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Rural exposure: Med students practice giving care in the wild

What some students at the University of Washington Medical School did on their summer vacation was experience medicine, country style. The program intends to introduce students to the special joys and challenges of rural practice, in hopes of attracting new physicians to underserved areas.

By S.J. Komarnitsky, amednews correspondent. Sept. 10, 2001.

After putting in eight hours at the local medical center, Stephanie Cooper was ready for some time off. But everywhere she turned, she saw patients. The woman to whom she administered a Pap test waved at her as she walked down the street. The teenage boy on whom she did a physical exam served her dinner at the restaurant. And the diabetic she had counseled just that day to take better care of his diet was at the bar downing a beer.

That's a taste of what Cooper, 30, a third-year University of Washington medical student, experienced this summer during six weeks in Wrangell, a town of 2,400 in Southeast Alaska. The town is so small that when two drivers stop on the road to talk it qualifies as a traffic jam.

Cooper is one of a hundred or so students from the Seattle-based school sent to practice medicine at rural and inner-city sites this year as part of an effort by the university to boost the number of doctors in underserved areas.

A plug for rural medicine

As the sole medical school in a five-state region, the University of Washington has made it a mission to recruit doctors to work in areas such as the rural communities that dot the western states. In addition to Alaska, students worked in Washington, Montana, Idaho and Wyoming.

The university hopes that the students' experiences in small towns and inner-city neighborhoods will encourage them to choose a career in those areas, or at least consider the option, said Tom Norris, MD, an associate dean of the UW School of Medicine.

Rural areas average 75 doctors per 100,000 people, vs. 300 in metro areas.

Surveys by the American Academy of Family Physicians show most graduating family practice residents are choosing to work in big cities, drawn by higher pay and quality-of-life issues. The number of doctors working in large metropolitan areas has nearly doubled in the past 60 years. Small rural areas have seen little increase.

According to the Bureau of Health Professions, large metropolitan areas now average about 300 doctors per 100,000 people while small rural areas -- those with less than 10,000 residents -- average only about 75 doctors per 100,000 people.

Dr. Norris cites several reasons for those trends, including students' desires to specialize and to pay off school debts, which for the average University of Washington graduate total $80,000.

"One of the reasons is, as medicine becomes more complex, some people feel they do better mastering a small area," he said. "Another reason is financial. Specialists get paid more."

The shortage of doctors has little effect on people who live in suburbs close to big metropolitan areas, who can conveniently drive to large hospitals. But it can make a big difference in remote areas such as Alaska, where the nearest surgeon may be a plane ride away, Dr. Norris said.

"It can have subtle consequences in your likelihood to travel to get health care, and in critical care situations, your chance of surviving something can be affected if it involves the need for urgently applied medicine," he said.

In addition to sending third-year students such as Cooper to rural locations as part of a six-week clerkship, the university also sends dozens of first-year students to rural sites for up to four weeks at a time.

The university doesn't track how many school graduates decide to work in other underserved areas, Dr. Norris said. But between 40% and 50% of the university's graduating medical residents choose to go into primary care, which is the front line of medicine in rural areas, Dr. Norris said. The national average is 21%.

David Van Leeuwen, 27, spent four weeks this summer on Prince of Wales Island in Alaska at the Alicia Roberts Medical Center, and he found the experience exhilarating. The island, the third largest in the United States, is home to a few thousand people, including many members of the Tlingit and Haida tribes.

Small town charm

His first night in town, Van Leeuwen was invited to a dance attended by tribe members from all over the island and other states. "I got introduced to, like, 50 people," he said. "That was just fantastic. I would go to the supermarket and I'd know people in front of me in line."

At one point, he lost his wallet and was sure he had dropped it in the harbor after a fishing trip. He mentioned it at the clinic, thinking nothing of it, and suddenly everyone started scrambling.

"Ten seconds later, five people are running around. Someone is calling the harbormaster, and one guy had a cousin who had scuba gear," he said. "This guy went down with scuba gear and for a half hour scoured the bottom of the harbor looking for my wallet. That really moved me."

Van Leeuwen was later chagrined to discover the wallet buried in a pile of dirty clothes.

As a first-year student, Van Leeuwen mostly observed other doctors, sitting in on patient treatments, including a woman who accidentally shot herself in the leg with a nail gun. He also assisted with a woman in labor who needed to be flown to the nearest hospital in Ketchikan, Alaska, 70 miles away. Doctors scrambled to try to find the drug they needed to stop her labor.

"The work here feels more meaningful to me than working in the city," Van Leeuwen said. "You can see people really appreciate you being there."

Cooper and Van Leeuwen enjoyed the slower pace of rural medical centers. The doctors spend a half hour or more with patients, though in some ways the job of caring for people in these towns is more challenging.

One-stop medical care

Each clinic has only a few doctors and limited equipment. There are no machines for MRIs or CAT scans, no anesthesiologist and no radiologist.

Sometimes a diagnosis has to be made more by intuition than on facts, said David McCandless, MD, chief of staff at the Wrangell center. And doctors have to be quick if a patient takes a turn for the worse, because in that case they need to be packed up and flown to Ketchikan.

