After two decades of formal education, today I’m finally set loose with real patients. It’s the actual moment I’ve been waiting for my entire life.

We’re each assigned to a family doc for the month. I scroll down the list of third-year medical students, place my right index finger beside my name, slide it across the page, then read aloud: E. Sinks McLarty, Jr., M.D., III.

The next morning I find his office—a small nondescript building with his name on the side—and enter the waiting room, which features 1970s-style wood paneling, faded and covered with the grime of decades of cigarette smoke. Centrally located is a large oil portrait of E. Sinks McLarty, Sr., M.D., who opened the place nearly 100 years ago. I pass rows of empty chairs to the front desk, where I meet three bouncy women—all relatives of Dr. McLarty. I introduce myself to the friendly, frenzied group of chatty chart finders, then the garrulous gang scurries me down a narrow, smoke-filled hallway where I meet Dr. McLarty’s nurse, affectionately nicknamed “Olive Oyl.”

A friendly, slender, snappy-tongued woman with a gravelly voice, Olive Oyl chain-smokes at her desk. Her deep red lipstick and nail polish are the color of freshly clotted blood. She escorts me into a dimly lit room where I’m not at all sure I’m safe. There, on the couch, I meet Dr. McLarty—a seventy-year-old cowboy eating Metamucil wafers while puffing on a pipe. He wears Wrangler corduroys and sports a crew cut with some gray hairs shooting through. With his thick Texas twang, he slurs his words together around southern slangisms and medical anecdotes.

With pen, paper, and stethoscope, I follow Dr. McLarty around to see what I can glean from him. I’m immediately struck by his speech with patients. He calls all the men “pahdna” and all the women “shuga.” Isn’t that sexual harassment?

Dr. McLarty has no tolerance for big-government rules. When a patient needs a triplicate form signed, he snaps, “Well, now, shuga, that’s a bunch of horseshit!” or “I don’t give a ram dam or a rat’s butt!” While cursing, he signs the forms, gives one to the patient, and throws the other two across the room in a wad. “Hell, I’ll make toilet paper out of it one day,” he rambles as he tramps out of the room.

Dr. McLarty makes even the common cold an event to remember. “Okay, now, pahdna, let’s look in that there snoot. Ah, a little redness, nothing to say grace over. Let’s listen to your ticker while I gotcha here.” Slamming down the chart, he exclaims, “You’ve prob’ly got some of that damn crud we’ve seen going around!”

In the next room, an elderly woman complains of joint pain. His diagnosis: “You’ve got arthritis! Well, hell, you can see that. No need to pay for that, shuga. Now hold that cane in your left hand and tell Byron to give ya a damn golf ball to carry around in the right.” He didn’t cure her arthritis, but she looked like an avid golfer when she left.

After seeing a few patients in the morning, Dr. McLarty closes down for a two-hour lunch. We all squeeze into his office on the couch to watch soap operas. During a romantic interracial scene, they shake their heads in unison. “Oh, no! We don’t believe in that!”

So I offer the clan some of my chocolate soy ice cream and one gal gasps, “Oh, no! My husband wouldn’t like that!” Dr. McLarty puts down his Metamucil wafer and grabs a spoonful. “That’s pretty darn good!”

After lunch we’re getting ready to see a man named “Sunshine.” Before entering the exam room, Dr. McLarty pulls me aside and says, “This family’s been shot in the damn butt with bad luck!”

“What’s going on?” I ask.

“He got cancer. I’ve known a week, but gonna break it to him now.”

“Why didn’t you tell him last week?” I ask.

“If he lived by himself, I’d a told ’im right away this is how the cow ate the cabbage, but his wife, Lordy, ya couldn’t scrape her off the wall last night,” he rants as he trudges down the hall.

I gathered that Sunshine’s wife was extremely anxious.

We enter the room. Doc pats the old fellow on the shoulder and says, “Sunshine, now I ain’t gonna pull any punches by tellin’ ya we got a drug.” After a few cryptic sentences, he asks, “Ya get what I’m sayin’?”

Sunshine replies, “Yep! Lights out.”

That was the entire office visit.

Most of Doc McLarty’s patients are old white guys who have aged right alongside him. But this afternoon, we jump into Doc’s old pickup to see a young gal in the hospital. On exam, he notices her breast implants and asks, “Hey now, shuga, how long ya had these damn things blown up that way?” She answers politely and the interview continues without a hitch.

We only saw one kid that month. As the boy raced around the exam room, Dr. McLarty quickly warned, “Hey now, pahdna, get back up there on that there table. We don’t want ya to bust your gazoo!”

I’ll always savor my month with E. Sinks McLarty, Jr., M.D., III. I didn’t learn much about diagnosing or treating disease, but I learned a lot about human relationships and the art of medical practice.

I sure miss him.

So, after fifteen years, I track him down to thank him.

He answers on the first ring.

With my heart pounding, I ask, “Is this really Dr. McLarty?”

“Yep, this is Doctor McLarty. Who the hell is this?” he shouts.

“I’m a medical student you mentored long ago, and I just want to say thank you.”

“Well, thank you, sweetie, but I got cancer of the bladder and just had therapy today, and I’m bleedin’ like hell!” Before I can express my sympathy, he quickly blurts out, “What comes around goes around. Thanks for calling on me, but I gotta go pee again!”

He hangs up on me.

That’s it.

I never even tell him my name—not sure he would have remembered me—but I do get to thank him before lights out.

Chapter 66 from Pet Goats & Pap Smears,  Dr. Wible’s best 101 patient stories from 20 years of medical practice.

Evan, a retired police officer, calls for an urgent appointment. I can hear the angst in his voice.

“Sure Evan, come right over.”

An hour later, he arrives in obvious distress. “I gotta show you something, Doc.” We proceed to the exam room. He pulls his pants down and points to his left testicle. I put on gloves, turn on the exam light, and l lean in real close.

“What’s the problem?” I ask.

“Look, Doc. Can’t you see?”

“What?”

“My left testicle is hanging real low.”

“That’s it? No pain?”

“No pain. But look how low it is!”

I stand up. “Evan, here’s the deal: most people hang lower on the left. In women, the left breast is slightly larger and hangs lower. For men, the left testicle generally hangs lower. So you’re in with the main crowd.”

“I’ve been this way my entire life?”

“Yep. You’re normal.”

Evan smiles. Relieved, he hands me his co-pay and a five-dollar tip. As he leaves, I add, “Just so ya know, most curvy penises also curve to the left.”

Chapter 52 from Pet Goats & Pap Smears,  Dr. Wible’s best 101 patient stories from 20 years of medical practice.

Many busy clinics display a large fish tank in the waiting room. Staring at fish can help patients relax and lower blood pressure and anxiety before appointments. But how do fish feel about staring at miserable patients all day long?

In the fall of 1999, an exotic eel makes his feelings known. One morning he jumps out of the tank, flinging himself across the waiting room.

A kind older man picks up the eel; that’s when the eel attacks him.

When I arrive at work, the poor man is in the procedure room, with doctors pulling the eel off his finger while the clinic manager is on the phone with the malpractice carrier. I’m not sure whether we have liability coverage for eel attacks.

Chapter 70 from Pet Goats & Pap Smears: 101 Medical Adventures to Open Your Heart & Mind by Pamela Wible, M.D.

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