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.

March in Soldotna

No surprise here – I had an incredible time in Soldotna.  The rotation exceeded my expectations and I checked more than a few things off of my clinical and life bucket list (snare a colonic polyp, see the northern lights, etc).

Peninsula Internal Medicine

PIM is a practice of 6+ attendings who are passionate about primary care and know way more about medicine than I can ever hope to know.  By the end of the rotation I was still surprised when I could ask questions about everything from central hypothyroidism to treatment of metastatic esophageal cancer to echocardiograms and get detailed answers backed by the latest evidence.  Most people have traditionally worked with John Bramante, a UW grad and former chief, who will welcome you to the PIM and his own family with enthusiasm.  He’ll be spending most of the 2013-2014 academic year in Florence on sabbatical though, which means you’ll work with Bill Kelley, one of the original founders of the practice, who is equally experienced and devoted to his patients and teaching.

Most mornings there are colonoscopies/EGDs to be done – after you’ve tried your hand at the controls a few times, you can sit these out and prepare for the patients that are mixed in between cases.  Afternoons are filled with more clinic.  Lots of general internal medicine but many interesting cases too.  I initiated one of Bramante’s UC patients on infliximab/azathioprine, took care of a patient with leprosy, had a discussion re:sorafenib with a stage IV HCC patient, and also saw a patient with MAI.  I also was involved in a few stress tests and TEE cardioversions.

In and Around Soldotna

March was a perfect time to be in Soldotna – there was an abundance of snow and sunshine.  Among the things I did:

  • rented XC Skate skis for a week ($80) at Beemun’s True Value/Variety store and skied at Tsalteshi Trails, just 5 min from the apt
  • hiked Hideout Trail at Skilak Lake, perfect on a clear day, 45 min from Soldotna
  • snowshoed Homestead Trail just outside Homer, and more locally at Kenai National Wildlife Refuge in Soldotna where moose can be found
  • watched a Kenai Bears hockey game
  • dog sledded with Bramante
  • went to Homer a bunch of times and: explored around the Wynn Nature Center, went to the Two Sisters Bakery which has amazing things called Boca bites which are perfect with coffee, wandered around art galleries.  Make sure you go to Homer on a clear day because it’s one of the most beautiful places you’ll ever see. also in Homer checked out Pratt Museum and Alaska Islands and Oceans Visitor Center both of which are worth the visit

The Perks

  • Free lunch every day at Central Peninsula Hospital – pretty tasty.  Halibut, jumbo shrimp and ribs are just a couple of my favorites.  Get the mozzarella sticks too.  Cookies are addictive (just squish them a little first to make sure they’re chewy…)
  • PIM will arrange housing for you in a 1-BR apartment right on the Kenai river.  Sue and Dale Cain take good care of you if there are any issues that arise.
  • PIM also provides a sweet 2008 Subaru Outback with studded tires.

Northern Lights from Soldotna Dogsledding with John Bramante! Kenai River right in your backyard! Bishop Beach at Homer Hike at Skilak Lake Moose up close and personal at the Kenai Wildlife Refuge Bald Eagles outside your apartment Peninsula Internal Medicine

March in Anchorage

Still cold, but an amazing four weeks.  I highly recommend rotating at the Alaska Native Medical Center in Anchorage!

Clinical rotation:

  • You will be given a choice of (1) outpatient clinic, (2) inpatient medicine, or (3) ICU.  You can pick 2 of 3 if you want to mix/match.  I chose a mix of outpatient clinic (and requested a GI focus) and inpatient medicine.
  • For outpatient clinic, you can work with a general internist and see everything, but you can also request to work with the specialists, assuming they are available.  There are two infectious disease docs, a gastroenterologist, a rheumatologist, a neurologist, a dermatologist, nephrology PA, pulmonary, etc.  Many of the specialists see patients in the clinic, but also perform inpatient consults.  You get more weekend time off.
  • For inpatient medicine, I was assigned to an Attending (who rotates weekly).  I carried about 5 patients of a 12-15 pt service.  Rounds are pretty informal and you have independence, but still have opportunity to discuss the plan with the Attending.  I admitted from the ED.  There is good support for PT/OT, social work, etc.
  • ICU is a busy service, generally.  Less weekend time off, but a lot of procedure opportunities.

Alaska Native Medical Center:

  • Beautiful facility.  Very modern.  The patients are also amazing, mostly Native and from villages hundreds of miles away requiring travel in by a bush plane.  I learned so much about Alaska geography and native culture throughout the month.  The patients are very warm and friendly.  I really enjoyed interacting with them.

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Anchorage:

  • A big city.  Plenty of supermarkets, coffee shops (Kaladi Bros!), restaurants, gyms, museums, etc.  Even in March, snow can be challenging and I would recommend considering upgrading to a slightly nicer car with all-wheel or 4-wheel drive, especially if you plan to take some road trips.

