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.
I spent the best rotation of my residency experience in Livingston MT (town of 7,000 nestled between the bigger cities of Bozeman and Billings) on the banks of the Yellowstone River about 1 hour north of Yellowstone Park and about 13 hours east of Seattle. The rotation itself is spent working with an internal medicine physician (and former Chief Resident in Boise ID/UW) Dr. Wadle. His energy and enthusiasm for his career, teaching and this town were infective. Your time on this rotation is spent about 70% outpatient and 30% inpatient with time also spent reading ECHOs and doing scopes (EGD/Colonoscopy) with Dr. Wadle as well as covering a few shifts in the ED and visiting the local nursing home. The variety was stimulating as was the ability to admit patients from clinic or ED into the hospital and continue to be their physician for their entire medical experience! The hospital in Livingston (a critical access 25 bed hospital and an affiliate of the bigger Billings Healthcare system) will be brand new for future residents on this rotation–opened in the Fall of 2015. The patient’s presented to the hospital and clinic with complaints that ranged from the day-to-day aches and pains and chronic illnesses of a rural community with requisite mining, farming, logging accidents mixed in) as well as some more rare experiences due to being near Yellowstone and the Rodeo circuit (bison goring or bucking bronco injuries anyone?)
On my time off I enjoyed the town of Livingston–I challenge you to find a better 4th of July parade anywhere and the rodeo over the 4th of July is a must if you are there. The people are friendly and welcoming–although don’t be surprised if you recognize patient’s at the grocery store! The town has a weekly farmer’s market (with food trucks and live music) and the town and several surrounding ones have great music festivals. There is so much hiking to be done–in Yellowstone as well as closer mountain ridges (Dr. Wadle is an outdoor enthusiast and can provide a plethora of recommendations). I had some great food in both Livingston and Bozeman, as well as at the hospital itself (which believes in farm to hospital cooking!)
I can’t recommend this rotation highly enough. Please reach out if I can answer any specific questions.
Amy Thomas
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.
Livingston in NovemberI 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.
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 ParkGrand Teton National ParkYellowstone Lake, Yellowstone National ParkPine Creek Falls, Gallatin National Forest, LivingstonSunrise over Yellowstone National Park
My month in Livingston was wonderful. The small town (~7000) is in a beautiful setting…”A River Runs Through It” was filmed there for reference. Dr. Wadle is a great doc and good teacher. The entire staff at the clinic, nursing home, and hospital are welcoming and really make you feel like you belong.
Nuts and Bolts: The 25 bed hospital has a med-surg floor and a 4 bed ICU. I had a bit lighter month with only a few inpatients at a time and no ICU patients. You round on them each morning and stop back in the pm if there are any active issues. Then head over to clinic for a usually pretty full day of patients. Easy to go back and forth b/c the clinic is right next door to the hospital. Also run over to the hospital for stress tests throughout the week and colonoscopies every other friday alternating with nursing home visits. There are also 24 hr ER shifts…I saw ortho stuff and kids which was a bit different than usual but great. I had a ton of continuity between the ER, inpatients, clinic, and nursing home visits. Was on one weekend to round but otherwise had weekends free. The patients are great, all ridiculously friendly and welcoming.
Despite the various work activities that keep it interesting, the pace is more laid back and there is plenty of time for fun especially if you are into outdoor activities. Yellowstone is only 50 miles away and is gorgeous any time of year. Spent a few days snowshoeing and exploring the wildlife. Dr. Wadle is big into cross country skiing and running so took me out for both of those activities and even provided the ski equipment. There is also a fair bit of downhill skiing close by that is supposedly wonderful ( i was too chicken to try and too busy with other fun activities). In addition, because it is somewhat of a tourist area, the restaurants in Livingston are actually pretty darn good, as is the local gym I joined for super cheap. There are also a ton of small art galleries downtown (big artist community). And, of course, can not forget the hot springs of which there are many, but I recommend Chico just south of town.
I could say so many more wonderful things. I highly recommend this rotation and would be happy to answer any specific questions.
Lookout point from a snowshoe/ski trail in yellowstoneMoose on the snowshoe trail at yellowstone
I went to Dillon early in my R2 year and very much enjoyed my month there. I spent the first half working with Dr Ron Loge and the rest with Dr Sandra McIntyre. They are both wonderful (and beloved) internists who completed their residencies at UW–about 25 years apart. We rounded in the (20 bed) hospital in the mornings, spent the days in clinic, then rounded again in the evenings. We saw a broad range of medical problems and it was great being able to follow patients closely because I was in one place all day, every day.
I highly recommend this site to anyone interested in an experience of real rural primary care that is mostly outpatient with a bit of inpatient, procedures, nursing home visits, and home visits.
It was an unseasonably warm Sept/Oct and I hiked in the mountains around Dillon and went on weekend trips to both Yellowstone (3 hours away) and Glacier (about 6 hours). It was a great month! Email me if you have questions.
I’ve gotten pretty comfortable working in Livingston over the past month. I’ve learned an enormous amount by working with Dr. Wadle. His clinic patients are some of the nicest people I’ve ever met, and they have different problems than many of my continuity clinic patients at Harborview. Dr. Wadle takes care of his patients in the clinic and the hospital in addition to doing his own screening EGDs and colonoscopies every two weeks. I also enjoyed visiting one of the local nursing homes with him. Working in all of these settings allowed me to get to know Dr. Wadle’s patients very well; the continuity of care here is amazing.
I also had some time to explore the surrounding areas. I went hiking and snowshoeing in Yellowstone, swimming in the Boiling River (you MUST do this in Yellowstone), dog sledding, skiing and snowboarding. I also went running with Dr. Wadle on Tuesdays at lunch; he goes rain or shine with one of the family practice doctors from the hospital.
Visiting the sled dogs
Livingston Memorial Hospital
Paradise Valley
Buffalo Crossing in Yellowstone
The Boiling River
Snowshoe Adventures in Yellowstone
Livingston itself is pretty small, so I ventured out to Bozeman few times (it’s only 25 miles away). Working in Livingston for the month has been amazing – I highly recommend it!
The reason I chose to go to Dillon was to have the opportunity to experience what it is really like to be a small town rural doctor who does it all, and that is exactly what I found. I worked mainly with Dr. Sandra Mcintyre who is a smart, dedicated, charismatic graduate from the UW program who is deeply loved by her patients. Our days were spent going between clinic and the hospital to check on our inpatients. On Monday afternoons we would do stress testing, and on many mornings she performs her own endoscopies. One of the most rewarding parts of the month was seeing patients who I took care on in the hospital back in clinic after their discharge. There were patients I saw 4-5 times during the month, true continuity! Of course, you cant beat the location, so close to yellowstone, world class fly fishing, and miles of open beautiful prarie. If you go in September you will also get to experience the big rodeo that comes through town…this is one of the truest cowboy towns in the country and a must see!
Missoula was my second WWAMI month and quite different from the first. Missoula is a university town and significantly bigger than Livingston. There are multiple hospitals, plenty of subspecialists, and even some UW students running around; it has less of the “small town doctor” feel. That said it’s quite different from Seattle, and the exceedingly well-connected Dr. Schlesinger is eager to customize the rotation – I did two weeks of sports medicine and two weeks at a Community Health Center. But one gets the sense Dr. S could arrange anything from the ICU to podiatry, probably with someone not used to having a resident and excited to do some teaching. Go to Missoula to get away, see a different place, do some hiking/skiing, and all of that, but also take advantage of the opportunity to learn whatever you want.
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