Doing it all in Jackson

sam.jpgLooking at residency, it’s Jackson where the breach between what I knew and what I felt I needed to know was widest. I’d wake up to a patient in the ICU and a few more on the wards, and expect to be a nephrologist of sorts, the critical care person, a medicine consultant for local family doctors. After one of those days, my preceptor Mike Menolascino had me make a house call on a rancher with wide-open mitral regurg and Staph endocarditis. His wife wanted to stop the IV antibiotics. Mike said I should stay until they were finished asking questions, and then stay a halfhour more. Having grown up in Idaho, I know that rural places are places of extreme weather, where you get resistance from the environment. People have to struggle a little bit to live and over their dead body they’re going to a specialist in Salt Lake City. So it’s a tribute to the vitality of ranchers that we stopped the antibiotics and he’s still alive today … People in Jackson possess a strong sense of place. After being in the Tetons, I’d talk about moose spotted on trails, wind scouring the range from the west, spring slough slides. When you come back from the mountains, everybody knows exactly what you’re talking about.

Oncology in Missoula

mountain.jpgI was putting in a lot of hours, by my choice, because I was learning so much. The community doctors constantly impressed me with how good they were at everything. They were amazing diagnosticians. The oncologist I worked with, John Trauscht, was an outstanding teacher, and I loved his curiosity. John had a great way of communicating with his patients, bringing everything to their level, and always gave patients the choice of doing nothing. I saw all of his new patients and performed bone marrow aspirates and biopsies, so I was first to see and diagnose patients rather than the fifth or sixth person down the chart. One memorable patient was a middle-aged man with Burkitt’s who continued to decline despite aggressive chemo. He developed PCP in the hospital and then an HIV test came back positive. The diagnosis was incredibly devastating and it was interesting to see everybody’s reactions. He died three days before I left. Taking care of him made a huge impact on me … I loved Montana. Everyone in Missoula loves living there, and I felt very much a part of the land.

Medicine in a small, small town

kim.jpgIt was so hard to come back from Livingston. The place is so small that I got to know people from all walks of life, and I made incredible friends. Everybody has personal as well as professional connections with patients. The hospital is a tiny little place, with four ICU beds. Everyone at the hospital supported and respected me, and I felt looked out for. There were so many memorable patients and several that I saw over and over. I saw them get sick, I saw them get better. I was totally integrated into every aspect of their care. Four times a month I did a 24-hour ER shift where I was the only physician in the hospital. I really became comfortable doing everything, clearing c-spines, taking care of heart failure and infants and reading my own x-rays. What’s unique about a WWAMI town is a sense of balance. The doctors love medicine, they’ve chosen Livingston for the diversity of patients and the intimacy they get with people. But the emphasis is on time away from the hospital, which we’re not so good at.

Career plans in Cody

doug.jpgCody at sunrise after camping on the Shoshone River the night before and my first thoughts were how beautiful the country is in the early morning and that I could definitely live there. Cody is a town of hard working blue-collar people, a lot of ranchers, and of course people were very friendly. It was fun being geographically isolated, getting to practice true general medicine and take care of things specialists would take care of in bigger cities. We got the sickest patients in town. Every week, we spent a half-day in even smaller places – Powell, Meeteetse, Grable – and people appreciated us. I was already 100% interested in small town general medicine before Cody, because of rural rotations I did as a student at Colorado. In Cody, I learned I want to practice in a place with an established medical community, where internists work together and share call. I look forward to being in Soldotna in the spring, to see a medical practice with a reputation of being well run.

Taking care of the same patients for years

River near DillonIn my Seattle clinic, I usually feel I have one chance to fix a patient and all I’m doing is trying to get in the ballpark, so Dillon was so educational. It’s the only rotation where you’re in the same clinic every day, eight hours per day. The patients were ranchers and cowboys, tough guys with terrible problems that you could do something about, like a guy with diabetes who brought me his home glucose numbers and actually followed up the next week. My clinical skills improved so much from seeing patients back and seeing if what I’d tried had worked. My preceptor, Dr. Loge, has been in Dillon twenty-five years. He’s one of the most important mentors I’ve met. He has that clinical intuition you only develop after years and years, and he really knows the medical literature. The rotation with him really changed my outlook, even though I’m not doing primary care. I’m going into cardiology and I’ve thought about being a small town cardiologist with a small primary care practice, now that I’ve experienced what it’s like to know patients for twenty years.