Who Will Heal The Healers?

Pamela Wible On What's Missing From Healthcare Reform

As a girl Pamela Wible had recurring dreams in which she’d find dying people, bandage them, take them home, and nurse them back to health. She knew even then that she wanted to be a doctor. Wible became a family physician, believing it would allow her to serve not just her patients but also their families and communities. At the age of thirty-six, however, after working in six different clinics in ten years, Wible was ready to quit. Rushing through thirty office visits a day, she wasn’t meeting her patients’ needs — or her own — and she grew so depressed she stopped working.

Wible’s depression lasted six weeks before she was, as she recalls it, “jolted out of bed” with a vision of how healthcare could be. Within weeks she led a series of healthcare forums in Eugene, Oregon, where she lives. The ideas gathered at the forums became her business plan, and within months she’d launched a clinic designed entirely by her community.

At her two-room office in the basement of a wellness center, Wible is not just the doctor but also the receptionist, the nurse, the bookkeeper, the insurance biller, and the janitor. Yet she works only part time, sees patients for up to an hour apiece in a living-room-like setting, and makes house calls. She is relaxed and quick to laugh. She even finds time to travel the country and encourage other doctors to leave what she calls “assembly line medicine” and to create clinics in collaboration with their communities.

Wible’s not alone in her dissatisfaction. A recent Physicians’ Foundation study of twelve thousand U.S. primary-care physicians found that 78 percent of them believed medicine was either “less rewarding” or “no longer rewarding,” and 76 percent said they were either “overextended and overworked” or “at full capacity.” Another study shows that physicians can experience “empathy burnout” after seeing just ten patients in a day; most doctors see three times that many.

Wible was born in Philadelphia, Pennsylvania, to a lesbian psychiatrist and a Jewish medical examiner. Her parents’ marriage didn’t last, and she spent part of her childhood in Philadelphia with her father and part with her mother and her mother’s partner in rural Texas. She says living with two lesbians “on the buckle of the Bible Belt” forced her to develop a sense of humor. With her father Wible spent much of her time in the morgue. She also accompanied him to his part-time jobs at a jail and a methadone clinic, where he introduced her as a “doctor-in-training.”

Wible attended Wellesley, a liberal-arts college for women, and went on to medical school at the University of Texas at Galveston, where she protested the vivisection of dogs, believing that the same lessons could be taught in humane ways. She started petitions, but few students signed, because, they told her, they feared they would be “blacklisted.” She was eventually granted exemption from the vivisection labs. Wible describes this as the first of many times in her life that she would stand up to authorities, express her beliefs, and persevere.

Wible is as optimistic about changing the face of healthcare in the United States as she is angry about the current system, calling it “predatory” and “submerged in a putrid stew of greed, bureaucracy, and unethical leadership.” She’s currently writing a book with the working title Doctoring for Democracy.

I met Wible two years ago, when I was looking for a new family physician. At the end of my first hour-long appointment, she pointed out that the plastic sippy cup I’d brought for my toddler contained harmful chemicals. I was both shocked and thrilled at the level of attention and care. During my husband’s first appointment — for a cold he couldn’t shake — Wible took stock of his diet and recommended more fruits and vegetables, especially leafy greens like kale. He was skeptical at first but now makes kale smoothies most mornings and hasn’t been sick in more than a year.

Wible told me how, after Hurricane Katrina in 2005, she flew to Houston, Texas, of her own accord, despite official warnings that physicians should not “self-deploy.” Before she went, she had been working on a presentation about community-designed ideal medical practices, and the irony of the situation had hit her: “Here I was writing about how to transform our healthcare system. Meanwhile I was waiting for official instructions to tell me the right thing to do. Don’t we all know the right thing to do?”

Entering the Astrodome, Wible and a colleague were greeted by a tired young physician who asked them to take charge of the medical clinic. Wible didn’t feel equipped but worked the night shift for a week. Her resting heart rate increased fifteen beats per minute and didn’t return to normal for weeks afterward. She believes this is how most doctors are living: in a constant state of stress. A month after she returned to Eugene, Wible received official word that she was free to volunteer.

Passaro: Before you started your own practice, you worked at what you call “assembly-line” clinics. What was that like?

