Residents in Salem, Oregon, are designing an ideal medical clinic. Slated to open by April 2013, the clinic may feature a dinosaur exam table, a cool gecko that greets patients at the front desk, and maybe even a pet goat. But the final design will be determined by citizens gathering at town hall meetings over the next few months.

Community-designed health care is nothing new. Citizens in Eugene, Oregon, pioneered the first community-designed ideal clinic back in 2005 (see video). Now, ideal clinics have opened all across America.

Dr. Lara Knudsen, a board-certified family physician, and her husband, Chris, are bringing ideal medical care to families in Salem at Happy Docs Neighbors’ Clinic. They imagine relaxed appointments; walking visits in a beautiful park; patients’ pictures on the walls; superhero gowns; weekend hours when the whole family comes in; an annual clinic picnic; and lots of laughter.

Now, Lara and Chris are turning their dream over to the community. They’re asking residents to design Salem’s ideal clinic. I spoke with them after their first town hall meeting to find out how things are going.

Pamela: “What are you specifically asking citizens to do?”

Lara:  “We want to know what patients would love to get out of seeing their doctor, what they imagine an ideal clinic would look, smell, sound, and feel like. We are asking citizens to attend one of our town hall meetings and share in writing, voice, song, prose, or dance their wildest ideas.”

Pamela: “Why open an ideal clinic?”

Lara: “In medical school and residency, I often questioned my choice to go into medicine. Pretty early on I realized that when I had TIME with people, to sit on their hospital bed and hear about their families and jobs and lives, then there were few things I loved more than medicine. It’s hard to have enough time with patients when working in a large system, so I quit my job and decided to ask the community to help me design an ideal clinic.”

Chris: “The big secret is that most of the things that patients hate about the system are exactly the things that doctors hate. Most of the things that patients want are what doctors want, too. So why not put our heads together and figure out a way to make our clinic what WE—patients, families, and doctors—want? Let’s build a beautiful healthful system, however small, that we can all be proud of, that reflects our values and encourages us to treat one another as neighbors.”

Pamela: “How did your first town hall meeting go tonight?”

Lara:  “We met for an hour and a half at the Salem library. We handed out paper, pens, markers, and asked folks to imagine their ideal clinic.  People were already brainstorming about ways they could help. They didn’t share everything on their sheets so when we got home and read the comments, it was really like Christmas as a kid. I should be headed off to bed, but I am still tingly and excited from it.”

Pamela: “What makes a doctor all tingly and excited?”

Chris: “It’s connection with patients. Folks had so many cool things to say. One man, a current patient, told me after the town hall that he and his wife believe that Lara’s approach to caring for him saved his life. Now he wants to give back to Lara and the community. And another patient hadn’t gone to a doctor for 67 years. He was literally shaking when he met Lara. A shut-in, scared and diabetic, he came and shared his love for Lara and his aim to help us create a clinic. It was really wonderful.”

Pamela: “So now patients are healing doctors?”

Lara: “Yes. Healing goes both ways. The current system is dehumanizing for patients—and doctors.”

Chris: “Doctors who don’t know you flipping through charts asking you the same questions over and over again is depersonalizing for everyone. A guy offered this analogy: ‘It’s like when you go to your public defender and you’re in court and he tells you, ‘Just say no, no, no, to everything.’ And you’re like, ‘But what about my case? What about my file?’ And he’s like, ‘You think I have time to read that stuff? I don’t have time to read anything.’”

Pamela: “Yeah, great analogy. So who came up with the idea for a dinosaur exam table?”

Chris: “A 20-something computer store employee said, ‘If the exam bed were in the shape of a dinosaur, I would go to the doctor then!’ So now we’re looking for carpenters to make our dino-exam table.”

Pamela: “And someone else wanted geckos?”

Chris: “As brainstorm fodder, I wrote words and questions on the white board. One word was animals? So a guy asked, ‘What did you mean by animals?’ I told him some clinics have cats, dogs, fish, and even therapy goats. He smiled and looked relieved, ‘Well then I would say geckos. We have a gecko and he is really cool and I would love to bring him.’”

Pamela: “What surprised you most from the evening?”

Lara: “People thought that we’d get overwhelmed, inundated by patients. ‘Everyone in town will want you!’ one guy said.  We told him that yes, at some point, we’d post a notice on the website: ‘Sorry, but we are not accepting new patients until our current ones get healthier. Keep checking back though!’ And one guy in the back (the same guy who talked about his public defender’s lack of personal attention) said, ‘You know? That makes me feel accountable to other patients. Like, knowing that other people won’t get to be in this clinic because I am still sick would actually motivate me to take better care of myself.’”

