This interview is excerpted from a 90-minute 2021 Awakin Call conversation with Demetrio J. Aquila III.

Cynthia: Our moderator for the conversation today with Dr. Demetrio Aguila is Ameeta Martin. Ameeta is a pediatric cardiologist in Lincoln, Nebraska. In fact, she has been the only pediatric cardiologist in that town of 300,000 people for the past 30 years. Although her specialty is in pediatric care for newborn babies and children suffering from congenital heart conditions, her patients continue to see her well into their adult years -- a testament to the deep care and relationship she invests in her patients. She will now introduce our guest and begin this conversation. Ameeta, over to you.

Ameeta Martin ("AM"): Thank you so much, Cynthia. I'm Ameeta Martin and I'm so thrilled to introduce and visit with our guest today, a fellow physician and now a fellow Nebraskan, Dr. Demetrio Aguila. Dr. Aguila is a surgeon based in Eastern Nebraska who draws patients from all across the United States, six countries and four continents to the clinic he founded, Healing Hands of Nebraska. Patients come to receive his innovative and life changing surgeries for chronic pain and other health challenges. But they're also coming for the compassionate payment option he offers, which we will dive into during our conversation. Dr. Aguila is also addressing the opioid epidemic associated with narcotics taken for post-surgical pain -- by offering alternative therapies and partnering with addiction recovery programs in a novel way. Before Healing Hands of Nebraska, Dr. Aguila spent 21 years in diplomatic, combat and medical missions across Afghanistan, Japan, South Korea and Eastern Europe. He is a doting husband and father of four children whose ages range from 4 to 13 years of age.

Thank you so much, Dr. Aguila, for joining us today.

Demetrio: Thank you for inviting me to be on this call today. I'm very excited to be here and I'm very humbled and flattered that we have this opportunity to chat.

AM: In your clinic, you created a compassionate payment program, M25 [where people can pay for their surgery by doing community service]. How did that come to you?

Demetrio: I spent many years in the Air Force, and much of the work that I did was taking care of military members and their families. But during my last deployment which was to Afghanistan, I spent most of that time doing humanitarian work, taking care of the local population. This was back in 2007 and 2008. And I remember watching the news, because we got satellite broadcasts of various news channels from the States. And I remember watching on the news every day and they would talk about how this many American service members died today. This many American service members were injured today, so forth and so on. And all we ever heard was bad news. 

But that wasn't what we saw when we were there in Afghanistan. And I remember so many of us being disheartened by the fact that they would talk about all these terrible things that were happening, but nobody was talking about how many schools we had opened up on that day. Nobody was talking about how many girls got to learn how to write that day; how many children got to go to school that day; how many people were fed that day and how many people were learning how to feed themselves that day; and then of course, how many people we had helped; how many people we had saved through our efforts and taking care of the local population.

We were set there. The primary mission was to take care of those who are battle injured. But when I looked back at the numbers as I was getting ready to leave, I did over 300 operations. Literally 95% of them were humanitarian operations on civilians that had nothing to do with battlefield injuries.

I remember thinking to myself -- I wasn't the only one that voiced this -- there were a number of us who had said this to ourselves on a number of occasions, "If I could just take the work that I do here and transplant this practice back in the United States, that would be awesome". Because there were really only two things that I didn't like about the work that we were doing there. Number one, I was away from my family. And number two, of course, I had to think about whether or not somebody was trying to blow me up. So obviously those things weigh on you, right? But if I could be with my family and if I didn't have to worry about the risks of injury -- that was a very fulfilling mission. And that's really what it was. It was a mission.

So since that time I've been asking, how can I do that again? I left the Air Force in 2014. So for the last seven years I've not been in uniform.  Or some might say I'm wearing a different uniform -- of a civilian's now. But I've been asking how can I do that medical mission work again?

Then on the other hand, there was this question of how do we help the underserved here in the United States? How do we help the poor? How do we design a mechanism by which people can get the care they need whether they have money or not?

I thought of these as two separate questions. For months I spent hours, countless hours praying about this and how we might take care of this problem, how we might take care of that one. And in the back of my mind, I was playing one of those little games, like so many other people do well -- which is to ask -- what I will do when I win the lottery.

The answer was that I'm going to set up one clinic to take care of people who are underserved. I'm also going to spend some of that money going and traveling to different places to help people like we did in Afghanistan. As I was praying one night in church rather fervently, it was as though God just punched me right between the eyes and he said, "okay, now is the time; here is the answer."