Wible: I didn’t have time to connect with my patients. They had to fight through the phone system to get an appointment, and when they finally got in to see me three weeks later, they had maybe fifteen minutes to get all their questions answered. Sometimes we would rush through one or two main concerns, but there were still five more we didn’t have time to discuss. They would speak fast to get all their issues on the table. I didn’t feel that I could ask questions about patients’ lives unless they were the last patient of the day and I stayed late, or maybe if they came around noon and I was willing to skip lunch. I rarely took bathroom breaks, just so I could spend more time with them. That was the price I paid to develop real relationships with my patients.

I was extremely disheartened, because I felt I was destined to be a doctor, but I couldn’t sustain my enthusiasm on the assembly line; it was such a dehumanizing experience. I was tired of interrupting crying people to say, “Sorry, we’re out of time.” I wanted to be kind to patients, even if it meant a huge cut in my salary. Many doctors feel this way. I’ve met several female physicians who are ready to quit medicine and find other work.

Passaro: Does the “assembly line” affect women more acutely than men?

Wible: I think so. Nothing against men: it’s just that Western medicine was designed by men, and men are more willing to turn healthcare into a competitive sport of who can see the most patients per day. But we all had to play that game; the rules were drilled into us to the point that, if I had a no-show, I’d worry, Oh, no, I’m down one. One employer gave us monthly color-coded charts that compared us to our peers in terms of speed and number of patients seen. They spent a lot of money on special software for these slick report cards. It took me hours to figure out how to read them. Ultimately the message was “You’re a shitty doctor.” That’s the kind of intimidation used to control physicians.

The pressure to see as many patients as possible is driven by high overhead. In one job my overhead was 74 percent. So if I rushed thirty patients through in a day, twenty-two of them were to pay the overhead. There was no time to slow down, no time to think, no time to care.

Passaro: It must have been dispiriting to have so little time for your patients.

Wible: I was physically, mentally, and emotionally exhausted. When I was out in the world at a grocery store, for example, I sometimes saw someone I thought might be a patient, but I wasn’t sure, because I hadn’t had time to get to know them during the office visit. So I used to hide behind my grocery cart to avoid them. I felt bad that I couldn’t even remember my patients’ names.

Passaro: How is it different for you today?

Wible: Now my practice is relationship based. I’m never thinking, How many patients did I see today? Just the other day I was in the grocery store, and there was one of my patients in front of me in line and another behind me. Plus the cashier was a patient too! We were all so happy to see each other. We embraced, and I snooped in their carts to see what they were buying. That’s what it’s like when you’re a community doctor. I ride my bike to work, and people wave to me. I feel as if I’m in a Norman Rockwell painting from the 1950s. [Laughs.]

Practicing medicine looks so complicated. It doesn’t have to be. Providing care is actually simple.

Passaro: What do you offer now in your practice that you didn’t before?

Wible: The most important therapy I deliver is a human relationship. I’m not doing anything controversial or woo-woo. I never thought of myself as practicing alternative medicine until a colleague pointed out that spending time with patients is now “alternative.” We live in a world with all this electronic communication, but is anyone sitting down for an hour and making eye contact and talking, relating on a spiritual, emotional, and physical level? When patients come into this office, it’s a refuge from the frenetic outside world. They tell me things they might not have told anyone else in their lives — not even their spouse. They open up to me.

Another thing I do that I didn’t have time for before is talk about medicinal foods and dietary prevention. You can wait to get bad news, or you can actually heal yourself every day by eating the right foods — which, by the way, don’t cause side effects like liver failure or five-hour erections. [Laughs.]

In medical school we received only two hours of nutrition education. I pretty much had to discover, through my own research in the medical library, how diet can heal or prevent diabetes, hypertension, and high cholesterol. A plant-based diet is essential to human health. It’s disgraceful that many people in this country don’t have access to fresh fruits and vegetables, only junk at convenience stores. Some poor neighborhoods don’t even have grocery stores. We do this to people, and then we’re angry when they develop diabetes. When I cared for Katrina refugees, everyone over thirty was on insulin.

Passaro: Can you offer an example of how you approach certain health problems now versus how you did when you were in the factory system?

Wible: One little girl came into my office because she was urinating frequently at night. This had started when she’d moved in with her dad and stepmom. In a standard clinic, if a patient has urinary frequency, you automatically start with a urinalysis. But because I could take time to talk with her, I realized that her anxiety about living with a new mother was causing her symptoms. I told her to tell the adults when she wasn’t comfortable about something. I allowed her to access her feelings and speak her truth. Days later her symptoms disappeared. I didn’t even have to touch her.

