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I just want to share with you some of the joys I have had
in my career. And a lot of those were spent
in rural family medicine. So before I get started,
it's always nice to know the biases of your speakers,
you know, making sure I'm not associated with any
rural medicine head hunters organization, or anything like
that. My bias is education.
And also, you should know that I am somewhat of a granola
tree-hugger. ( light laughter )
So that's my bias. I love to see how nature
does it, and so we don't fray too far from that.
I also love being in nature. That's a lot of what pulled me
to rural medicine at the beginning of my career.
So, let's talk about the versatility.
I'm going to talk about two loves of mine.
Actually, I'm not going to talk much about integrative medicine,
but about the versatility of family medicine, about having
an education in all aspects of human living and disease,
and creating a foundation of understanding the multicomplex
process of what it means to heal, not only for the person,
but also the community. Because when you go into rural
medicine, you're not only a physician for a person,
you're also a physician for a community.
And that's a lot of fun. You're automatically placed
at a place of importance in that community.
You're actually seen as a community "healer," if you will.
But, let's look at a lot of different family docs.
You can pretty much do anything in the world that you want to do
after getting a good foundational training
in family medicine. David Satcher was the
Surgeon General, a family doc. Nancy Dickey, the fist woman
AMA president, was a family doc. Sir Arthur Conan Doyle,
the creator of Sherlock Holmes was able to create those
good mysteries because of the understanding of his
generalist background. Our deans here
in our medical school. Our Dean Schocholac,
Dean McBride, Dean Hawk, Dean Krause--
Rural Medicine, Global Health, Academics,
Preventative Cardiology. Whatever you want to do,
this is a great foundation. But I would argue that the best
education I got were those first five years in private practice
in a little town in rural Idaho. And we're going to explore that
a little bit together. Part of the challenge we've had
in our healthcare system is that we've gotten so darn good
at technology, we've forgotten about the aspects of what it
means to really understand how a community
or an individual heals. And going out in rural medicine
is really a great opportunity to explore those foundations.
So, we want to do more than this, right?
You go through all these years of training.
Four years of high school, four years of college,
four years of medical school, four years of internship
and residency, "Here take an aspirin."
You know, when I got out of my training, I wanted
to cure the world, you know. I wanted to do stuff,
I loved to fix stuff. I loved to fix it if you can.
But once you get out into private practice, you realize
that you fix it when you can, but most things that we see
in medicine now can't be fixed. And they have a deeper
underlying etiology that requires understanding of
the bio-psycho-social-spiritual influences of that individual.
So, this is a famous TIME magazine article
on "The Country Doctor," of a doctor up in rural Colorado.
I thought I'd just start with some photos of some
country rural docs. I bet you would still see this
up in Northern Wisconsin. Here is a family doc.
I'm not sure why he had to pack heat, but he did.
( laughter ) Maybe he had some unruly
patients, I don't know. But the art of being a rural
doc, is sometimes you don't have access to the technology.
Sometimes you don't have access to the MRI or the CT scan.
We didn't. So you really have to use
the art of medicine to really understand what may influence
the body's ability to heal. If you don't have that
technology to rely on, you have to rely on you heart,
or your humanism. And sometimes just sitting down
with the patient and using that art
to help facilitate their belief in their ability to heal is
one of the most important tools. Sir William Osler,
one of the fathers of Medicine said, "It is much more important
to know what sort of patient has a disease,
than what sort of disease a patient has."
And in rural medicine, this gets driven into you,
because you can't help but seeing how that community
influences their health. And that was the biggest thing
I learned in rural medicine is that you become
part of a community. You understand what happened
in that person's life before they come to you
with reccurring headaches. And being part of that community
gives you insight that they're much more than a disease,
that they have a story behind their disease.
Every disease has a story. Being a part of a community
gives you insight into that story, so you're better able
to help understand how they can heal.
Now, this is a great place to learn medicine,
a tertiary care center. But how much medicine
or healthcare is provided in our tertiary care hospital?
