Rural medicine lessons for residents

Last week marked a new rotation in the academic medicine schedule, and 2 residents landed in Yellowknife to begin their rural internal medicine rotations. One of them joined me yesterday for clinic. By the end of the morning, he asked if he could ask me a “program” question. “I’m not sure I understand how you utilize subspecialists up here in Yellowknife,” he commented. “Do you call them for advice, or send patients down for consultation?”

I remembered my first few months in rural practice, which included several desperate phone calls back to McGill (where I had trained) for advice. During those days, I was intimidated by the clinic setting and spent hours each day checking notes and viagra cialis online pharmacy pharmacy education resources to ensure I was managing patients appropriately. Six years later, life has changed considerably.

“Well,” I replied, “I send patients down when they need a procedure – an MRI, cardiac catheterization, perhaps a MIBI scan. I’m not as strong at rheumatology or outpatient neurology these days, since we have excellent locums who come every 3 months and see patients from all over the north here in Yellowknife. I don’t usually send patients out for an opinion on a cardiology or diabetes patient, since we’re able to offer good service here in the north.”

He thought back over the morning. We had followed up a patient post-ablation for WPW, discussed pharmacologic and other options for SVT with a teenager and her mother, and reprogrammed the pacemaker of a patient from Ulukhaktok, a tiny hamlet on an island in the Arctic Ocean. I had spoken to an Edmonton specialist regarding changes to an outpatient tuberculosis regimen due to drug intolerance, and I was trying to book a pregnant type II diabetic within the next couple of days, to start her on insulin. The tuberculosis and pacemaker cases presented us with some good teaching opportunities, and we also discussed the benefits of continuous glucose monitoring systems in selected diabetic patients.

“I guess I didn’t expect all of this to happen in one place,” commented my resident. “I don’t think that’s what internists do in downtown Calgary, is it?” Having never worked in Calgary, I had no details to give him regarding the outpatient life of internists more familiar to him. “I’m sure that each of them has a practice profile suiting their expertise and meeting a need in their community,” was the best I could do.

I never chose tuberculosis, or pacemakers, or insulin pumps, as part of my job description; in a small community, a specialist’s role develops around local needs and to complement local expertise. Most gastroenterology questions are punted from my desk to a couple of colleagues down the hall, and they reciprocate with nephrology referrals since I work most closely with our dialysis and renal insufficiency programs.

In the afternoon, the resident joined me for stress testing, and we started out with a patient from the small community of Fort Smith. A young man with previous coronary bypass surgery and chronic atrial fibrillation, he clearly needed consistent care to prevent future cardiac events. I listed him for annual stress tests – not because they are necessarily indicated, but because they will guarantee he sees an internist at least annually to review his lipids, diabetes management, ventricular rate control, and cardiac status. “Fort Smith just lost its only permanent physician,” I explained to the resident, “so I can ask the nurses to watch his heart rate, lipids and so on – but I can’t guarantee continuity of physician coverage unless he’s kept in our system.”

The next patient, from Yellowknife, had been unable to find a family physician for months. He had a reassuring stress test but multiple cardiac risk factors. “Our nurse practitioner will follow up his lipids and smoking cessation,” I told the resident; “If anyone can help him stop smoking, it will be an ex-smoker who has plenty of time for phone and clinic follow-up.”

Sometimes it seems that every community in the Northwest Territories has a different model of care, which changes as local medical resources ebb and flow. My resident will soon board another plane for a 1-physician community, where the visiting internist is treated to lunch in exchange for a spontaneous lecture to the local nursing staff on the topic of their choice. He will see patients from the bush and patients from the town, and offer advice and encouragement to the nurses who give most of the medical care to the region’s scattered population.

Perhaps one day my resident (or one of his colleagues) will give himself to a small community, becoming the internist for an otherwise unserved population, learning and growing with local needs and programs. Granted, it is a model he has not seen before; but it is the only life I have known since I was foolhardy enough to accept a 1-way ticket here from Montreal. I do miss the opera, but otherwise I wouldn’t change a thing.

-- Dr. Amy Hendricks

Men's Health Weight Loss News...

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Lose weight & transform your life

MensHealth.com is going to transform you in 2007!

Five lucky guys have been selected from the Men's Health wide-ranging audience to get a personalized fitness and nutrition plan from Men's Health trainer Craig Ballantyne.

The soon-to-be "Fit 5" will take us along on their struggle through their blogs, video diaries, and weekly question and answer sessions with the trainer.For the first 5 weeks of the plan, our millions of online users will not only follow their progress, but they'll be able to join them.

You will be encouraged to select a guy most like you—whether you need to lose a lot of weight, want to go from scrawny to brawny, have no time to work out, or need to banish the belly fat you're just noticing—and try the plan.