I’ve recently begun to teach my patients how to examine their partners’ bodies. A lot of women are afraid to examine their own breasts, so I instruct them and their partners on how to do it. I’ve taught them how to examine ovaries and how to screen for melanoma, which is most likely to start on the back. It’s hard to examine your own back, so it’s often the partner who discovers a suspicious mole.

Passaro: What advice do you have for patients who don’t have the luxury of hour-long doctor visits? How can they foster better communication with their doctors?

Wible: They should probably follow the advice of an elderly woman I know. She went to her doctor for one of those fast visits. When the doctor rushed in, she asked, “How much time do we have?” He said ten minutes. She said, “Well, I want you to take off your coat and hang it up, and I want you to lean forward and look me in the eye and really listen to what I’m saying before you answer my questions.” You have to get physicians out of their robotic, technical mode and into a state of being fully present, which I think most doctors are still capable of attaining.

Passaro: Why has medicine changed so much since the days of house calls and family doctors?

Wible: In the last fifty years all these third parties have inserted themselves into the sacred patient-physician relationship: insurance companies, pharmaceutical companies, government regulators, technology — “advancements” that we don’t want and that might not even be good for us. Many of the tests we can order now only make people more anxious than they were before. How is that helpful? We get a lot of information that we don’t need, but we’re not even gathering information about lifestyle and nutrition. We don’t ask basic questions like “How’s your life going?”

Passaro: How did the medical profession get away from individual practice?

Wible: I trace the industrialization of medicine back to two programs: employer-sponsored healthcare, which started just after World War ii; and Medicare, which started in 1965. Before those programs, doctor-patient relationships were more transparent and more personal.

Then major employers started going with complex insurance programs, such as health-maintenance organizations [hmos] and preferred-provider organizations [ppos]. The physician was put in a position of either signing on to work in a big group or else losing any patients who worked for, say, Ford Motor Company. The preferred-provider system was also sold to doctors with a promise of more money for less work, because of less overhead. Doctors wouldn’t have to worry about staff and business and paperwork. There were slick brochures and free trips to Hawaii when you signed up. You can see how doctors got seduced.

There’s an element of prestige when one belongs to a big group and can say, “I’m a preferred provider.” We doctors basically want the American dream like everyone else. After all the effort and expense of our education, we generally feel we deserve some comfort in life. So when these third parties promised us the world, it was pretty easy for us to fall for it. But then some administrator on the fourth floor turned up the speed on the assembly line, and before we knew it, we were churning patients through and skipping bathroom breaks.

And with the big providers came an increasing complexity that, it seems to me, was created by bureaucrats to justify their own existence. At a certain point you had more complexity and headache than service being rendered.

Now, instead of walking or biking to see your neighborhood doctor, you have to drive across town to a big clinic, park in a parking garage, and sit in a cafeteria-sized waiting room. This isn’t what people want. People want home visits. They want it to be the way it used to be. And there’s no reason why we can’t have that now.

Passaro: Are there not any advantages to group practices?

Wible: There is less need for the physician to deal with business and administrative tasks. Plus co-workers become sort of a family. You can easily consult with colleagues: if I saw a rash on a patient and wasn’t sure what it was, I could talk to the dermatologist down the hall. You get retirement benefits and group health insurance. And when I was one of twenty family-practice doctors in a group, I was on call only once every twenty days. Of course, on that day I was slammed because I was responsible for all twenty doctors’ patients. But for the other nineteen days I didn’t have to think about it.

Passaro: What inspired the design of your current practice?

Wible: My original vision was that citizens would come together and articulate what they desired in healthcare. I wanted to facilitate the design of a dream clinic. I woke up with this idea on December 7, 2004, and held my first community forum on January 20, 2005. About thirty people showed up. I did eight community forums in all and got about a hundred pages of written testimony, which became my business plan. Eugene is a pretty creative town, and those pages were overflowing with wonderful ideas. We were open for business by April 1, just a few months later.

Passaro: What are some of the changes people wanted most?

Wible: People said that they wanted to be heard and to be treated as a person, not as a commodity. Simplification was another theme: people wanted to eliminate the medical assistant who weighs and measures and takes notes that the physician doesn’t read, anyway. Many people wanted to make sure that nobody would be turned away for lack of money. They wanted their doctor to be willing to barter, which I am.

Passaro: What are some items you’ve accepted in trade from patients?

Wible: Dog care, carpentry, gardening, massages, cleaning services. Local artisans have donated the use of a kiln and glass-fusion classes. I donate many of these traded items to other patients in need. Then there’s the delicious homemade bread and homegrown produce. I will work for food.

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