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SPEAKER: The thing which differentiates a small community and its lifestyle from a large town or an urban area is probably the importance of people. Everybody in a small town is necessary and is important and contributes to other people's welfare. In an urban area, there are 20 people waiting in line for everybody's job or scrambling to get a hint. I think people who understand and are able to accept the importance that they must assume in small town life are the ones who do it successfully. And this, I think, is going to be-- it's going to be interesting to see if it really does help us keep doctors and other professionals in that role throughout more of their life.

SPEAKER: It certainly makes a difference as to whether you have an appreciation, if he's a baker or a farmer or a car dealer or what this man is involved in, in what his family style and what his previous lifestyle was like before he came to have the condition. And can we improve or retain the quality of this person's life? Well, you've got to know what that quality was and how he viewed that and his expectations. And so yes, definitely, you can know your patients better from that viewpoint, know what their expectations are with regard to the quality of life because I know back in the larger hospitals in the cities, a very important part of the history and physical on a hospitalized patient is a social history or a patient profile or whatever you want to call it, where you attempt to get some insight into the patient's views and expectations regarding lifestyle.

And this oftentimes, though, it just comes across verbally, and there are many different ways of communicating. And if you can communicate on various levels and communicate at different times, not just one setting, like in a hospital, and know this patient, you can know so much more about what he expects out of life, how he views life, what his lifestyle is. And knowing that, then, you can help him manage his disease or his condition to a point to attain as closely as possible a lifestyle that's compatible with his expectations so there won't be anxiety produced when this isn't met.

SPEAKER: I'm interested in working where there is a need for physicians, for primary care. And so I know there are many needs in Minnesota. And it most likely would be a rural area, someplace where they have a shortage of physicians or are unable to keep or maintain a physician.

SPEAKER: I think that practicing in a small town is going to have problems. A practice anywhere it's going to have problems. And it depends on what problems you're willing to take. You go into a city where there's lots of doctors, and there's problems there too. You may not have a big variety of patient types. You tend to go into specialties. And if that's what you want, I suppose that would be the kind of thing to go into.

But there's a real need for family practitioners, and it's really challenging. It's much more challenging-- most people really admit that they go into specialties because they're a little afraid, or would go into specialties because a little fearful of the variety of things that they would have to know as a family practitioner.

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SPEAKER: A Sense of Place, a documentary series which looks at regions and regionalism in the state of Minnesota. Produced by Minnesota Educational Radio under a grant from the Minnesota humanities commission, this program is called "The New Doctor on Old Main Street."

SPEAKER: The problem is when you get there, you have an appointment usually, and the waiting problem. I like to see if I have an appointment to get there, and let's get the job taken care of and not wait an hour or two hours. We had this problem about three years ago when our son broke his arm and had to [? take ?] it to a specialist at St. Cloud. There were instances where we waited two hours before we saw the doctor.

SPEAKER: And you can't really afford to lose that kind of time.

SPEAKER: Not on the farm. I mean, I don't say anything because I feel that he's a busy man, too. But when you do visit him, he's at ease. And he just puts in his eight hours, and I imagine probably once or twice a week, he's [? at ?] emergency call.

And in this situation, these doctors were in a group. There was more than one involved. So I felt that if they are so far behind, why doesn't the next man pitch in and help them along?

SPEAKER: A Stearns County farmer voices some of the annoyances Minnesotans, both city dwellers and small town people, experience when they seek medical care. And valid as these complaints are, we are in a way fortunate to be able to make them because in a lot of places in this country, many places even in this state, you can't complain about how long you sat waiting in the doctor's office. There's no office to sit in, no doctor to see. Physicians just haven't been locating in rural areas lately.

Dr. Robert Carter, Dean of the Medical School at the University of Minnesota Duluth.

ROBERT CARTER: The medical school here in the Duluth campus of the University was started by the regents, the university administration and the legislature, to try and do some very specific things. For many years, there has been a shortage of doctors in the rural parts of Minnesota. The metropolitan area has about 2/3 of the doctors to serve half the population. 1/3 are left for the other half of the people in Minnesota.