Out of 1,000 patients, one percent, or 1 out of 1,000
is taken care of in the places we do
most of our training. Most of healthcare is delivered
outside of the ivory tower tertiary care healthcare center.
Most healthcare is provided out in communities.
And this is just a reminder of the importance of that.
Now, this is a Michelin Man at a very young age.
( laughter ) But the joy of being
a family doc is that we get the opportunity to practice
womb-to-tomb medicine. We can deliver babies.
And we can sit and hold the hand of a dying friend.
Everything from delivery, to newborn care, to pediatrics,
to adolescence, to geriatrics. People often ask me,
"how can you do all that?" You know, with good
common sense, good support and good training, you can
take care of almost 93% of what comes through your door
in rural medicine. You learn what you can handle,
and you learn what you can't. When you can't,
you ask for help. So, the family physician
provides continuity of care, provides comprehensive care
regardless of age, sex, or diagnosis.
We have no biases. We'll take anybody
who comes through the door. You share trust, respect,
and friendship with patients. What a joy to be in a profession
where your friends pay you to take care of them.
You know? You can make a living
taking care of your friends. That's worth a lot of money,
you know, that's payment often in itself.
We manage an individual's total health.
We understand multi-influential aspects of health,
the bio-psycho-social-spiritual uniqueness of the individual
that helps us best help them. And it is founded
in relationship-centered care. That relationship gives us
insight into what that person may need to be healthy.
So, after I finished training, I went to Baylor
for my undergrad. I went to Greeley, Colorado
for my residency training. And that was a residency program
that really focused on training someone to go out
into rural medicine. And so, we got to do a lot
of C-sections, and put in chest tubes
and manage acute MIs. And so, after my training,
I said, "Okay let's go out and fix the world."
And my wife and I, we opened up the atlas and we said
where do we want to live? And this is the nice thing
about this type of training, is you can pretty much pick
anywhere on this planet and go and be of service.
We picked this place, Driggs, Idaho,
that is in this box. Driggs, Idaho,
is on that southwest corner of Yellowstone National Park.
This is where we lived. There is a little town here
called Victor. Over here is Jackson, Wyoming.
Anybody ever been to Jackson, Wyoming?
Good skiing and fishing. Anybody ever been
to Driggs, Idaho? One!
Why were you there? Oh, Pocatello,
right down here. Very good.
So you know this place. It's grown a lot
since I left there. But when I was there,
we had a little 14-bed hospital. I was one of two physicians.
We had a nurse practitioner and a physician's assistant.
And we had the best nursing staff in the world.
And we provided that womb-to-tomb medicine.
Now, when you're a well-trained rural doc, and
you go into a community that needs healthcare professionals,
you can really have a positive influence on the health
of that community. Let's look at this
a little bit more. This was published in JAMA.
And it shows that a new doctor to a healthcare
community in need provides tremendous benefit.
But once that place gets saturated with care,
a new doctor doesn't actually provide benefit.
But once there are so many people providing health,
that healthcare system can actually produce harm.
Now, we saw this in Jackson Hole, Wyoming,
and Driggs, Idaho. Jackson Hole, Wyoming, that's
a nice place to live, right? Great skiing, you've got
all the outdoor stuff. Worry if there is more
physicians than hospital beds in a town.
This town had more physicians than hospital beds.
They had a saturation of orthopedic surgeons.
And there was a big fight for ACL repairs in that town.
( light laughter ) People would come off
the mountains skiing, and they would tear their ACL,
and boy you'd see all the fangs coming out.
And there was probably a lot of ACLs repaired
that probably didn't need to get repaired.
And there was so much access to healthcare, the technology,
that that technology was probably overused and
actually created more harm than good.
So we have an opportunity to really go into areas
that can really enhance healthcare delivery
and really serve the benefits of that community.
But once we get to that saturation point,
our services can actually do more harm.
Sounds a little silly doesn't it?
But it's true. All right, where
do you want to live? This is where I wanted to live.