If you have time off, consider going to:

  • Anchorage museum
  • Drive 2.5 hrs south to meet up with the Soldotna resident and then continue on south to Homer, AK
  • Hatcher’s Pass
  • Talkeetna
  • Seward (I never made it here)
  • Fairbanks is quite far and unless you have a lot of time, you would probably need to fly.  You can also take the Alaska Railroad
  • In winter, plenty of downhill skiing, cross-country, snowshoeing.  You can even organize dog-sledding/mushing, ice fishing, snowmobiling or a flight over Denali if you want.
  • If in March, try and see the start of the Iditarod (pretty amazing!) and the Northern Lights.IMG_0986

 

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Steve Vindigni

December in Alaska

Despite the negative five degree weather, snow, and a highly functional Kia Forte… this was an absolutely amazing rotation. I spent 4 weeks in the ICU working as a fairly independent entity with my own patients and responsibilities. The highlights of this were close interactions with the attending, making vent changes on your own, and the procedures. I did somewhere around 13 subclavians, 5 IJ, 1 tunneled line, 2 broncs, and helped with an EGD. The staff are great and they are interested in you and your education. I would get in around 7:30, round at 8:30 and usually leave around 7 pm unless it got busy. Overall a great rotation. Anchorage is nice, but cold. Although I did do a fair amount of running which was spectacular! I would totally recommend this to anyone interested!

Andrew Prouse

December in Soldotna

To be honest, I was nervous about Soldotna in the winter, but it was one of the best months I’ve had yet in my whole medical education. The clinic is amazing, as others have explained. The docs up there are top notch, I think I saw more complex patients up in a day there than I would in a week in Seattle, and all being completely managed by internists! It’s awesome. I have prescribed triple-therapy for a patient with MAI pneumonia, high dose steroids for a UC flare, and amio-loaded someone for refractory a-fib in clinic without any specialist help. The clinic runs smoothly, they have a fully functioning EMR and laptops for everyone. The support staff is wonderful and I became friends with several of the nurses and MAs.

There is still plenty to do in Soldotna wintertime, though I will say it’s the coldest weather I’ve ever been in. The scenery is just incredible. We went to Homer and Seward, like others have posted about, but it was a cool different feel to be there in the dead of winter with only the locals and the awe-inspiring views. We went cross country skiing (right out of the backyard if you want!), snowshoing, dogsledding, and ate wonderful meals at all of the doctors houses.
Don’t pass this rotation up!!

August in Soldotna

 

I spent mid August through early September in Soldotna.  My wife, Tiffany (pediatrics), joined me to work in Katy Sheradon’s Family Practice during that time.  I think plenty has been said about the quality of the rotation, but I’ll add my perspective.  John Bramante is the main doc with whom residents work.  He is in a practice with ~5 other docs called Peninsula Internal Medicine.  They are a private practice across the street from the hospital, but also provide hospitalist coverage.  During my month, that actually stopped, as the hospital hired some hospitalists, but things may change again.  I spent 3 weeks mostly in clinic.  I worked closely with John Bramante and also Bill Kelley.  They are both excellent docs (UW and UCSF trained, respectively) and do a surprising amount of speciality care (cardiac stress tests, EGDs, colonoscopies, HCV treatment, chemotherapy, rheumatology).  Their patients were also quite interesting and wonderful to treat.  I spent one week working as a hospitalist as well. 

The most memorable part of the month was my time away from work.  There is quite a bit to do in the area, particularly if you like the outdoors.  August on the Kenai Peninsula is popular with many of the locals, as the weather is still nice but the tourists are gone.  By the end of my month, fall was in full swing (with a pretty brilliant color change).  I went out fishing with Bill Kelley on various stretches of the Kenai on multiple occasions.  He took me drift boat fishing down the upper Kenai for rainbow trout, where we saw several brown bear fishing from the shores.  We also fished the lower river for silver salmon and trolled the middle river/Skilak lake for rainbows.  I have been to a lot of rivers and this one is one of the most beautiful anywhere.  The fishing is also excellent, if that’s your thing. 

On weekends, Tiff and I did a lot of the usual trips to Homer and Seward.  Homer is a quirky town SW on Soldotna on the coast.  There are some good restaurants and great hikes – see the Grace Ridge photos below.  Seward is a smaller town with not as much going on, but nearby Kenai Fjords National Park is amazing.  All of the glacier shots are from that area. 

We didn’t make it to Denali, given the distance, but I know some others have made the trek.  I think the experience is highly weather dependent, as the mountain is only out 1/3 of the time.

The best part of this rotation were the people.  We were invited to dinner and fun activities with so many docs and their families.  Indeed we were made to feel part of their families.  Tiffany got to eat moose heart once too! 

Glacial silt gives the river its characteristic color. The silt is called “stone flour” because it is incredibly fine, leaving the river unusually cloudy.

