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An Interview with Dr. Logan McGhan

Dr. Logan McGhan, Anderson Valley’s recently hired General Practice physician, was born in Goleta, California in 1981 and grew up on an avocado ranch between Santa Barbara and Ojai, then later an orange grove in Ojai.

Dr. Logan McGhan
Dr. Logan McGhan

I went to a small, alternative private school in Ojai which got me into a lot of outdoor stuff, backpacking, camping, fly-fishing, art, music. There was a rival private school in Ojai that was much more of an East Coast style prep school, and always destroyed us competitively both on and off the field. This turned out a useful experience going forward. We were definitely the more humble, down-to-earth of the two. It was a great time in my life. After graduation, I went to UC Berkeley.

While growing up, I visited Latin America quite a bit. When I was 12 or so, I was obsessed with the jungle. We had a little money at that time so I was able to convince my mom to take a trip to the Amazon. We visited a leper colony there that affected me a lot, and probably sent me off on the medicine path I’m on now. Third-World travel in general really got to me. I made lots of friends there when I was very young, and met a lot of amazing people who were going through things much more real and scary than anything I can compare to even today. I took Spanish classes in school. My mother, who spent 20 or so years in Mexico City, spoke Spanish as well, and was a big influence. By the time I was 12 or 13 I could get by pretty well in Spanish. With that and the time spent in medical school in Mexico, I became quite fluent.

At UC Berkeley I majored in molecular and environmental biology with a minor in Native American Studies and graduated in 2003.

I spent some time on the Navajo reservation for a couple of summers in college herding sheep and supporting the Black Mesa resistance. At Cal, I was really impressed by a professor named Nimachia Hernandez. She was Ivy League-educated, and grew up on the Blackfoot reservation in northwestern Montana. I took all her courses. She is the smartest person I’ve ever met, someone I still ask questions to in my head. In high school, I had a Lakota teacher/friend named Quanna Fireshaker. These two were major influences early on in this journey.

I was not entirely career-oriented in school. Visiting Third-World countries seemed much more interesting to me. My grades at Cal were good, but not quite enough to get into the competitive medical schools in California. I knew about the medical school in Guadalajara. I ended up combining a desire to live in Latin America with going to medical school. I met my wife in the library of that med school. We have a 2 year-old boy.

Medical training in Mexico is different in that while it can lack in organization and lecture quality, it is in general much more hands on. We take the same United States Medical Licensure Board examinations series, which sets the bar for all graduates from US schools and any doctor wanting to practice medicine in the US coming from a foreign country. There are five or so national standardized exams to be passed from starting med school to completing residency. This is in addition to the board specialty examination. In general, as the actual classroom instruction wasn't always that consistent, you had to be a lot better at self-education. For that matter, these days most of what passes for education in the universities around the world is just a series of PowerPoint presentations, which should be banned. I'm not that old, but I remember a time when professors used chalk on a blackboard, actually lectured, and brought you along through their thought processes, without a script.

I graduated from the Autonomous University of Guadalajara Medical School in 2009 and started a pre-internship in New Rochelle, New York— a transitional program in Mexico for international students to learn about the United States hospital system. I then did my internship and residency in Family and Community Medicine at UCSF-Fresno. This program has a heavy urban, inpatient component with a lot of obstetrics, as well as a rural health care aspect with mostly migrant field workers.

And now I'm here. The move to Boonville seemed a natural fit. This position in Anderson Valley is my first experience as a licensed, specialty-boarded physician. (Laughs.) Most people who knew me in residency would not be shocked I stirred things up so quickly.

Q: I read where the clinic said they spent two years trying to recruit someone. Is that you?

Yes, but they didn't exactly recruit me. I recruited myself more or less. I was initially looking at jobs with the Adventist chain in Willits and Ukiah off a friend’s suggestion. A doctor named Lynne Cohen in Ukiah mentioned the Anderson Valley to me several times. I called the clinic out of the blue, drove up, took one look at the valley in the springtime, and knew this was the place to be. Mark [Apfel] made us feel right at home immediately, continues to do so, and here we are through thick and thin.

Q: When did you actually start at the clinic here?