Chris: “Amazing! We hadn’t even thought about that, but it creates patient accountability. Patients will rise to the level of functionality we expect. And that guy blew us away with this immediate understanding of what we were getting at. He saw it before we did.”

Pamela: “So how can people get involved? What do you say to get folks to participate?”

Lara: “Attend the next town hall meeting! Would you and your in-laws like to have a dinner with me? Perhaps your church has members who would like to help design an ideal community clinic. What about your classroom of third graders? Your coworkers, softball team, economics class, motorcycle club? We want to build our meetings through the people we meet. More adventure that way. So send us your group, the number of people, and a proposed date and time. We’ll fit you in.”

Pamela: “Anything else?”

Chris: “Location! Think outside of the sterile, florescent-lit, paper-gowned box. Think of the coolest, most comfortable, most convenient place where you would want to visit your doctor. Then consider if you have friends who happen to have that place. Look for easy walking distance to a park, 250 square feet minimum, and rent between free or barter and $700/ month.”

Pamela: “How can people contact you?”

Lara: “Have a great idea? Go to our website and share it with us at Happy Docs Neighbors’ Clinic!”

A drawing of Chris and Lara planning an ideal clinic.

Pamela Wible, M.D. is a family physician in Eugene, Oregon and author of  Pet Goats & Pap Smears, a book that documents how Oregonians pioneered the first community-designed ideal medical clinic in the nation. She trains physicians (and other health care workers) to lead town hall meetings and open ideal clinics at her biannual retreats.

Dear Gregg,

I’m thinking of you tonight. Five years ago your wife told me you died. You were at a medical conference. They found you in a hotel room with pain pills. You were just 44.

You gave your life to medicine. We all did. We just wanted to help people. Remember our dreams?

I was a first-year student. You were a year ahead of me. We were all exhausted. I was lonely. You were nice to me. You cheated on your girlfriend—with me. We shouldn’t have done it. After your death, I found your old girlfriend and I apologized for both of us. She accepted our apology.

I invited her to your funeral. I told her your autopsy was inconclusive. She wanted to know your toxicology results. Nobody gave me the final report. Nobody wants to talk about your death. Still.

When we met, you told me you had a half-sister. You said she was hit by a car and paralyzed on one side of her body. I’m so naive. I didn’t get your joke.

You were funny and so damn smart. You never studied for tests and you made straight A’s. I’m still jealous.

You wanted to be a doctor, but your med school interview was rough. They gave you a tour through the animal labs where you witnessed the dog and sheep experiments. You fainted. They transported you to the emergency room where you completed your interview. And you still got in!

Remember third year? You were nervous on your first day with patients. So you let me cut your hair and dress you before you went into the hospital. When you entered the surgery suite, you fainted. Everyone saw your bald spot (oops!) and Fred Flintstone socks. They rolled you out into the hallway on a gurney. As you came to, a nurse yelled at you for sleeping.

You wanted to be a radiologist. I told you a dark room is no place for a narcoleptic. So you picked internal medicine.

I know your inner torment, your nightmares. I know stuff I can’t write about. I know that medical education is dehumanizing and it’s nearly impossible to save one’s soul. You never loved yourself. But I loved you. And I adored your family.

Some weekends we went to visit your parents. Your mom claimed I had the “gift of gab.” Your mom and I used to sit in the living room, laughing into the wee hours until your dad got up to scream, “Lil, it’s time for bed!” Your mom begged to stay up for “just one more story.” Meanwhile, you missed everything. You were snoring on the floor.

All three of you are gone now.

Here’s the only photo I have of us together during medical school. Sleeping on top of our books.

I’m still in Eugene, Oregon. We’ve lost so many male docs in town. Firearms are the primary method. Overdose is a popular choice. I went to the last guy’s funeral. That’s when it hit me: Maybe you died by suicide. Took me five years to get it. I’m still naive. Like most docs, I was in denial. Nobody wants to talk about it. Still.

Anyway, I’m thinking of you tonight. I don’t know why. Then I looked up the date of your death: January 19, 2008.  Your five-year anniversary.

There’s so much suffering in our profession. Nobody wants to talk down here. Help me out, Gregg. Why are we losing so many doctors?