Really the concept of the M25 program came to me all at once. It was a fully formed concept. BOOM. Just like that. It wasn't a partial idea or a clue which I needed to tweak or make additions to. The whole concept was there in its entirety, ready to go. It was as if somebody said, "okay, here's your happy meal, go eat." It wasn't, "here is the recipe, go make it".  It was “here's everything you need to run with it.” In that moment I knew that this is what I have to do. My life changed at that moment. I realized I needed to change my practice structure. I need to figure out how we are going to implement this idea. I knew what the core was, the heart and soul of the practice. And I said -- let's build it, and let's follow the mission.

AM: You don't accept traditional insurance because you offer this M25 program. So you have a very transparent pay-for-service type option. Then, you have this M25 compassionate program option where, for a particular service or surgery, you offer patients the option to pay for that service by doing volunteer service.

Demetrio: That's correct.

AM: Everybody talks about financial capital, but we know that there's lots of different forms of capital -- like social, intellectual, cultural, and human capital. So how did you end up choosing volunteerism as your form of capital that you wanted people to invest in?

Demetrio: That's a great question. Thank you for that.

I am an Eagle Scout. I was a Boy Scout growing up and I was fortunate enough to have great mentors and great opportunities and had the chance to become an Eagle Scout. I just grabbed it and hung on until my knuckles turned white. There was always this sense of volunteerism that surrounded me. I also found that it was very fulfilling for me to spend some of my time helping others without expecting anything in particular in return. Just the satisfaction of knowing that I had done it was wonderful.

But it wasn't until I was much older that I realized that when you do that you're actually making an investment. In those people that you're helping. While you may not realize it and the people who you are investing in may also not realize that, the fruits of those investments will blossom if given the right circumstances.

As we were setting up this model, the question was asked, "why don't you just do this surgery for free?" And I thought about that. I did. But as a surgeon I'm a perfectionist. I want my patients to have every tool available to them in order to get the best results possible.

So I could do the surgery for free, but here in America what do we know about how much the average American values something they get for nothing. They typically value it about that much. So the question isn't about money. The question is how do you get somebody who has no money to invest in themselves. Because study after study has demonstrated that people who are invested in their outcome get better outcomes. And as a surgeon, because I want my patients to get nothing but the best results, I want them to have every tool available to them. By doing their surgery without that investment on the part of the patient, I'm taking away one of the most important tools for a successful result. I'm handicapping that person right off the bat. I have a sports analogy; let's say we take a star football player and tell them that they are really, really good. And that we are going to go out there and win this game. But I want you to wear a blindfold for the first half.

I'm not going to do that to my patient. So the question was how do we get these patients to invest in themselves. And that's really what turned it. My principle was as follows: I'm investing in my patients. I just want them to partner with me to invest in that. So, next we thought about how to do that. And, then this concept of volunteer service came in because at one point somebody had suggested that the patients could work in my clinic as a part of the investment. Similar to washing dishes in a restaurant to pay off a meal that you didn't have cash for. (laughs) I could have had my patients do that but that's not necessarily the approach that I want to take.

But there was a nugget of an idea. What if I partner with some non-profit organizations who are already accepting volunteers, and then we collaborate together in order to help them get the volunteers that they're looking for in order for this patient to have an opportunity to invest in themselves. And then to show the patient, okay, look, we value the investment you made. We're going to invest in you.

In a typical scenario we would have somebody come in who needed surgery. We'd say, "your surgery is going to cost X number of dollars." We also show them how much would this cost if they were to do this in a more conventional way using their insurance. Patients are often shocked about how much it costs when they have to go through insurance, when we show them all the overhead and all the different pieces. If you take that overhead out of the question, then you can reduce your costs and make it more reasonable. So patients see how there is a significant discount if we don't involve the insurance companies. But not everybody has that money.

So when a needy patient comes in, what I say to the patient is this, "okay, this is what I want you to do. I want you to go down to the Least Of My Brethren, which is a nonprofit organization here in Omaha (just to take an example; there are many such partners throughout the country) that helps get homeless people back on their feet so that they have homes and they have jobs and they get their lives back. I want you to go to the Least Of My Brethren and I want you to take this M25 card to them. They'll know exactly why you're there."

When the patient shows up, Least Of My Brethren calls me up asking what I need. I'll pick an arbitrary number. Let's say 400. They hang up the phone and they tell the patient that the doctor would like you to volunteer 400 hours of your time. Once the patient is done, Least of my Brethren calls me. Obviously don't do that all at once. But they've volunteered their time. As soon as they're done, they call me back and I ask to send them over. We'll take care of them. Then we do the surgery.

