Silvia was just 42, a petite woman with a brilliant white smile and jet-black hair. She had three children in school, and a fourth on the way. She was still in love with their father, whom she had met at age 16.
Life was good, except for some stomach pain. So in the spring of 2013, she went to the North Portland Health Center to see her primary care provider, Daniela Schlechter-Keenan — a physician assistant who’s earned regional attention for her quality of care. Tests at Oregon Health and Science University soon revealed Silvia had cryptogenic cirrhosis of the liver; without a transplant, she would die.
Silvia immediately returned to the North Portland Health Center, where Schlechter-Keenan folded her into her arms. “She hugged me and told me everything was going to be OK,” Silvia remembers.
Schlechter-Keenan tried to make it all OK. She lobbied organ donation and transplant organizations and wrote letters. But Silvia doesn’t have legal residency in the United States, so she didn’t qualify for the Oregon Health Plan. And without insurance she was denied a spot on any transplant list. Schlechter-Keenan then convinced OHSU to treat the symptoms of Silvia’s condition, regularly draining liquid that built up in her abdomen.
“She’s the one making sure people care for me,” Silvia said. “She’s there, pushing and pushing. She doesn’t stop.”
Four years later, with nothing to offer but palliative care, Schlechter-Keenan and her team from North Portland Health Center drop by Silvia’s home. They bring holiday baskets filled with food. They attend the children’s birthday parties. Schlechter-Keenan buys bins of produce from Silvia’s family to share with coworkers.
Schlechter-Keenan’s coworkers say she gives the same kind of attention to each of her patients.
“It’s not just Silvia, but it’s all of her patients,” said Adriana Cardenas, a community health worker on Schlechter-Keenan’s team. “Her world revolves around her patients. It’s not just a 15-minute appointment. It’s more than that for her.”
Her supervising physician, Dr. Robert Henriques, said Schlechter-Keenan models the best of primary care — a role that extends beyond detailed charting and thorough preparation. “It’s her advocacy for disenfranchised people, to make sure they have the same access to healthcare as everyone else,” he said.
Schlechter-Keenan shrugs off the praise. She says it’s a team effort.
“I don’t feel like I’ve done anything special,” she said. “Everyone in primary care works incredibly hard. I do as well as I can because of my team. It’s thanks to them I can get through every single day.”
Her peers seem to disagree. Schlechter-Keenan will be honored next month as one of the region’s Top Doctors & Nurses, a list published annually by Portland Monthly. It’s the first time a physician assistant working for Multnomah County has been named.
Her reputation has already earned Schlechter-Keenan offers from private clinics, where she would make more money in a less stressful environment. This recognition by her peers is likely to bring new opportunities for a more comfortable job. But she’s not tempted, she said.
“Yeah, I’d make more money, but I wouldn’t have my families. I really love my families. I really feel close to them,” she said.
She also feels an obligation to treat and to fight for Silvia and other patients who came as immigrants desperate for the American Dream, desperate to survive. She feels an obligation to pay forward the kind of treatment that propelled her into the medical profession, the kind of care that saved her own life.
“My story is the story of many people, how they gave from the heart and moved heaven and earth to get me here to the doctors who were able to help me, and who continued to help me throughout my childhood,” she said. “My family was given so much opportunity. It’s not fair that Silvia’s was not.”
Daniela was born in Viña del Mar, Chile, in 1979, the first child of William Schlechter and his wife, Monica Pino-Schlechter. William had just graduated engineering school, and Monica was as a physical therapist. But their plans changed when Daniela was born, diagnosed with a condition called bladder exstrophy, in which her abdomen was open and her organs exposed.
Hospitals in Chile weren’t equipped to treat such a complication. Infection would likely kill the baby within three months. But her parents wouldn’t listen, and the extended family launched a campaign to boil and sanitize cloth diapers and keep the little girl’s stomach wrapped in Saran Wrap.
It wasn’t long before Monica got a call from Bliss, Idaho. She had lived there with a family seven years earlier as part of an international exchange program. The family heard about her case through the exchange program liaison and they wanted to help, according to a news story published at the time.
The host family brought Monica and her baby north, and a surgeon from the University of Utah Medical Center offered to perform the necessary surgeries for free.
Soon the family realized Daniela would need a series of procedures performed over many years. Shriners Hospitals for Children had joined in her care, but Monica and Daniela couldn’t stay in the country without permanent residency. That’s when local lawmakers began to mobilize. Pete Cenarrusa, then Idaho’s secretary of state, and Sen. Frank Church lobbied the United States embassy in Chile to grant a visa to Daniela’s father, in 1984, so the family could be together. In 1987 Sen. James McClure drafted a bill granting the family permanent residency on humanitarian grounds.