I dreamt of you on solstice. I was carrying a camcorder. I interviewed you about your death. You spoke to me for three hours without falling asleep. Amazing. Please come again. I miss you.

Love,

Pamela

Change your name. Don’t friend patients. Delete your Facebook account. This is official social media advice for today’s medical students and physicians.

What fuels physician Facebook phobia?

Patients may make romantic advances or request appointments on Facebook. Patients might view a physician’s personal posts or vacation photos. One silly picture can forever tarnish a doctor’s reputation. And physicians who post political and religious comments may harm patient relationships. Really?

Physicians must first do no harm. Any patient can post their medical records online, but a doctor should never reveal anything about a patient without consent. Physicians who break confidentiality risk fines up to $250,000 and/or imprisonment. Share health news and tips, but medical care is best face-to-face, not on Facebook. Ultimately, patient confidentiality is upheld by physician integrity and common sense.

But doctors are warned to go beyond such ethical safeguards. They are advised to separate their personal and professional lives. So some docs have separate personal and professional Facebook pages. Will that protect physicians from tarnishing themselves and harming their patients?

Can physicians maintain privacy in a world wired for accessibility? Will medical hierarchy survive the digital age? Does Facebook undermine physician professionalism? How far should we go to protect physicians from friendly patients?

But the bigger question is: Why fear patients at all?

I’m a family doc. I’m trained to care for patients physically, emotionally–and socially. A patient once explained, “An ideal physician is a friend who happens to be my doctor.” I’m no fan of professional distance. Physician closeness is often the best medicine for patients. I’ve taken a dying man out for breakfast and a woman with fibromyalgia to a writing conference. I attend patient funerals, go to patients’ homes for Thanksgiving–and yes, I’m Facebook friends with my patients.

Sharing personal information can actually strengthen the doctor-patient relationship. I love looking at Joanna’s wedding album. I “like” the photos of her daughter smiling in a bubble bath. I enjoy commenting on Misty’s midnight political rants. Facebook has given me a magnificent view of my patients’ inner worlds. Some patients have scheduled follow-up appointments via Facebook. Some docs have solved medical mysteries by perusing a patient’s posts.

So why hide from each other?

Is it possible to be too vulnerable?  Today I posed this question on my page: “Anyone think it’s not okay to be Facebook friends with your doctor?” Bettie replies, “Why not? They have seen everything else! LOL! Haha.” Maybe it’s liberating to trade professionalism for humanism, privacy for transparency.

We live in an age of authenticity. Join Facebook. Share that photo of you dancing with your dog in a pink tutu. I just posted a photo of a goat wearing a stethoscope in my exam room. It’s 2013. Go ahead. It’s safe for doctors to be human.

Still suffering from Facebook phobia? Maybe it’s time to Facebook your physician for an appointment.

Pamela Wible, M.D., is a family physician in Eugene, Oregon. Her best patient stories from twenty years of medical practice are included in her latest book, Pet Goats & Pap Smears: 101 Medical Adventures to Open Your Heart & Mind. Friend Pamela on Facebook.

Remember:

I pick up a Glock semiautomatic, the model used in the Virginia Tech massacre. I need to hold it, to feel it, to rub my finger across the trigger.

I don’t fear death. Raised in a morgue, I worked with my dad, the city medical examiner. As a kid, I watched autopsies and talked to dead people and made up heroic stories about their lives.

Now I’m moved by slaughtered innocence. But I can’t find peace–until today. Obsessed, I have to hold the Bushmaster AR-15, the model that killed those school kids. I need to feel the cold metal on my heart. I hug the gun, but still can’t feel all the pain. So I beg to hold the biggest, deadliest gun on display. When I look up, a crowd is smiling at me. I smile back. A doctor with an assault weapon makes people laugh.

Some things never make sense.

At today’s gun show, I’m offered assault weapons. No paperwork. I don’t even have to give my name.

Some guns are pink for girls. Some are really tiny. They all shoot–and kill. One seller mumbles, “Everybody wants something that will fit in their pocket and destroy the world.”

Providing health care in a country of gun lovers has its challenges.

In Oregon, rifles and shotguns are legal to own at 18. Handguns are legal at 21. I was 28, with 24 years of education, before I was legal to provide health care.

In Oregon, I don’t need a license to use my gun, but I do need a license to use my stethoscope.

