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Sandpoint

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Sandpoint is hands down the best WWAMI experience! You work with Dr. Charlie Crane who embodies the old-school internist of “doing it all.” He alternates working a week in the clinic with a week doing a hospitalist gig (and a little clinic thrown also) in addition to doing his own EGDs, colonoscopies, TEEs, intubations and reading his own ECHOs. I had hands on experience doing all the aforementioned procedures and also placed 2 subclavian lines and 2 tunneled lines plus several other procedures including an intubation! It was an amazing learning experience to work in a small town with limited resources and really improved my clinical skills.

Beyond the medicine, the outdoor opportunities here are endless. I skied 5 days (even though I was only there for one week when Schweitzer was still open), mountain biked, hiked and went on trail runs. In the summer, the lake is warm and there are ample watersport activities. The nightlife is also surprisingly busy for such a small town- I went to two different concerts and enjoyed hanging out at some of the local bars.

I cannot recommend this rotation enough! I will definitely be coming back to Sandpoint in the near future.

Susie

5 star review of the ANMC rotation!

The WWAMI rotations are a big part of what make our residency program special, and I recommend prioritizing at least one of these experiences during training. The ANMC rotation is an incredible experience that I would recommend to all comers, particularly those interested in specialty medicine. The people who work at ANMC are delightful, and the attendings (particularly Dr. Lovely and Dr. Gitomer) are so fabulous that they alone make the experience worth the trip. It was a fantastic month, both for my medical training and for my life experience. Since so many of the other posts go into detail about the rotation structure, amenities, etc., I’ll spend more time her talking about my personal experiences.

In the hospital: I spent my first two weeks at ANMC in the ICU and my second two weeks in outpatient specialty medicine. The ICU is a general critical care unit, so you take care of a combination of medical and neuro patients with all sorts of different pathology. This rotation is a great opportunity to do procedures (including subclavian lines); the attendings knew that I wanted to do as many procedures as possible, so even after I had gone over to the outpatient part of my month, the attending would come get me to place non-urgent lines. You see a lot of advanced pathology, and it’s a great way to start feeling comfortable with independence in the ICU setting. The outpatient specialty rotation was also tremendous. I rotated cafeteria style with several different specialties over the two weeks, but if you have a particular area of interest in mind, you have the freedom to focus your time. Alaska is tricky for delivery of specialty care, as the population is so spread out and sparse, so patients often fly 700 miles to come to Anchorage to see their specialists. This experience enriched my medical training profoundly, and I hope as many of you as possible choose to take advantage of it.

Outside the hospital: There is a lot to do in and around Anchorage, and I really enjoyed getting out of the hospital and going hiking, halibut fishing, sea kayaking, and getting to know the city. I was there during September of 2013, which is the rainy season in Anchorage. That time of year it was generally overcast/rainy and in the mid-50s, not unlike a slightly warmer version of a Seattle winter. Anchorage is a wild place, and I saw a lot of wildlife. Kinkaid park is a great place to see moose, but I also saw one in my attending’s neighbor’s yard one night. University Lake right next to the hospital has a nice walking trail around it and is home to a lot of beavers.  Potter Marsh on the south edge of town is a must-see, and you can frequently spot swans there. Alyeska ski resort is a short drive south of town if you like beautiful views of glaciers and the off-chance of seeing a bear.

Moose are everywhere in Kinkaid Park!

Moose are everywhere in Kinkaid Park!

This is Eklutna Lake, the water reservoir north of Anchorage, in late September, 2013, the day after the first snow was dusting the mountains.

This is Eklutna Lake the day after the first snow dusted the mountains.

I took this picture while sea kayaking in Kenai Fjords national park in late September, at the very end of sea kayaking season.

I took this picture while sea kayaking in Kenai Fjords National Park at the very end of kayaking season.

In short: go to Anchorage! Please feel free to contact me if you have any questions. I love talking about all the things I got to do and see in Alaska!

