Life in Community

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Life in Community

Money-Free Medicine: Where Doctors Don’t Charge and Patients Don’t Pay

September 10, 2018 by

Today we’re sharing an interview from the latest Plough Quarterly magazine about how healthcare works on the Bruderhof. If you’d like to watch the interview, here’s the video. If you’d like to read it, the published transcript is below.

Watch on YouTube.


What’s it like to practice medicine in a community where doctors don’t charge and patients don’t pay? Plough sat down with two Bruderhof physicians, Milton Zimmerman and Monika Mommsen, to talk about house calls, new technologies, the moments of birth and death – and why having fun is a vital part of care.

Plough: How did you get into medicine?

Milton Zimmerman: When I was four years old I had rheumatic fever. The doctor who took care of me came on house calls again and again, and he was such a friendly guy whom I enjoyed so much. I thought, “Hey, when I grow up I want to be like him.” That’s where it started. After Amherst, I attended the University of Pennsylvania Medical School, class of ‘54.

During medical school I found Jesus – or Jesus found me. That set a direction for my life, and I was looking for a church that really followed the Sermon on the Mount and Jesus’ life and teachings. That led me to become a pacifist. As a result, in 1957, when I was looking for a place to do my alternative service in lieu of going to the military, I chose the Bruderhof-run hospital in Paraguay. Two years later, my wife and I joined the community.

I practiced medicine for sixty years. All but two of those were as a family doctor working within the Bruderhof community – mostly treating community members, but also working at the local hospital and in the clinic treating migrant farmers nearby.

Monika Mommsen: I’ve practiced for forty-one years. Ever since I was little, I had always wanted to be a nurse – I grew up in the Bruderhof community. But in my senior year of high school, after I expressed my wish to become a member, the community asked if I would become a doctor, since they were eager to have a female physician. That came as a surprise, but I said yes and I’ve loved it ever since. After getting an undergraduate art degree I studied at the Albany Medical College, class of ‘75. From the beginning, Milton has been my mentor.

Monika Mommsen and Milton Zimmerman

Were there other women doctors in the Bruderhof community at the time?

Monika: Yes, two English women doctors had joined in England before World War II and moved down to Paraguay, South America, where they helped found a hospital. But they weren’t practicing much anymore. And Dr. Miriam Brailey, a pioneering epidemiologist who had taught at the Johns Hopkins School of Medicine, was also a Bruderhof member and a family friend.

MEDICINE IN COMMUNITY

Practicing in a Christian community like the Bruderhof, you are able to offer cradle-to-grave care. What does this look like?

Milton: Well, our care is better than cradle-to-grave – it starts six months before the cradle. Isn’t that right, Monika?

Monika: Often mothers confide in me if they think they may be pregnant. We usually see them in the office at twelve weeks when we can hear the heartbeat. Of course, we offer them best-practice prenatal care, and if there is any cause for concern, we’ll make sure a mother is seen by a qualified specialist. But one of the most wonderful things I can tell them is that actually there is so little doctors can do medically at this stage other than monitor – God is in control of this pregnancy. In a way, the fact that medicine’s ability to intervene is so limited before the birth can be a healthy reminder to focus on what’s most important: that here we are witnessing a mystery, the creation of a new life.

“One of the most special ­experiences is to see a new soul arrive in the world and hear that first cry.”

I’m usually present at the birth, which takes place very much in the context of prayer – and joy. That is one of the most special experiences, to see a new soul arrive in the world and hear that first cry, which is vital for the little one’s life really – to take that first deep breath of air, to cry.

Then I’m there for all the checkups and immunizations, and there may be the normal childhood events like bronchiolitis and ear infections, and later, teenage acne. Then I see them again when they get married and start having children. Recently, I’ve begun to see the grandchildren of people I first cared for as children.

Do you use alternative therapies?

Monika: No, it’s conventional, science-based medicine.

As physicians, you are also the ones present when people face a tragedy.

Monika: There are very hard moments – for example, accompanying a mother through a birth when she knows that the child is not alive. Yet it can be a very moving experience to welcome a child who was already taken, realizing that this child had very much value in God’s eyes and had already done its work on earth, even while inside the mother. Then it’s our privilege to grieve with the parents and do what we can so this is an experience their family, and the community, can share with them.

Every child, even an early miscarriage, has a message – certainly for the father and mother, but also for everyone who is involved. One’s reverence for life, for the preciousness of life, only grows as you get older, I think.

Outside of a communal way of life, medicine is typically practiced in a commercial environment: money flows between doctor and patient, between doctor and his or her employer, and from both doctor and patient to their insurance companies. What difference does it make to practice medicine without it being a monetary transaction?

