Rural rotation brings new life experiences

Submitted by Garon Coriz

During my first week of my rotation with the Northern New Mexico Family Medicine Residency Program at St. Vincent’s Regional Medical Center in Santa Fe, I had the privilege of being the first-assist on a couple of C-sections. My very first day on the inpatient service brought me into the operation suite within the first hour. It was such a treat to work with Dr. Manske and Dr. Bacon as they did a great job teaching me during the surgery. For the first time, I had the chance to place my hand inside the uterus and separate the placenta from the inner wall with the guidance of the doctors there – a moment that will live in my memory for the rest of my career.

Dr. Rigales gave me the opportunity to work with him in the newly created family medicine center. I received training in the EMR used in the clinics and saw a wide range of patients from sick children to senior citizens with chronic pain. His style of quizzing and teaching never put me on edge, and it was a pleasure to work alongside him. He really embodied the ideal family practice physician and I hope to model myself by his example.

Dealing with difficult cases
Dr. Chyorny helped me improve my communication skills by permitting me to see the more difficult patients in clinic. One patient had suffered a traumatic brain injury many years ago. The patients’ ability to communicate clearly had obviously been undermined with the injuries sustained. Not only was communication hindered, but also the general mood and affect had undergone major changes leading to a diagnosis of depression with occasional outbursts of anger. I found it extremely difficult to communicate with the patient due to their consistent perseverating – another manifestation of the brain injury. It turned out to be an excellent experience by which I was able to practice my patience, direct patient conversation, and tweeze out pertinent information. I found myself in good standing when Dr. Chyorny came in and had about the same difficulty as I did and retrieved not much more information than I had.

Sleep deprivation and being prepared to move quickly
In my last week, a 24-hour call provided me with a glimpse into how challenging residency, and medicine, can be. Dealing with sleep deprivation through the night after an already-long day proved quite a struggle. A major lesson reinforced by the experience was how intolerable snippets of sleep can be. Rather than getting three hours of sleep from six 30-minute naps, I think having no sleep at all might be best. I felt like I was operating with a flat tire in the morning and now I know how to avoid it.

On one occasion on labor and delivery with Dr. Rigales, a multiparous woman struggled through a fairly long labor. We had started her on Pitocin to speed up the process but it seemed not to produce the kind of acceleration we were hoping for as she had stalled at 6 cm. We left the room momentarily to write orders on the patient, taking only minutes. To our surprise, upon our return, the baby’s head started to crown. We scrambled calling for additional supportive nursing staff, bringing out the sterile equipment, and getting into position for the delivery. The baby came out completely with only two pushes. The experience served as a prime example of how things can accelerate to extreme speeds in multiparous woman in labor.

Outside of the work in the hospital and clinics, I also had to deal with the difficulties of still being based back in Albuquerque. Though I had a room in the home of family friends in Santa Fe during my rotation, I had to handle the problems that arose from moving out of my house and back in with my father in Albuquerque. In addition, unplanned trips back to Albuquerque were too common a problem (2-3 times per week) due to family health emergencies including cholecystitis, labor, and surgeries.

Overall, I believe I received a well-rounded taste of medicine in Santa Fe in the clinical setting as well as a hefty load of life experiences that have contributed a lot to my growth in medicine and life in general.

If you’ve had an experience in rural medicine from medical school and want to share your story, please use the Share Your Story link.

Patients are patients: A reflection on experience

Submitted by Wit Davis

During the month of January I had the unusual experience of spending my time working in medical clinics in rural Maine.  Although most people think that all of Maine is rural, leaving the major catchment hospital in Lewiston everyday to drive an hour northwest towards logging, skiing, and an extra foot of snowpack provided me with a few reflections on people, medicine, and the health of Americans.

A quick-fix pill
My first reflection on life in Rumford, Maine was that the people were about the same as anywhere else.  Sure, they weren’t really interested in going to the latest trendy restaurant, but like all people they were essentially good-natured and just wanted to live their lives without medical problems.  The reason I say without medical problems, rather than that they wanted to be healthy, is because unfortunately, like many Americans, several of the patients whom I encountered were utterly reliant on the idea that medicine would provide that health, rather than their own decisions and actions.  There was a strong reliance on the perceived quick fix of a pill, particularly for things like depression, and little desire to commit to take matters into one’s own hands.

I found this a bit fascinating at first, because I expected rough and tough “Mainers” to avoid diagnoses like depression, and therefore avoid anti-depressants.  Instead, I think the belief that Mainers are independent and self-reliant has actually been superimposed on the modern problem of depression.  Rather than being independent by living off the land, modern rural Mainers appeared far willing to take a pill that came with a diagnosis rather than seek conversation and the support they may find in counseling.  Or perhaps I’m reading too much into what is essentially an American problem – the desire for the quick fix which is often perceived to be a magic pill.