Rural Primary Care in Dillon

I had a great month working with Dr. McIntyre in Dillon, Montana. My month there was all outpatient, but the doctors all do several weeks of inpatient medicine a year so I think sometimes that is mixed in. The average day consisted of seeing about 10 patients in the clinic. There were typically 2 yearly physicals and the remainder were problem-based follow up. Dr. McIntyre definitely made an effort to get patients to follow up while I was still in town so that I could follow cases along. We suspected temporal arteritis in a patient while I was there and managed to get her to Butte for a temporal artery biopsy and get the results back all while I was still in town . I probably saw her 5 times during the month and I think that gives you a flavor for the type of devoted care that is given to the community. All of the patients were so nice and appreciative of the care they received. We also went into the hospital for personal visits to see Dr. McIntyre’s own patients and also to do procedures like EGDs. I also shadowed the orthopedist and OBGYN who worked across the hall for a few days as well. I think Dr. McIntyre makes an effort to let you do things like that if you are interested at all. It was never a matter if you seeing patients to “take work off of her hands” or anything like that, it was all catered to what experience you wanted and how to make that happen.

As for the Montana piece, I thought it was awesome. I had every weekend off and got to travel to Missoula, Bozeman, Livingston, Helena, and all the hot springs in between. For someone who had only driven through Montana, it was such a fun way to experience a new scenery and culture. I thought Dillon was a super cute and affordable community. The provided housing was great, the taco bus was delicious, and then there is the Patagonia outlet – which has new things on sale every week… Meghan Johnston can tell you more about because evidently she used to work there.

Anyways, go to Dillon!

Beaverhead Rock

Halloween in Soldotna

I had to pick a holiday to identify the season rather than saying that I spent a month in Alaska in that awkward in-between time after summer and before the first snows. A sort of weather that shouldn’t feel foreign after a year in Seattle. But that said, there was no lack of activity. It was perfect weather for jogs through local parks. Dr. Bramante’s sled dogs seemed just as happy to be hooked up to an ATV for a trot down the beach. (And I can’t help think pleased to cover me in mud in the process.) There were some beautiful views of the mountains from Dr. Kelly’s bush plane. Not to forget the title, the halloween celebration included my being pulled out of clinic to crawl through the local hay maze. Incidentally also teaching me why the docs tend to wear clinic casual.

I spent that clinic time mostly with Dr. Kelly and McDonald during a year when Dr. Bramante has been living the dream in Italy with his family. The patients were a representative sampling of the town and surrounding region ranging in age and background, but if I had to compare, remind me of the VA population. Living in Alaska takes a sturdiness that sometimes causes people to present late with disease. Young guys came straight from the “slope” oil drill, middle-aged folks boast about living without power in the wilderness, professional fisherman come with stories (and sometimes fish), and I was surprised at the number of zebras that showed up with them. While some are sent to Anchorage or Seattle for further work up, the majority are evaluated by the very capable crew of docs in town. Dr. Kelly reads all of the cardiac echos for the hospital and does a fair share of the colonoscopies and EGDs (I decided they’re just like playing video games).

All this I could have taken as a great experience making me more aware of the docs that practice “out there” far from where I might ever find myself. The more surprising and wonderful part was that I would love to go back. The practice in Soldotna is unique in that the docs there have trained and worked in big cities – most with stints at UW and UCSF – and made the thoughtful decision to continue an intellectual and progressive practice in a small town far from home. Whether by instinct related to living in relative isolation or just out of goodness of heart, the community is the most welcoming I’ve ever experienced. I got to know and spent time with the docs, clinic staff, their kids, friends of the family and even was on a first name basis with one of the grocers. It was hard to leave that kind of connection and even more amazing to think that these folks make it over and over with generations of residents.

Please drop me a line with any thoughts or questions about the rotation. Clearly happy to talk about one of my favorite experiences of residency.

Anchorage in the Summer!

Doesn’t get much better than Alaska in July/August when I was in Anchorage.  You get a sweet apartment that comes with a bed INCLUDED AND a rental car.  When I was there I split time between the hospitalists and the outpatient world.  My recommendation to people going there would be to skip the inpatient side of things (can’t speak for MICU) and do all four weeks in the ambulatory setting.  The hospitalists are all really cool but you will mostly be dealing with alcohol withdrawal, some CHF and CVAs.  The ambulatory setting on the other hand has AWESOME pathology and really super interesting medicine since people come from all over Alaska.  The general internal medicine model is super interesting there as patients are primarily followed by ARNPs, PAs, family med, etc for there general primary care needs and are referred to an outpatient internist for interesting/difficult cases.  You also have the opportunity to work with an Endocrinologist (who is awesome), nephrologist, dermatologist, GI doc, etc.  I spent a lot of time in GI and by the end he wasn’t even dressing up for the EGDs and I was doing them independently as they are mostly diagnostic scopes in patients who arguably don’t need them.

