Return to their Routes: Laurel and Jim return to Montana

If there is a theme in our trip, it is that many of our talented friends have established themselves in rural towns around this nation, often returning to the places where they were raised. After leaving the Turtle Mountain Reservation in North Dakota, we turned westward, beginning the long journey home. Fortunately the route took us through Livingstone, Montana, where our friends Laurel and Jim live with their two twin daughters, Nastia and Larissa.

Laurel Desnick and I have been medical school colleagues for many years, and for the past few years she has worked with me in the Rural Underserved Opportunities Program (RUOP), through which we introduce students to practices that serve disadvantaged popultions . Most of the sites where we send students are in remote rural communities, much like the ones Fernne and I have been visiting.

Laurel trained in internal medicine at the University of Washington, but at heart she is a family doctor, and indeed she sees not only adults but also children in her part-time practice in Livingstone. Laurel and her husband Jim Baerg hail from remote rural areas themselves, and moved to the small town of Livingstone many years ago where they married. Laurel later went to medical school after years as a house painter, and Jim used their time in Seattle to finish an architrecture degree. They adopted twins from the old Soviet Union, and we have been part of the extended network that watched, and tried to help, as the girls slowly recover from the devastating experience of having been neglected and abused in the orphanage from which they were rescued.

Livingstone is a charming and complex town, at once containing remnants of the flagging embers of the agricultural base upon which Montana was built, and also host to wealthy exurbanites who have traded in a city existence for the stunning beauty of the Montana landscape. Livingstone is only an hour from Yellowstone Park, which adds to its allure. But, as Jim told me, "you can't eat scenery", and for those without a profession or an inheritance it can be tough to make a go of it in this immense state.

Laurel represents the ability of many of the rural doctors in our five-state medical school to combine clinical practice and teaching, a combination that enriches both of these callings. Their dedication to their children and their community are steadfast and inspiring, and the warmth and ease of small town living remind me of the best parts of my own childhood in rural New Hampshire.

Another Family Comes Home: Dave and Phyllis Jollie and the Renaissance of the Turtle Mountain Chippewa Reservation in Belcourt, North Dakota

I met Phyllis Jollie when I hired her to work in the Seattle Office of the National Health Service Corps sometime around 1975. Her husband Dave had forged a very successful career with the Bureau of Indian Affairs, but like many government employees, he and his family were transferred every couple of years. To our good fortune Phyllis felt like she could go back to work after having the fourth of their daughters, and when Dave got transferred to Seattle she came and joined our team. Fernne also became part of this intrepid crew shortly after, and we had a truly exhilarating and rewarding time building primary care practices in small towns throughout the West.

I was a bit flabbergasted when Dave and Phyllis decided to ditch their secure and reasonably lucrative government jobs to return to the reservation of their birth, the Turtle Mountain Chippewa Reservation almost at the Canadian border in central North Dakota. Home was calling, they told me, and they wanted their girls to grow up in the midst of their family and their people. And so they went. We always kept in touch, and found out that they had opened the first supermarket in Belcourt, North Dakota, the town that is owned and managed by the Turtle Mountain band of Chippewas, a tribe whose roots are in North Dakota, Minnesota, and Wisconsin.

We kept in touch with the Jollie family over the years, and hung the yearly calendar they sent us in our Okanogan Cabin, wondering what the scenes from Indian life really represented in the lives of our friends. When this road trip materialized, we decided to find out, and drove the hundreds of miles to a state and region we had never seen.

Driving into Belcourt was a surprise. Unlike the Colville Reservation with which we have worked and where we have travelled for many years, Belcourt seemed to be a flourishing and busy town. The Jollies lived in a beautiful house on a hill in the center of town, about a two minute drive from their mall - it turns out they had bought the entire mall when the previous owner foundered several years after they opened their supermarket. Not only did they host an impressive number of shops inside the mall, but they were heavily involved in almost every aspect of the town. Their most recent accomplishment was to open the first full-service bank in Belcourt, and the first Indian-owned bank in the country, surmounting decades of resistance from bankers in the non-Indian towns near the reservation.

But strong as their commercial ventures had become, their family was even stronger. All four of their daughters with their husbands and children, had moved back to Belcourt. Three worked in the family business, and one was a clinical psychologist in the mental health center. Wherever we went - the impressive college that the tribe had built, the clangorous casino, the Indian Health Service hospital with a full staff of doctors, several from the tribe - we met members of their extended family. The warmth and respect among them could be seen in every gesture, and heard in every word, no matter how mundane. To our eyes, Dave and Phyllis were the foundation stones of both a remarkable family, and the engines behind the renaissance of the most successful Indian reservation we have visited.