The last week in August. I worked for about eight weeks before the CEO fired me.

Q: What are your impressions of the clinic so far?

Dr. Apfel was running a one-man show here for 37 years. The clinic, out of necessity, had developed entirely around him. Most clinics are organized where people in a certain position can move into a similar function in another clinic elsewhere, and things should go relatively smoothly. Staff should be more or less interchangeable, skill-wise. There should be a system in place to see that people have those basic skills. When I got here there was no real system. People's roles and responsibilities were largely undefined. I started asking questions — Why isn't someone designated for referrals? Who specifically supervises the medical assistants? I've worked in clinics elsewhere where people’s jobs are known, but it wasn’t clear here who was responsible for what. If Dr. Apfel was not in the building, things seemed to become impossible at times. He did his own referrals. He was doing all of these extra things on top of seeing maybe 25 patients a day. Then about the time I showed up, he was sort of sidelined under the new management structure, and many of those things didn't get done at all. My initial complaints were ignored and nothing much was done about it. Dr. Apfel had no real authority at that point.

Q: Are you saying that the clinic kind of developed around Apfel so much that when the outside managers came in and sidelined him the clinic wasn't really functioning very well?

Well, sort of. They brought in Dr. Gorchoff as medical director who never saw any patients. It was hard to get answers to even the simplest questions. Certain supplies were hard to get or even find in the clinic. The dispensary was closed. Nobody really knew what to do on their own. At first, my biggest issue was that I didn't have a nurse! How can you practice medicine in a clinic without a nurse? This is an urgent care facility, and you need to be able to screen people and evaluate situations on top of actual routine medical care. There were times when no one was there to put in an IV. Doctors are not taught to put in IVs anymore — which is stupid, but we're not. I was taught in Mexico, but of course haven’t done one in six-plus years. Dr. Apfel does them all the time. But not having a nurse most of the time was infuriating. They fired the other nurse, Stephanie. Plus they wouldn't give me a working computer in the exam rooms, which also got to be frustrating.

Q: Any good things?

Well, when Shannon [Spiller] was gone, everything seemed to run a lot better. The medical assistants weren’t freaked out. Everyone got along really well. There was a semblance of teamwork. Even if it was not always that well organized, everyone got along great and got things done. This is an isolated community. There needs to be a solid, well-organized team in place, and proper preparations made.

Q: I was under the impression that the federal audit and the checklist requirements associated with being a “federally qualified health clinic” were behind the big changes in management. I saw that checklist. It was somewhere around 50 pages long — on and on with requirement after requirement. I guess some of it was legitimate. But a lot of it seemed to be just paper requirements. I had the impression that management priorities shifted from patient care to dealing with those audit requirements. Couldn't that have been done in a more orderly manner? Especially since I gather that Dr. Apfel is not exactly a bureaucratic person.

Well, part of my hiring was to address some of those requirements by taking some of the caseload from Mark [Apfel], and giving him a shot to do it. When they brought the consultants in, and then gave them the keys to the whole show, there was an obvious clash. I never met any of these eventual outside bosses during any of the interview process.

Q: What's the status of the dispensary?

It's still closed. It was closed when I got here, and it's still closed, which was a point of contention from the beginning. It really became hard to explain to every patient who came in needing medication that I couldn’t give him or her any, even though there was plenty in the little room next door. You now will have to take a whole day trip up and out of the Valley for your kid’s eardrops, even though you might have to work all week and don’t have a car, etc. I would have liked Dr. David Gorchoff to do a little of that as well, since he’s the one who closed the dispensary. After doing nothing for 2 or 3 months, a dispute occurred over the dispensary remaining closed, at which point a pharmacist consultant was contacted by Mark to come take a look at the operation, which apparently was all that was needed. This all happened the week Sharon let me go, so I do not know the result of the consultant’s visit. Hopefully, when I get back to work this week, they’ll have some good news. Nonetheless, it was a constant source of frustration. If there is a medication or treatment at hand, or something that I can do to help someone’s suffering, I won’t be able to look at myself if I just do nothing.

Q: It would be like withholding somebody's catheter.