It was a pretty cool place. We had our little town,
Driggs, Idaho, right here. We had the Teton River,
great trout fishing. Although the fish
were too smart for me. They wouldn't bite my fly.
We had Grand Targhee Ski Resort, which was up here.
Our house was right here in the foothills.
And I had a snow machine that we would take up here.
And we would play up here with this view.
And that was the most gorgeous place on earth.
Now, these are the Teton Mountains.
And this is the road up to our ski resort.
And the nice thing about being a small town doc
with a ski resort, is that you get to be the medical director
for that ski resort. ( laughter )
And the medical director got a free ski pass.
And that medical director could bring a buddy
for a buddy pass. And all we had to do
was carry a radio. Sometimes, I get called down to
reduce the dislocated shoulder or deal with an ACL tear.
But the majority of time, it was great powder skiing.
And I had Tuesdays off. And I would usually
take Tuesdays off to go skiing in the wintertime.
But then again, we had to work a lot of weekends.
You know, being one of two doctors in a rural town,
is you're on call every other night.
But we had an excellent physician's assistant
and a nurse practitioner who were in that call schedule.
So really, I only had to go in about every fourth night.
But we had good nurses, who also kind of triaged and
said, well, that earache can wait until the morning,
when the doctor is in clinic. So the community
takes care of you. They know if you burn out,
you're probably not going to stay.
So the community has a sense of taking care of their own.
This was our valley, Teton Valley.
And I'll bet it's grown a little bit since then.
And this was our little 14-bed hospital.
Now I'm going to tell you some pluses and minuses.
You should always have polarity in anything you talk about.
But there were a lot of pluses, and there were some minuses
to rural practice. One of the pluses was freedom.
Freedom to do a lot of cool stuff that
you were trained well to do. We did C-sections.
I did ultrasounds. We did post-partum tubals.
We had a surgeon that came over from Jackson to do
our more complicated surgery. So we had an opportunity to
do some of these procedures, and we did them well.
We had about an 8% C-Section rate.
Eight percent, considering the national C-Section rate
is now about 28%. So I delivered about 50 babies
a year. So that was about four
or five C-Sections a year. Not a lot.
My partner also did them, so we did just enough to
probably keep our skills going. I don't do them anymore, because
I have all my colleagues here who do a lot more than I do.
We provided a service there, to provide these procedures
that were really beneficial for that community.
We also had a lot of excitement. And the polarity of that
is stress. You never knew what was going
to come through those ER doors. And you're the only one,
as well as your team. So the excitement was that--
This was a patient of mine. Let me tell you his story.
He was a good guy, but he had bipolar depression;
he had alcoholism. He had been dry
for a number of years. I delivered two of his kids.
I did his vasectomy. And one day, his wife had
had enough, because he had such a hard time maintaining
a quality relationship. And he started drinking again.
His wife left him. And he got a gun and went to his
wife's house and he sat outside. More or less, I think he
was meaning to commit suicide through the cops.
He had a gun in his car. He was sitting outside
his wife's house. He pointed the gun
out the window, or he got out of his car
and he pointed the gun, and he got shot by our cops.
He came into our emergency room. Let's say his name is Bob.
He looks up, "Dr. Rakel." "Bob."
This is continuity of care. ( laughter )
"Bob, I need to put a chest tube in you
and I need to intubate you." So we did.
And Bob survived. I'm not sure
his marriage survived. But he may not still be
in our hometown. But that was an example
of continuity of care. A little bit of excitement.
I was able to talk to Bob and his family because I knew him.
This was a guy who came in with chest pain.
He came in what that fist to the chest.
He was having an acute anterior MI.
You know what we call these? That's right.
Tombstone S-T elevation, or widow S-T elevation.
Unfortunately, that was the case here.
But whenever you see this S-T elevation
over the V-2 and V-3, that's right over the anterior
aspect of the heart. The reason that's so dangerous
is the AV Node is right over that part of the heart.
And if you lose perfusion to the AV Node,
you lose electrical activity to the heart.
So this is the most fatal type of MI you can have.