So what have we accomplished in that case?

Number one, the patient got the surgery s/he needed.

Number two, the patient did not incur crushing medical debt, which is responsible for more than half of all of the individual bankruptcies in the United States last year.

Number three, the patient is invested in his outcome. The patient is on some level thinking to him/herself that they just volunteered 400 hours of my time to get this surgery, and better not to mess this up because I'm going to have to volunteer more time in order to get it fixed. So patients, we've found, are much more likely to follow all their postoperative instructions and do what needs to be done so that they can make sure that their investment is not wasted.

Then on top of that, the charity that the patient has volunteered with has benefited from their work. The community, which the charity serves, has benefited from this person's work. And that patient, no matter how poor he or she is, has seen that somebody else out there is worse off and they have helped that person. So what does that do for them? Patient's dignity. What's that do for the patient's self worth? What does that do for their self-esteem? I mean it goes through the roof. To top all of that, my entire team has the satisfaction of knowing that we invested in that patient as s/he invested in themselves. We were able to do medical mission work right in our own backyard.

We didn't have to go to Zimbabwe. We didn't have to go to Venezuela, Vietnam, Timbuktu, you name it. We didn't have to go all the way across the world to spend all this money on an airplane ticket. And then all this time away from our families, we could do it right here with the people who are in need right around the corner. Neighbors helping neighbors. Who loses? Nobody. Who wins? Everyone. This is all a fully formed concept when it came to me.

So the question then arises, as I had one person say to me rather bluntly -- "well, you must hate quadriplegics or you must hate people with cerebral palsy."

I asked back, "What do you mean?"

He said, "Well, what about people that can't go and volunteer their time? You just hate those people?"

I said, "I'm glad you asked that question. I'm not so glad you asked it the way you did, but I'm glad for the question itself. I have a patient who has cerebral palsy. He is functionally a quadriplegic; he's bound to a wheelchair. He doesn't speak -- he is nonverbal. So he can't answer phones. He can't open envelopes. He can't do any of these types of things. But when that patient came to see me, how did he get there? Did he just miraculously appear in my office? No, somebody brought him and that’s somebody who brought him, loves him. Somebody at home is helping to feed him. Somebody at home is helping to make sure that he has clean laundry and somebody home is making sure that there's a roof over his head, and clothes on his back, and all of these other needs. Those people who love him, I'm sure would be happy to go just a little bit farther to make sure he has what he needs.” So through the M25 program, we have patients recruiting family members, recruiting neighbors, recruiting people from their community, even recruiting strangers to help them complete those volunteer hours.

So what are we doing in that case? In addition to all the things we talked about before, we're strengthening family bonds, we're strengthening communities, we're volunteering and investing in our communities and in people who have a need that is otherwise not being met. And what we've also found is that a lot of those people who volunteer, who maybe never had a history of volunteering, even after they've completed the hours for this friend of theirs or even for this stranger they'd never met before, they find themselves so fulfilled by that volunteer service that they continue doing it. I don't have the exact numbers, but the last time we looked, more than 10% of the people who had started the volunteer service continued even after the amount that we had asked them to do.

What are we doing then? We're fostering a culture of volunteerism, much like the culture that I grew up in, but one that I've seen fade over the years, as we become more urbanized and more disconnected from each other, for all the different reasons that everybody knows about. Therefore, we are fostering connections. We are fostering community. We are helping to grow the love of our neighbors. Through that love, a sense of sacrifice on behalf of those in need.

AM: How did your spiritual upbringing in that way lead to the founding of Healing Hands of Nebraska?

Demetrio: [...] Our M25 Program was born out of Chapter 25 in Matthew's gospel. And so, in that section, Christ talks to the sheep and he says, "You fed me when I was hungry. You clothed me when I was naked. You visited me when I was in prison. You took care of me when I was sick." And they say to him, "Lord, when did we take care of you when you were hungry? I don't remember seeing you when you were sick or when you were in prison. I don't remember clothing you when you were naked." He said, "These things you did for the least of my brothers, you did for me. Welcome into the joy of your Master's house." 

And those are the words that inspired our M25 Program. And that's the reason for the name the M25 program, because it's underpinned by the words of Christ in Matthew Chapter 25.

