Microsoft Word - In the Eastern Fields of Eden article.docx Published by University of Minnesota Libraries Publishing In the Eastern Fields of Eden Austin R. Clark, J. Tyler Smith, Cody S. Tucker, Eli W. Travis, William J. Crump, MD. DOI: https://doi.org/10.24926/jrmc.vXiX.XXX Journal of Regional Medical Campuses, Vol. 1, Issue 5 (2019) z.umn.edu/JRMC All work in JRMC is licensed under CC BY-NC Austin R. Clark, Second Year Medical Student, Trover Rural Track Student, University of Louisville School of Medicine J. Tyler Smith, Third Year Medical Student, Trover Rural Track Student, University of Louisville School of Medicine Cody S. Tucker, Second Year Medical Student, Trover Rural Track Student, University of Louisville School of Medicine Eli W. Travis, College Rural Scholar and a pre-medical student at University of Kentucky William J. Crump, MD., Associate Dean, University of Louisville School of Medicine Trover Campus at Baptist Health Madisonville. Corresponding author: William J. Crump, MD Associate Dean University of Louisville School of Medicine Trover Campus at Baptist Health Madisonville; 200 Clinic Drive, 3rd North, Madisonville, KY 42071; v: 270.824.3515; f: 270.824.3560; e: bill.crump@bhsi.com All work in JRMC is licensed under CC BY-NC Volume 1, Issue 5 (2019) Journal of Regional Medical Campuses Original Reports In the Eastern Fields of Eden Austin R. Clark, J. Tyler Smith, Cody S. Tucker, Eli W. Travis, William J. Crump, MD. Abstract July is an interesting time at our small rural clinical campus. In addition to the bright faces of our new M-3 students just settling into their routine while awaiting their USMLE step one scores, we host a group of our rising M-2 students just before they return to Louisville for their second grueling year of basic science education. They spend three weeks shadowing their future faculty and working with our college rural scholars as they solve a clinical case in small groups. Also these two groups conduct free school and sports physicals at local health departments in towns of 600. The rising M-2s perform the physical exams under the watchful eyes of certified health department nurses and supervised by myself or another family medicine faculty. The college rural scholars assist during the physical exams and then take each schoolchild for individual anticipatory guidance. The students use a script they have developed as a group and provide the counselling in a room that includes hands-on props they have collected to keep the kids engaged. Both college and medical student groups leave us with wistful looks and eager anticipation of returning next summer. This July an interesting opportunity arose. One of our rising M-2s had grown up in close proximity to a rural Amish enclave and visited there regularly as the Amish men shod his grandfather’s horses. A certain bond had developed, demonstrated perhaps most beautifully and touchingly by an Amish horse-drawn wagon bearing his grandfather to his final resting place after his funeral (Figure 1). This student contacted me suggesting that we provide some kind of health screening for one extended family, with the primary contact being the pastor of the congregation church, a man in his thirties. We had just begun a cardiovascular screening project in the county that hosts our campus, and we set out to do something similar for our student’s friends who live 90 miles away in an agricultural area. On a very warm, clear summer morning, I arrived about 15 minutes late because of call responsibilities and my inability to believe that the first sign I saw for squash and tomatoes could really be my turn. My students were already busy inside. As I carefully pulled my car out of the way among buggies undergoing repair, I noticed a very large van with a conventionally dressed woman loading vegetables just bought from the Amish vegetable stand. As I approached the house and noticed the traditional garb of the men and women, they all stopped and looked up with the quizzical gaze I’ve seen among the deer with which I share my backyard. Once inside, as I watched our students work I felt a sense of peace within the strange but welcoming atmosphere. As a reflective exercise, I asked each student to put their impressions on paper separately, and what follows is an interesting summary of their perspectives. As I had hoped, each viewed the same experience through the lens of their previous life experience and their level of medical training, resulting in a rich mosaic. The closing piece by the student closest to the Amish community provides a perfect biblically-inspired summary of what we all felt as we returned to our all-too-modern lives. -Bill Crump, M.D., Associate Dean, Trover Campus I pulled up to a large, white house that was bustling with women in dresses that covered their ankles and bonnets that covered their hair, men in long sleeves and suspenders, and children who were dressed exactly like their older counterparts. To my relief, I spotted a medical student, dressed differently from the bustling crowd. Next to him was a young Amish man dressed in a blue, long sleeve button up shirt with black pants, suspenders, and straw hat, smoking a corn cob pipe. I didn’t realize it at the time, but I was looking at the two critical components in making this health screening possible. A relationship between the young Amish man and the medical student bridged the gap between our cultures and allowed us, as strangers, to