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