AM: Were there any specific formative experiences that you had that planted seeds for the kind of work that you're doing?

Demetrio: Absolutely. My father is a retired physician and I remember watching him, particularly when he first opened up his own practice, watching him go into work. He'd leave the house around 5:00 AM, often getting home between 8 and 10:00 PM. And then, sitting at the dining room table, doing more work until about midnight, and then he'd start all over again.

And I remember watching my mom. My mom said to me more than once -- she said, "you know, you should be very thankful for your father. He works himself to the bone." And I remember at one point, my mom reminds me of this, that at one point I -- well, my dad was at the table working, kind of took a close look at his fingers to see if I could actually see the bones poking out. And she would also say, "you know, your father, he sweats blood for you. So you should appreciate that." And I would look for that, too.

But the one thing that stands out more than anything is that no matter how hard he worked, it was never a burden, never once did he appear to be saddled with distress over what he was doing. It was always a labor of love. [...]

Much of that was anchored in his Filipino upbringing. Much of it is anchored in his faith, and my mother's faith, in God through the Catholic church. You know, I'm a cradle Catholic. I was born into a Catholic family and raised as a Catholic, And, you know, the concept of sacrifice is one that was core to our core, to our being, a core to our daily lives. And sacrifice not in the sense that you might remember from -- from those old Dunkin Donuts commercials -- you know, time to make the donuts, sacrifice out of joy.

That's one of the things that I remember about my father and his work and everything he did. There was always joy in everything he did. When we would go to church and I would see him pray very fervently or when he was praying at home before he went to bed, it was always a very, very profound prayer, but there was always this sense of joy that just exuded from him and it permeated the whole house. And I remember thinking to myself when I was younger and then throughout my formative years, "Whatever it is that I do, I want that joy. I want to have that sense of fulfillment that comes from carrying out the mission that I've discerned." 

If you had asked me when I was a teenager, I wouldn't have been able to articulate it that way, but in retrospect, I realize that's really what I was looking for.  I was looking for that mission, that sense of purpose, that meaning. Over the years of discernment and sometimes a lot of stumbling, it's become clear to me exactly why I'm here and what I'm supposed to do. I remember as a young boy, as an altar boy, spending hours in church helping the priests and thinking to myself, "These men, they have purpose, they have a mission, they have a calling. My father, he has a calling. My grandfather, my mother, my grandmother, all of the people that I love, they've discovered their calling and my goal is to find mine."

AM: The vast majority of physicians have to work through hospital networks that have these contractual insurance obligations. [...] For lots of physicians who would want to participate in similar type programs -- how would one even go about this?

Demetrio: You know, that's a great question. The number one reason I went into private practice was this program. I used to be part of a larger health system, and I actually had approached my employer and said, "Hey, can we set something up like this?" Because I was working for a nonprofit organization, and I said, "Can we do this?"

At first they said, "well, that's an interesting concept," but we found that there were lots of hoops we had to jump through in order to make it happen. And as you mentioned, there are lots of contractual obligations with insurance companies and with all kinds of regulatory agencies that occur. And it became obvious to me that the only way I was going to be able to do it was to just throw off the shackles of the conventional way of practicing medicine and build a practice around this program.

Now, a lot of physicians ask me the exact same question you did. And my answer, it's a little bit pointed, but I say this out of love. You know, we as physicians, as a group, are one of the smartest, if not the smartest, group of people in the United States. I find it very difficult to believe that if we were invested enough, that we couldn't put our heads together and come up with a solution that's better than the one that we have right now.

But there's one thing that prevents us from doing that. And it's, we are often afraid to try something new, to try something different, to think outside the box. And you know, when I was on CNN talking about this, I was asked, "what is your hope with this program?" I said, "Obviously I want to help all these people, but I'm only one person. And there's a finite number of people that I can help." And it's admittedly a small number in the grand scheme, right?

I said, "My bigger hope is that what we're doing would inspire other physicians, many of whom are a lot smarter than I am, inspire them to throw off fear, to not be afraid, to think outside the box. And to say, 'You know what? There's a better way.' And maybe the model doesn't work in my community in Oklahoma or in Manhattan or in, you know, in Seattle or wherever it is you might be living, but there's a community there near you that has a need, a need that you can help meet. And if you give yourself the freedom and the opportunity to really spread your wings and use them, that creative mind of yours that helped you get through medical school and residency and possibly fellowship, then you can do something in your community, which is just as revolutionary, if not more so.”