Milton: When I first started practicing medicine, I had my own family practice in a semi-rural area outside Philadelphia. I charged $3.50 for an office visit and $5.00 for a house call. Can you imagine? But I was able to pay off my debts within one year and it was a lot of fun. You can’t get around it, though: the monetary transaction between doctor and patient is always there in the background defining the relationship.

“Technology is so often put at the service of money, not of the patient’s best interests.”

Here in the Bruderhof, it’s not there at all. Because we share a common purse, money is irrelevant to both the patient and me, and has no bearing on the care we give. That allows a relationship of full trust between doctor and patient to a degree that’s rarely possible elsewhere.

Monika: It frees us to care for somebody as a human being first and foremost. We get no pay, so whatever I do or don’t do doesn’t affect my income. In conventional medicine nowadays, doctors have to see twenty to twenty-five patients in a day, every ten to fifteen minutes, and there’s just no time that they can actually take to listen. Here we have that time and we’re not driven by economics. Also, the relationship between colleagues (there are about a dozen Bruderhof doctors), nurses, and staff is close because we have the same faith and are committed to this community. There are no employer-employee relationships between us.

Still, my practice is not just for community members. I also have patients from our neighborhood who don’t have money, and I always do it for free. I have such joy in doing that – it actually makes it easier to care for someone if there isn’t an economic reward system involved.

So this gives you the freedom to make house calls?

Monika: Absolutely. For example, I will often visit a mother at home with her new baby. You get an entirely different impression of both of them, and you have a cup of tea together and talk about how things like feeding are going – it’s much less formal. I’ll do the same if a mother has a sick child on the weekend, and certainly for patients who are getting older – after a certain point, I basically do not see them in the office at all – it’s just home visits. Of course, everything’s much more convenient in the office, but I think it shows care to come to someone’s home.

Milton: You also learn a lot about what’s going on – to see how the family interacts with the patient, whether the neighbors are supportive, whether the house is messy or too scrupulously clean.

Monika: If a patient needs to go to the emergency room or visit a specialist, we’ll often go with them. In these situations, our job is to be our patients’ advocates. Often the specialists are very surprised that the patient is bringing her own personal doctor, but generally they’re appreciative, and we certainly get much better care that way.

Monika Mommsen with a mother and newborn

TECHNOLOGY AND MEDICINE

Over the decades that you’ve been practicing, researchers have developed increasingly powerful forms of technology, from fertility treatments to experimental cancer drugs to life support that can keep people alive for years. What are your views on the technologization of medicine?

Milton: Rightly used, many of the new technologies can be a tremendous blessing. But so often technology is put at the service of money, not of the patient’s best interests. Medicine used to be a profession, but it has turned into a business – so openly, so blatantly. Mammon drives the so-called healthcare industry from top to bottom. (I won’t even talk about the pharmaceutical companies.) So the doctors end up ordering too many tests and treatments that don’t actually benefit patients. Insurance covers big operations and expensive drugs, but not the day-to-day care that would, for example, be of far more value to an elderly person than a dramatic intervention.

“There’s ­absolutely no conflict between asking God for healing while also using medicine.”

A related factor in the use of technology is doctors’ strong drive to overcome a disease – to “win the battle” by curing the patient. Again, in its right place this drive can help motivate us to do our very best to help someone. But it also can influence the doctor’s decision-making in a harmful way, where “winning” becomes more important than caring for the patient. For example, three years ago my daughter-in-law was dying of cancer. On her last visit to one oncologist, she was abruptly and curtly dismissed with the words, “I have nothing more to offer you.” The oncologist recognized that he could no longer “win,” and as a result ceased caring for the patient. She and her husband walked out feeling crushed.

But there’s always more we can do for a patient. I learned that early on after I started practicing in the community, when a mother brought in a child with a high fever. I checked him over – everything was OK; it was just a viral infection that would run its course, and the boy was in no danger. I said to the mother, “He doesn’t need antibiotics; there’s nothing more to do here.”

She put her hands on her hips and looked at me with a real scowl and said, “Is that all they taught you in medical school? What this child needs is aspirin, juice, and love. Don’t tell me there’s nothing more to do!” And she was right – we can’t always offer a cure, but we can always offer care.

Monika: Technology can give us the illusion that we’re in control. Yet as human beings, we have to accept that not everything is how we wish. For example, I’m all for helping a woman who has problems conceiving, but there comes a limit. How can it be right to use in vitro fertilization if it results in so many frozen unwanted embryos? Obviously, there are countless forms of medical technology that I am grateful for. But there is a time to step back.

A technology-focused approach to medicine also interferes with the doctor-patient relationship. I recently visited an eye doctor, and apart from glancing at me maybe twice, she spent her whole time on the computer. We’re losing the priceless value of examining, of touching a patient.