If you want a heart attack, where do you want it?
You want it inferiorly. If you're going to have
a heart attack, that's usually the dominant artery
that goes to the base of the heart.
There's not a lot of electrical stuff down there,
but you lose the pump. So when you have an inferior MI,
you need to give fluids. You need to give a liter
of fluids, because they lose their cardiac output.
But that usually doesn't kill you.
These kill you. He had re-perfusion arrhythmias,
because we gave him the thrombolitics and the Heparin.
And then the blood starts to re-perfuse the myocardium.
It can trigger an arrhythmia. We shocked him out of it.
We got him on the helicopter. He made it to Idaho Falls.
And he died three days later of an aneurysm
because the MI weakened his anterior wall so much
it blew out. He had two kids.
He was 43 or 45. So, I was able to deal with
his wife, who obviously went into some depression afterwards.
I knew why. I got this off the Internet.
I thought it was funny. What's the diagnosis here?
( laughs ) Something to do
with the cranial nerves! Or some sort
of viral exanthum, right? Let's look at his diagnosis.
( laughter ) I'm sorry to gross you out.
You see a lot of this stuff in rural medicine.
One of my most scary stories-- I'll go back so you
don't have to look at that. ( laughter )
One of my scariest stories in little Driggs, Idaho,
was a boy a little older than him who came in
and there was no history. His mom said she went into
his room and found him sloughing at the mouth,
coughing. He was beet red and was having
a hard time breathing. That's all the history I got.
Any time you see a kid sloughing at the mouth,
is beet red, you think of hydrocarbon poisoning.
You know, maybe he drank some sort of gasoline
or cleaning product. So I had a medical student
with me. And I said, "Go to their house
and get everything he could've ingested."
So the medical student runs over there and pretty much
cleans out their whole house. He comes back and we're going
through each of those. We'll call him Matt.
"Matt, did you take this?" He said, "No, no."
"Did you take this?" "No, no."
I was scared to death, because I thought he was going
to die on me, and I had no idea why.
None. And when you have a little
five-year-old who you think is going to die on you,
boy, that gets your heart rate. I went through.
And we're turning around, going through,
what could he have taken? And all of sudden in the back
we hear this-- ( makes burping
and vomiting sounds ) He threw up something
in the emesis basin. And it was a little toy horse.
I've never gone from such fear to such delight in my life.
He had fallen asleep with this in his mouth.
He had swallowed it and it got stuck in his esophagus.
I always think of foreign bodies first in kids.
And eventually, he got to the point where he vomited it out.
And boy, that was such a relief. I thought he was
going to die on me. All right.
So, one of the negative parts is isolation.
You're kind of isolated out there.
You don't have this tertiary care medical center
to support you. But then again, you realize
what you can do. You can do a lot with
common sense, good training, and humanism.
I think this is a positive and a negative.
Your friends are your patients. This is one of my buddies.
He had a bunch of wild mustangs that he trained.
And we'd ride his mustangs into Yellowstone Park and go
to Union Falls, which is this gorgeous falls.
He developed eosinophilic fasciitis.
Now in a small town, you understand why some of these
autoimmune diseases might come after a significant
social stressor. He was losing his farm.
It was interesting, during that time, he developed
this autoimmune allergic eosinophilic fasciitis
that went all through his body. He got better.
He's a good guy. They're all good.
This is a good lesson, also, the importance of hearing
someone's story. And it gave me a good lesson
on how not to label people. I got this phone call at 2:00am.
I was on call. We've got a headache in the ER.
You've got to come in and see it.
I get out, 2:00am. I drive into the hospital.
And there's Betty. There's Betty rocking
back and forth on the stretcher. My first analysis,
critical judgment of this human being was,
ah, it's a chronic painer. She just wants narcs.
But in a small town, you have really incentive to go
and listen to their story to understand what's going on,
because you don't want to have to get up three days later and
go to the emergency room again. But you also want
to serve this person's needs. I sat down with her and she
told me a story that would make your head spin
in regards to abuse. And each disease has a story.
