Dr. Yost Advances Medical Provision In Puerto Rico

Saturday, December 1, 2012

David Yost, MD, MSc, graduated from the University of Arizona College of Medicine in 1987 and the University of Arizona Family Practice Residency Program in 1990.  He grew up in Northern Arizona on the Navajo Indian Reservation, spent time in Tucson, Phoenix and Pinetop, Ariz., but currently is practicing medicine in San Juan, Puerto Rico. Although his new U.S. Public Health Service appointment there kept him from attending this year’s reunion celebration, the family practice and public health physician is working to benefit the people of the commonwealth territory, advancing the provision of medicine in unpaved ways.

Why are you practicing medicine in Puerto Rico? What is life like there?

I am a Commissioned Officer (CO) in the United States Public Health Service (USPHS).  I joined the USPHS after residency as a way to work with unique underserved rural populations via the Indian Health Service (IHS).  The IHS is just one of the many branches of the USPHS where Commissioned Officers can be assigned.  Other branches include the Centers for Disease Control and Prevention, the National Institutes of Health, the Food and Drug Administration and as health care providers to the U.S. Coast Guard.

My first 22 years as a CO had me stationed at the Whiteriver IHS Hospital in Whiteriver, Ariz.  At that facility, I was fortunate to work with numerous UA medical school and residency alumni. I also was able to teach dozens of third- and fourth-year UA medical students who rotated through our site. In addition to doing primary care at Whiteriver, I quickly found myself as the medical director there and also worked for IHS nationally as a mentor and consultant to IHS sites around the country.

In 2010, my wife, Laurie, and I sent our youngest child off to college. With an empty nest and a lifelong interest in different cultures, I decided to seek another opportunity with the USPHS. The opportunities for COs were numerous, particularly with the CDC. After briefly considering CDC positions in eastern and southern Africa, I accepted the role of Tuberculosis Program Director for the Commonwealth of Puerto Rico.

The TB Program in Puerto Rico had lacked stable medical leadership for some time and the island had recently experienced several TB outbreaks that showed the need for an experienced public health physician who could reorganize the unit and provide medical consultation to local program staff. In my time with the IHS, I had oversight responsibility for numerous public-health projects, including multiple vaccination and infectious disease prevention projects (influenza, Hepatitis, TB and Rocky Mountain spotted fever). I had also completed my master’s degree in infectious disease through the University of London School of Hygiene and Tropical Medicine in 2003. These roles gave me the basic skills I needed to be selected for my current position.

Of note, I arrived here speaking very little Spanish and having never visited Puerto Rico before. My wife and I had deliberately selected this site to improve our Spanish language skills in a tropical environment.

Life in Puerto Rico is an interesting cross between things you see every day in the United States (Home Depot, Costco, Walgreen’s, every fast food chain you can think of) and Central America (pick-ups loaded with plantains, lush tropical mountains and rainforests, amazing beaches, bustling mercados, street vendors with delicious and sometimes unrecognizable foods). Although Puerto Rico is roughly the same size geographically as the Fort Apache Indian Reservation where I previously worked, it has more than 150 times as many people (3.4 million vs. 20,000). While many Puerto Ricans speak English, the population also includes a large number of non-English speaking immigrants from places such as the Dominican Republic. Health-care resources range from exceedingly modern in the private sector (MRI units, new hospitals) to under-resourced in the public sector where clinics lack telephones, air conditioning and computers.

What does your job entail?

At the request of the Puerto Rico Department of Health (PRDOH), I am assigned here on a two-year contract through the CDC to supervise approximately 30 TB Program staff members (physicians, nurses, technicians, epidemiologists, health educators) who operate seven TB clinics around the island. I provide medical oversight to the TB cases we manage each year and design the TB surveillance programs used on the island. I also am charged with providing state-of-the-art TB education to physicians and other health-care providers in Puerto Rico and the U.S. Virgin Islands. Finally, I design and implement activities to address TB outbreaks, including working closely with other federal and state health agencies such as the CDC’s Quarantine Division. Although I am based in San Juan, I routinely travel through the island as well as to other U.S. territories in the Caribbean and back to the United States. This is designated as a “capacity-building” position by the CDC, meaning that one of my ultimate goals is to train local staff to eventually take over the program.

What makes you passionate about this type of medical practice?

The challenge of creating high-quality public health systems out of limited resources is amazing.  The people I have worked with in such systems (IHS in Arizona, CDC’s Division of TB Elimination in Atlanta, and local staff here in the PRDOH) are dedicated and driven by interests other than money and recognition.  It is rewarding to bring services to people who have been ignored as high-tech medicine swept on by. For instance, I spent the better part of this week organizing and staffing a TB screening clinic at one of urban San Juan’s largest homeless shelters. This was a site where virtually no TB screening had been done in the past and patient after patient came up to my team to express their gratitude for their presence.

Aside from the obvious, how did your College of Medicine training prepare you for what you’re doing now?

Some of my best preparation came through the College of Medicine’s Commitment to Underserved People (CUP) Program, which was coordinated (at the time) by Ron Pust and Larry Moher. It was in this program that I first met the type of unselfish role models who dedicated their lives to difficult clinical settings where creativity and tenacity were needed to address the needs of underserved and forgotten people. I have great memories of volunteering at St. Elizabeth’s of Hungary and doing clinical rotations at El Rio.  Many of my medical school and residency colleagues chose similar paths to mine due to the impact of CUP and these learning settings.

On the fun side, I was lucky enough to be at the UA in the initial golden era of Lute Olson and UA basketball. My wife and I lived in Palm Shadows, the aging apartment complex that I believe still stands on the Northwest corner of Speedway and Campbell. With the basketball dorm just to the west, it was not uncommon to see UA basketball stars Steve Kerr and Sean Elliott in the McDonald’s next door.

Do you have any special College of Medicine memories?

As above. I also remember (fondly) the campus as being much smaller than it is today. With just 88 classmates, you ran into everyone on the medical school campus.  It was too small a place to get lost or be ignored.

What makes you proud to be a College of Medicine alumnus?

Whether it is statistically provable or not, UA alumni seem to pop up all over the country and have prominent roles in public health. When I was a practicing with the IHS and calling urban areas for important specialty consultation, more often than not it was another UA alumnus who was helping me out on the other end of the line. Maybe I’m biased, but the UA people were always some of the most genuine and receptive people I ended up talking to in the middle of the night when I needed help.

Ironically, the legacy of helpful alumni continues here in Puerto Rico. When I first arrived in July as the sole CDC Medical Officer within the Puerto Rico Department of Health, I was immediately befriended by Hal Margolis, MD, a UA medical school alumnus from the 1970s. A world-renowned researcher and infectious disease expert who currently heads up the CDC’s Dengue branch unit in Puerto Rico, Dr. Margolis was key in making me feel at home and introducing me to the island’s public health leaders. This is just another example of UA alumnus camaraderie.

Do you have any advice to others about practicing medicine outside of the states?

Between my third and fourth years as a medical student at the UA, I did an eight-week rotation in rural Tanzania through the Department of Family and Community Medicine. I strongly recommend such experiences and was exceedingly glad when I was on the other end of practice and able to mentor UA students visiting rural Arizona. My advice: Stretch your comfort zone, get out in the world. As nice as Tucson is, the world goes a lot farther than Ina and Oracle roads (the edge of Tucson when we lived there).