Milton: This subject was covered in a recent New York Times Magazine article about Dr. Abraham Verghese, professor of internal medicine at Stanford University, who described his own experience as a hospital patient. Too often the doctors and nurses were totally engrossed in the monitors and lab reports and imaging. He comments, “I received care but did not feel cared for.”

Monika: Even at the end of life when there’s actually nothing you can do because they’re dying – if they have pain, touch them, examine them. I learned the importance of this from my sister, who died a few years ago of metastatic cancer. When I examined her, she felt that I heard her and was listening to her, that I was legitimizing her worry. I would be honest and say, “Yes, the mass is growing.”

MEDICINE AND FAITH

Some Christians seem to feel there is a contradiction between trusting in medicine and believing in prayer. Do you see that as a conflict?

Monika: Not at all. I think it always has to go together. I often pray before I see someone, especially in situations where I don’t know what to do or am having difficulty, so that my frustration doesn’t show in my encounter but rather patience and love. It’s a prayer both for myself and for the patient, for peace of heart.

Milton: There’s absolutely no conflict between asking God for healing while also taking action using a tool like medicine. In the Lord’s Prayer we ask for our daily bread, but the fact that we’ve prayed for our food doesn’t keep us from planting crops and cooking in order to put meals on the table. We do both: pray and take action.

What about sicknesses that involve both a physical component and an emotional or even spiritual component?

Milton: Well, every illness or health complaint has what you might call a spiritual or emotional or psychiatric aspect – whether it’s a headache, asthma, cancer, or a serious infection. A person’s attitude toward an illness makes all the difference in the world. We may of course need medical help to get over the problem, but we can’t neglect the inner, emotional, spiritual side to it.

Monika: Chronic headaches or chronic pain often belong to the category we’re talking about – the tests come out normal, we can’t identify what’s going on, and we may not find a drug. Then we have to find a way to help such patients without labeling or mistrusting them. For them, this may involve learning to accept the pain, which is not an easy thing. We need to stand by them and believe them, because we don’t know their pain.

“We can’t abolish pain. It’s part of life, ­especially as you get older.”

Of course mental disorders are often not exclusively medical in nature. I’m reminded of one patient of mine, a young girl with anorexia, who definitely had medical issues that we treated. Ultimately, though, the most important thing I could do for her was tell her that I believed in her but that she had to be the one to make the decision to overcome her disease – nobody could do it for her. When she finally could do this, she made big steps forward in her health.

One’s attitude to life and to one’s ailments is extremely important. We can’t abolish pain. It’s part of life, especially as you get older.

FACING THE END OF LIFE

You’ve accompanied dozens of people as they face death. How do you approach telling a person that he or she doesn’t have long to live?

Milton: First and foremost, you need to be open and honest. We never lie to the patient.

Monika: And actually, we try to start that honest conversation earlier, before any diagnosis. When patients come for their routine checkup at age seventy or seventy-five, I will talk to them about the end of life. I’ll ask, “Have you ever talked with your spouse or family about your wishes? Have you thought what you want us to do if you suddenly become unable to communicate because of a stroke or heart attack? Do you want treatment in hospital, comfort care at home, or some other arrangement? Have you considered a healthcare proxy?” This conversation can lead to a meaningful sharing about life – often they haven’t thought about it or wanted to think about it, and this is an opening for them to do so.

Then when someone is diagnosed with a potentially terminal disease like cancer, we’ll generally meet with the patient as well as their family and a pastor. In these conversations, as Milton said, honesty is really important – also honesty along the road, especially as you get nearer to the end. Of course, we have no idea when someone will die, and I’ve become very humble about making a prognosis. But when you can see the end is close, tell the family openly – often they don’t realize that they may only have hours or days left.

I experienced it about twelve years ago with an older couple. The husband had almost certainly had a stroke and was very agitated; we couldn’t communicate with him anymore. I sat down with the wife and said, “I think your husband is dying.” She had such a shock, and then she said, “Thank you, thank you so much. I had no idea. And now I’m really going to spend every minute I can with him.” A week later he was gone.

Milton: It’s so easy for doctors to get wrapped up in the lab numbers and data, reports and consultations, phone calls and plans, treatments and drug doses; we can get so wrapped up in that, we forget to tell the spouse, “She is dying.”

Milton Zimmerman with a longtime friend and patient
Milton Zimmerman with a longtime friend and patient

What’s the place of palliative care?

Milton: It is different in every case, but we try to consider with the patient prayerfully: What does God want us to do here? How far should we go in pursuing aggressive treatments? If there are some good choices, we’ll go for them. But at a certain point, one of the jobs of the family doctor is to help the patient discern when a course of treatment could end up being more hurtful than helpful. The patient makes the decision, but it’s our job to give them the information they need.

