Soldotna or Bust!

I had the pleasure of rotating in Soldotna in late September-October 2017 and it has been a dream! One of the best experiences of residency by far. I came to UW hoping that I would be able to do a WWAMI rotation in Alaska and it has vastly surpassed my expectations.

Like other residents have mentioned, your work in Soldotna is at an internal medicine clinic that functions like a referral center.  You see an incredible breadth  of primary care. In my month, I’ve diagnosed myasthenia gravis, carcinoid syndrome, in addition to managing pulmonary hypertension and post-CVA care after a 30 year old had an embolic event from an atrial myxoma.  It has been quite the learning experience and has solidified my decision to go into primary care!

The doctors here have incredible work/life balance. Dr. Bramante and I would often go on long runs together after work and go dog-sledding. Like other residents have written, there’s a ton of outdoor activities to do on your three days off per week! My favorites included hiking on glaciers, watching sea otters in Seward harbor, and seeing grizzly bears fishing in the wild (though also terrifying!).

For those of you lucky enough to come to Soldotna, good luck exploring the 49th state!

Courtney Tuegel (R3)

 

Soldotna

I am writing this from Soldotna, where I am wrapping up a really great month here. This is a great rotation, which I would sum up as a superb and unique primary care experience with plenty of time to explore one of the most beautiful places on earth.

Clinically you work primarily with Dr. John Bramante, a former UW resident and chief, and see patients with him at a private group practice affiliated with the major hospital for the Kenai Peninsula. He is great to work with, and extremely knowledgeable and supportive. Because this is a rural site with limited access to specialists, you get to manage a very wide range of medical conditions and often patients are referred from PAs/NPs or family medicine doctors with interesting problems or diagnoses. There are also plenty of people with bread and  butter medical issues who are presenting for their annual visit and need someone to work with them on their DM, HTN, CAD, etc and tweak their medicines. The best part is that the schedule is set up so that you can usually take your time to really talk to the patients to get to know them a bit and do good counseling and education.

The hours are very reasonable and flexible, leaving lots of time to explore. My month here has been in September, and the days are still really long. On the weekends I went to nearby Homer (1st picture), kayaked to and hiked on a glacier (2nd picture), went white water rafting on class IV and V rapids, and did lots of superb hikes. The third picture below is of a beach that is 20 minutes from the apartment here, and on nice days the sunsets are amazing and there are firepits to have bonfires.

This is a special place with really good doctors, warm and welcoming people, and stunning scenery. Check it out!

wenatchee

From a professional standpoint, I think this is a good rotation. Dr. Smith (the oncologist who both runs the practice and coordinates with you) has made sure the rotation is well-organized. The 5 attendings all seem to enjoy working with residents, and the workflow is very straightforward. I’ve seen a good variety of general Hem/Onc – I would estimate my patients have been approximately 5-10% benign hem, about 30% leukemia/lymphoma, and 60% solid oncology (breast is most common, but they see everything including GYN onc). Especially in comparison to the UW inpatient Hem/Onc rotations, it is refreshing to see how upbeat and generally happy the outpatient oncology world is. Having spent most of my medical training in academic hospitals in cities, this was also an interesting window into community medicine. 4 days a week are spent in Wenatchee and you spend the 5th traveling with an attending to clinic in Moses Lake.

Work-life balance here is also good. Like most ambulatory blocks, weekends and holidays are off and rarely am I in clinic past 6 PM. The logistics of the rotation itself are easy – they take care of most of the paperwork/ID badge stuff, an apartment is provided directly across the street from the clinic, and it is not a far drive (2.5 hrs) from Seattle. Nestled in the foothills of the eastern Cascades, the town is beautiful. It is surrounded by foothills on all sides and the Columbia and Wenatchee rivers slice through town. There is lots of great Mexican food (for a city of 30,000 people, there must be 20+ Mexican restaurants). There are all the typical Cascasdes outdoors activities (camping, hiking, mountain biking, climbing, skiing/snowboarding) which tend to be less crowded than in the Seattle area. Leavenworth is just 30 minutes away. For a WWAMI rotation, the ease and convenience of the rotation cannot be beat.

ICU at ANMC in Anchorage in June

Anchorage, Alaska. Home to bears, moose, liver dialysis and abundant subclavian central venous access. I chose to spend all 4 weeks of the rotation in the ICU and would definitely recommend the experience (although I hear that residents enjoy their time with all specialties up here).

At ANMC all critically ill patients end up in one unit under the care of the ICU team, so you will see patients admitted with trauma and other “surgical problems” (NSTI, ICH requiring craniectomy etc.) in addition to the things we are more used to managing. If the variety doesn’t interest you it’s possible to pick up only the more classic medicine patients, but you will at least have the opportunity to manage a broader spectrum of critical illness. You will probably get to do lots of procedures (all manner of central lines, bronchoscopy) and intubate relatively often if you are so inclined. A more unique thing you will see here is MARS “liver dialysis” which gets used for acute liver failure and Tylenol overdose. The attendings and other hospital staff are very friendly and a lot of fun to work with.

