The Clinic of Your Dreams
A Burned-out M.D. turns to her community she asked what they wanted in a health-care clinic, then built it — and was transformed. Here’s what the future of medicine could look like.
When I was little I used to press my face against the bathroom mirror, stare into my eyes, and ask myself, “Why am I here?” I’d repeat those words over and over again until my eyes got so wide that I felt as if I could jump inside them.
When I got older I sought professional help. My cadre of counselors included astrologers, palm and Tarot card readers, and a pet psychic who facilitated communication with my dead dog. Obsessed, I tried soul-seeking Southern gospel church services, Native American sweat-lodge ceremonies, tribal African grief rituals, and even four years of medical school.
Now I am a family physician, the expert with all the answers. What an illusion! Life is so mysterious and science often does not soothe me. I’m never certain I have the answers my patients truly seek. Still, I have managed to create a new type of medical practice where I can hold their hands and walk the path of an open-hearted doctor in a disheartened health-care system. To rediscover my calling, I had to dive deep into a place I could not see, into a time when my life was just an idea waiting to be born.
The Making of a Revolutionary
I was conceived by the unlikeliest pair — a lesbian psychiatrist and a philosophical pathologist — and gestated during the Summer of Love, race riots, and Vietnam War demonstrations. That summer, I also apprenticed in the emergency room with Mom, while Dad taught at the Women’s Medical College of Pennsylvania, the original training ground for women physicians in the United States. On my birthday, as Dr. Spock was taken in during a war protest, I was pulled out by C-section, and my dad polled his students for a name: they voted Pamela.
Raised in a morgue, I spent my childhood playing in the hospital halls. The word autopsy, derived from the Greek -autopsia, means “to see with one’s own eyes.” And I did. I saw blood, guts, and stainless steel — and I loved it all. My father made it fun. He even talked to the dead people in the coolers. So I did, too. From the morgue, we made our rounds to the city jail, methadone clinic, and the psychiatric hospital. Introduced as a doctor-in-training, I was set loose on inmates, heroin addicts, and schizophrenics while most girls my age were playing with Barbies.
After work, I examined the human remains stockpiled all over our house — brains, kidneys, miscarriages, gallstones. Dad was a real pack rat. I watched cartoons as a heart floated in a plastic tub atop the TV. But the babies intrigued me most. A row of wide-eyed Buddhas leaned toward me on the shelf. They stared straight through me and seemed to know something I didn’t. Who were they? And why were they trapped in jars instead of me? When Dad retired, he offered me his miscarriage collection. I was honored in a way, but I couldn’t see stuffing them into my carry-on bags and holding up the line at airport security while trying to explain myself. I kept one in my pocket — a six-week-old calcified embryo about the size of a pebble. When I hold that tiny person in my hand, my eyes tear, and I get a momentary glimpse of the big picture.
My parents warned me not to pursue medicine. They shared the sorrow, corruption, and escalating bureaucracy — and saw the future getting much worse. But I chose to follow my heart and became entangled in the same mess. I found the practice of doctoring was dumbed down to a numbers game with cookbook protocols and computerized flow sheets. My soul was more than irrelevant; it slowed down the production line and got me into trouble with administrators. After six jobs in ten years, I was tired of being a factory physician, pushing pills and tests I didn’t always believe in. I was tired of interrupting panicked patients to say, “Sorry, we’re out of time.” I was sick and tired of being mean to people and neglecting myself in the name of health care.
So I gave up my life’s calling — my once beloved profession. Then my dog died. I didn’t get out of bed for six weeks. Nothing mattered anymore. The greater tragedy: I wasn’t the only physician contemplating suicide. According to the American Foundation for Suicide Prevention, we lose a doctor every day. And the 2008 Physicians Foundation Survey reveals that half of all physicians want to quit three years after receiving their degrees.