enter their home and collect private medical information. The day began with our liaison gathering his Amish family in the large living room of their house. Men and women ranging from their late teens to older adults, mostly married couples, were present. These were the people that we were to screen. The screening included a finger stick that would yield blood DOI: https://doi.org/10.24926/jrmc.ADDHERE Journal of Regional Medical Campuses, Vol. 1, Issue 5 Original Reports glucose and total cholesterol levels, a blood pressure reading, and a discussion of past and present medical issues. We began the screening in the same living room that everyone had gathered in earlier. The room had two large windows, sturdy wood floors, and I took notice of an oil lamp sitting on a table in the corner. Sweat began to collect on my forehead- it was a hot day and little relief from the heat came when we walked into the house. I was unsure of how many people lived in the home, but I had been told that several people traveled to the house solely for the screening. As the family had requested, we took one couple into the room at a time to be screened, with the exception of two women whose husbands were too busy to come that day. These women participated in the screening by themselves. With each couple or individual that we screened, my expectations were proven to be more inaccurate. I anticipated this extended Amish family to be slightly suspicious, and I predicted them to be outwardly critical of my modern way of life. Instead, I found nothing but thankfulness and welcome from our hosts. The men were somewhat stoic but always verbalized their gratefulness for what we were doing. The women always gave warm smiles and even gave a small laugh each time a certain medical student reused his joke comparing collecting blood from a stuck finger to milking a cow. One of the women even poked fun at us, asking, “How are you all doing without AC?” There was no lack of small talk. I will confess that we spoke more of crops, weather, and farming than I would have with people of my culture, but it was no less pleasant than conversation I have with strangers in the supermarket or at a restaurant in my hometown. They even gifted each of us with vegetables on our way out as a way of thanking us. My perception of the Amish community as an isolated, unhospitable people was completely changed by my short morning spent there. The couples love one another, the parents love their children, and they thoroughly enjoy fellowship, just like the people in the rest of the state of Kentucky do. While our lifestyles are vastly different, it turns out that when it comes down to the important things, the Amish and the general population differ in the things we have but not so much in the things we value. -Eli Travis, College Rural Scholar A small sign for squash and tomatoes was the only indication of where to go. The gravel driveway was long and passed in front of the man’s large white house next to a larger red barn. If I didn’t know Amish people lived there, I’d think it was just another house owned by an average Joe neighbor who had a good paying job. In the yard, women and men were dressed in attire I would have expected for Amish people only based on my knowledge from movies and the Internet as I had never really met or seen any Amish people. The man of the house greeted us and welcomed us to his home. He seemed very nice and excited to have us there. His excitement surprised me because I was unsure whether the Amish approved of modern medicine or not. We set up our table and equipment in one of the front rooms of the house. It seemed like a room that would be a living room with a big couch and tv in most modern homes, but this room had nothing but wooden tables, chairs, no power outlets, and only oil lamps indicating the source of light that would be used at nighttime. I thought of how interesting it would be to see this house lit up at night using only oil lamps. As we interacted with these people, I learned that most of them had actually seen a physician at least once or twice. However, with this limited exposure to modern medicine, I was impressed at some of their medical knowledge. One woman mentioned being tired and was worried that it could be her thyroid. Additionally, they didn’t seem to be apprehensive or nervous about us evaluating them. I know that many people in the city might be anxious about getting their finger stuck and strangers touching them, but these people met this uncertainty head on. As many of the women said, getting their finger stuck wasn’t as bad as some of the times they had stuck themselves with sewing needles. It seemed to me that if one of them had needed a surgery or some invasive medical procedure, then they would approach it positively and would tolerate any difficulties with the procedure well. From my recollection of the numbers, almost everyone had normal results. From health interviews that our lead student conducted, we learned that everyone was very active due to their daily chores/work and ate vegetables frequently. Some reported eating fried foods every so often and even confessed that when they go into town they sometimes get fast food. Due to their work and diet, I expected their health numbers to be good, but learning about the town trips and eating fast food was a surprise to me. It made me laugh internally and think; well at least some fast food every once in a while might just be