She parts her long straight black hair in the middle, and looks like a sophisticated version of a woman in a Diego Rivera painting.

Rafael's face was scrunched up angrily as he related the insurance snafu to Villela, who sympathized. Next, they discussed the pain in his knee that impeded his walking and gardening. She wanted him to take two Tylenol with codeine instead of one, but he worried about side effects. Villela assured him that two Tylenol was less of a problem than his pain.

She listened to his breathing and took his pulse. "Muy agitado," she said. As they chatted, he seemed to relax. Villela retook his blood pressure. It had dropped to a safe 120/60.

She smiled at him. "Stress induced, would you say?" They both laughed. She had given him 20 minutes of her time to prescribe two Tylenol, but her calm and assurance had worked wonders.

"Maybe we should dance," Villela joked.

Villela's parents are known for their graceful dancing. Her dad delivered furniture and her mom was a janitor in a hospital in Tucson, to which they moved from Tuxpan, Mexico, when Teresa was in the fourth grade. She arrived in America speaking no English.

Villela was not considering college until a high school math teacher, who recognized her potential, came to the house with an application to Yale. Villela credits her admission in part to affirmative action. She and Alicia Fernandez met in New Haven, Conn., when both were at Yale.

But Villela left college without completing her degree. She went to work in a clinic for poor women in New Haven, where she was deeply impressed by a retired OB/GYN from New York whose Park Avenue clients were so attached to her that they drove to Connecticut and shared the waiting room with the clinic clientele.

When it was suggested to her that the loyalty of the Socarras family was not so different from the loyalty shown to Villela's early role model, Villela considered it, then said: "It hadn't occurred to me that way." A few days later she also said: "I'm very superstitious. One of the things about my culture is you don't show pride because the goddesses will take it away."

After several years at the women's clinic, she finished her degree and was accepted into medical school, Villela said.

In 1989, she began a three-year residency at General, and in her last year she was chosen to be chief resident of family medicine, a singular honor. She decided to remain at General in part because as an institution it does not divorce health care from politics. Its AIDS clinic was a pioneer, and remains the foremost in the world. And it is the only place in San Francisco where a woman 20 weeks pregnant can get an abortion.

Six years ago, after some hesitation over whether she would be an adequate leader, she agreed to lead the residency program. It is one of the most sought-after programs of its kind in the world -- every year 600 applicants, half of them from outside the United States, apply for 13 openings.

Longtime colleagues speak of Villela with reverence. "I idolize her," said Dr. Ron Goldschmidt, who is 20-plus years her senior. And Peter Sommers, who has been on the clinic's faculty longer than anybody, calls her "a natural. Someone who is a great, great clinician and a great teacher. She has so much wisdom about how to use your knowledge in your relationship with patients and families."

Marcia Hernandez showed up for her April 25 appointment with Villela 30 minutes late, wheeling a small suitcase and carrying an oversize handbag. The 40-year-old was perspiring heavily and on the edge of becoming hysterical.

"I've got to talk to Dr. Villela," she whimpered. "I've been sick. I lost my Fast Pass, I had to walk all the way," more than a mile. "I lost my Medi-Cal card." She began to cough and cry.

"Everything's just been happening to me bad," she gasped, her face contorted. Beneath a cascade of oiled black curls, Marcia's face even at the best of times seemed bruised, not by physical blows but by the unseen punishment life inflicts upon some souls more than others.

Villela's face by contrast was a mask of composure, her tone level. "What's going on, Marcia?" she asked.

"Everything! Everything again. I'm so stressed. I've got to pass my GED before June 30 or I'll lose my job." Marcia worked for the city as a monitor looking after autistic kids on their bus rides to and from their special school, and she was deeply attached to the children in her charge. "Everything is not good enough. I relapsed again," she said, and broke down.

"Calm down," Villela said. "You need to help me figure out what I can help you with." Her tone softened almost imperceptibly as she added: "You've been through this before. You've gotten out of this before. So you can do it again."

Marcia nodded through her tears. "Yes, I will."

"Of course you will."

Marcia began to talk somewhat disjointedly about her fears about passing the high school equivalency exam, which she had flunked once before.

But that isn't what Villela wanted to talk about. "Are you going into a program?

"You're not going to pass your GED if you're doing drugs. Getting into rehab has to be number one."

Marcia said she had called the director of a church-based residential rehab program she had retreated to before. "But I want my GED," she wailed. "I want my job. I love my kids, they're so beautiful."

"Your GED doesn't matter if you're lost somewhere South of Market," Villela persisted. "So can you go? Tonight?"

"My dad wants me to go as soon as possible, too. I don't want my dad to go through any more pain. He got very, very sick seeing me the way I am. Thank God for my mom and dad. They never turned their back on me."

She was sobbing again. "What can we do?"

Villela waited a beat, then replied, "What can you do?"

"Are you upset with me?"

"No. I can see you're upset. You were clean how many years?"

"Two years."

"So you can do it. You are going to call Irma," who directs the rehab program, "and set a date." Villela also promised to complete paperwork to let Marcia's work know she was on disability, which might help get her more time to complete her GED.

Marcia wanted to see her husband in prison to say goodbye. Virtually every weekend for close to two decades, she and their now-grown kids had visited him. She blamed herself for Jesse's crime.

During an argument while she was pregnant with their third child, she threatened him with never seeing his kids again, then fled with them to her parents. He got drunk, she said, and because he had no car commandeered a taxi at knifepoint, trying to reach his children. After Jesse was sent to prison for life in 1987, she began using PCP, to numb her pain.

Suddenly Marcia sounded more angry than self-pitying and lost. "My husband's been locked up," she said to Villela. "So damn long. Trying to be mother and father. I want my husband home."

The appointment, Villela's last of the day, was scheduled for 20 minutes. It had gone on for 48 minutes before Marcia left, and Villela, late to pick up her daughter, rushed to the nursery, arriving just at the drop-dead time.

She reacted impatiently when Marcia came again the next afternoon without an appointment, badgering the doctor to complete the paperwork for her job. Villela was embarrassed by her response; how she reacts to patients is crucial to her. She knew Marcia was deeply disappointed in herself, and that her own frustration came from wanting Marcia to succeed. For a moment, the doctor had forgotten that conquering addiction is a lifelong process.

Marcia had asked her to do one simple thing.

"I'm sorry, Marcia," she said. "I'll do it today."

Four generations of the Socarras family were in their kitchen at lunch time. "I throw away my Blue Cross/Blue Shield," Rafael said. He was going to rely on Medicare. The ceaseless agitation of being told he couldn't see Villela -- because he was doubly covered -- was too much.

Rafael's brother Angel had dropped by from his Mission neighborhood gift shop, and was playing with his grandnephew Elijah, bouncing him on his knee.

Marcia had visited her husband in jail -- he approved of her going into rehab -- and was wrapping up her affairs. She said she was clean. Her niece Brandy, a college student, had arrived to drive her to an eye appointment.

Laura Socarras was at the stove, doling out bowls of gallo pinto, a Nicaraguan beef stew made with rice, beans and onions.

"Anyone in this family can come here and eat," said Brandy. "This is a welcoming house, a very Christian house, a loving house." She tucked into her gallo pinto. "If you're heartbroken," she said, "just give me some of this."




E-mail Mike Weiss at mikeweiss@sfchronicle.com.
http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2006/12/10/MNGVOMT3NL1.DTL