Why Doctors Want Out
Why are doctors so desperate to escape? And why, according to a 2007 CBS/NYT poll, do 90 percent of Americans believe that our medical system should be “completely rebuilt” or that “fundamental changes” are required? How could it go so wrong? During my six weeks in bed, I found easy places to put the blame.
THE CULT OF MED SCHOOL: A colleague convinced me that graduating from medical school was like surviving a cult — the memorized minutiae we were never expected to retain; the isolation and sleep deprivation; and the ritual-like animal sacrifice. I protested the live dog labs, circulated petitions, and was the only one to graduate without killing animals. Nobody signed my petitions, for “fear of repercussions.” It’s not that med students enjoy torturing dogs or even accept the dogma, but where individualism is discouraged and critical thinking wanes, intimidation works wonders, and a herd mentality makes it all, somehow, normal. Fear-based education is not normal and certainly not healthy.
THE BIRTH OF FACTORY MEDICINE: After graduation my classmates and I were funneled into what seemed like an automotive assembly line. Then, one day in the hospital library, crouched between renal and urology texts, I discovered a secret section on . . . Toyota. Whoa! Surreal! I lost myself for hours in Toyota manufacturing protocols. I’m all for lean systems, but . . . umm . . . most patients need more than a new muffler. Sure, I could be as efficient as one local psychiatrist who zips through ten clients per hour, but then I’d rather work at Toyota than treat a schizophrenic in six minutes.
THE DIS-EASE OF PROFESSIONALISM: Given that we all pledge to “first, do no harm,” why do we make physicians the first victims? While patients are encouraged to tell all, doctors must remain detached, sterile, untainted by emotions. No “irrelevant” personal anecdotes. No off-the-cuff commentary. Physician self-disclosure is a no-no. Decades of practicing professional distance — emotional and spiritual disconnect — destroys from the inside out. Who really wants to be treated by someone whose heart has died?
THE LOSS OF AUTONOMY: I never understood why those sharply dressed, smiley people with clipboards used to follow me around the clinic and leave not-so-nice sticky notes on my door while I was doing all the work. Where did this managerial class suddenly come from? Or maybe it’s the red tape that turns a twenty-five-minute appointment into six pages of computerized chart notes, four pages of billing, and a game of 1-800 phone tag? Still, we slog through twenty-eight patients per day, even though an informal survey has revealed empathy burnout — complete emotional exhaustion — after the first ten patients. That means that at around eleven in the morning, docs tune out the chatter so that they can survive. But ignoring patients leads to defensive medicine, malpractice suits, and basically just another bad day at the office.
My own stupor culminated in a near-death experience. Just before dawn on Pearl Harbor Day 2004, a bomb exploded in my head. The force catapulted me out of my body and up into a tunnel.
I raced by shadowy figures, yet somehow floated in slow motion. Everything was blurry-gray, yet so perfectly clear. At the end, a brilliant light enveloped me, and a panoramic view of images flashed before my eyes. Masses of people were united in solidarity in churches, neighborhoods, and community centers all across America. Doctors stood hand in hand with patients and healed each other. The visceral feeling was so intense, so invincible, that it had a life of its own. I was called to birth the vision.
The Revolution Begins
I found myself asking, what if Americans were free to dream their wildest dreams for a new health-care system — a system without lobbyists, experts, or stakeholders; without government officials; without hidden agendas? What would such an ideal clinic look like? Sound like? Feel like? And what if a physician promised to bring those dreams to life? And what if that physician were me?
On January 20, 2005, I invited my entire community to a town-hall meeting and asked ordinary citizens to describe the medical clinic of their dreams. Each participant was handed a pink piece of paper that read: Create an ideal medical practice. The rest was blank.
This was more than a New Age vision quest; it was a science experiment in democracy. And a strong democracy requires a healthy, empowered populace. Life, liberty, and justice fail without health care for all. I believe in the greatest American dream: health care of, by, and for the people. As pens and pencils raced across pages overflowing with floor plans, diagrams and doodles, poetry and prose, I witnessed democracy in action. And I welcomed their wisdom and embraced their fantasies as I listened to their testimony.