You will also get more time off and have earlier days to enjoy the endless sunshine.  Everyone gets a 5 day weekend and that’s the one I used to go to Denali where it was in the mid 70s, the mountain was out every day and I saw tons of grizzly bears, moose, and other creatures of the wild.  Do the coastal trail, climb flat top, go fishing, get a kayak and bike from one of the hospitalists and cruise around.  Let me know if you questions or need advice on what to do.

It should definitely be #1 on your schedule wish list.

ANMC MICU

I spent october of 2012 in anchorage at the ANMC MICU.  I had originally set it up as a split block: half MICU, half wards, but decided to just extend my ICU time once I was there.

It’s  a very interesting ICU to work in.  As always, spectacular nursing staff and respiratory therapists make ICU rotations some of my favorite.  They use pressure control instead of AC style ventilation as a default up there, which is a transition that was definitely useful if a bit challenging at first.

There’s an incredible variety of patients, ranging from the worst hyponatremia I’ve ever seen (Na of 98, a combination of beer potomania and schizophrenic polydipsia, wowza), to intense alcohol withdrawal, to the usual mix of sepsis and stroke management.

The opportunity to do procedures varies a bit based on the pathology mix, but even on slow days I would head across the hall to the OR and do scheduled intubations.  There was a nice mix of bronchoscopy, intubations, central lines, LP’s, and art lines otherwise.  Some people had much more procedural months than I did, I only did 3 or 4 of each of our internal medicine procedures.

The attendings come from all over, as they rely on a fair number of locums.  Dr. Madhani-Lovely is spectacular, and will force the residents to really justify decision making with an evidence base when she is on service.

The hospital itself is great, and the sheer splendor of alaska is literally breathtaking at times.   When I would leave the parking lot near sunset, I’d sometimes find myself waxing poetic and wishing for paints. The logistics of licenses and such can be a bit of a drag, so try to get started on those things way in advance.  In general, the people in the hospital are pretty motivated to help you out.

October in Anchorage

I spent this last October in Anchorage which was a great experience.  You are provided lodging in a modest apartment and a rental car.   October was a great time of the year to go, as it wasn’t too cold and there was no snow on the ground so exploring the surrounding areas was not particularly difficult.

I split my time between the hospitalist rotation and the outpatient clinic. The hospitalist I was paired with was none other than Ted Wright, former UW Boise track graduate.  I carried about 7-8 patients and admitted every weekday.  The hours were not bad. The case mix was bread and butter medicine (pneumonia, urinary tract infection, chest pain, DKA). One of the more interesting parts was discharge planning as the patients you take care of come from some very remote areas in AK.  In fact, they have a hotel in the hospital to stay at while you get outpatient follow up if needed.

The outpatient clinic experience was subspecialty medicine (renal, ID, pulm, rheum). The paired faculty are great and there was a lot of teaching.

All in all, a great month.

Four weeks in Livingston

Livingston in November

Livingston in November

I had the opportunity to spend four weeks in Livingston this November and it was great! I was expecting to have bad weather, but it was mostly sunny and the snow was just starting to fall. The hospital and clinic experience was so enlightening. My first day there in the ED, I saw a woman with a femur fracture, a child with urinary retention and another child with a BB up the nose– all things I had not seen in my first two years of residency! In all of these cases, you take the lead on evaluating and figuring out how you are going to treat it. Thankfully, the nurses are kind and helpful! The ER was busy, but it was so much fun.
My schedule was similar to that described previously– a couple of hours of hospital medicine in the morning and then clinic afterward. I did more general primary care this month than in all of my residency! It was exciting and refreshing. The patients really wanted to hear your advice and were happy with your care. I realized how much I had to learn. Dr. Wadle and his nurse are fun and cheerful. I would recommend this rotation to anyone who wants to see the complete spectrum of general internal medicine.

August in Livingston

I can’t say enough positive things about my experience in Livingston, MT! It gave me a great taste for rural medicine and was a nice balance between the inpatient and clinic worlds.

Clinical experience:

Livingston Health Center is a small hospital with about 25 medical beds and 4 ICU beds. The physicians and staff are a close knit group who are all extremely friendly and supportive. I worked closely with Dr. Wadle during my 4 weeks and had an amazing experience! UW trained, he is passionate about his work, extremely knowledgeable, and eager to teach. He clearly loves practicing rural medicine and is generous and welcoming.

