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.
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.
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.
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.
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.
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.
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
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!
I never saw a grizzly bear during my month in Livingston, even though I spent the entire time reading about them and keeping an eye out for them on hikes. This was probably a good thing. There were 9 grizzly attacks in Montana this year; two of the victims came to Livingston Hospital while i was there and I got to help care for a Hunter who had been severely mauled (had his face torn off). I heard about the attack on NPR the next morning.
The mountains surrounding Livingston are amazing (the Absorokas, the Bridgers, the Crazies). I spent my free time hiking among these mountain ranges and exploring Yellowstone. The Paradise Valley is literally a two minute drive from the house and is breathtaking. Be careful not to drive off the road while you ogle at the Absoroka Mountains.
The clinical experience is priceless, no matter what you go into, ranging from clinic, to inpatient, to ER. The main preceptor (Dr. Wadle) was a great teacher and host. The hospital staff treated me like one of the family. Pop me an email if you have questions about this experience; I can’t say enough about it.
In August I saw grizzly bears, wolves, bighorn sheep, and more bison and elk than I can count. I also got to see a model of medicine very different from anything in Seattle: rounding on inpatients (including the small ICU) in the morning, then off to clinic for the bulk of the day. It’s a great combination and much more balanced than a Seattle ward/clinic day. With daily clinic you can establish continuity even over a single rotation. In my month, there was a lady with COPD who I saw in clinic, admitted to the hopital, transferred briefly to the ICU, and had follow up with me in back clinic a few days later.
The few ER shifts and visits to SNFs add some variety. The scheduling was very flexible, allowing for plenty of time to explore. Plus, Wadle, a former Boise chief, is an all-star doctor and preceptor.
I had one of those magical days that can happen in a place like Livingston. It was a blustery Wednesday morning in March with gray clouds hovering heavily overhead and a few scattered snowflakes falling to remind us that spring was not here, yet. I was finishing a 24 hour shift covering the ER and admitting patients to the hospital. I had started at 6AM the morning before. The day had been busy with a wide variety of patients including minor trauma (table saw vs. finger) and children (mostly ear infections). At midnight an 80 year old woman was wheeled in by her daughter. She had been getting progressively short of breath over the last few hours at home. By the time we got her settled on a stretcher her oxygen saturation was dipping into the mid 80s. The x-ray technician, lab technician, and respiratory therapist had to come in from home, which they all graciously did. She was septic from pneumonia. Over the next three hours we put in a central line, started broad spectrum antibiotics, placed her on BiPap and admitted her to the ICU, where I followed her care until 8AM. Leaving the hospital, exhausted, I contemplated going home for a well-deserved sleep. But the mountains, hidden by clouds, beckoned. The snow report at Bridger Bowl, the local ski area, boasted 4 inches of fresh powder. By the time I arrived 45 minutes later there were six inches of light as air “cold smoke” powder and a parking lot that was largely empty. Delirious from lack of sleep, I took the chair lift to the steepest part of the mountain for a warm up run. After the first turn I found myself face down in a mound of snow as soft as a feather bed. Using better judgement on my next run I began to get a rhythm and soon was floating on powder. Over the next four hours I skiied 14 runs and quit skiing when I was either going to fall asleep on the chair ride up or break a leg coming down. I drove back to Livingston through majestic ranching country with stunning snow-capped mountains in front of me and in my rear-view mirror and big blue sky above me. The next morning I hobbled into the hospital, legs sore from over-use the day before, to find my patient had pulled through and was ready to be transferred to the floor.
It 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. Whatâ€™s unique about a WWAMI town is a sense of balance. The doctors love medicine, theyâ€™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 weâ€™re not so good at.
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