Rural Doctoring

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 3: Lessons from Residency

By the time I entered my intern year, I thought I'd had a lot of exposure to OB and childbirth care. After all, I'd done four rotations and delivered ten babies, a good record for a mere medical student. I had a few moments of pure hubris in thinking I'd seen enough to be ready for the large number of deliveries I was looking forward to doing at my program's hospital. In this post, I'll discuss what I learned about childbirth and maternity care in during my three-year family practice residency.

Dr. Santell's Rounds #1: Make Time For Breakfast

The first time I met Dr. Santell I was a fourth-year medical student arriving for my first day of a rural family practice elective. I'd been told to show up at 7:30am in the main conference room to attend the Morning Report. When I arrived, the room was empty, so I took a moment to decide where to sit. There were about ten 6-foot long rectangular tables lined up in rows of two, each with three seats. I didn't want to sit in the front row like a geek, but I also didn't want to creep around in the back and look like a slacker on my first day, so I sat in the first chair in the second row, closest to the door.

Morning Report was an institution at this hospital, where I went on to do my residency. Because the residents ran all the services in the hospital--Medicine, Peds, OB, ICU, Surgery--the different services did not meet individually. Instead, the daytime residents finished pre-rounding at 7:30 to meet with the Night Float or post-call residents at the Morning Report. The conference room was next door to the cafeteria, so everyone picked up breakfast and ate it while the night team presented cases.

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.

Dr. Santell's Rounds: An Introduction

Fat Doctor recently shared her grief over the loss of a colleague on her Twitter feed. My sympathy for her loss motivated me to begin a project I have been planning to share on this blog even before I launched it: Dr. Santell's Rounds.

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.

Night Float, Part Four: A Modest Proposal

Since beginning this series, a few other bloggers and commenters have raised several points important to any discussion of resident work-hours or Night Float:

Night Float, Part Three: Sign-Out & Other Problems

In the last post in this series, I discussed the necessary evil of nighttime cross-coverage and the need for adequate communication between doctors to ensure this coverage is optimal. This post delves deeper into a couple of factors that can derail such communication:

Night Float, Part Two: The Art of Cross-Coverage

In his recent Slate article, Dr. Sandeep Jauhar wrote about concerns regarding Night Float systems:

"Night float is the product of reforms in medical education that limit the number of hours that residents and interns—doctors in training—can work. Because they can no longer rely on the same doctor caring for a group of patients day and night, teaching hospitals have had to arrange more cross-coverage when the primary resident is not on duty. Most have created the position of a resident who works the night shift, usually for a few weeks. The upside is that other residents can sleep. The downside is frequent patient handoffs, which can result in the transfer of faulty or inadequate information. The nightmare of night float raises a central question about work limits for interns: Is it better to be cared for by a tired resident who knows your case or a rested resident who does not?"

The topic of cross-coverage is important to any discussion of Night Float or resident work-hours generally. In this post, I'm going to expand the definition of cross-coverage and lay the foundation for a later discussion of patient handoffs or, as I call it, sign-out.

Night Float, Part One: What is Night Float?

In a recent Slate article, Sandeep Jauhar, M.D. criticized the institute of Night Float. Since then, the venerable Dr. DB has responded with his own love/hate relationship with Night Float systems. Like anything in life, there's more than one perspective on Night Float, and this post will introduce my own.

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.

Fully Fledged Doctors

In my enthusiasm to congratulate graduating med students, I forgot that RESIDENTS are graduating too! Liana at Med Valley High and Michelle at The Underwear Drawer (via her twitter feed) have written about unexpected moments of depression and pangs of nostalgia during their last days in residency. This may take some people by surprise; after a bazillion years of long hours, low pay, excruciating mental challenges, you'd think a graduating resident would be sprinting for the door. But pangs of grief?

I felt exactly the same way as my Family Medicine residency was winding down. Even though I'd had most of my worst days at my residency hospital, I'd also had many of my best. And then there was saying goodbye:

This is a photo from graduation day, 2004. From left to right: Dr. Santell, our mentor and conscience; my sister resident, Cori; me; and our great resident colleague, Suzin. (Yes, I know I'm rumpled, I know I have baggy eyes--I was TIRED, okay? I'll tell you the story of how we put graduation together, and how it very nearly killed me, another time.)

When you leave residency, even though you're probably going towards something wonderful--the rest of your life, for example--you're also leaving something you might never find again: the camaraderie and friendships formed in the pressure cooker of resident life. After three years working side by side, running from crisis to crisis, I know I could trust my life to Cori and Suzin, and they know the same about me. As for Dr. Santell, who died unexpectedly on March 24th, 2006, all I can say is: he taught me everything I know about being a doctor. I think about him every day. Whenever I'm the least bit tempted to cut corners on a workup or an H&P, I imagine the expression on his face whenever he caught one of us in such an error, and I turn around and do the right thing.

There aren't that many other experiences wherein such relationships are forged. I suppose comrades in arms feel the same way--I couldn't say. But I can say that--although my college loyalty has faded into nothing, and my med school bragging rights have fallen flat--my residency years grow in importance with each year that passes. I believe I formed the core of my personal code of ethics during those years, and perhaps this is the reason why sometimes I long to be back there, with my friends and Dr. Santell.

(Of course, I might have Stockholm Syndrome. Hm.)

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?

Tales from the Crypt: Final On-Call Page Posted

I've finally finished plowing through my old blog posts.  The final on-call post is here

A snippet:

" ...One of the worst part of residency, maybe about doctoring in general, is the need to move on from one scene to another, without the chance to sit down and let the experience seep in. The transitions from grief to joy, if you get to feel them at all, if you can remember to feel them, whip by so fast that it hurts your head. Maybe even breaks your heart."

For a complete listing of all the residency on-call reports, go to this page.

Tales from the Crypt: On Call Page Updated

On-call archives has made it to the R3 year.  Go read it!

A snippet:

...Geez, there's going to be another C-section. The hospital has recently changed their policy allowing a woman to labor after a previous C-section. We were not meeting all of the stringent requirements set out by the hospital's insurance carrier, so the administration decided we could no longer assume the additional risk of permitting attempted vaginal birth after Cesarean section (VBAC). This means that all women who were unlucky enough to have a C-section for their first pregnancy now must be delivered by repeat C-section, without ever attempting a vaginal birth. The policy change has resulted in a lot more C-sections, longer hospital stays for mothers and babies, and a lot of bad feeling among those of us who believe that VBAC is an important birth option to offer to women. 

Residency Work-Hour Reform: Is this progress?

Thanks to Dr. Happy, I found MedSchoolHell's mention of an upcoming IOM proposal to reduce resident work-hours from 80 to 56 hours per week.

I have mixed feelings about the proposal. On one hand, when the original movement to reduce resident work-hours was proposed, I was all for the change.