On an average day, I showed up at the hospital around 7:30 or 8 to round on any patients on the floor or in the ICU. The number of patients varied, but ranged between 2-5 on any given day. The mornings might be filled with procedures like colonoscopies or stress tests. And then, clinic started around 9:30. The clinic is right next door to the hospital and during lunch, we sometimes ran over to check on patients. Most afternoons were filled with clinic, but once a month you accompany Dr. Wadle on nursing home rounds or rehabilitation center rounds. Every Tuesday, Dr. Wadle takes a 2 hour lunch to make time for a 5 mile run through the town to his favorite lunch spots, which I’d recommend definitely joining! Clinic offers ample learning opportunities and procedures (joint injections, biopsies, etc). As a rural medicine physician, Dr. Wadle often fills in where we would typically refer to a specialist.

One of the great things about the Livingston experience is that it is very flexible. Because there are a number of internal medicine doctors working in a group, you are free to do as little or as much inpatient work as you are interested in. I only worked one ER shift (essentially 28 hour call), but I saw everything from COPD exacerbation, symptomatic bradycardia, broken bones, screaming babies, and on and on. Working in the ER is a great experience because it is just you and the ER nurse covering 6 beds. Livingston is well situated in the sense that it is the biggest medical center to the North entrance of Yellowstone, so you end up seeing patients from around the world with a variety of medical issues.

Everyday Life:

  • Livingston Health Center rents a 3 bedroom vacation home for you, which is 1 block from the hospital and clinic and is very convenient.
  • Livingston is driving distance to Jackson Hole, Grand Teton National Park, Gallatin National Forest, and Yellowstone National Park. With most weekends off, there is ample opportunity for outdoor fun!
  • Livingston is a small town, but there are cute cafes and restaurants, as well as a farmer’s market. Also, Bozeman is only 25 minutes away and has a Portland feel with fun festivals, ethnic food and shopping.
Mammoth Hot Springs, Yellowstone National Park

Mammoth Hot Springs, Yellowstone National Park

Grand Teton National Park

Grand Teton National Park

Yellowstone Lake, Yellowstone National Park

Yellowstone Lake, Yellowstone National Park

Pine Creek Falls, Gallatin National Forest, Livingston

Pine Creek Falls, Gallatin National Forest, Livingston

Sunrise over Yellowstone National Park

Sunrise over Yellowstone National Park

Primary Care in Montesano WA (2hrs from Seattle)

I didn’t expect anything life-changing by doing a WWAMI rotation, but that’s what I got out of my time in Montesano, WA with Drs. Ki and Clara Shin.

They are a husband and wife duo, UW grads from 16 years ago, who have a fantastic tiny practice in a town of 4000. The experience changed my life because it opened my eyes to a completely different model of primary care than I’ve experienced at the VA (where I have my continuity clinic).

Thanks to Ki’s focus on “the big picture”, I had a chance to learn about the nitty gritty of how his clinic stays afloat (by looking at his quarterly financial reports, hearing about his business decisions regarding hiring PAs, how he handles billing for patients on medicare, how he designed the floor plan of his clinic to improve communication between staff) as well as some exposure to small town medicine (he does his own treadmill tests and places acupuncture needles in some patients with musckuloskeletal pain).

Ki hand-picked patients on his schedule who I would benefit from seeing. Specifically, he grabbed me for any procedure or interesting rash, and consulted me on the most interesting medical mysteries he faced. I have tremendous respect for the Drs. Shin with regards to fund of knowledge, patient rapport and interest in teaching.

I also had a chance to work for a few days in the local hospital and at another IM clinic in Aberdeen. Both of those experiences served to reinforce that Dr. Shin has set up an amazingly high functioning and rewarding clinic.

Ki and Clara are also remarkably generous. They lent me a car for the month, took me mountain biking and gave me eggs from their chickens.

So how was this life-changing? I’m actually thinking of going into private practice. Think that’s crazy? You won’t after seeing how rewarding the practice that Ki and Clara have set up for themselves. It’s a completely different career than I had been considering previously, and I’m excited to have Ki as a mentor to help guide me through it.

I can’t recommend Montesano highly enough for anyone who is into Primary Care.