Once you listen to that story, you understand, I'd have
worse headaches than you, after you hear that story.
After that night, I started to see her on a regular basis.
And that "chronic painer" that my judgment mind labeled her as,
became one of my best friends. We had a lot of fun together.
She probably still has headaches to this day.
But they were much less and she needed much fewer medications,
and she required fewer visits to the emergency room.
When I left Idaho, she gave me this little meditation bluebird.
And that's Betty. This is a medical student from
the University of Washington. He came and did a rotation
with me. And we had an outfitter
right there in Driggs, Idaho, that would train their guides
to take people fly fishing. And they had to train
their guides, so they used us to train.
We volunteered to go in the boat and have them tie our flies
and do all this stuff. So that was a perk
for the medical student. I can't remember
which river that was. Meaning and purpose.
Another fun thing about being involved in your patient's lives
is you get to understand what gives their lives meaning
and purpose. Gizmo.
That's his real name. I'm going to use his real name,
because he's gone on ahead. Gizmo.
His claim to fame was he dated Shirley Temple in the Army.
Gizmo had Stage 4 heart disease. Stage 4 is when your heart gets
such congestive heart failure, it just quivers.
I had to have him on about five or six medications to improve
his cardiac output so he could walk.
But he would still get short of breath going from
this end of the room to that end of the room.
But once a year, Gizmo would look forward
to being our town's St. Nick, our town's Santa Claus.
And we'd have a holiday parade. And I would sit there on the
side of the road with my kids. Gizmo would dress up
as good old St. Nick, with his donkey
and have a sack of toys over his shoulder.
He would walk from one end of our town
to the other end of our town, much longer than this.
Not much. ( laughter )
With a smile on his face, but no shortness of breath at all.
I started to think, boy, this event that he looked forward to
once a year, trumped my medication by far.
You start to appreciate the importance of the human
condition. And how, if we can bring that
out, the body can heal itself given the right opportunities.
We get a lot of rewards. Your patients
really appreciate you. And you really appreciate them.
That old saying if curing goes one way--
I love to cure if I can, us to them.
But healing goes both ways. When you get in that healing
relationship with your patients, you get just as energized
as they do. And they give you stuff.
And I still have this hanging in my office.
This is, I'll call her Barbara. Barb was one of my favorite
patients. She would come and see me.
But I got a lot more out of that visit than she did.
( laughter ) She just had
this healing presence. You know, you just felt good
being in her presence. She knew I was going to study
complementary and alternative medicine, so she gave me
this salve that she made from a weed in the woods that
she said would cure everything from rheumatism to sepsis.
And she also made me huckleberry jam.
And huckleberries, boy, in the mountains of Idaho,
people put where their huckleberry patch is
in their will, because they don't want anybody to know.
Just them and the bears, you know.
So when you got this as a gift, you savored it.
Am I right? Have you ever gotten
huckleberry? Oh, it's great.
It tastes so great. Now, another patient, similar
to her, who also had a very fascinating hobby.
She was an artist. And she would paint various
things and go across Idaho and sell them
at arts and crafts fairs. And when I left Idaho,
she gave both me and my wife a piece of her art.
And I was going to show you that.
It's quite unique. But this woman
was about 82 years old. This is what she sold
at her arts and crafts fairs. ( laughter )
It has no meaning whatsoever! But that 82-year-old woman would
go around and make a killing with the biggest smile
on her face. When you look at what really
makes people happy, you know, that was probably her best
medicine, was going across this state of ours and selling
this at arts and crafts fairs. So let's look at the greatest
satisfaction of rural medicine. Relationship-centered care.
Having your friends as your patients is a joy.
Clinical autonomy. You get a sense of control.
People come to you for everything.
And you're the first person that they see, so you have
all these diagnostic dilemmas, therapeutic challenges.
Here, if I had to pick a practice that I was
most happy with, I wouldn't practice here in Madison.
I would go back there in an instant.
I like being here, because I like to teach.