A wispy woman wrote: An ideal clinic is a sanctuary, a safe place, a place of wisdom where we can learn to live harmlessly, listen with empathy, observe without judgment. It’s a place where a revolution starts, where we rediscover our priorities. In the back, a bearded man raised his hand. “Is it possible to find a doctor who’s happy?” I wasn’t sure, but the community mandate was clear: the doctor must be happy, have a big heart and a great love for people and service, and be someone whose presence itself is enough to cheer a patient. Others suggested a complimentary massage while waiting, a juice bar, intriguing magazines, and a pet cat who greets people at the door. But most essential, as one woman wrote, patients [should] leave feeling warm, nurtured, loved, and important.
When I invited my community to create their ideal clinic, I knew my dream was embedded in their dreams — and in the dreams of all Americans who came before us.
Holding their 100 pages of testimony in my hands, I had a glimpse of my tiny piece in a very big and beautiful picture. For the first time, my job description had been written by patients, not administrators. By embracing my community, I found my way home and recaptured my beloved profession.
We opened four years ago on April Fools’ Day, 2005. I relinquished the security of high-paying jobs with perks to pursue an unconventional path — to blaze a trail, maybe. Foolish? Some would say yes. But the fool — an ancient and universal archetype — disrupts cultural norms while speaking truth to power, even at the risk of ridicule. In the Tarot, the fool represents the beginning of a fearless journey of self-discovery.
My journey has led me to a wellness center tucked into a wooded residential neighborhood near my home. Inside, clients can enjoy yoga; massage; a wheelchair-accessible, solar-heated saltwater pool; and a soak in the hot tub before their appointments. They relax on plush overstuffed chairs in a cozy office and look forward to warm exams as they’re wrapped in fun, flannel gowns. Antioxidant-rich chocolates and smiley-face balloons surprise the unsuspecting on random patient-appreciation days. “Wow! It’s like going to Grandma’s!” one woman said. I inspire healthy lifestyles by bicycling to the office and rewarding folks who walk, bicycle, or ride public transit to their visit with a selection of local handmade soaps, lotions, and other cool prizes.
Office hours are Monday, Wednesday, and Friday afternoons and evenings, although everyone has 24/7 access by phone and email, with same-day and weekend visits if needed. I handle administrative tasks at my home business office so there’s no beeping or buzzing of phones or faxes to disrupt medical visits. Leisurely appointments begin on time — guaranteed — or patients get a gift as compensation for their wait.
The clinic charges standard fees, accepts most insurance plans, and offers a 40 percent discount for payment at time of service. In exchange for medical care, cash-strapped clients donate items to our community gift basket that are then recycled to other patients as rewards for healthy behavior.
Recently, an artisan donated a workshop on glass-fusing at her kiln in trade for an asthma follow-up, and another patient traded a supply of beautiful journals, bookmarks, note cards, and stickers for a mole removal. Nobody is ever turned away for lack of money.
How is all of this possible? By slashing overhead, I can work less and earn more because my patients and I no longer subsidize fancy buildings with cafeteria-style waiting rooms and huge parking garages halfway across town. With no staff, we don’t have administrators ministering to us or managers managing us. Inexpensive technology streamlines scheduling, billing, and record keeping. Veronica, my two-dollar laminated “secretary,” hangs from the door, smiles, and announces, “The doctor’s in.” It’s so simple.
For the first time, I can see my patients unimpeded. I sit in my wicker chair and ask, “Why are you here?” Every day I get the same responses: “Depression. Migraines. That pressure behind my eyes . . .”
And so my ritual continues, discovering the truth for my patients. In that sacred moment when our eyes lock, I lean forward and peer deeper, pry further, and listen longer.
Pamela L. Wible, M.D., pioneered the community-designed ideal medical practice. She writes and speaks nationally on health-care reform. To learn more go to idealmedicalpractice.org.