Not that all is roses and honey. The Chippewas have the same struggles with alcohol and drugs as other indigenous people, and wrestle with the high rates of unemployment that come from being a very small place far from any commercial center or rail head. But it was inspirational to see what a few determined people could do catalyze change, and how a family can maintain its integrity and mutual support despite the enormous strains of living in a remote and at times hostile environment.

Setting deep roots in the South Dakota soil: Tom and Kathy Dean of Wessington Springs

Tom Dean and I were residents together at the creation of the Family Medicine program at the University of Washington. He was one year my junior, and was a rock-steady farm kid from a place that I'd never heard of and couldn't imagine: Wessington Springs, South Dakota. A number of us in that new residency program had rural roots, but Tom's town seemed in many ways to be the most remote and alien. But all of us were by definition a bit weird for choosing a specialty as untested and improbable as family medicine, and only by cleaving together and supporting one another did we get our residency accepted in an academic medical center that knew little about either family medicine or rural towns.

Our group was also fortunate that Tom managed to dazzle one of the most important people in the hospital: Kathy, the chief obstetrical nurse. All of us were smart enough to know that the nurses were the ones really in charge of the wards where we spent countless hours, and when Kathy extended her grace and knowledge to our fledgling group of family doctors, we all prospered. Tom went further than the rest of us, married Kathy, and moved with her after residency to Hayden, Kentucky, where she became a nurse mid-wife.

When they finished their Kentucky stint, they moved back to Tom's ancestral home of Wessington Springs. There are now 6 generations of Deans who have been baptized ion the small country church near Tom's family's farm, and Tom and Kathy's daughter-in-law is the pastor of the church where the latest baptism occurred. Although Tom began driving tractors at the age of 6, rather than become a farmer he decided to follow in the footsteps of his uncle, who was the solo GP who helped create the remarkably strong and unified health care system that Tom and Kathy inherited and improved.

Over the last 35 years Tom and I have remained friends and colleagues, our bonds strengthened because of our mutual interest in rural health care. Tom has become one of the most influential rural doctors in the entire country, and in addition to the enormous responsbility of providing care to several small towns on this vast prairie, he is currently the first and only rural doctor to sit on Medicare Advisory Committee, one of the most important policy jobs in health care in the entire country. Kathy delivered the majority of children in the area over her career as a midwife, and now looks after Tom and the sixth generation of Deans, 5 of whom live in Wessington Springs.

Tom and I share another bond. He, like myself and Susan Schmitt, developed a rare and lethal cancer about 2 years ago - multiple myeloma. Tom had the same experience as Susan and I - collapsing unexpectedly in his very rural town, and surviving through pluck, luck, and the skill and compassion of family, friends, and the skills of some very good doctors. Tom at this point has gone through a stem cell transplant and is on continuous medication. But you would never know it if you saw him, and he has returned to his work in the clinic, hospital, nursing home, and conjugate care facility that he helped to build during his years in his town.

Trees are only as strong as our roots, and Tom's go deep into soil of this remote and productive land. From that soil he and Kathy have drawn not only strength and nourishment, but the wisdom and insight to devise ways for scores of other rural towns to continue to receieve superb medical care despite isolation and the inanity of our crazy-quilt medical care system. The winds are strong in South Dakota, but these sturdy souls will not be dislodged.

The Black Hills of South Dakota

We left Colorado in a torrent, punctuated by lightening, on our way to the Black Hills of South Dakota. No matter. We perservered, and ended up in an a very funky cabin (built in 1929) in the town of Hot Springs, at the southern fringe of the Black Hills. The next day we began to explore this glorious corner of our vast nation. There were unusual impediments in the road. For someone skilled at hitting a deer, the notion of hitting a bison seemed a bit more catastrophic.

Not being too bright, we decided to go on a hike in Custer State Park despite the rain. we chose the "Lover's Leap" trail - go figure. Although we didn't jump, perhaps we should have. There were 7 creek crossings before we got out, thoroughly drenched. Why didn't we see anyone else on the trail? Oh, well, this sign sums up our existential insouciance:

Today the sun shone. It was still a bit cold, and it had snowed in the mountains overnight:

Undaunted, we climbed Mt Harney, a glorious peak deep in the Wilderness at the center of the Black Hills, and the highest point between the Rockies and the Pyrenees (think about that for a moment). We basked in the sun at the top, our breath frosty, our thoughts rhapsodic:

Next Generation: Boulder, Colorado

The Next Generation: Boulder, Colorado

 

A major bonus of our re-arranged travel itinerary was that when we landed back in Denver, we were close to Boulder, Colorado. Our "god-children", Daven Henze and Elena Hartoonian - Roger married them in 2007, and Daven has been like a son to us since his birth - had migrated to the University of Colorado.  Not only were they both in Boulder, but they had recently purchased a delightful and spacious town house walking distance from the University with four bathrooms (!) and a lovely basement guest room.