Yes, and that's the way insurance companies work. That's how they make money, by withholding care from people. I didn’t come all the way to Boonville to operate like that.

Q: How would you characterize the patients you’ve seen so far?

They are very interesting and diverse. I love working with the vineyard folk. People love to tell stories here more than most places. Some are more stoic than I would have expected. A lot of the older locals don’t always seem willing to admit how much pain they're in. They seem pretty tough. Even some of the better off people don’t always seem willing to admit what's wrong. You have to spend extra time drawing it out of them. I do, however, really enjoy talking to patients and usually combine it with charting during the conversation to be able to spend more actual time with the patient.

Q: How would you compare this clinic to the clinics in Mexico?

Well, the overall Mexican health care delivery system might be better organized. They do more with less much better than we do. I’m definitely not a full proponent of their system, but they seem to do the best they can for the most amount people, which we do not. For a comparison, look at their disaster responses compared to say Hurricane Katrina. There are obvious limitations in rural areas in Mexico, but if you're near any kind of decent sized city, you will get cared for. They have their limitations with resources, technology, extreme corruption, racism, and poverty, but without the bureaucratic litigation environment, they can sometimes do a better job for the vast majority of the people with less. Of course you still have to be selective with which doctor you see, and these are all big generalizations, but they don't let their people fall through the cracks as much as we do here. If you are an average, working-class person in the US, and you don't have insurance and you have an accident or illness, the rest of your family’s financial future could very easily be ruined. Likewise the uninsured avoid preventative health care maintenance, and use the emergency rooms for simple things that could easily be taken care of in an outpatient clinic for a tenth of the cost. If you come to this clinic with pain in your side, the visit might end up costing a few hundred dollars, as compared to the same complaint seen in an emergency room that's easily going to cost thousands of dollars on the low end. This could be easily fixed by providing everyone a primary care physician and paying for healthcare upfront.

That, in a nutshell, is how our healthcare system is working. If you treat people with chronic or terminal conditions on the cheap, the back-end, when they're at their sickest, by doctors trained to save your life after a car accident or heart attack, not to make sure you don't die a slow death from diabetes or opiate addiction, you pay ten times the cost.

It seems, however, there is an incentive in the American health care system to keep people sick. The sicker a given population the more profit to be made. There are obviously more cost-effective ways of doing medicine, such as keeping people with chronic or terminal conditions out of hospitals and reducing the bureaucratic nightmare stranglehold that has grown up around the people who actually went out to help people.

While being horribly expensive, the hospital experience can be quite terrible for many people as well. After a long stay, someone who at baseline might be a little on edge, with nowhere to go after discharge, after not sleeping for a week or two from the constant IV beeping, 5am lab draws, and the 2-4-6 AM vital checks, might start to complain or get agitated. They'll be labeled crazy, and placed under various physical and chemical restraints until things start to run smoothly again, from the hospital’s standpoint. People and loved ones can be held hostage by this hospital maze they find themselves in, particularly at the end of life. The general public is largely unaware of what the end will look like for their loved ones. In the last few months of life, comatose after beating death back with pacemakers, breathing machines, chest tubes, gastric tubes in an intensive care unit after 10 plus re-admissions, thousands of lab draws and painful procedures, invasive monitoring methods, noxious medications until it is all just too late to turn back. As a result, most doctors when asked would prefer to die far from a hospital bed. These things can be hard to forget.

Q: Do you have any sense of what the health center's finances are like?

Not really. They tell me they are in the black. Hopefully, that gets attended to soon by whoever they hire to administer the facility.

Q: How do you see things developing in the next few months to years?

I think they'll go great! I love working with Dr. Apfel. I get along with everybody else as well and look forward to seeing them all again soon. There are things that have to happen of course. The dispensary must be opened. I think the clinic can handle the rest of its federal requirements in time. Likewise, eventually I’d like to recruit some contacts of mine, like-minded medical providers, to come live in the Valley and work in the clinic. The AVHC provides a good wide range of services — much more than the average family medicine doctor's office — x-rays, casting, urgent care, lab draws, dental services, pharmacy services, behavioral health, close community involvement — things that make this clinic much more than a doctor's office.

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