I try to keep a rural filter on the Wrap, but not everything rural makes it on the list, and a lot of posts of non-rural origin do. Truthfully, rural as a way of life has a broad range. The true filter on this list is my own experience--fruity, funny, and frustrating as that may be--of being a rural doctor. Thus:
I was interested to read, via the Daily Yonder, about Idaho's shortage of rural doctors. Dr. Richard Paris's work is what I would describe as extra-rural: he makes clinic rounds via airplane, because so many communities have no doctor to serve their clinics. I'm lucky to be in a much better-staffed rural area, but there are commonalities between what Dr. Paris and his colleagues face and what I do here in Rural, CA.
The Country Doctor writes about one of the satisfactions of being a comprehensive care provider: closing the loops of what happens to a patient across time.
Med Valley High is working a mobile clinic these days, seeing up to 300 patients per day along with an equally-stretched volunteer staff. Many rural communities rely upon mobile clinics, and I had the satisfaction of volunteering for one when another doctor went to help Hurricane Katrina efforts. Mobile medicine is by far from ideal medical care, but it extends the range of help from four walls to four wheels.
I benefit from the work other bloggers put into reviewing clinical literature. Ramona at Suture for a Living has reviewed lymphedema, a problem I see commonly in rural practice. The Buckeye Surgeon described a harrowing case of ascending cholangitis, a dreaded cause of sepsis I have seen a few times too often since moving to Rural.
Leave it to Dr. Happy to capture the specific unpleasantness of practicing hospitalist medicine, such as the imperative of nudity for a proper physical exam, and the underreported menace of the hospitalist junkie.
Bongi takes a Proustian trip down memory lane after smelling alcohol-tinged bodily fluids. I know exactly what he means. Those of you who think we're smelling a fresh gin & tonic on someone's breath vastly underestimate the scent we're talking about. I remember one patient who arrived in the ER when I was a resident. He was a long-time alcoholic who'd sustained a complicated open fracture of the ankle after falling in a ditch. The ER staff reduced the fracture without sedation because the patient's alcoholic neuropathy was so profound, and the deep, penetrating odor of vodka emanating from his open wound gave physical evidence to the statement "feeling no pain."
A number of bloggers discussed what kind of training it takes to produce good doctors. Via DB's Medrants I found this paper in Academic Medicine proposing a fundamental change to outpatient experiences for internal medicine residents. These changes would abandon the concept of continuity clinic for residents and have young doctors do outpatient rotations in blocks, just as they do inpatient rotations. This is a highly pragmatic solution, since most residents find the imposition of continuity clinic on an inpatient rotation annoying.
Meanwhile, Dr. Happy exposes the efficiency of the VA model as exploitation of hard-working residents. Even if internal medicine residencies revamp outpatient experiences to improve depth of inpatient rotations, I don't see much improvement in the quality of education if attending physicians continue to be as remote as Happy describes.
Whatever the specific structure of your residency training, it will be hard. Reformers would like to reduce work-hours even further, whereas moderates feel there must be some vigor to the experience in order to produce efficient, quick-thinking, widely-experienced doctors. I tend to align myself with the moderates, and Fat Doctor gives an excellent example of how a difficult training prepares you well for even more difficult real-life job.
great wrap up
Posted by: bongi | October 20, 2008 at 01:42 PM
What a great weekly summary. You're not stalking me, are you? JK :)
Posted by: The Happy Hospitalist | October 17, 2008 at 12:17 PM