But if I had to practice somewhere, I'd go back
to rural medicine, because I could explore our craft.
Here, you know, a patient comes in.
You know, you don't need to deal with that, I go to
my diabetes doctor for that. That's me.
I'm your diabetes doctor! What are you going to that one
over there for?! It's almost gotten to a point
where, oh, I've got a specialist for the fifth toe
on my left foot. ( laughter )
Oh, thank God. Our healthcare system
has gotten so specialized that we're starting to know
more and more about less and less.
And when we do that, we start to see the finite
and lose the larger whole. That's the beauty
of rural medicine. You can't help
but see the larger whole. Whoops, did I go over
all the other ones? Providing care to everybody.
Everybody who needs care, you're there for them.
And life in small communities. I like that,
because they adopt you. Least satisfied.
Access to urban amenities. I like this one.
My wife likes to shop at malls. And we were able to pay off
our debt quickly. ( laughter )
It was 70 miles to the closest mall.
Available time away from medical practice.
This is a challenge. You know, people knew
where you lived. You'd get a knock on the door,
"Doc, he's just not breathing right, could
you take a look at junior?" "Yeah, I will."
But you'd have to leave town for a break.
We'd go to Hideout Falls, get a room at a hotel with a pool
in February for our vacation, for our time away.
Because that was nice, no one knew you.
I had a hard time going to our liquor store
to buy a six-pack of beer, because you know, "Dr. Rakel's
boozing it up. Isn't he delivering your baby?"
( laughter ) I had to go, "Would
you go buy me some beer?" ( laughter )
So that's a little bit of a challenge as well.
Let's look and see the challenges
of our healthcare system. I want to save some time
at the end for questions. But we've got a really
dysfunctional healthcare system in America.
We've gotten really good at treating disease, but we
haven't really done a good job at facilitating health.
We're trying to take what we're good at,
acute, catastrophic care. If you have an acute illness
that needs immediate help by the experts in the world,
this is the place for you. But we've tried to take
that success and push it into primary care
where there's disease oriented-- There's this epidemic
of chronic disease care, that we're trying to use
the same tools for acute and chronic care
to treat the chronic disease, it doesn't work.
So we have the most expensive healthcare system
on this planet, $2 trillion. Number two is Switzerland.
They're 47% cheaper. When you look at
our quality that we provide, we're number 12.
We're number 12, rated for all the industrialized countries.
We're not really getting our money's worth.
Why is that? I would argue that we have
this XYZ model. The X is we have a healthcare
system where you come in. I give you a diagnosis X.
That leads to a treatment Y that I get reimbursed Z.
An XYZ model. Diagnosis, disease focused,
treatment of the disease, reimbursement.
The disease gets reimbursed. That's what gets honored
by our economic system, is the disease.
That leads to fragmentation of the human condition.
Hypertension, obesity. If you're a good primary care
generalist family doc, rural doc,
you're going to realize that all these diseases
have something in common. That if we just treat one
without the whole underlying story, we're really going to
not serve the patient well, and we're going to fragment
their care. So this might lead to certain
drugs SSRI for the depression, PPI for the GERD,
and that's what gets rewarded. That's how we get paid,
is through this process. What does
this healthcare system do? It fragments
the human condition. It breaks the human body
into segments. And pretty soon, we're starting
to see the person as diabetic, or fatigued, or depressed,
instead of Betty, John and Joe. We start to label them
as a disease, instead of understanding what Joe, Betty
and John need to be healthy. Forty percent of what
will reduce mortality the most in this country
is human behavior. That has the biggest reduction
on mortality. If everybody has access
to our technology, that reduces mortality by 10%.
Human behavior changes through relationship-centered care.
So this is sometimes how I feel in our current model.
I'm asked to see more and more patients,
with fewer amounts of time. And if I have less time with
someone, what am I going to do that's accepted by my culture?
Take this medicine. Or, let's do an MRI.