I see some of our poor neighbors getting all kinds of invasive treatments at the hospital that are so fruitless and futile, and I just ache for the unnecessary pain they have to go through in order to die. To what extent does the profit motive on the part of the medical industry play a role here? You wish it wouldn’t, you hope it doesn’t, but the fact is that many of these desperate treatments are moneymakers.

Monika: It’s also not the case that choosing palliative care over treatment amounts to “giving up.” On the contrary, recent research suggests that often cancer patients who choose palliative care live longer and better than people who get chemo. Whether a patient decides to pursue treatment such as chemo or surgery or to forego it, I will support them equally.

“You need to learn to look at the whole person, not just the medical issue.”

In the end, as the New Testament tells us, death is the final enemy. All of us will have to face it one day. When the moment comes, it’s vitally important to surround the person with peace – peace between us as caregivers and patient, peace in the patient’s family, and peace in the community around them. If it’s someone who has lived a full life, it can be one of the most wonderful experiences, as difficult as it is.

Milton: That is so true. To be present at such a moment enlarges my life, my love, my love for Jesus. I’ll never forget a patient who died of lung cancer. On his last morning he looked out the window and saw Venus, the morning star. His son and I pointed it out to him: “Look at the morning star, how bright it is today!” And he looked over and saw it, and smiled, and died. Just like that.

HOW TO BE A GOOD DOCTOR

How have you changed in your approach to practicing medicine?

Milton: I’ve learned that serving people because you love them includes and surpasses all ideals of professionalism and humanist ethics. Too often, professionalism is a little like diplomacy: diplomacy is knowing how to tell lies politely, and in a similar way professionalism is caring for your patients as though you love them. Well, gosh, if you really do love them, you both fulfill and surpass professional standards.

Monika: I agree. When I started medical school, my father wrote me that I should do it totally as a service, in the same humility shown by the example of Jesus washing his disciples’ feet. Being a doctor should have nothing to do with one’s own ego.

Listening is really important. I’ve learned the most about mental illness from my patients – to understand what it’s like to suffer from depression. I had a woman in her forties who was bipolar and she told me what it felt like – a much better description than from a textbook.

I take much more time with my patients than I did at first. I try to have more compassion too. Don’t be so quick to judge them. Believe in the patient. Believe in what he or she is saying and asking about, even though it may be clear that it’s not actually a medical need.

What advice would you give to medical students preparing to practice medicine today?

Milton: Learn from your patients. Sixty-five years ago I was told in the second year of medical school: “Spend as much time as you can on the ward with patients. Don’t just get wrapped up in books.” That’s still the case, though it has been forgotten in some places.

“We as doctors are only helping along a process of healing that God is doing.”

Second, don’t be afraid to practice medicine in the context of faith – that opens up more doors and possibilities for healing than trying to practice medicine without faith. So have faith, pray, study the Bible as well as your textbooks, and don’t let technology become a barrier between you and the patient. Work with the family, work with the pastor and the church – the church community can be a fantastic web of social support.

Monika: Humility is essential. When you get out of medical school, you’re young and full of energy – and you’ve also had a lot of arrogance pumped into you, especially if you’ve done well academically. You’ll have to shed that pride, because humility brings compassion. You need to learn to look at the whole person, not just the medical issue. There’s so much more to a person than the medical side of things: the soul and the spirit, the whole social aspect of family.

And also: have fun. For instance, when someone comes with unexplained chronic pain: first of all, you have to believe the patient – but then, find humor! When they leave your office, they should go encouraged. I had one woman with a long-term mental illness, and my one goal each appointment was to have a laugh together. Another patient, an older woman with advancing Alzheimer’s, was my neighbor, so I saw her every day. At times she was very agitated, but if you could find something to laugh about, it always broke through the barriers of her disease.

Practicing medicine is an enormous privilege: to accompany somebody, to enter into their lives in a way that very few people can, except maybe a pastor. The longer I’ve done it, the more I’ve loved it. And I think I’m very lucky to have practiced all these years in a community that supports me in that.

Milton: In caring for someone, we as doctors are only helping along a process of healing that God is doing. Knowing that changes our attitude to our work – it’s what gives medicine its value.

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  • I am so blessed for hearing this beautiful true life story. As a Christian nurse, hearing Drs., speaking of Love, Compassion, Commitment. Their insight re the human condition, coupled with their living faith in and of Jesus, is just....., words I cannot find to describe as I write; tears are flowing, tears of joy I must add. I am so fortunate to have come across your web sight. Please, may ask that your Family remember me in your prayers. In the love of Jesus, Yours sincerely, Pauline R. Summerfeldt- Acworth.

    Pauline Rose Summerfeldt-Acworth