At least in the summer there is lots to do here, four weekends is just not enough time to see all the cool stuff in the area. The hiking/wildlife is incredible. Homer and Seward make great weekend trips. This also seems like the place to be if you like fishing.

real sign at Kenai Fjords National Park
if this kind of bear attacks you, fight back
If this kind of bear attacks you, only fight back if it literally starts to eat you
seriously though, get bear mace if you are going to be hiking here in the summer
moose chowin’ down at Kincaid park

ANMC/Anchorage!

I spent May 2017 in Anchorage and had a great experience at ANMC. I ended up only having 3 weeks there and did 1 week in the ICU, 1 week in a mix of clinics (Rheum, Endo, Pall Care) and 1 week of ID consults. In general if there for 4 weeks I’d recommend 2 weeks in the ICU to get the hang of it and a range of experiences and I think the staff there prefer it for some continuity. Schedule in the ICU was M-F 7am to 7pm for sign out (able to leave early some days). I worked with Dr. Worth who is great and trained at UW! I also really enjoyed the clinic experience – great way to learn more about the native health system and how subspecialty care is delivered to such a broad geographic area. Great teaching too and pretty relaxed schedule. Lastly ID consults was great with really interesting cases and fun attendings who love to teach. I was initially given a pretty short list of options of what to do but when I got there but I found that people were happy to have me in most clinics and if you ask they will make most things work.

As far as Anchorage itself it’s a very livable small city and easy to adapt to quickly. People at the hospital were all really welcoming and eager to provide recommendations for what to do and see. May was a fun time of year there as spring was really just starting but days are long. Be sure to check if hikes in the area are still icy/snowy! For housing AirBnB worked well to find a spot – midtown isn’t the most attractive part of town but halfway between downtown and ANMC. Start housing search early if you want to do a monthlong rental especiall in summer/spring. Enterprise renal car through UW also very easy to do.

I loved visits to homer (halibut fishing!), seward (kenai fjords tour/kayaking), hikes around anchorage (power line trail, eagle river nature park, flat top).

Portage Glacier Hike, at end of Whittier Tunnel
View of Anchorage from Earthquake Park
Otter enjoying Seward!

 

 

 

Soldotna!

The Soldotna rotation was amazing and I would highly recommend it! I was there this past April and had a blast. I worked primarily with John Bramante who is a former UW grad / chief and all around an awesome doc. Good learning in a relaxed environment with opportunities to manage a broad scope of problems. For example, I had a chance to evaluate and manage new hep B, hep C, sarcoidosis, Addison’s disease, possible carcinoid, and a variety of malignancies. You can learn more about doing endoscopy, echos, and stress tests. There is a good mix of conferences. Overall, this rotation has great work/life balance and there is plenty of time to explore Soldontna and surrounding towns. Scenery is breath-taking and there are hikes galore. See rave reviews by other residents as well.

View from backyard of the apartment.

Kenai coast line 

Get Sold on Soldotna!

Spent an incredible 4 weeks here in September/October, and can’t recommend it enough!

You work 4-5 days a week at Peninsula Internal Medicine, an independent practice with 5 MDs and 2NPs but right across the street from Central Peninsula Hospital where you’ll go for some procedures, ECHO reading, and of course, free lunch. You work predominantly with the legendary Dr. Bramante who is an incredible internist and even more incredible human being. Most of my experience was outpatient, alternating seeing patients with him on one of his normally scheduled clinic days. The patients are super interesting from both a social and a medical perspective (you see a fair amount of the standard T2DM, HTN, CAD, COPD/combo of the above but I also diagnosed/helped manage things like IPF, polymyositis, HIV, CML, aldosteronoma and a host of others).  I also spent time working with some of the other physicians in the group including Dr. Kelley, Dr. Pokorney and Dr. Mitchell and even got to do some outpatient clin ed with the med student who was there at the same time. Overall everyone is super awesome, friendly, and smart and all are supportive of you doing the things you want to do and having the experience you want to have. This includes doing a week or two of inpatient if you are so inclined.

Soldotna itself is awesome, as is the Kenai Peninsula in general. Your drive down is breathtaking and just the beginning – activities are limitless! Make sure to spend at least a day if not a weekend in Homer, a beautiful town surrounded by magnificent mountains and nonstop views, good food, and cool art shops. Also journey over to Seward, where they have a nice little aquarium, kayaking in the summer, and you can take a short hike right up to the edge of Exit Glacier. So many amazing hikes and areas to explore like the Skilak wildlife refuge, North Beach in Kenai, and Cooper’s landing.  I was also lucky enough to be there at the right time to go Halibut fishing with the Kelley’s and no doubt JB will invite you over to run with the pups. Truly a once in a lifetime experience to be pulled on the back of a 4 wheeler by a pack of dogs while clutching your attending for dear life. Incredible!