In addition to the shortage in absolute numbers, there is a very severe shortage in several types of doctors. This is most marked in the people doing general medicine or family practice. The number has been declining year after year in all parts of the country. Minnesota is no exception, and it's reached really critical proportions. The regents and the president of the university and everybody hoped that this program could both learn more about training people for this type of practice and could expand the total production of doctors by the university.

SPEAKER: By 1980, close to 400 freshman medical students entering training each year will be needed to meet the demand for physicians in Minnesota and to approach a solution to the problems of health care for rural parts of the state. Where those young people will come from and the kinds of educational experiences that will be provided them are questions being considered today in programs like the one at the Duluth campus and in the Rural Physicians Associate Program, which is operated out of the Family Practice Department of the university in Minneapolis.

ROBERT CARTER: First of all, we have to have students who are intellectually able and well prepared to do graduate work. There is no substitute for intelligence and proper application of this in a health science. In addition to this, however, we're looking at certain characteristics within people which we hope are going to be important.

For example, we know there has been a great migration of people from rural areas into urban areas in this whole country for many, many years. Fascinatingly, there has been really no counter migration. People born in the urban areas almost never go back to a rural area for a prolonged period of residence or work. There are a few exceptions, of course, but the odds are overwhelming that the people who stay in a rural area started there, or at least had some early experience in their life which showed them what it was like.

Many of the things in life that we do, we do too late. And as I think Joseph Conrad said in Lord Jim, there's never time to do the last thing or say the last word in anything that you're going to do. Never, I think, is this more true than in a person's training. If you start too late or if you count on last experiences, they more often than not fail.

As with our children, our own children, we simply don't realize that much of your life pattern is established very early in your life. What you feel comfortable with, what you understand, and what you feel has value are things which you experienced either as a preschool child or in your earlier years in school. Many of them, of course, were values which your parents transmitted to you consciously and often unconsciously. For this reason, we are very much interested in attracting people into this program who have had early experience in what life in a smaller community is really like. These are the young men and women who will understand it, and these are the people who can participate in it and do so comfortably.

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It is true that as knowledge increases as rapidly as it has been that we are seeing very, very strong forces towards specialization in every profession, school teaching, chemistry, medicine, so forth and so on, engineering. It is equally true that we must retain generalists in all professions, otherwise you have such a fragmentation of service and so little communication between specialists that the patient is in a hopeless maze. They really don't know how to sample or partake of things.

The real issue appears to center around what you can educationally do to keep a person as a generalist. You must not only start with the right raw material, but you must do everything you can to properly train them for this role. I think this is basically the university's interest in this program. It's an experimental learning model to find out as much as we can, under very carefully controlled circumstances, how to do this job of education. We may not succeed, but we surely are going to know why we failed very well if we do fail in finding an important advance in this.

I think, though, we probably will succeed more than we will fail. And it's already becoming apparent that anybody, be they a radio engineer or be they a professional actor or actress or this, maintains a general role, if they have a strong feeling of competence and ability in themselves, confidence in what they are doing, it has to be realistic. They can't think they can do things they can't, but a realistic self-esteem and confidence in their ability permits somebody to play a broader role. So what we're doing with these students is making sure that they learn, under as good circumstances as we can, the real concepts of the basic science they must apply to patients and that they will come out of this knowledgeable practitioners, confident in their knowledge, and willing to use it in a broader field of application.

SPEAKER: Betty Bowers and sister Mary Sue House are two young physicians in training in the Duluth Family Practice Program. They reflect on some of the situations they can expect to encounter in medical practice in a rural setting.

SPEAKER: If you have a problem and you need some help and you look around, there's probably two people that at least in a small town situation that you can go to. There's clergyman or there's your doctor. They don't have extensive counseling services, and they certainly didn't way back.

And if you were really stuck and you need help, you need some outside consultation, and somebody who's not necessarily personally involved, then you would have to come to one of these two people. And I think that's probably they came from. And then when you do have a lot of people's personal problems on your shoulders, then I think that, too, makes it somewhat of a barrier to getting to get more personally involved on a social level.

SPEAKER: I guess my concern is I think about it is, again, thinking about the other person that I'm going to be coming in contact with and that I'll be seeing in the hospital or will be coming to the office. And I think just being a woman, for one thing, is going to make some people uncomfortable because the traditional role is a masculine one. I think males, for example, are not readily at all going to be inclined to come to a woman physician. And that, again, is why I see another disadvantage for solo practice for myself.