I can be with a patient for 20 minutes
and day dream the whole time. They're telling me about
the chaos in their life. I can not listen
to a word they say. But at the end if I say, okay,
let's do an MRI and put you on this medicine, they're
going to see that as worthy. Because that's what's accepted
by our medical culture. When you're out in rural
medicine, you realize how dysfunctional that is.
And you start to feel like this guy.
You know, you start to realize that this isn't really
helping people. You know, they don't need
my drugs. They need my humanism.
A lot of times, they need both. They need my drugs
and they need my humanism. Or they need my manual therapy
and they need my humanism. Sometimes,
they need the MRI, too. So what we're trying to do
is create a healthcare model, not a disease care model.
The healthcare team is going to be different
than the disease care team. A disease care team, I'd have
surgeon, a dialysis tech, an internist.
The healthcare team might have a nutritionist, an exercise
physiologist, a health psychologist,
a primary care doc. That team is going to be
much different than the disease-oriented team.
Both are important. I like doing both.
I like to fix it when I can. I like to heal it when I can.
So, if you can be a healing fixer,
that's what rural medicine is all about.
So if we create this health focused care that is based on
relationship that gives us insight on what the patient
really needs, we provide access, we address all these areas of
need, the most expensive interventions will go away.
Now if we can do that, we show cost savings.
But unfortunately, in our current model,
healing doesn't pay. The disease pays.
So it's really hard to change that model, but we're trying.
We're trying to do it. And primary care in the rural
setting does that by default. They can't do anything but that.
Primary care based on relationships,
human relationships, improves quality of care.
This is all in excellent evidence-based medicine.
Improves quality of care, reduces hospital admissions,
reduces expenditures on diagnostic testing,
lowers healthcare costs. Now if we look around town here,
what are some industries that are really growing
and building new buildings? Business school, that's good.
( laughter ) That's one.
Hospitals. Is there a Walgreen's
on every corner, or what? Yeah?
I like to look at communities and see what businesses
are flourishing. In our community, Walgreen's,
are we getting a little dependent on drugs?
Maybe so. New hospitals.
Dean. New hospital.
Disease is paying well. It pays well.
What if we had a healthcare system that first and foremost
focused on health? Salutogenesis,
the creation of health. Other than pathogenesis,
the creation of disease and suffering.
Most of your training is in pathogenesis.
Why does disease and suffering occur?
But what if we switched your training to salutogenesis?
How can we understand how to create health.
If we first start there, maybe we won't need
as many of these hospitals to treat disease.
They're all important. All right, I'm going to end
here with a few slides of the importance of the whole.
That if we just study the parts, if we just look at the liver,
or just the blood tests, we do an MRI
of the color red, can we understand what's wrong
with that whole person? I would argue no.
That you need someone to understand what's going on
beyond their physical, that also brings in their emotional
and their spiritual. The whole is much greater
than the sum of its parts. And when you put the parts
together, you get an impression of something much more
beautiful. Now this gives you
a feeling, right? That's what changes human
behavior, is your ability to touch the patients' feelings.
That's why rural medicine is so rewarding for me.
They invited me into their lives.
I could do nothing but touch their feelings, or have
insight into their emotions. That often, is what influenced
their body's ability to heal. So this is my Monet
painting right here. Guess how old this couple is.
Guess how old she is. Was, this was ten years ago,
or so. 80? 91?
Really? 91? ( laughter )
She was 85. I thought she looked
like she was 60. He was 78.
She was robbing the cradle. But you know, they weren't
health nuts, but they were some of the healthiest patients
I've ever met. They had each other.
They lived in a community that supported them
and gave them love. And they were vibrant in health
at this stage of the game. So when we understand
the foundations of healing as well as fixing,
there are some key rules. We develop rapport and trust.
We develop insight. We develop an understanding
of the patient's beliefs. We read their emotions.
We're a good listener. We're given two ears
and one mouth to be used in that proportion.
And we're there with intention and compassion.
So cure sometimes, heal often, support always.
And Rachel taught me this. Let's get into payment
a little bit. You're not going to make as much
money going into rural family medicine as you would
on what's that ROAD to success.
