119 Dave Radel on Rural Medicine

- 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.