And it wouldn't be able to be a partnership with other women. It would necessarily, I think, for the comfort of the people that we're trying to care for, it'd have to be some kind of male partnership in some way. I guess we've been warned by some of the women doctors here in town who have spoken to us that probably after the age of 12, we won't necessarily see any male patients until maybe around the age of 60.

So I think until women are more-- I don't want to say accepted, but seen as professionals in this area and people can be comfortable with either a masculine or a feminine physician, that it's the people that will just have to try and get used to it. And ourselves, we'll have to not take things personally either when people do not choose to come to us for one reason or other because women in medicine are still not that common, and particularly in family practice.

SPEAKER: The small town doctors that I know from when I lived in small town go to the Rotary Club, they do all those things.

SPEAKER: I'm going to cross that bridge when we come to it.

SPEAKER: And that's going to be interesting because a doctor in a small community has a very definite social position.

SPEAKER: I guess that's one of the things that I'm really impressed with, with my classmates, sometimes impressed, and sometimes I think it's maybe accentuated a little bit. But I think if there's a main theme in this group of people that I'm going to school with, the theme would be one that there is a strong emphasis of breaking out of that social role. Why should friends of doctors necessarily have to be exclusively lawyers, other professional physicians, or just other professionals of some sort?

Why can't they be just cross cut of all the people in town? Just we're people, you're people. Make friends that way instead of on a professional basis or a working career basis. So I think that medicine in general is maybe moving out of that kind of the doctor has a social role to fill.

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SPEAKER: From the 1920 novel Main Street by Sinclair Lewis, Dr. Will Kennicott talks about the problems of his role. "Do you realize what my job is? I go around 24 hours a day in mud and blizzard, trying my damnedest to heal everybody, rich or poor. You, you that are always spilling about how scientists ought to rule the world instead of a bunch of spread-eagled politicians, can't you see that I'm all the science there is here?

And I can stand the cold and the bumpy roads and the lonely rides at night. All I need is to have you here at home to welcome me. And I don't expect you to be passionate, not any more, I don't.

But I do expect you to appreciate my work. I bring babies into the world and save lives and make cranky husbands quit being mean to their wives. And then you go and moon over a Swede tailor because he can talk about how to put ruchings on a skirt. Hell of a thing for a man to fuss over."

SPEAKER: Anybody who gets to know me from here on out will be acquainted with the fact of what I'm thinking of doing. And I'm sure that cuts a lot of people out of the competition, [? because ?] I'm competition. But when you have your plans laid out, and although I haven't got extensive plans, my future is somewhat definite right now.

And anybody who gets to know me after this will necessarily have to include that in whatever they're thinking. And I think that, that way, a relationship would develop where we would not have that many problems. It would be somebody who would want to do the same things that I do.

SPEAKER: I think the girls, excluding myself, have been talking about the problems of possibly getting married to someone who was not earning the kind of salary that they were earning, and would this be hurtful to their relationship and what kind of problems could result from that. And I think these are all very practical things that, again, need to be crossed when the situation arises, and you really can't pre-plan any kind of an approach, I don't think.

SPEAKER: No, you can't. Pre-planning doesn't do anything because those plans are just so much fantasy up in the air. But the whole thing about people's maturity and things, and especially now, most of the people I know most of the males that I have come in contact with in school, here and in college, don't have a traditional outlook on life. You know, I'm going to be the man of the house, and I want a little wife that's home in the kitchen.

That type of thing is more prevalent now than, say, 30 years ago, I'm sure, although I wasn't here 30 years ago. I just have a feeling that it is. And the fact that many people have marriages where both spouses are working that work out fine, the people are happy, they're doing what they like to do, and neither one of them has to feel like he's being put on, and I think that that's the type of relationship it will have to be. And I think it's very possible. It's happening for lots of people.

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SPEAKER: And another sequence from Main Street, in which Carol decides to show an interest in her husband's medical practice. "'Don't I, in looking for things to do, show that I'm not attentive enough to will? Am I impressed enough by his work? Oh, I will be. I will be, if I can't be one of this town, if I must be an outcast.'