President Ronald Reagan signed his name in November 1988. Daniela was 9 years old.
Daniela grew up in hospitals, where she raced wheelchairs down the hallways, and where Santa Claus visited at Christmas. It was cold always, and lonely at night when her parents went home. It was scary when doctors poked her, and she didn’t always understand what was happening to her.
But it was also where she decided to go into medicine, an idea spurred by the actions of one nurse in particular.
“The nurses were holding me down while a doctor was trying to put a catheter in,” Daniela recalls. She was fighting them off until a nurse told everyone to let go of the girl.
“Wait, let’s show her what’s happening,” the nurse suggested. She took Daniela’s Kewpie doll — her most precious possession — and catheterized the doll.
“Then she helped me practice on the doll,” Daniela said. “I understood better why, and that it wasn’t going to hurt and it’s temporary.”
Daniela began attending school as her health improved. Her parents, meanwhile, worked on a potato farm, where Monica sorted good potatoes from bad ones, and her father drove potatoes to market. Each afternoon Monica would see the school bus approach and hop off the harvester to greet her daughter before returning to the field. Daniela would climb into the family’s Volkswagen Van and study until her parents finished their day.
Neither parent returned to their trained professions in the United States. Monica went on to work as a physical therapy assistant while William became a mechanic. As a little girl, Daniela felt guilty for making them leave Chile for the harsh work of field hands and the bitter cold of Idaho winters.
“They gave up everything,” Daniela said. “I knew it was because of me.”
But her parents never saw it that way.
“We were really happy we were able to make it and we had jobs. It was a good feeling,” her father, William, said. “We had a problem, and we had to solve it. It was a little tough, but we were all together.”
The Schlechter family later moved to Oregon, where Daniela graduated high school and enrolled in the University of Portland. She continued to undergo medical procedures, but was healthy enough to spend a year in Salzburg, Austria, where she met another Portland student named Joseph Keenan, whom she later married.
After graduating with a degree in biology, Daniela spent a year as an AmeriCorps volunteer. She coordinated a free health clinic in Hillsboro, where volunteer providers cared for uninsured patients, including farm workers and others who suffer complications such as avoidable asthma attacks or urinary tract infections that become kidney infections.
That’s where she met volunteers studying to become physician assistants. They seemed so knowledgeable that she enrolled in a physician assistant program through Pacific University and graduated two-and-a-half years later.
Daniela Schlechter-Keenan was hired on with the North Portland Health Center in January 2013. She joined a team that included a physician, two nurses, two medical assistants and a community health worker. On any given day, she sees an average of 18 patients. But her days can run long.
Nurse Koh Metea says it might be because Schlechter-Keenan prepares so thoroughly, reading each patient’s chart before entering an exam room, “so patients feel special,” she said.
Nurse Ruth Mullen says it might be because of Schlechter-Keenan’s charismatic and caring bedside manner. She walks into a room smiling and makes eye contact with patients, rather than staring at her computer screen, and sits down to listen. “She sits on the stool and scoots right toward you,” Mullen said.
“Even on rough days, if she’s behind, if she has a difficult patient, she shakes it off before walking into her next appointment,” nurse Nina Spring said.
Schlechter-Keenan said she’s chronically running behind as she juggles the constraint of 15-minute visits with the detailed accounts of her patients when she asks, as culture demands, “How are you? How is your family?”
“It’s very hard,” she said. “My Latina patients want to talk and sometimes they’re very colorful. Part of me feels guilty interrupting them. In Latina culture, you don’t interrupt people.”
And she’ll often agree to see multiple members of the same family when one person schedules an appointment.
“She might not have time, but she’ll see us,” patient Silvia said with a chuckle. “She is always running around but she always makes time for us.”
“It’s beautiful the way she is with me,” she said. “I feel so comfortable with her. With her, I can talk about what’s in my heart.”
The women’s connection is mutual.
“I dream about her family a lot,” Schlechter-Keenan said. Perhaps because the case gnaws at her.
“The sense of unfairness, the feeling that I can’t do anything for her,” she said. “The fact that a 45-year-old woman has a terminal disease in a country so wealthy that it would not be terminal if she had insurance.”
Silvia smiles sadly when she thinks about Schlechter-Keenan’s own struggle to accept of her death. One time Schlechter-Keenan told Silvia that she wished she had a magic wand to wave and make Silvia better.
“It gave me such tenderness, because doctors don’t care so much,” Silvia said. “With Daniela, she tries to help as many people as she can; with her heart. She has a beautiful heart.”
