Video by Vickie Kettlewell

Osakis, Minn. — Dr. Susan Rutten Wasson sits on the corner of a bed in the cramped bedroom of Alice Johnson, a 91-year-old Osakis resident everyone calls "Grandma Alice." She's examining Johnson's arm, which is swollen, she's determined, because of a tight sleeve cuff.

Also in the room are Alice's daughter, Ione, and granddaughter, Anne, who lives downstairs in the farmhouse Johnson has occupied for decades. A Rottweiler mix as big as a Shetland licks the face of 18-month-old Sarah, Rutten Wasson's daughter, who sits on the doctor's lap.

It's more a scene from the days of frontier medicine than from the modern health care system. And that's because Rutten Wasson, 42, is a throwback to a time before HMOs, electronic health records and hospitals with fountains in their lobbies. She sees patients the same day they call if she's not booked up, spends at least a half-hour per visit — compared to the more typical 15 minutes — and usually charges only $50 for a consultation. She takes cash or check, but no insurance — and sometimes accepts gratuities of a dozen fresh eggs or a pie.

"I have a few bottles of homemade wine in the fridge from patients," says Rutten Wasson. "In summer, I'll get pickles or tomatoes. I've received pork sausage, the kind that would convert a vegetarian."

Rutten Wasson is decidedly not a vegetarian. She and her husband raise sheep and chickens she butchers herself. "Occasionally, I have people pay me more than my fee because they think I've earned it. It's nice. I don't complain."

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Dr. Susan Rutten Wasson heads out on a house call from her Osakis office. MPR Photo/Jennifer Vogel

In an era of high overhead, ever more byzantine regulations and payment models, cuts to Medicaid and Medicare benefits, and large medical systems swallowing independent practices, Rutten Wasson relishes her straight-forward manner of practicing. Since many federal health care reforms — such as those requiring electronic medical records — are tied to Medicare, they tend not to apply to her.

Her practice serves as a critique of the modern health care system, the complexity of which has pushed some providers and clinics to find dramatic work-arounds, despite the fact that it can be tough to make a living outside the mainstream. A small but growing number of physicians practice "concierge medicine," charging patients annual retainers for basic medical care. A 2010 nationwide survey commissioned by a congressional agency pegged the number of concierge doctors at 756, up from 146 in 2005.

Walk-in clinics are another alternative. MinuteClinic, for example, started in Minnesota in 2000 and has spread to 26 states. At these clinics, nurse practitioners and physician assistants treat a menu of common illnesses and injuries and perform physicals for reasonable, stated fees, no appointment necessary. Exams typically run between $79 and $89.

In rural Minnesota, where there are too few doctors to treat a sparse, aging population, being creative is both more possible and an imperative.

Compared to other doctors, says Rutten Wasson, "I don't waste anywhere near as much time on paperwork. Yes, I do other things. I take out my own trash. I clean my own instruments. I clean my own toilets." She prefers this to working within the insurance system. "I'm autonomous. I don't let third-party payers or clinic staff get between me and the patient."

Rutten Wasson asks Johnson questions about her arm and her hips and lungs, often repeating herself slowly and loudly, and checks various areas of complaint. Johnson has emphysema, likely from the wood-burning stove she used to heat her farmhouse. She's also, it turns out, allergic to mold and geraniums. Johnson had been misdiagnosed as having heart trouble, until Rutten Wasson made the proper call seven years ago.

"When mom was doctoring in [Alexandria], she was popping nitro tablets like crazy," says Ione, who notes that her mother used to dislike seeing a doctor but now looks forward to it. "Then we met Dr. Wasson and she figured out it was her lungs. Dr. Wasson will dig and dig until she finds out what's wrong. We can call her anytime if we have a question and we are not going to get laughed at. We love her."

Rutten Wasson hails from Michigan, where she attended Wayne State University School of Medicine in Detroit and did rotations at Detroit Receiving Hospital. There she got a crash course in trauma medicine. "I started my residency with an enormous amount of clinical experience," she says. "I was very well prepared." She did her post-graduate training, specializing in internal medicine and pediatrics, at the University of Minnesota. Her first job as a physician was with Allina Hospitals & Clinics in the Twin Cities.

It didn't take long before Rutten Wasson became disenchanted. She was shocked to learn how much money the clinic brought in. "They made four times what they were paying me. I looked at that and thought, where is the money going? Rent can't be that high. I had the most hideous art and ugly furniture. My assistant wasn't paid that much. Where is it all going?"