When Kennicott came home, she bustled, 'Dear, you must tell me a lot more about your cases. I want to know. I want to understand.' 'Sure, you bet.' And he went down to fix the furnace.

At supper, she asked, 'for instance, what did you do today?' 'Do today? How do you mean?' 'Medically, I want to understand.'

'Today, there wasn't much of anything, a couple of chumps with belly aches and a sprained wrist, and a fool woman that thinks she wants to kill herself because her husband doesn't like her, just routine work.' 'But the unhappy woman doesn't sound routine.' 'Her? Just a case of nerves. You can't do much with these marriage mix-ups.'

'But dear, please, will you tell me about the very next case you do think is interesting?' 'Sure, you bet. Tell you about anything that-- say, that's pretty good salmon. Get it at Howland's?'"

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Gopher Prairie, Minnesota, according to Lewis, had a population of 3,000, including the family of Dr. Will Kennicott. Sauk Center, Minnesota, the model for Gopher Prairie, still has a population numbering about the same. And for the last year, it has included the family of Dr. Michael Bess, who has been working with a local family physician, Dr. John Grant, through the university's Rural Physicians Associate Program.

Driving up Highway 10 from the cities and across the new leg of I-94 that stretches west from Albany, Dr. Bess looked out over the same prairie land, immense, vigorous, harsh, unsoftened, that Carol Kennicott saw some 50 years earlier. But he didn't view it through her eyes.

MICHAEL BESS: And I decided not to read it while I was here, either. I had a very great temptation to buy it and read it while I was here. But then I thought, well, I don't know, if I'd do that, then I might formulate some opinion that subconsciously, at least, that I shouldn't. So I may read it when I get back.

And I have no idea what's in that book. I've heard that at the time it was published, it wasn't very popular here. But now Sinclair Lewis is quite popular here, and there's a great deal of effort being made by this community to preserve Sauk Center and his boyhood home.

SPEAKER: Though he may not have come to the town knowing what it was like, Michael Bess knows Sauk Center pretty well by now. And the same might be said of family practice. His association with Dr. Grant has taught him a lot.

MICHAEL BESS: I think Dr. grant has been in practice in this town now for 30 years. And there are so many things that he has learned about dealing with people and dealing with diseases and injuries that could never, I don't think ever be written in a textbook. And yet here you've got first-hand access on a one-to-one basis.

And I kind of admire the fact that a guy like this is willing and able to help you with these things and to share. Really, some of these things are just real pearls when it comes to dealing with certain conditions and with certain people, say, in the community. He's seen Mrs. So-and-so or Mr. So-and-so off and on for the last 30 years and knows that this particular complaint, although it's not typical, is referable to a certain problem.

And of course, unfortunately, when you've just come out of training, if a complaint doesn't fit the typical textbook pattern, you kind of come unglued sometimes because that's not what the book says. And he'll be willing to say, I don't care what the book says it. It's really this way.

And you go on, and you progress it and you follow along. And darn right, too, it's really not that way, and you can do more for this particular patient if you follow his experience. And it's all the physicians here, too, not just Dr. Grant, although he is the preceptor.

But their generosity is really amazing. They're generous with their time and generous with the knowledge which you might say they've come on the hard way because you know darn well they didn't learn it in medical school because you didn't learn in medical school. And of course, it works its way down. Dr. Dubois Sr. was here before, and he I'm sure imparted certain things to these people when they were starting out. And there's some things that just must be passed on.

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When you first go into medicine, it's especially popular now, and I think especially true, that you say you're not going to be a deity. You're not going to be an image. You're going to be a real human being and relate to your patients on that level.

And yet there are certain patients who do not care to relate on that level and who will not relate on that level. And if you don't modify your thinking to take into view and into consideration the patient's feelings, you may have difficulty dealing with that patient. And the way medicine is set up, it's a quotes, "free market," end quotes. A patient can go anywhere they want.

And if you attempt to deal with a patient on a very human level and they don't particularly care to be dealt with on that level, you're going to lose possibly the continuing care of that patient, and some of the most important things that can be done have to do with continuing care. Acute medicine is very exciting and it's very rewarding, but sometimes the only way you ever get anywhere is on a chronic basis and to see the patient repetitively. And sometimes you never make a diagnosis until you see the patient maybe three or four or five times and get to the root of things.