alright. -Tyler Smith, Trover Campus M-3 I wasn’t surprised that the first Amish I’d met were also some of the warmest and welcoming people I’ve ever encountered. I was only marginally surprised to see children with a container of fruit loops and to hear the adults confess to eating fast food. It had never really occurred to me that Amish ate fast food. Their concerns about their blood sugar and cholesterol were born from the same place as my own! Fast food almost certainly makes up a lesser percentage of their diet than mine. DOI: https://doi.org/10.24926/jrmc.ADDHERE Journal of Regional Medical Campuses, Vol. 1, Issue 5 Original Reports I did have one significant dislocation of expectations during my time in the small Amish homestead, though. They were shockingly health literate. They seemed much more educated on the state of their current health situations than many patients I’ve encountered in the city. As I listened, I began to understand that they weren’t averse to modern medicine at all as I had expected. Some had problems like high blood pressure and heart burn that were managed with Lisinopril and Omeprazole. As their concerns would often reach outside of our limited understanding, our routine was to suggest follow up with a physician. This was when I was struck by a great similarity between the Amish and wider society. The barrier to care for them wasn’t cultural at all, as I had previously ignorantly imagined. Access to care was restricted by the same barriers that affect other minority populations: transportation, financial concerns, and limited availability of providers. I thought of doctors and nurses in the city that I’ve overheard talking about patients with unmanaged disease states who only come in once their situation has become dire. The comments are made without consideration of a lifestyle and circumstance vastly different from their own. I thought of the need for primary care physicians who are willing to reach out to these varied and sequestered populations and embrace them as part of their practice. Before leaving we were offered gifts of fresh vegetables as a thank you for performing the screenings. We of course were pleased to accept these, though I earnestly questioned the value of the service we had provided. Had we actually helped them at all? As I drove away, I thought about a map of Louisville created by the Department for Health Equity that demonstrated the health disparities in certain parts of the city compared to others. The map is designed in layers that each show a different health measure (social and clinical) stratified across the city. When I think about the overall health of the state I try to think about it in this model. There are different map layers for different groups in need. And there are different map layers for the unique barriers that exist for each. Where does the need for care exist and what affects a population’s access to care? Is the healthcare model practiced in these areas capable of accommodating and serving the populations in need? I came away with more questions than answers, but also with a new level of understanding and appreciation for a neighbor’s culture, as well as a new layer for the map. -Cody Tucker, Trover Campus M-2 In the Book of Genesis, a story is told of how Adam and Eve lived in a state of paradise where all was perfect; hunger tethered, worries meaningless, and disease non-existent. Amish culture is not something we would necessarily call “paradise.” Hard work under a relentless sun, trading of the Mercedes’ for several black buggies, and hot days without air- conditioning are potentially the stuff of nightmares. Yet, my experience with my Amish friends reminded me that “paradise” just may have more to do with our state of mind and that we modern-folk just may have a thing or two to learn from the simple life. I have heard it said that medicine is a complex science with a multitude of factors contributing to health. That heuristic applied in our case as well. The highest blood pressure reading was 145/81, with most readings falling at or below the normal. Not surprisingly, the highest total cholesterol reading was 210 mg/dL, and this could actually have been considered low risk if further testing had shown the high HDL expected of really active folk. What is incredible about these readings is that the participants take very little medication and rarely see a physician or other healthcare provider. During our conversations with them, most were reluctant to take even aspirin for everyday aches and pains, so daily medications that control blood pressure or cholesterol levels would take some time with which to become accustomed for many. If anything, our Amish friends demonstrate the strength of the association of lifestyle with well-being. As I reflect on my experiences of that day, I find the noise of modernity falling away like a morning mist and feel an abiding sense of amity amid the clicking of horse hooves and the aroma of freshly harvested vegetables. To say that peace does not contribute to health, I think, is a fool’s claim. Thus, maybe we modern folk do have something to learn from simplicity after all, and maybe, if we think deeply, we will be able to recall that long-forgotten memory of a healthy and natural Eden. -Austin Clark, Trover Campus M-2 Acknowledgement We wish to thank our Amish friends for inviting us into their home and providing us with this special opportunity and the superb tomatoes.