You’re also provided with a cozy apartment right on the Kenai river and a short drive from the clinic. Everyone takes care of you and is more than excited to have you over for dinner and show you all the amazing things Soldotna has to offer. I also had the opportunity to present a grand rounds style lecture for local providers. Definitely prioritize a rotation up here, you won’t regret it!


Black bear at the Alaska wildlife conservation center


Kenai river in your backyard (literally!)


Halibut fishing with the Kelleys!


View from the Homer spit


North beach at Kenai with relaxed resident feet included as proof of ample down time


Exit glacier near Seward


Ready for a run!

ICU at ANMC in Anchorage, AK!

Let me start by saying that if you’re reading this and are already scheduled to do your WWAMI rotation at ANMC though haven’t yet submitted your Alaska resident license application…stop reading and go do it. For real, you’ll thank me later. Getting that beast of an application out of the way about 4-6 months ahead of time will allow you to cruise on up to Anchorage stress-free knowing that you’ll be all set for your rotation!

Anyway, with that said, I spent my entire month of March in the ICU at ANMC and as those before me have already said, this was absolutely one of the best experiences that I’ve had in residency! As the only resident in the ICU, everyone is super willing to give you procedures and the attendings are all excellent teachers. By the end of the rotation I had done about 10 central lines (mix of IJs and subclavians), 2 intubations, 3 bronchoscopies, many arterial lines, and even a handful of chest tubes! Overall, you get a ton of autonomy and really feel like you are the primary provider for your patients, while the attendings are always available for guidance. The staff at ANMC are awesome and the ICU nurses in particular are very knowledgeable and always willing to help. From a cultural and systems perspective, working at ANMC is also really interesting as it serves the Native population not only in Anchorage but from all around Alaska. Many patients are flown in from various parts of the state, including Little Diomede, which is the westernmost island of 110 people that is right on the US/Russia border in the Bering Sea! The ICU itself is about 20ish beds, and they’re actually in the middle  of some construction to expand it. The acuity of patients ranged quite a bit, and we certainly had some sick folks with interesting pathologies.

As far as Anchorage goes, it’s not a very big place but definitely has a lot going on! If you’re heading out in March, I would recommend catching the start of the Iditarod. Overall it was pretty darn chilly with temps in the negatives most of the month until late March and snow/ice pretty much everywhere. I stayed in an apartment close to the hospital and got around just fine in my trusty Ford Focus rental car, though there were a couple of hefty snow storms and those not used to driving in the snow might feel better with a 4WD. Otherwise it was awesome exploring the city and surrounding area. Check out the pics below!

Start of the Iditarod!
Resting up before the big race.
The Diphtheria antitoxin is on its way!
I thought the thermometer would stop at 0, but apparently it goes into the negatives…
Flattop mountain just outside of Anchorage. ‘Murica!
Skiing at Alyeska in Girdwood, just 45 minutes outside of Anchorage.
Denali on a rare, clear day.
Walking across Portage Lake to Portage Glacier.
Portage Glacier
Found some old skates at a thrift shop and got in on some pond hockey!
Pond hockey after work.

 

St. Patrick’s Hospital, Missoula, Montana

I spent the month of January 2017 in the ICU at St. Patrick’s Hospital in Missoula, which was awesome.

The work: St. Pat’s is different than many other WWAMI locations I’ve heard about, it is still in a rural setting but is actually a level II trauma center and provides a fair amount of specialty care, so a lot of patients get flown there from the surrounding smaller hospitals. This means the ICU takes care of a wide variety of medical, trauma/surgical, and neuro patients. The ICU team is more focused on the medical patients, but you can get involved with the others if you’re interested in getting more experience with these patient populations in the critical care setting. The attendings were all great to work with and motivated to help you get procedures, and there was ample opportunity to do them. I spent a day in the OR with a couple different anesthesiologists and got some concentrated time doing intubations, which was set up for me by one of the ICU attendings when I asked to do it. There is a family medicine residency program there and medical students from UW, so there are conferences during the week and they ask you to present a journal club and a morning report, which was fun.

The fun: Missoula is  like a mini-Seattle. There’s tons of great outdoors activities, numerous breweries, and a nice downtown area with some good restaurants. In general, if you like Seattle and Seattle-type things, you will love Missoula.

Overall, highly recommended!

Soldotna. Do it.

Literally one of the best months of residency… literally.   I recommend using two wishes.  I think you can do that.   The clinical experience is diverse.  A sample day can include EGDs, colonoscopies, stress tests, reading echos, and doing primary care with limited resources for subspecialty care.  The physicians at PIM are fantastic educators.  You’ll spend most of your time with #GHITKU legend, John Bramante.  If he or Dr. Mitchell have inpatient responsibilities spend a few days seeing what the hospital is like.  There is so much to do in the evenings/weekends.  Seriously, this month is the best.

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