You know, I've been in medicine since I was 10 years old. And I know that sounds crazy, right? But as I mentioned, my dad is a retired physician, and I started working in medicine when I was 10 years old in his office. I would empty out the trash cans and I would scrub the toilets. And that's what I did. And through my years of high school and into college, I did every single job there was to do in a doctor's office other than see the patient. So now I've done that too, right? And so I've seen every piece of medicine.

And I will tell you, when I was 14 years old, I was the billing manager for my dad's office, okay? I did his billing for him. That wasn't because I'm some kind of mathematical genius. No! As a matter of fact, you know, there were a lot of people that did better than me in math at school. It's not because of that. It's because the system was simple back then. And, you know, I mean, if you'd like, I'm happy to share my insights and my experiences seeing how the system evolved from one in which a 14-year-old could do all the billing to what we have now. Because I think if you take a look through the lens of history, you'll realize, wow, a lot of these problems we have in our inability to take care of those in need is a self-inflicted wound. There's a way to heal that. But it requires, what I like to call, an approach which is radically unconventional. Most of us find that very intimidating.

But I would tell you that again, those of you who graduated from medical school, that was pretty intimidating too. I just got some statistics from Boston University, where I went to medical school, and every year they send us statistics telling you about the incoming class. Well, there were 120 spots, I think -- 12,000 applicants for those hundred 20 spots. Those are pretty daunting odds, right? And then, I remember our last day of orientation, the Dean of the School of Medicine got up and he said, "take a look at the person standing or sitting in front of you, take a look at the person behind you, take a look at the one on your left and the one on the right. One of you will not be here four years from now. Which one of you is it going to be?"

So again, you know you're one out of a thousand people. For one out of a hundred people, whatever, I can't do mental math, but those odds are pretty significant, right? So, you know, the odds of getting into medical school are small and then a certain number of those people, a sizable minority of those people aren't going to make it all the way through. Those are really intimidating numbers. Those challenges, in my humble opinion, as though I've ever had a humble opinion, are far larger than the challenges that we face today, trying to find a better way to deliver healthcare. Because we've grown accustomed to doing things in the way that we've been told, we're no longer accustomed to facing those kinds of odds again and just say, "you know what? Get out of the way. This is where I'm going. You can help me, or you can move, but this is where I'm going."

If we can recapture, rekindle that fire that we had when we were applying to medical school and applying to residency, if we could apply that to the challenges we face today, I am confident that physicians all around the country and all around the world would deliver healthcare in a way that's more affordable, that's more accessible, and that is higher quality than what we do today.

AM: That's very motivating. [laughing]

Demetrio: It's scary. I don't disagree; that's scary. You know what I mean? I can't tell you that I haven't had sleepless nights as a physician, trying to employ these things, these ideas.

AM: Well, the systems become so large. It just seems that it's almost impossible to take on as individual physicians -- and they've done a good job of making sure, you know, that there's systems above that control what we do, so therefore that they're trying to deny our individual voices in trying to change the system.

Demetrio: Exactly. But again, if we go back to our original discussion, when you applied to medical school, those odds were stacked very much against you. But I would guess that you weren't afraid. You said, "You know what? This is where I'm going, and this is what I'm going to do.” But you can’t get into med school, you could not have one of your classmates help you get into med school. You got into med school on your own -- obviously with the help of your friends and your family and your loved ones. But it was you that was getting into medical school.

We have an advantage in trying to redesign our healthcare system in that we can collaborate. We can team up as physicians to say, “there is a better way, and we're going to do this together.” We just have to choose to do so. That's the only thing that's preventing that from happening, is our commitment to doing that. And I know it's scary. I get it. Believe me. I have sleepless nights sometimes, but nothing worthwhile is easy.

And again, if we bring this back to the spiritual journey, I take comfort in knowing that this isn't my mission. I didn't come up with this on my own. I didn't say, "Ok, look at how brilliant I am. I am going to come up with this idea."  [...]

And so a lot of that stress that I used to have about this from thinking, “Oh, wow, I gotta do this all on my own” -- a lot of that stress is gone because I realized it's not me doing it on my own. I just happen to be the face of the program right now. And at some point, somebody who's better at this than I am, somebody who's smarter at this, will take the lead. They will say, “You've given us a good start. Let's expand this. Let's grow this even further.”

This interview is excerpted from a 90-minute 2021 Awakin Call conversation with Demetrio J. Aquila III. For more, read the in-depth full transcript, or watch the webcast below.