 

After fumigating our forlorn car - the cheese we had left in the car had turned into a failed science experiment - we pointed ourselves towards Boulder.  We got there with no problem, but found ourselves in gridlock when we got near campus.  Thousands of brightly dressed young folks moved languorously through town, policemen were at every corner, and a helicopter buzzed nosily over-head.  What the hell was going on?

 

When we called Daven to check-in, he told us with a chuckle that we had arrived in Boulder on 420 (April 20^th), and perhaps we ought to avoid the campus until later that afternoon.  We had no idea what he was talking about, but then we noticed that many of the throng wore a serrated greenish leaf around their necks or tattooed to their foreheads.  420 is Christmas for potheads, and literally thousands of acolytes had congregated in Boulder.

 

So after repairing to one of the more sedate coffee shops in town until the mobs had ebbed, we found Daven and Elena’s delightful pad.   Daven showed us around, and then took as up to Chautauqua Park, one of the 40,000 acres of open space that encircles this amazing town.  This splendid park is encircled by several mountains called the Flat Irons, jagged shards of rock that provide endless challenge for the legions of rock climbers who live in this hyper-athletic town. We capped off the day by dining at an amazing seafood restaurant, presided over by an owner who had won the recent Top Chef completion on TV.  Only in Boulder.

 

The next day we explored the enormous park on our own while Daven and Elena worked.  Daven is a newly minted Assistant Professor in the School of Engineering, and is totally immersed in unraveling the mysteries of atmospheric chemistry, in particular in relationship to the production of greenhouse gases in the atmosphere.  Elena is a first year graduate student in the math department, and in addition to her own studies teaches introductory calculus.  So while they toiled in the academic vineyards, we scurried up to the Royal Arch, one of the places in the Flat Irons recommended by Daven. Under the Arch we gazed over the town of Boulder which hosts not only the University of Colorado, but also the National Center for Atmospheric Research and a number of other major scientific institutions, such that PhD’s probably outnumber marijuana enthusiasts (unless of course these brainy folks also inhale).

 

The high point of our visit was not the lofty spires of the Flat Irons, but seeing Daven and Elena as a joyful married couple, and as two aspiring and extremely promising scientists.  Although most of the folks we are visiting on this trip are our age, it is heart-warming to see that the generation whom we have helped shape are managing to make their way in an increasingly complex and imperiled world.  There is no way to know how the story will end, but for us it means a lot that our children and their friends will keep embellishing the never-ending tale.

 

A Heroic Rural Doctor in remote West Virginia

We reached the furthest point on our journey last weekend when we visited a person who had become very close to us over the last two years, but whom we had never met. We were introduced to this remarkable person, Dr. Susan Schmitt, by my brother Leon. Leon and his wife Lucy are avid folk-dancers, with a passion for contra dance. Every year they escape from the Eastern winter to dance with a convivial group on St Croix in the Caribbean. To my good fortune one of the couples who shares in this winter migration are Susan Schmitt and Doug Wagner, from Thomas, West Virginia.

When Leon visited me about three months after my abrupt and catastrophic encounter with a rare abdominal sarcoma called a GIST, he told me that that one of his dancing partners, a rural doctor in West Virginia, shared this unusual diagnosis. More remarkably, she was still vigorously alive, working as a solo rural family doc, and clicking her heels in St Croix five years after emergency surgery for the same condition. Although I initially thought he probably had misunderstood what she told him, when I was struggling with the side-effects of the chemotherapy for this rare cancer, I got Susan’s number from Leon and called her.

This was the beginning of a phone and e-mail friendship between two intense family doctors grappling with the reality of a bad disease, the side-effects of powerful medicine, and the various disruptions resulting from the fairly heroic surgery that had saved our lives, but altered both our anatomy and physiology. Each of us had discovered different strategies for coping with the disease, and the emotional and physical challenges that come with cancer and its treatment. We shared our discoveries with each other, used each other for informal consultations as new symptoms would crop up, and became a powerful two-person cancer support group.