You'll see just almost anything. I'm continually amazed at the things that walk-- or the things that come into the office in the course of an afternoon. Now, obviously, I'm talking about the patients that come into the office. But the way things present and the way people present and the diseases that they present in the office, many of the things are rechecks of, say, a follow-up, a three-month follow-up of a high blood pressure or something like that, or an OB check, something like that, and we see our OBs once a month. But many of the things that are just absolutely fascinating from my point of view, from a scientific point of view, and extremely interesting from the human point of view, sometimes I'll get enveloped engrossed in talking to a patient and spend maybe 45 minutes with one patient, and this just puts you behind. And then the next time you go out and look at your charts waiting for you, you could just fall over.

But at the same time, it's time that I think is very worthwhile. You've spent maybe 45 minutes with a patient, finding out things about that patient and having him relate things to you that I don't think would have come out any other way. And just sit there and keep digging into the things that are deeper than what they superficially appear.

As I mentioned before, it's not uncommon at all to have people come in with some very minor thing. And then after you look at that and reassure them that it's really nothing to worry about, the phrase comes out, the real reason I came here was to ask you about-- and then some very serious conversations go on and some very difficult times for some of these patients because it's obviously something that they're having trouble talking about. And if you keep your schedule right on that 10- or 15-minute basis, well, you're obviously not going to have time. You spent 10 minutes looking at the minor thing. You can't spend 5 minutes on what it is that's really bothering them.

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A lot of times you can help people simply by offering them the chair that's next to your desk, and say, this is the place you can come to-- let's say it's not a medical problem, but falls more into the realm of a family problem or something like that, because this is something you'll spend a lot of time with often, making it known to them that this is always available to them. And almost always, on the various levels of communication, you'll at first see a patient sitting in a chair very rigid, with their hand usually toward their face and their legs crossed, and in various posturings which are very tense. And as you talk to this patient and draw things out, things that have been bothering them, you'll just watch the posturing.

And sometimes I draw this to the patient's attention. I'll say, now, notice the way you're sitting now, and think about the way it was when you came in. And they always kind of get a chuckle out of that.

But a lot of times, the main help you can give is to reassure, or just to listen and try and help them figure out what's going on in their life because sometimes the most vexing problems can be rooted in the fact that one cannot sort out what is going on in one's own life. And we all have these problems. We have to sort out our own problems every once in a while.

SPEAKER: If Michael Bess hasn't found the same Sauk Center Sinclair Lewis knew and wrote about, it could be that the town has changed in 50 years. But more likely, the answer lies in the man and his experiences, both personal and educational.

MICHAEL BESS: After living in the city now for 5 years-- yeah, 5 years-- the little things really show up big. When we first came here, I remember, the first night we slept here, neither one of us could get to sleep because it was so quiet. And we lived near the freeway back in the city, so we had the rush of the freeway traffic and everything. And you just come to appreciate the seasons and just the scenery and everything. It is really great.

The people, the generosity of the people in a small town is almost beyond belief. And I'm sure that my position has had something to do with it. But even going back to my boyhood experiences in the similar type of town in Illinois, I can see that people are quite generous, and they're lacking many of the suspicions that people in the cities have. And it's really almost unbelievable how good people have been to us and our family here, and that has really made us quite fond of living in a smaller community, as well as other things.

But the people-- anywhere you go, I think the people that you deal with eventually turn out to be the most important things. And I'm not putting down people in the city at all. But I think that in the hustle and bustle sometimes, you do lose consideration for the next person.

You don't know him. You've got nothing to lose or gain. Here, you may not know the person either, but there seems to be more of a rapport and a generosity between people.

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SPEAKER: Excerpts from Lewis at Zenith-- A Three-Novel Omnibus, published by Harcourt, Brace, and World, New York. Music from the album The Red Pony by Aaron Copland, a Columbia Odyssey recording.

A Sense of Place was written and produced by Claudia Daly for Minnesota Educational Radio under a grant from the Minnesota Humanities Commission. Engineering by [? Glenn ?] Owen.

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