Starting January 8th, Transform Yourself 2007 will be featured every day on the home page of MensHealth.com. Monday through Friday for 5 weeks, one of the Fit 5's ongoing stories will be highlighted, including his "homework" assignment for the upcoming week. This program will be featured in our Men's Health newsletters at least twice a week.

Rob Gerth
Online Editor
Men's Health

**************
That's right, I've added another project to my list for January...that makes about 6 major projects I have on the go for the start of 07. I plan on helping a lot of people achieve their fitness goals, and I hope you are one of them.

I think you will all enjoy this transformation series running over at MH. See you there in January.

CB

Straight to the Heart

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Read this paragraph this morning and was overjoyed to find words for what I've experienced this lent, wanted to share with you:

When I look up from feeding the outside dogs to see the full moon coming up through the bare trees like the wide iris of God's own eye, when I feel the beam of it enter my busy heart straight through the zipper of my fleece jacket and fill me full of light - I am in prayer.  When I spend all afternoon chopping onions, stewing tomatoes, and setting the dining room table with every piece of silver I own for a supper of soup and bread with friends, I am in prayer.  When I am so sick that I cannot do anything but lie in bed with a jar of Vick's Vaporub and a blister pack of cold cheap cialis lost somewhere in the sheets, with all the time in the world to remember whom I love and why, I am in prayer.  



- An Altar in the World, A Geography of Faith by Barbara Brown Taylor

Blessings on your prayers this Holy Week,

Circumcision of Penis

Circumcision is the surgical removal of the sleeve of skin and mucosal tissue that normally covers the glans (head) of the cheap cialis. This double layer, sometimes called the prepuce, is more commonly known as the foreskin.The foreskin serves three functions: protective, sensory, and sexual. In most cases, the foreskin is still fused to the glans at birth and will separate over a variable period of time over the first few years. During the diaper period, the foreskin protects against abrasion from diapers and faeces. Throughout life, the foreskin keeps the glans soft and moist and protects it from trauma and injury. Parts of the foreskin, such as the mucosa (inner foreskin) and frenulum, are particularly sensitive and contribute to sexual pleasure. Specialised nerve endings enhance sexual pleasure and control. The inner foreskin (mucosa) is the skin directly against the glans. The foreskin provides ample loose skin for the cheap cialis to occupy when erect. It is a movable skin sheath for the penis during intercourse, reducing chafing and the need for artificial lubricants, and allowing the glans and foreskin to naturally stimulate each other. Phimosis is the inability to retract the foreskin fully. In babies and young boys this is normal. As the baby grows older, the foreskin separates from the underlying glans penis. In some individuals, this separation does not happen fully or due to repeated infection in that area the skin becomes scarred. It might also happen later in life. When the foreskin does not retract, it predisposes to repeated infection in that area. Also, sexual intercourse may become painful and result in bleeding. The only treatment at that stage is a minor operation called circumcision, in which the foreskin is surgically removed.Is circumcision painful?When done without pain medicine, circumcision is painful. There are pain medicines available that are safe and effective. It is recommended that they be used to reduce pain from circumcision. Local anaesthetics can be injected into the penis to lower pain and stress in infants. There are also topical creams that can help. Problems with using pain medicine are rare and usually not serious.After the circumcision, the tip of the penis may seem raw or yellowish. If there is a bandage, it should be changed with each diapering to reduce the risk of the penis becoming infected. The plastic ring that is left on the tip of the penis usually drops off within five to eight days. For both newborns and older children, circumcision is considered a very safe procedure with complete healing expected.Possible benefits of circumcision include:
Circumcision prevents infection and inflammation of the foreskin. And it may decrease the risk of penile cancer.
It might play a role in reducing the risk of sexually transmitted diseases. Practicing safe sex, however, is a far more important factor in preventing these diseases than whether a man is circumcised.
Infants who are not circumcised may be more likely to develop urinary tract infections. These infections early in life may lead to kidney problems later in life. Infants who have kidney or bladder abnormalities are at higher risk of urinary tract infections, so circumcision may be advised for these babies.
In rare circumstances problems can occur with the uncircumcised penis that may require circumcision at an older age. These problems include inflammation of the foreskin or adherence of the foreskin to the tip of the penis. Circumcision during infancy eliminates the possible need for the procedure at an older age.
Circumcision makes it easy to keep the end of the penis clean. However, the shedding skin cells that naturally accumulate on the glans of an uncircumcised boy are not harmful. Do not try to force the foreskin back to clean the penis of an infant or young boy. Washing externally with mild soap and water is all that is necessary.Possible risks:Like any minor surgery, circumcision poses some risk to the newborn:
Circumcision may cause excessive bleeding or infection, but this is rare.
Circumcision does cause pain. Local anaesthesia is frequently used. If you decide to have your son circumcised, you should to talk to your doctor about whether local anaesthesia will be used.
Circumcision is a preventive measure but is by no means a guarantee that medical issues will not develop later in life at the tip of the penis.