Doctors also have to prepared for anything -- from a person with an overgrown toenail to an amputated arm from a logging accident. Dr. McCandless even stitched up a goat whose ears had been ripped by a dog.

"The value of these internships is learning how to make decisions in things you're not an expert in, and without an expert down the hall."

Cooper's toughest adjustment was to the lifestyle in Wrangell. The island is full of natural beauty, surrounded by waters that are home to whales, salmon and seabirds. But the town has no movie theater or bowling alley, and the late-night restaurant closes at 9 p.m. Most residents make a living by fishing or logging. "I don't think I could ever live permanently in such a small town," she said.

Van Leeuwen, who is seriously considering rural medicine, said he's not sure he could handle living on Prince of Wales for more than a couple years and if he were single he'd think twice about doing it at all.

Still, both said other students should at least try their hand at medicine in a rural area.

"If you never see it or you don't know what it's like, you'll probably never do it," Van Leeuwen said.

ADDITIONAL INFORMATION:

One patient dies, another is born and a student learns more than medicine

We all knew the end was coming. For days now the crackles in her lungs were coarsening, despite the drugs we could offer her. Her family decided not to fly her out to Ketchikan or Juneau, Alaska, for advanced technology and treatment, so Patricia Johnson would meet her last days here in the town where she was born and the town in which she wanted to die.

I had run my fingers down her rippled skin, pinkish turning to gray. Her breathing was raspy and her pain crushing, and her old heart just couldn't pump forcefully anymore.

An ancient Tlingit woman, she still wore traditional silver rings on her trembling arthritic fingers. One bore the image of a raven and an eagle, as her clan was Raven and she had taken an Eagle as her husband. They perched, forever united, on her fourth digit, in a Tlingit symbol she called the "lovebirds." The other ring, a salmon, represented the woman whose spirit is the source of all rivers.

Just a few days ago she was teaching me how to say "I love you" in Tlingit, and today she lay catatonic, between worlds. I wished I could have said it once more to her. Earlier, when she complained of the hospital food, I brought her smoked salmon, parsed it into chunks and fed it to her as if she were a feeble bird.

But not today. Today her relatives piled wet-eyed into Room 4, bidding goodbye. When I stopped in earlier, Patricia was unresponsive, her high cheekbones more pronounced now that we had removed the useless oxygen cannula from her nose. That evening she slipped peacefully into the next world, her family a mere six blocks away, eating dinner, as she silently passed.

I had never seen a recently dead body before, so I walked into her room. Her chest was warm, but without a heartbeat, like rocks still radiating heat from a day of sunshine.

We all knew the beginning was near. She had already given birth to three children in an impeccably punctual fashion, always within two days of her due date. This time, almost a week late, Nadia was still walking the streets with her protuberant belly. She was supposedly a quick laborer, but a real screamer.

At the check-up on her due date, fetal heart tones were normal at 150, the baby was vertex, the stage was set, and the whole town was waiting for the one-woman show to begin.

Because Nadia's three previous births had gone so smoothly, she elected to deliver in Wrangell, despite the growing trend among young women to transfer their obstetrical care elsewhere. In the event of an emergency, mom and soon-to-be-baby would require a $15,000 Medivac to Ketchikan, Alaska, where the closest obstetrician, anesthetist, and surgical suite could be found. But Nadia was confident, and she wanted her friends and family around her.

That morning, we got a call from the nurse saying that Nadia was coming in. We rushed to the hospital, no pregnant lady to be found. Finally, somebody visiting another patient told us they'd just seen Nadia walking along the coastal trail, burgeoning with child, but walking comfortably.

In a few more hours, she came through the hospital doors, her sheepish husband at her side. We rushed her into delivery and gowned up. Unlike all other deliveries I'd seen, Nadia did not get an IV. No fetal heart monitoring frenzied the air with its intense lub-dubbing thrum. No pediatric resident waited expectantly for the new patient. No anesthesiologist had gingerly placed an epidural.

Instead, just beyond our blue sterile table outfitted with pads and tools, stood Grandma and Nadia's good friends, one of whom kept a minute-by-minute diary of the event. There they were -- her community -- to be there for this child, from the very beginning. An hour or so later, with no pain meds, a few intermittent fetal heart tone monitorings, and quite a bit of the forewarned screaming, the baby was crowning.

Betwixt the frenzy of coaching and maneuvering, I could hear the friends' excited squeals.

Suddenly, with a great push, the baby emerged. I suctioned the nose and mouth and the baby boy, with a tremendous cry, turned from blue to pink right before our eyes. Dad cut the cord, and the baby was placed on his mother's chest. His eyes opened, and I was filled with the wonder that the community there in that room were the first human beings that baby had ever seen, and they are the same human beings who will continue to nurture and sustain him throughout his life.

On my nightly walk home from the hospital, I looked out to the far islands across Zimovia Strait and pondered how each day the color, mood and texture of the waters can look so miraculously unique amid their changelessness. But perhaps the same can be said for the tides of human life, of health and of sickness, in this small town -- the death of an old Tlingit woman, balanced the next day by the birth of a baby boy.

For today, the population of this tiny fishing hamlet remains the same.

-- Stephanie Cooper