Access to resources
In this regard, medicine was not much different in Rumford.  People came in asking for quick fixes, doctors tried to offer other alternatives, and in the end neither party was completely happy with the final decision.  But overall, there were some differences to the way things worked in Rumford.  For one thing, most patients were unemployed or underemployed.  While most people had MaineCare for insurance, which seems to provide decent support for many conditions, it may have explained the reliance on medications over some of those longitudinal solutions.  For instance, a discussion about the need to eat healthier and find a way to work out – you can imagine the reaction to suggesting getting access to a cheap all season swimming pool in rural Maine for someone who can only do low impact exercise – will not go very far for a person living hand to mouth.  However, if we can prescribe a $4 medication that might help them address whatever health problem they’re encountering, that’s a solution, no matter that it’s not ideal.

All in all I think my time in rural Maine was not all that different from working in medicine in much of the U.S., unless of course I were to compare it to a nice suburban specialty practice in an affluent community.  I think it’s important to remember that the people in rural parts of the US are probably pretty similar to those in a lot of the rest of the country, and that they’re struggling with similar medical problems as well.  Perhaps it’s more important to make sure they have the resources that are available to many people in urban areas, and that we continue to educate Mainers, the same as Americans, that there are no quick fixes, not even in medicine.

If you’ve had an experience in rural medicine from medical school and want to share your story, please use the Share Your Story link.

A true rural rotation

Submitted by Amber van den Raadt, OMS III

I had the privilege of doing a one-month rotation at Hanford Family Medicine Residency Program in Hanford, California.  I feel that I have been given a very good perspective of residency life here in Hanford and I found that it’s far more comfortable than I imagined.  The residents were so nice to me and to one another.  I was glad to see that they worked as a team in rounds and lectures.

Respectful and welcoming environment
I was impressed with the relaxation of the learning environment and it really put me at ease for the process to come.  I was imagining this cutthroat environment with long hours and unreasonable demands on me as a student.  What I found was a respectful teaching environment where I had ample opportunity to express the knowledge I had already acquired, as well as ask questions and learn what I had not yet come to know.  My preceptor was so genuine in his teaching, both to me and to the residents.  I felt very welcome.

I was really taken aback one day while in a conversation with a 3^rd year resident and my attending.  The attending was discussing a case the resident had sought his guidance on, and the attending then turned to me, a mere 3^rd year medical student, to ask what I would do.  I was obliged to have been treated as though my treatment opinion mattered, even as a 3^rd year medical student.   I was equally impressed that I indeed did have a treatment opinion.  I was amazed at how far I had come in this medical school journey.   I realized that I am starting to gain confidence in the tasks of diagnosis and treatment.  It’s so refreshing to realize that all this hard work and study has paid off.

A true rural experience
I got a true rural health experience in that my preceptor actually worked at 4 different clinics at 4 different rural sites.  Thus, our clinic location changed each day.  I enjoyed the diversity that I was able to see in the 4 different clinics.  Between the staff and the patients, each clinic had a culture all its own.  However, my very favorite moments were when I would see a patient for a 1 week follow up.  I enjoyed the continuity of care and the ability to see them again and remember what I had learned the week before about their history.   There were some patients that had such serious health needs that I got to see them 3 times during the month.  It was great to get a taste of what it feels like to really know the patient and follow them over time. I kept thinking how nice it would be to have my own memory of a patient’s history instead of having to refer to another physician’s chicken scratch that I couldn’t interpret.  I got excited about someday having my own patients that I could follow over time.

This rotation served to encourage me about what lies ahead.  I’m impressed with the support of the residency program in encouraging the residents to follow their own path to learning.  I’m impressed with rural healthcare training and with the respect I have been treated with in this stage of my learning.  I think this is truly a rural benefit.

If you’ve had an experience in rural medicine from medical school and want to share your story, please use the Share Your Story link.

Full spectrum family practice in a friendly environment

Submitted by Leslie Bradbury

I recently had the pleasure of rotating at Central Maine Medical Center’s rural track program in Rumford, Maine.  I was struck by how much being back in a small town made me appreciate what I have been missing since I have been away from my own hometown in order to study medicine.  There was an excitement to teach that medical students tend not to expect, but feel as if they’ve won a contest when they experience it.  It was incredibly refreshing as a student, who often feels as an imposition or burden on providers, to feel as if the emphasis of the rotation was on the quality of the teaching and not purely on the ability of the student to self-learn.

