Rural Doctoring

Windows Into the Soul

Via a link on Scalpel or Sword, I read a post by Catholic blogger Dawn Eden which summarized a post by a medical student blogging under the name Pudu Overload who felt unnerved after observing abortions at a Planned Parenthood clinic.  Pudu Overload apparently identifies herself as a supporter of abortion rights, yet felt "incredibly freaked out about the whole thing and [I] don't know how to think about it.  It simultaneously seems like a small and an enormous thing."

Premedical Education, the Long Way, Part 2

Yesterday I discussed pre-undergraduate and undergraduate educational experiences, today I dive into pre-medical requirements, medical school, and other educational experiences I've accumulated over the years.

Premedical Education, the Long Way, Part 1

Recently the Anesthesioboist wrote a lament on the state of premedical education--specifically the ruthless science-based focus imposed on/embraced by young students interested in medicine.  She would like to see more humanities and liberal education in the average pre-med's curriculum, and so would I.  Reading her post made me reflect upon my own long and winding path to medical school.  Here's a brief summary:

Dr. Santell's Rounds: Don't Be Common

During an intern year rotation in Surgery I saw a patient with a large abdominal wall abscess. My progress note looked something like this:

Childbirth Philosophy, Part 2

I'm writing about my childbirth philosophy in a series of posts. Like many doctors and some midwives, my experience attending births began in large teaching hospitals, in my case during third- and fourth-year obstetric rotations. In this post, I'm going to describe these experiences and what they taught me, and examine the implications of these early experiences on a learner's later beliefs about childbirth practices.

Childbirth Philosophy, Part 1: Introduction

As you know, I’ve been writing Birth Stories regularly on this blog because I treasure these stories and writing them reinforces the love I have for attending births. Anything I can do to reinforce this love is a good thing, because it is physically arduous and mentally exhausting to accompany women through labor and delivery. As the Birth Stories have gained readership, a number of midwives, home birth advocates and doulas have read this blog and left their comments. They join an audience of doctors, medical students, nurses, and laypeople who share a fascination for the experience of birth.

Update on Rural's Med Students

A while ago a commenter asked how the osteopathic medical students (OMS) were doing on their rotations in Rural. I've had a few interactions with them and have had one young woman run around with me on hospitalist rounds. They're a nice bunch of people, very motivated to learn and with the luster of the beginning of 3rd year not yet worn off. I don't think I ever had that luster, but that's another story.

Becoming a Rural Doctor, Part 5: Procedures for the Rural Doctor

Now that we've addressed medical school and residency for the rural physician, it's time to discuss common procedures with which rural physicians should be comfortable. In earlier posts in this series I've mentioned one effect of fewer specialists in rural areas: the broadening of rural primary care physician's scope of care. One element of this wide scope is performing procedures many primary care doctors might not do in a metropolitan area.

Teaching and learning medical procedures is a hands-on process, so I'm not expecting to provide you with everything you need to know to go out and do these procedures. What follows is a list of recommended procedures to go after during your training so you'll have experience under your belt by the time you enter practice. Some items are merely mentioned, others have references for you to consider.

Becoming a Rural Doctor, Part 4: Residency for the Rural Doctor

Late in the third year of medical school, most students begin to contemplate the Match--the baroque hoop-jumping performance students need to complete in order to enter residency in the specialty of their choice. I am not going to describe the Match process here--they've probably computerized it more effectively since I matched--and I am not going to go into the strategic variations between matching in, say, Internal Medicine vs. OB/GYN. Instead this post will concern itself with planning a residency experience to prepare oneself for rural practice.

Becoming a Rural Doctor, Part 3: Medical School

In the last two posts in this series on education and training for potential rural doctors, I have emphasized generalist education and presented a basic socioeconomic portrait of rural versus urban practice. Today's post will take a look at applying to, financing and attending medical school for the potential rural doctor.

Becoming a Rural Doctor, Part 2: The Generalist's Mind

When I think of rural doctors, I think of family practice. Part of this is training bias, because I am a family doctor, but this bias is supported by surveys which demonstrate that a significant number of rural communities would be medically underserved if it were not for the presence of family physicians:

"A recent study from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care indicated that, if family physicians were removed from the 1,548 rural U.S. counties that are not Primary Care Health Personnel Shortage Areas (PCHPSAs), 67.8 percent of those counties would become PCHPSAs. On the other hand, removing all general internists would make only 2.1 percent of the counties PCHPSAs, and only 0.5 percent would become PCHPSAs without pediatricians or without ob/gyns." (Fryer et al., 2001, cited by an AAFP Position Paper)

In this post series, I will emphasize the family practice model of medical training as an approach to preparation for rural practice. I do not mean to imply that other primary care specialties--such as internal medicine, pediatrics or OB/GYN--have no place in rural communities. Quite the opposite, in fact. My job in Rural, CA. would be so much more difficult if I did not have the support of the other primary care specialties. I hope this post series will be useful to medical students and residents who are training in those specialties as well, even if the content tends to veer towards family practice. I will argue that it is the generalist's mind, rather than the specialty, which will suit a doctor for rural practice.

Becoming a Rural Doctor, Part 1: The Rural Landscape

I've been reading the blogs of medical students and residents with some interest lately.  Their stories about the trials and tribulations of learning to stay awake night and day and how to deal with cranky attendings and even crankier patients take me back to the bad old days of my own residency. I've also had a few glimpses of the osteopathic medical students (OMS) who are rotating in Rural, CA. as they assume their new roles as clinical learners. Hearing about and witnessing these experiences makes me reflect on my own training and the steps I took to become a doctor in a rural community. This new post series is going to examine these steps in more detail, and I hope it will be helpful to trainees who are considering a career in rural healthcare.

Cultivating Rural Doctors

The latest buzz at my hospital is the imminent arrival of a group of 3rd year osteopathic medical students (OMS) who will be doing their core rotations in Rural.  A number of medical schools are trying to encourage more young doctors to work in rural areas by having them rotate in rural hospitals and clinics, which is a good idea because these programs will give students an idea what life is like in a rural community so they can make informed choices about where they will practice.

Professor Rural: Teaching Clinical Medicine

This week I'm precepting a physician's assistant student at the hospital. Although the student is going to be working in outpatient settings, her program requires her to complete a month of inpatient medicine in order to get a feeling for complications of common diseases.

Since moving to Rural, CA. I haven't had many opportunities to teach clinical medicine. There have been a few physician's assistant students who have rotated through our clinic, and recently a family practice resident spent several weeks working with us in the hospital on an elective rotation. The hospital also has nursing students from two local school who do their clinicals with us, and so does the local paramedic training program. I even had a paramedic intern deliver a baby with me--his first.

MEconomics, Part Two: The Long Reach of Med School

Part Two of this series on physician compensation and my personal bottom-line addresses where all the difficulties begin:  with medical school debt.  Let's walk through the process of accumulating educational debt and estimate whether the published averages tell the whole story.

The Impact of Diagnostic Errors

Bob Wachter has written a thought-provoking post on the hidden impact of diagnostic errors. The post discusses the current frenzy over preventing system-based errors (i.e. wrong drug, wrong side problems) which are made while providing patient care for an established diagnosis.  But what if the diagnosis is wrong?

It is the classic GIGO scenario: the result is only as good as the data inputs that created it.  As medical imaging becomes more sophisticated, genome mapping moves within reach, and competence in minimally-invasive surgical techniques increases, people naturally expect diagnostic accuracy to increase as well.  Why wouldn't it?