Alaska Native Medical Center Aug/Sept 2012

I just got back from a month at ANMC in Anchorage.  I did 2 weeks of hospitalist and 2 weeks of outpatient clinics.  Like previous posters have said, you see a lot of cancer and alcohol-related complications on the inpatient side.  And it’s true that you can get exposure to EGDs and doing treadmills, if you like those kinds of things.  You can pretty much see whatever you want, in terms of procedures or surgeries and whatnot since the place is small enough and the staff are very accommodating.

I’d like to put in a plug for the outpatient experience, since not many people have posted about that thus far.  You rotate through different clinics everyday, including a combined rheum/pulm connective tissue disease clinic (where you see more scleroderma with interstitial lung disease than you have ever seen in your life), GI clinic, hepatitis clinic, general medicine.  The outpatient attendings are all great teachers and excited to have us there.  The patients are great, appreciative, and come from very interesting places.

Aside from the clinical experience, the rotation is very well-organized with great support from the coordinators.  They give you a long weekend so you can go explore Alaska.  I made it to Seward for a glacier/wildlife tour and also to Denali National Park.  I don’t know if I was unlucky with the weather but by the second week of September there were more rainy days than sunny ones.  But no matter what the weather, the Alaskan wilderness is majestic.

Just make sure you have one of those nice cameras with the big lens if you want to take good pictures of wildlife.  You don’t want to have to be too close to a grizzly.

Montesano – Spring 2012

Montesano was a great place for a resident WWAMI experience! I encourage everyone who wants a WWAMI experience, but can’t be away from Seattle for 4 complete weeks (because of family, significant others, etc) to consider Montesano.

Montesano is a tiny little town, west of Olympia, out towards the Washington Coast. Though it brags of a population of 3500, it feels much smaller than this.  There is a grocery store, a few restaurants, a drug store and a coffee shop, most of these things close down by the evening.  There is a state park at the north end of town and a lot of beautiful countryside around Montesano. The town is about 10 miles east of Aberdeen which is, by far, the bigger town. This town has a couple more grocery stores, some bigger drug stores, some nightlife, more restaurants and a couple of museums. Not too much farther away is Ocean Shores which is a neat little beach community.  It is the greenest part of Washington I have personally seen, probably because it gets a very healthy amount of rainfall! Logging used to be the big industry, but Montesano is also home to the county jail, county court and sheriff’s office. The unofficial town slogan, at least according to Wikipedia, is “Come on Vacation, Leave on Probation!”

Housing is provided in the “med student house”. It’s a three bed-room house with a very decent kitchen, two living rooms, a dining room, back deck and large back yard. There is a washer and dryer on site. The house is literally located 1.5 blocks from the clinic and about 5 blocks from the grocery store and “center of town”. Though you need a car to get to Montesano from Seattle or to commute between Montesano and Aberdeen, you definitely can live in Montesano and barely drive at all. There isn’t much public transportation and I think the options are pretty limited in terms of getting to Montesano without a car.  Its about a 1.5-2hour drive from Seattle, depending on traffic. I came home to see my husband each weekend and the drive was very doable at peak traffic times.

The clinical experience is great! You will spend most of your time at the Montesano Internal Medicine Clinic. It is staffed by two, UW-grad, MDs – Ki and Clara Shin. There is also a nurse practitioner and a PA working there part time. It was a great way to experience “real world” primary care away from a tertiary referral center and to learn the skills of how to manage a variety of problems when there isn’t a CT scanner or cardiologist just down the hallway. Grey’s Harbor has limited sub-specialty care and most of those referrals go to Olympia.  Ki and Clara want to make the experience as personalized and as hands on as possible from seeing as many patients as possible to doing as many procedures as possible, while helping to manage the workload to learning is emphasized! In addition to the medical learning, Ki and Clara were also very open about how to start and manage a small practice as well as sharing their philosophic approach to primary care. Those conversations have really changed how I approach primary care as well as how I feel about it as a career option. I also spent time in another clinic in Aberdeen, run by a UW-grad. This MD is “the whole package” from seeing patients in clinic to rounding on his primary care patients who get hospitalized. He has a different approach to the general internist career and lifestyle and I really learned a lot from the week I spent with him.  Finally, I spent a week with the hospitalist service at the Grays Harbor Community Hospital. It feels like Harborview gets a lot of patients transferred from there and it was really interesting to see the other side of that equation. It’s a busy service, with limited sub-specialty backup, but a great way to learn about common hospitalized problems. It’s also an open ICU. My week there was slightly limited as I didn’t have the ability write orders independently, but they are working on that issue so that future residents can have a more independent experience.

All in all, this is a great experience and I would HIGHLY recommend Montesano!!

Livingston December 2010

Overlooking Livingston and Livingston Peak

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 yellowstone
Moose on the snowshoe trail at yellowstone

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