Full spectrum care
At no other point in my medical training to date had I been exposed to true full spectrum care.  In brief, you would start the day by rounding on clinic patients who were admitted to the hospital.  The small hospital of twenty five beds and friendly smiles at every turn, removed the intimidation factor that larger hospitals have a tendency toward, which can interfere with learning opportunities. When finished rounding in the morning, we headed over to the clinic for the day to see patients.

I had the opportunity to see anything from well child visits and prenatal appointments to management of chronic disease.  There were various procedures scattered throughout my days consisting of skin lesion removal, colposcopy and IUD insertion or removal.  On one particular day a female prenatal patient was induced for postdates first thing in the morning, a full patient panel was seen during the office day with checking on the prenatal patient briefly during lunch, and finally delivering her little baby boy around six in the evening after wrapping up at the clinic.  That day left an everlasting impression of what full spectrum family practice could be.

Hands on training
If another physician I didn’t happen to be working with in the office had an interesting patient or exam finding, they would take the opportunity to come find me and allow me to experience the patient in person.  Enough cannot be said about the value in this for a medical student.  Countless times in the past I can recall a physician describing that unusual patient they had earlier in the day and how they wished I had been there to see and learn from the case.  Hearing about these patients and missed opportunities is not helpful in terms of learning and development of my medical management skills.  There is no replacement for that personal interaction with patients and hands on care.

It was clear that the members of the medical staff are more than just co-workers.  After just a few brief interactions it became obvious that they knew each other’s families and were familiar with and invested in their community.  I was able to observe how they were able to share this relationship with their patients as well while maintaining professional boundaries.  They were also happy to extend their friendliness to a medical student, genuinely interested in my background and living situation, always approachable and helpful with all of my questions.

Tailor-made rotation
I appreciated that I was recognized as a fourth year medical student and that my rotation was tailored to reflect that.  Although history taking and exam findings remained important, the emphasis was placed onto differential diagnosis and development of a management plan.  I was asked during various points of my rotation if the way it was being run was meeting my expectations.  There were multiple occurrences where faculty members encouraged me to share with them what more I was hoping to gain from my experience at a rural facility.   I am truly grateful for having had the opportunity to participate in a month of full spectrum rural medicine; it was worth the sacrifice of time for traveling.

If you’ve had an experience in rural medicine from medical school and want to share your story, please use the Share Your Story link.

A place like no other

Submitted by Alex Spencer

My favorite rural tradition
With a cold wind pushing sheets of rain and waves across the sand, I look up to see my family keenly looking down searching for the signs of razor clams beneath the surface. It’s 8:00 p.m. and overcast on Long Beach peninsula in Washington, and I finally get to enjoy one of my family’s favorite traditions, a night clam tide during a winter storm.

The evening usually starts with board games as we await the best time for digging, which is typically 2 hours prior to low tide, with tonight’s low tide being 8:45 p.m. Once the time arrives, we all bundle up in our hip-waders and rain gear so we can brave the elements in relative comfort. The final preparation is to grab a flashlight and a headlamp so we can see the dime sized holes in the sand that signal a razor clam.

It’s a 20 minute drive on the beach to our favorite spot on the 27 mile Long Beach, a huge spit of sand formed by sediment from the Columbia River carried north by the ocean currents. As we approach the destination we challenge each other for who is going to get the biggest clam, the fastest limit of 15, and biggest overall limit (which we weigh for sport on a digital scale to settle the score).

Once the truck stops, we boil out of the car and race into the surf as we all love the excuse to be out in the rain and waves doing something that many would find absurd. After we all get our limits (and I do mean everyone) we get into the truck dripping wet, cold, and laughing.

Rural medicine offers best of both worlds
This is just one of many traditions I can imagine rural born medical students could share that are totally dependent on a wilderness setting. During this holiday break it occurred to me that being removed from these activities, by virtue of going to school in the city, may be part of a unique challenge for rural students. If other rural students are anything like me, the urban environments where I have to attend classes are not my preferred location and can’t afford me the opportunities for recreation that I find most reenergizing. When I am able to get the chance to run away from the city and engage in some of the favorite country traditions of my family, it makes my enthusiasm for rural medicine all the more intense, dreaming of a future where I get the best of both worlds.

I hope all of those sleepy medical students, refreshed from their holiday break, get a chance to acknowledge why rural medicine inspires them, and seize the opportunity to indulge in it.

Warm wishes from the Pacific Northwest!

If you’ve had an experience in rural medicine from medical school and want to share your story, please use the Share Your Story link.