To apply for my license, I had to submit a notarized application to the Oregon Medical Board with my birth certificate, medical diploma, photograph, fingerprints, national board exam transcript, and specialty board certificate, plus proof of internship, residency, and medical education with dean’s letter. I had to verify past employment, staff privileges, state licenses, and comply with a Federation Disciplinary Inquiry.

In Oregon, I don’t need to know how to read or write to buy a gun from a licensed dealer. My one-page background check can be legally filled out by just about anyone.

In Oregon, I don’t need a permit to use my gun, but I need permission to use my stethoscope–and that requires knowing how to read and write and complete pages and pages of documents. I had to account for all personal time since medical school, including nonmedical activities and vacations. I had to disclose all mental health treatment with names, dosages, and dates of my medications, plus names and addresses of my psychiatrists. Today, I don’t have to disclose any of that to get my gun.

In Oregon, I don’t need to register my gun. To provide health care I had to register and pay more than 1,000 dollars in fees to the Oregon Medical Board and Drug Enforcement Administration. Applications take 3 months or longer to process.

But there’s no waiting period for my gun. My instant background check takes less than 30 minutes and costs just 10 bucks.

In Oregon, it’s easy to get a gun. In Oregon, it’s easier to get an assault weapon than a doctor. In Oregon, our suicide rate is higher than national average, and physicians have the highest suicide rate of any profession. I’ve lost far too many colleagues. All men. Firearms are the method of choice. Some docs buy guns and kill themselves the same day. Receipt still in the bag.

Background check is done. Now one last decision: Bushmaster or Glock.

We have a constitutional right to bear arms.

We have no constitutional right to health care.

America is the most heavily armed nation in the world.

America also leads the world in mental illness.

Half of all Americans develop at least one mental illness.

Half of all cases begin during childhood.

Nearly half of all Americans have at least one gun at home.

The human brain controls the gun.

People will find ways to end their pain.

A civilized society offers civilized solutions.

A violent society offers violent solutions.

It’s easier to get a gun than see a psychiatrist.

It’s cheaper to buy a gun than see a psychiatrist.

Ammunition costs less than medication.

Bullets are just a few cents each.

God bless America.

Dr. Pamela Wible spends the afternoon with Tamara and Marlo on 7th & Washington in Eugene, Oregon. A photoessay by Pamela Wible, M.D.

Photos by Spark Boemi

I’ve been a doctor for twenty years. I’ve not lost a single patient to suicide. I’ve lost only colleagues, friends, lovers–ALL male physicians–to suicide. Why?

Here’s what I know:

A physician’s greatest joy is the patient relationship.

Assembly-line medicine undermines the patient-physician relationship.

Most doctors are burned out, overworked, or exhausted.

Many doctors spend little time with their families.

Workaholics are admired in medicine.

Medicine values competition over nurturing.

Many doctors function in survival mode.

Doctors are not supposed to make mistakes.

Caring for sick people can make you sick if you don’t care for yourself.

Medical education often dissociates mind from body and spirit.

Some medical students believe they graduate with PTSD.

Seeing too much pain and not enough joy is unhealthy.

For a physician, a cry for help is weakness.

The reductionist medical model is dehumanizing for patient and physician.

Many doctors are emotionally detached (especially male physicians).

Doctors are obsessive-compulsive perfectionists in an imperfect medical system.

Physicians are the nation’s social safety net with few resources to help patients.

Some doctors feel like indentured slaves.

Death is perceived as failure.

Doctors don’t take very good care of themselves or each other.

Many doctors are in denial about the high rate of physician suicide.

Physicians are often bullied by insurance companies, employers, and patients.

Doctoring is more than a job; it’s a calling, an identity.

Doctors are often socially isolated.

Doctors can’t just be people. They’re doctors 24/7.

Doctors can feel severe psychological pain.

Doctors can feel powerless.

Doctors can feel trapped. Some see no alternatives to their suffering.

Doctors have easy access to lethal drugs and firearms.

Doctors have the same problems as everyone else.

Doctors have marital distress. They get divorced.

Doctors have addiction to drugs and alcohol.

Doctors have economic hardship and unbearable debt.

Doctors have mental illness.

Doctors are human.

How does a Jewish doctor prepare for the holidays? By decorating her house with festive medical specimens, of course!  All have been retrieved from human bodies, many during autopsies. I’m a hoarder with a medical art fetish.  It started with my turquoise and heart valve necklace. Now my IUD Christmas tree. What should I make next?

Photo credit: Spark Boemi