Rethinking Residency sat down with Jessica Dong, MD, MBA, Primary Care Lead Physician for a new organization, Healthcare In Action. Jessica has had a fascinating path through medicine and business and we were lucky enough to hear her story about an alternative career path for primary care physicians. Jessica attended Dartmouth College for undergrad, University of Pennsylvania Perelman School of Medicine and Wharton School of Business for both an MD and an MBA simultaneously, then completed a residency at the University of California, San Francisco in Internal Medicine Primary Care. We discussed her motivations for becoming a physician and her plans to put both her MD and MBA into action in order to change the healthcare system from within.

Can you describe your path into medicine?

I studied biology and environmental studies in undergrad. After shadowing several doctors, I decided to commit to being pre-med. I realized that people come to doctors in moments of great vulnerability, and I was drawn to having the ability to be there for someone and help in those vulnerable moments. By that point, I had also heard that many doctors were dissatisfied in their careers and with the state of American health care, so I decided to work for a few years before diving into clinical work in order to learn more about the big picture health care system.

I took a job after college at a company called Close Concerns, in San Francisco, writing about diabetes and obesity therapeutics. We published articles around clinical trials, diabetes therapeutics, etc. I learned a lot about some of the biggest health challenges in the US and was afforded the opportunity to hear from prominent leaders in the field. It became apparent to me that most of what is needed to improve most people’s health is blocked by structural, social and political barriers, not necessarily a lack of scientific knowledge.

I brought this lens into medical school and wanted to do something broader in addition to 1 on 1 patient care. I thought I would pursue a Masters in Public Health but some of my mentors advised going to business school instead to understand how information and money flows in the healthcare system. I took this advice and enrolled in the joint MD/MBA program focusing in Healthcare Management. Learning about the financial structures in healthcare taught me that the fundamental reason healthcare in this country is broken is that all the wrong incentives are in place. Healthcare providers get paid to do things to patients, not to keep patients healthy. Sick people, needing complicated procedures, produce the most money for organizations, not healthy people. And when a system is set up to produce a certain outcome, that is the outcome you get.

I wanted to fix this somehow. During business school I was able to intern at an organization called Cityblock Health, a primary care tech startup providing comprehensive, integrated care to at-risk individuals, and was exposed to a different type of care system enabled by the right incentive structures being in place.

After medical school, I went into Primary Care, knowing that so many people in this field are burnt out and disillusioned with the system. Honestly I don’t think I would’ve chosen this path if I knew that I would ultimately be another cog in the machine but after my experience in business school I felt that I had some agency to build something different.

I recently completed my Internal Medicine residency in primary care at the University of California San Francisco. I was lucky to be in a program that helped develop the type of doctor I wanted to be – focused on health equity and serving marginalized populations. In residency I focused on clinical training and did not have much bandwidth to forward my non-clinical interests.

Did you always know that you didn’t want to just do clinical work?

I didn’t necessarily have it all planned out by the time I started medical school. I had the sense that direct clinical care would be rewarding on its own, but obviously had other interests. I do think it’s important to at least be interested in the clinical care portion of medicine in order to follow this path.

Talk to us more about Healthcare In Action and your current role.

Healthcare In Action is a relatively new organization that specializes in providing healthcare for people experiencing homelessness. I am the Primary Care Lead Physician in San Mateo County, California and as the first employee for our region my role has been to stand up a new team and clinic. I started the job 6 months after finishing residency. In the meantime, I traveled, volunteered on organic farms, backpacked and hiked for those months in between. I decided about halfway through residency that I was going to take significant time off after finishing, so I did try to line up a job before we left. Unfortunately most non-academic roles are challenging to set up concretely so far in advance. Throughout the winter and spring of my final year in residency I was putting feelers out. In February of 2022 I had connected with Healthcare In Action and heard that there was the possibility they might need someone to help start a new team in January of 2023, but it was very uncertain at that point. I also applied to several other positions at more established organizations.

I had 2 concrete job offers by May of 2022, neither of which I was as excited about as the potential position with Healthcare In Action. At that point someone said to me, ‘You know, you don’t have to have a job lined up before graduating.’ And a lightbulb went off. I took the plunge and rejected both of those offers, and for 2 months after graduating found a moonlighting gig and in my free time studied for boards, went camping and pursued pottery, and that life was really glorious. I figured that if I didn’t have a job lined up by the time I came back from our travels, I could just keep doing what I was doing and keep my options open. The Healthcare In Action job was solidified by October of 2022 though and I officially started working in January of 2023.

What is your role with the organization?

I have a combined clinical and operational role. We are based out of a homeless shelter in San Mateo county and provide primary care for anyone who needs it in the shelter. I am also responsible for starting up the clinic, leading the team, hiring, getting supplies, etc. My first month was a lot of really ground level things like ordering shelves, desks, chairs and just generally setting up the clinic. We had to establish basic clinical workflows like how to check people in, how to schedule appointments, where to send people for labs or imaging, and hire a team. Our team consists of providers, a medical assistant and peer navigators – the population we work with generally needs someone to help coordinate their care.

What does a peer navigator do?

We look to hire navigators that have ‘lived experience.’ Meaning they have experience with homelessness or substance use or mental illness in the past and are now in recovery. Many people who are experiencing homelessness are distrustful of healthcare providers or organizations as they have been failed by them time and time again. Having someone on the team who has been in their shoes helps to bridge that trust. The peer navigators help with care navigation and coordinating housing, benefits, and employment resources to support a patient in reaching their goals.

How is Healthcare In Action funded?

Most of US healthcare is based on a ‘fee for a service’ model. Doctors perform a service, bill insurance, and insurance companies pay for the service. In order to make ends meet, health systems want as many patients with expensive conditions and procedures. They do better when people get sick.

We do not rely primarily on payment for procedures or visits. Most of our revenue comes through a California Medicaid initiative, focused on higher risk patients. As of last year CA Medicaid plans will pay “Enhanced Care Managers” several hundred dollars per patient per month. The idea is that investing money upstream to get people the care they need and coordinate care amongst siloed actors could keep people healthier. And because we receive the money upfront, we can do what we need to do with it. Meaning we can use it to take care of transportation, food, phones or pay for medication or labs even if they don’t have insurance. We pay for Ubers to ensure that people make it to other appointments. Most street medicine organizations rely on grants or charity funding, so we are pretty novel to be able to rely on the revenue we generate. The idea is to fully rely on insurance payments, allowing us to be more sustainable and scalable.

Because of this unique payment system, I don’t need to focus as intently on seeing the maximum number of patients per day. Right now I schedule an hour with new patients and 30 minutes for returns, which most PCPs would see as really luxurious.

If you don’t mind us asking, how is your compensation compared to a more typical primary care position?

I make a $250k base salary with the ability to make more based on enrollment. This is relatively high for a new primary care physician but includes adjustment for cost of living in the Bay Area and for my leadership position.

Any advice for current residents?

Surround yourself with people that support and validate you. Also having something to look forward to post-residency made it a lot more bearable. For me it was the time off and ability to pursue my hobbies. Also know that if you want to do something different it will involve a ton of networking and convincing people that you can provide value. Crafting your own role is possible but it’ll take some work to do.