Rural rotation fosters appreciation for sense of community

Submitted by Virginia Hunter, OMS IV

As a fourth year medical student who is interested in becoming a rural family physician, I have been researching rural training sites for residency. For two weeks in October, l was pleased to be offered the opportunity to rotate through the Colville Rural Training Track which is associated with Family Medicine Spokane.

Established in 1986 as the first family practice rural training track site in the United States, this program has been used as an example for other rural residency programs in the country. The residency training track is located in Colville, WA, which is neatly nestled in northwestern mountains of Washington State. With a population of about five hundred, the medical facilities serve surrounding areas which are more rural even than the town of Colville itself.

Wide variety of services
The outpatient part of the program rotation is divided between three clinics, two in Colville and one in the neighboring town of Kettle Falls. Inpatient work is done at Mt. Carmel Hospital in Colville, which is staffed with more than the average number of specialists for a town of this size.

During my stay, the site coordinator Dr. Sam Artzis arranged for me to rotate with some of the physician educators and residents who participate in the program. On several occasions I worked with family physicians and residents in the clinic setting, and in the ER a couple of times. I also was able to work with an internist, an orthopedic surgeon and a dermatologist.

I was impressed with the main hospital facility, which is very modern with surgery units, an ICU, ER, labor and delivery services, and an obstetric unit. It was surprising and refreshing to find full obstetric services in a place this small. All of the staff physicians and nurses were very friendly and helpful. I felt at home in a very short period of time. In hindsight I wish I could have spent a whole month in the area.

A sense of community
Probably my favorite part of the rotation was the home visit to a sharp, but elderly lady who was a patient of Dr. Artzis’. I believe that the disappearance of the home visit was a detriment to those patients who cannot easily get out to their appointments, but still need good continuity of care. I was pleased to find the home visit still alive and well in Colville, as this is something I am looking for in a residency program.

Given the short period of time that I was in Colville I was really able to get a feel for the area and gain an appreciation for the sense of community in addition to learning about the rural residency program.

If you’ve had an experience in rural medicine from medical school and want to share your story, please use the Share Your Story link.

Finding the full spectrum of care

Submitted by Beau Links, OMS III

By the time I arrived at Mad River Family Practice (MRFP), I had already completed my required family medicine rotations. However, the physicians that I had followed previously served a predominantly adult patient base and I felt like I was missing a piece of the puzzle by not interacting with OB and pediatric patients. I was attracted to the family medicine residency program at Mad River because of their stated emphasis on continuity of patient care across settings and stages of life, as well as their high volume obstetrics practice, small resident to faculty ratio, and location in a rural setting. I had two weeks to spend at the Ohio State University Rural Family Medicine Program in West Liberty and I intended to get as much out of the experience as possible.

A warm welcome
From the very beginning I was impressed with the kindness and generosity shown by the program staff. Tara Wagner, the program director on site, sent emails before my arrival telling me about housing options (even offering her own home), outlining what to expect for the day to day schedule, and was genuinely interested in what I wanted to experience during the rotation. During my stay, l lived with Dr. McCreery and his wife, who were equally accommodating. It was not uncommon for them to take me out to dinner or welcome me along with them for a walk. They strived to make my stay in their home a comfortable one.

Full spectrum of care
I remember my first day quite clearly. In the morning I rounded with the senior resident and attended morning report. Immediately after, there was a scheduled C section, and then it was off to the office where I saw two babies for their well child checkups, three pregnant women for routine exams, and an equal number of pediatric patients and adults rounded out the day. It was fantastic. I was finally seeing the spectrum of patients I wanted to see. Each day was different than the one before, but one thing remained constant, and that was the variety of patients I saw throughout the day. I worked with a different physician each day and saw the full spectrum of OB to geriatric patients.  The time flew by – I hardly looked at my watch and when I did I was always surprised at how late in the day it was.

When it came time to sit down and write a review of my rotation for my medical school I struggled with what to write. Not because I couldn’t think of anything positive to say, but because I found it difficult to put into words the scope of my experiences during the two weeks. I ended my review with the following words, “If you want to see the full spectrum of family medicine, from OB all the way to geriatrics, spend quality time with patients, work with genuinely friendly physicians, and be treated as a peer, then this is the rotation for you.” I was excited to learn from the physicians at MRFP because they were excited about what they did. They were eager and enthusiastic teachers. In the end, I think the best thing to say about my experience is that the two weeks went by quickly and I wish I could have stayed longer.

If you’ve had an experience in rural medicine from medical school and want to share your story, please use the Share Your Story link.