Thus when this road trip progressed from fantasy to a concrete plan, visiting Susan in West Virginia became the compass pole around which we designed our journey. So our furthest point from Seattle became Susan and Doug’s majestic house on Backbone Mountain just outside of Thomas.

As part of the visit we visited Susan in her half-time solo practice in Parsons, a struggling town that was almost wiped from the map during the flood of 1985. Susan has a devoted following in the town, but the economics of rural medicine in West Virginia are so challenging that the practice works only because Doug is her volunteer receptionist and book-keeper, while both of them share some of the janitorial duties. The other half of her practice is in an other small town a perilous hour and half drive from her home, plus stints of taking call at a Critical Access Hospital in yet another small town.

Susan has also experienced some of the vicious politics of rural West Virginia, including a vendetta that led to her being fired from a health center that she helped to create at the same time she was dealing with the challenges of trying to survive a lethal disease. Not only did she lose her health insurance – the chemotherapy that has kept both of us alive costs thousands of a dollars a month – but she was slapped with bogus criminal charges. She fought back vigorously and successfully, being completely exonerated of the trumped-up charges. Fortunately, she had enormous support from her patients and some segments of the professional community, and soon returned to what she loves and does best – taking care of sick people in West Virginia. Not only does she take care of disease, but she is committed to trying to prevent the enormous toll that obesity and diabetes take in West Virginia, and started a Wellness Center in Parsons that has since been adopted and supported by the city.

Although Susan and I had never met before this trip, we felt like we had known each other for years. Her example, her fortitude, and her fierce embrace of life have helped me enormously over the last two years. Her husband Doug and my wife Fernne share the ability to sustain us without draining of us our fierce uncompromising independence. It was a powerful weekend.

Wandering in the Mountains of West Virginia

After the idyllic River Farm perched on Virginia’s Clinch River, we felt ready to tackle the mountains of West Virginia – or as Jim said, West “God Damn” Virginia. West Virginia has the distinction of being the only state to switch from the Confederacy to the Union during the Civil War, breaking away from Virginia to do so. One of the many state parks we visited was a testimony to the battles at Droop Mountain where the Confederates were expelled from the new state, at the cost of many hundreds of lives.

Our first stop was at Pipestem State Park, more a resort and major conference center than most of the state parks we have visited. Set on the edge of the Bluestone Gorge, we were attracted by the lovely woodsy cabins and the miles of hiking trails. For some strange reason April is emphatically off-season, and we felt like we had this enormous park to ourselves.

One of the major attractions of this park is tramway that takes people from the rim to the Bluestone River at the bottom of the Gorge. But the tramway doesn’t even begin to run until the middle of May. When we told the folks at the front desk that we intended to take the four-mile to the bottom, they reacted with horror and disbelief. Apparently this sort of excursion is not something that locals consider, and the rates of obesity and diabetes in these remote West Virginia hollows tend to validate that conclusion. Nonetheless we had a splendid day exploring the trail and its various spurs, and emerged from the gorge a little tuckered but unscathed.

After several days exploring the southern slice of West Virginia, we ventured into the “real” mountains of the Monongehela National Forest, traveling on sketchy roads that vied with each other in packing in the most hairpin turns per mile, while going steeply up and over mountains before plunging into improbably remote valleys. Cell phone coverage was non-existent, and we even passed that most extreme test s of true rurality: we could put both the FM and the AM dial in seek mode, and never come up with a radio station.

The other thing we discovered was that there were very few places to stay, and even fewer to eat. After rejecting a few motels that came right out of Deliverance, we ended up at Yokum’s, which had the advantage of being opposite some magnificent quartzite cliffs called Seneca Rocks. The only problems with this solution were that a number of very large men burst into our room several times since the owner had booked more than one party into the same room – the itinerant workmen were kind enough to move to the room next door; and the one restaurant we visited was so bad that the rib’ eye steak I ordered would have made a better shoe than a meal. It was an experience.

But the next day we got to climb to the top of Seneca Rock. Unlike the climbers from the mountaineering guide service next door, we donned neither helmet nor harness as we chose to take the trail to near the top. An easy scramble put us on top of the northern peak (on the left below), while cries of “belay on!) echoed from around the corner.

With Seneca Rocks under our belts, as it were, we spent our last night in the mountains at another delightful state park, high in expansive mountain valley (Canaan) that even had a ski area with a little snow left. Our main impression of the mountains was their soft beauty, and their relative isolation. It seems inconceivable that as I write this we are only 3 ½ hours by car from Washington, D.C. We have traveled into a dramatic fold in the landscape, and a major warp in the fabric of time.