Meet our Docs: Michael Miller, D.O., returns to Casper after training family doctors in Rwanda
By The Pulse Nov 18, 2013
Dr. Michael Miller recently returned to the University of Wyoming Family Practice Clinic after setting up family practice training programs for four years in Rwanda, East Africa.
Miller grew up in a suburb of Denver and became interested in medicine at an early age: “My dad is a family doctor, so I grew up around that. My mom was a nurse. We’d have conversations around the dinner table that would probably gross people out.”
The Pulse recently sat down with Dr. Miller to talk family medicine, Rwanda and training doctors to care for patients from birth to old age.
The Pulse: What got you interested in medicine?
Dr. Miller: When I was 13, I had a brain tumor – a cerebellar tumor. It was a low-grade malignant tumor, so they did surgery. I think that helped me to be interested in medicine. I just had a difference in perspective, I guess, having gone through that and being a patient.
And I have always been scientifically minded and curious. In college, I actually was studying pre-engineering. I decided to go back into medicine.
One of the things that I really like about medicine is the interpersonal part of it. It is an honor to be a part of people's lives when they are vulnerable and during momentous or life-changing times -- you know, births, diagnoses of cancer, and death of a family member. It is kind of a privilege to be a part of all that. I think that is what drew me into medicine, but particularly family medicine, because you develop these relationships with patients.
I like the variety of family medicine. We get to deliver babies, take care of people in nursing homes, and take care of entire families. I enjoy it.
The Pulse: I have read several articles about a shortage of family practice doctors. Why do you think there is a shortage, and where do you think some solutions lie?
Dr. Miller: I think there are different reasons. One is that family medicine is not a high-prestige position. It is not a high-paying position. So, very few medical students choose to go on to family medicine. I could look up the percentages, but it is a real small percentage of allopathic students. It is a little higher for osteopathic students.
Another cause for the shortages is that Obamacare is really a lot more primary-care based. There is need for a lot more primary care doctors, which there are not.
I do not know what the solutions are. You see an increase in mid-level providers, physician assistants and nurse practitioners that are filling primary care roles, so that is helpful.
The American health system is upside down. We should have a pyramid with a broad base of primary care doctors that then would funnel up to specialists and subspecialists. Instead, we have a system that is built on specialists and subspecialists, and primary care does not function in a way it really should.
You look at a country like Cuba, and they really emphasize primary care and preventative medicine in their medical schools. They call it “integrative medicine” instead of family medicine. They have an integrative medicine doctor and a nurse in every community, and then it funnels into a poly-clinic and up from there. This is a developing country, and they have the same health outcomes that we do in the USA, as far as mortality rate and all those indicators. There are no easy answers.
The Pulse: In 2009, you left Casper to set up a family medicine program in Rwanda. Tell us more about this experience.
Dr. Miller: I have always had an interest in global medicine. My dad was a doctor and growing up he was in a practice where every summer one of the doctors would go on a short-term medical mission for the summer. So I grew up helping with medical missions in Honduras, Dominican Republic, Ecuador, rural Alaska, Kenya …
The Pulse: What kind of things would you do?
Dr. Miller: Oh, you know, sterilize instruments, direct patients through the clinic. So those are really formative experiences, especially as a kid. I always had this interest in the cultures of developing countries.
In 2009, this opportunity came along to help build a family medicine training program in Rwanda through the University of Colorado.
The Pulse: Where in Rwanda were you?
Dr. Miller: We had three training hospitals in rural areas, and so I was overseeing all of those training sites and living in the capital, Kigali.
The Pulse: What were these hospitals like?
Dr. Miller: Well, very different. The ward is basically one big room, so there would be a male medicine ward, a female medicine ward, a pediatric ward, a postop ward. The patients are all in there in these beds two-feet apart all, and sometimes they would have to share a bed because it would get so crowded. Medical privacy was bad. Sometimes you would have a mom who just had a miscarriage or a still birth in the same room with all these other moms with healthy babies. They all seemed to be attuned to this, you know, and would help each other out.
The other thing is that the nurses were grossly understaffed and undertrained. If you are a patient in the hospital, if you have to have someone come change your bed, help you to the bathroom, bring you meals; that is problematic if you come from a couple hours walk away. So, there were actually stories of people who, not very often, would go unnoticed and starve to death in the hospital.
The Pulse: Describe the training programs you were setting up.
Dr. Miller: Family medicine students would rotate through all the different wards – medicine, maternity, pediatrics and surgery. Actually, because of the need at these rural hospitals, our family medicine residents were doing major surgeries like plating femur fractures, and things like that. They were the best trained to do that. They would do most of their training at the rural hospital and then maybe 15 percent of it at the referral hospitals with surgeons and other specialists.
The Pulse: What did the experience offer you as a doctor?
Dr. Miller: You learn to really rely on a thorough history and physical exam, rather than a barrage of laboratory tests and other diagnostics because they were just not available. They could do some lab tests, but it was only if the reagents were available and only about half the time. You did not do any cultures or anything like that.
The Pulse: How were patients different than those you might see in Casper?
Dr. Miller: The patients would not come into the hospital as readily because of a number of factors – it might be a money issue, it might be that the hospital was an hour's walk away. And they are just willing to put up with a lot more. For instance, we saw this guy who had been swinging his machete and dislocated his shoulder. When you asked him when it happened, he said three months ago. An older man fell and broke his hip and was hobbling around with a walking stick for six months before he came in. Chronic diseases like diabetes and hypertension are not diagnosed or treated until the patient goes into renal failure or has a stroke, and has an acute presentation.
The Pulse: What made you come back?
Dr. Miller: I guess the short story was our grant ran out. We were actually working under a grant from the CDC (Centers For Disease Control and Prevention). After 3 1/2 years, we said it was time to come back.
The Pulse: In medical school, were you ever tempted to specialize?
Dr. Miller: I cannot remember ever being tempted to specialize. I just think I have always been drawn to the relational aspect of family medicine, and, like I said, the variety of it. I think in family medicine you have to be willing to accept the unknown because we’re not experts in any of those areas. I think that bothers some people. I can see residents coming through and sometimes it is really hard for them to accept that they will never understand the EKG as well as a cardiologist, and that they will never understand diabetes as well as an endocrinologist because that is just the way they are wired.
In family medicine, we have the breadth of knowledge but not the depth. That way of thinking is not the way some people are wired. I was okay with that.
The Pulse: How does it feel to be back?
Dr. Miller: My job here is twofold: It is patient care but also training. I really like that about working with the residency – being able to invest in these young doctors, teaching them to practice patient-centered compassionate medicine, and to be aware of the global nature of the world we live in. Sometimes, you go to other settings to help out, but sometimes the world comes to us. We all come from different backgrounds, different cultures, and I think we need to be sensitive to that as we practice medicine.