She answers her own question. "It was going to administration, tiers and tiers and tiers of management, all of whom were busy making rules to make them look busy. Mostly they made my job more difficult."

What bothered Rutten Wasson most, though, was that she couldn't give a break to patients without insurance. "It's hideously unfair that uninsured people are given a bill for $375 and are expected to pay the whole thing, while the insurance company pays between 60 and 75 percent. It's not right. People without insurance are subsidizing people who have it.

"I view medicine more as a ministry than an industry," she says.

She stayed at Allina for two and a half years before opening her own practice in 2002. "If you are going out on your own, you need to know what you are doing. Also, I had to save up some money." She says her colleagues told her she was nuts. "They were sure I wouldn't last," Rutten Wasson says. "And here I am, nine years now."

Rutten Wasson was drawn to Osakis because Todd County, like many rural Minnesota communities, lacks physicians, with just one primary care doctor per every 727 people. Also, her dad, a farmer who worked for a pharmaceutical company, grew up nearby.

She practiced out of her home, her kitchen doubling as a waiting room. But then she got married and wanted to start a family. With the help of a real estate agent who is also a patient, in 2007 she settled on a converted gas station in town for an office.

Her clientele are people who can't or won't go elsewhere: people with no insurance or high deductibles, people looking for second opinions, Amish people and Latinos. Rutten Wasson, who speaks "medical Spanish" with ease, serves immigrants working in the area's dairies and meat packing plants. Other patients come from as far away as Bemidji and the Twin Cities, she says.

By Rutten Wasson's lights, they're drawn by a desire for privacy and because she listens and thinks independently. "Right now, the push with the third-party payers is, conformity equals quality. That works if you're building piston valves. But people are not all the same. You want every car to be the same. But with patients, one person is a Volvo and another is a Civic. You might have a Rolls Royce in there and maybe a Model T. I'm customized and personal. That's why people like to come here. I don't do the same thing for everybody."

If there is a case or condition beyond her capabilities, she refers the patient to a specialist — she keeps a list but drops a doctor from it if she hears two complaints — or a nearby hospital. Sometimes, though, she has no choice but to fix what's in front of her, especially given a clientele that's sometimes wary of official medicine.

"I had an Amish patient come in who had caught his finger in a wood stripper," she recalls. "His bone was sticking out. His father had brought in a potion made with black walnut extract. He was convinced it would make the finger grow back. I thought, I can't let them go because they won't go to the hospital. So, I got out a sterile nipper and I cut the bone off and rearranged the flesh on the end of it. I let them put some magical potion on there. I checked on him two days later and it was so much better already. The finger looks good now. The fingernail even grew back."

She says the same man returned later with glass shards in his eyeball, which she picked out one by one. "I wasn't comfortable doing that either. But the next day he went to church. His eye felt fine. If he'd gone to the emergency room, they would have called in an ophthalmologist or transferred him and it would have cost him a small fortune. I charged him $60. He paid me $5 extra, I suspect."

"Mostly what I do is think for people," says Rutten Wasson. "It's my brain that is my best tool." She doesn't overmedicate, believing the body can do a lot of recovering on its own. She ascribes the medical system's reliance on prescriptions and procedures to the profit motive. "Actions get paid for," she says. "Watchful waiting and follow-up doesn't pay diddley squat."

Rutten Wasson's practice hasn't made her rich. She leads a modest life on a fixer-upper farm with her husband, Rud, who is a Lutheran pastor, and their daughter Sarah. Yet, she says, "I'm not going to raise my rates. Some of my patients are on medical assistance or on fixed incomes. They couldn't afford to come if I raised my rates. I'm not going to be buying a yacht anytime soon. But we're comfortable."

"I look at what my patients make and I think I'm doing pretty well," she adds. "Doctors of yore used to be lower middle class, until third-party payers came into the picture. I'm a great deal happier doing this, even if my husband doesn't have the latest Nintendo."

After more than an hour at Alice Johnson's house, Rutten Wasson puts on her wool cloak while Ione writes a check. Johnson insists on giving Rutten Wasson a couple of hand-sewn black and red pot holders that match the doctor's kitchen. When Sarah was born, Johnson made her a black stuffed dog, which she delivered in person.

"If she ever went away," Ione says, "the whole community would really miss her."

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