Radiology, Ophthalmology, Anesthesia and Dermatology.
You're not going to make as much money as those fields.
But I would argue that it will far make up for it
in what you receive emotionally. That when you're really able
to create a positive influence in a community
that needs you a lot, you get rewards beyond the monetary,
beyond the physical. And fixing
means that you're broken. If I'm going to fix you,
I'm assuming you're broken. And all of the human condition
isn't broke. Helping is a little bit better.
But helping suggests that, you know, what am I
going to get in return? I help you, what are you
going to do for me? But serving.
Serving means that I'm there to serve you.
Because when I serve you, I serve me.
Boy, that feels good. Service means that you're doing
good work that fills your heart, that hopefully will make
the world a little bit better when we leave this life.
So these are the good days. You come out of that room
and you know you made a connection up there
in rural Wyoming or rural Wisconsin,
and you know a shift occurred. You can hear the angels sing.
And you come in that room and you know that this is why
I went into this field. Those are the good days.
And it doesn't happen every day, but it happens
and it makes you remember. But there's polarity
in everything. There's also those days
when they're not so good, and your patients
make you feel like this. ( laughter )
But you know what? That happens.
But you go back the next day and you try to do it
a little bit better. You learn from those mistakes.
You don't beat yourself up. You go back the next day and you
try and do it a little better. They'll forgive you if they know
you're trying to do your best. So when I went into integrated
medicine fellowship, I said, well, all my patients
are starting to use these other things, like acupuncture
and homeopathy. I want to learn
more about those. And so I thought I could go
and learn. Okay, if the pharmaceutical
doesn't work, maybe it's one of these
other complementary therapies that's the magic bullet.
And I found that the magic bullet isn't there either.
But there's one thing that always works.
One thing always works in facilitating health and healing.
And that's compassion. Compassion comes
with a root word, to suffer. Two people suffering together
is where that compassion comes from.
Mother Teresa said, "If you have a sick or lonely person at home,
be there. Maybe just to hold a hand,
maybe just to give a smile, that is the greatest,
most beautiful work." All right, how many of you
feel like this donkey? ( laughter )
I know. I've been there.
I teeter over there quite often. The interesting is this donkey,
if we let our life get there, the first things to go with our
ability to facilitate healing are those most important things
that facilitate healing: compassion, ability to listen,
patience, empathy. The most important things
in healing are the first things to go
when our life gets a little out of balance.
I like to use my dog as my biofeedback device.
You know, I come home, I sit down and I'm tired.
My dog comes over and gives me a little therapy session.
That's good for me. Hopefully, it's good for my dog.
But if I come home and I'm not really balanced,
and I'm upset and I'm uptight.
I'm mad at my patient who won't do what I tell him to do.
I come home, I sit down and my dog goes
to the other end of the house. And I learned from that.
It's not my dog's fault. I'm sending out some bad vibes.
And I've got to look inward to understand, okay, Dave,
am I getting out of balance? Is this load
getting a little heavy? It's my job to use that time
or that learning moment to step back and say, yeah,
I need to spend more time with my kids.
Or I need to go for a run. And then that teeter totter
hopefully will come down and we'll lose some of the load.
Rumi said, "Let the beauty we love be what we do.
There are hundreds of ways to kneel and kiss the ground."
In rural medicine, there are a lot of different ways
to kneel and kiss the ground, a lot of rewards.
All right. I'm going to end with a quote
from a hero's mind, the oldest documented living human being.
She died at 122. She was from France.
And they asked, at 121, what do you attribute
your longevity to. She said three things.
She said good red wine, olive oil,
and a good sense of humor. And at 121, she was quoted
as saying, "I have only one wrinkle and I'm sitting on it."
( laughter ) So it's really how
we look at life, right? That's true in rural medicine.
It can be one of the most rewarding things you do.
And if I was going to go really learn about being a doctor,
really being a doctor, I would go right back
to rural medicine, because that's where I learned the most.