Week 4 reflection

I'm sad that I have to leave Baker in a few days, but I'm so thankful for the time I've been able to spend here. It's also nice knowing that I'll be coming back (and this time with Mike!) for a rotation next January. What's really awesome is that we will be joining Dr. Schott and the gang on their annual medical mission to Honduras.

It's been a great week. A busy week. As I've mentioned in previous posts, the scope of practice of Dr. Schott and his colleagues is quite astounding. We go from delivering babies to admitting patients to the medicine unit to seeing patients at EOMA to seeing patients at Pine Eagle to attending hospice meetings. And we see so many types of patients, ranging from complex geriatic patients with several chronic conditions to more straightforward acute presentations to well-childs and so much more. That's the beauty of family medicine for ya. :)

Carol posed this question to me: "How much of yourself can you see in these rural docs?" and I've been thinking about this for quite some time now. I think that my enjoyment here has a lot to do with how much I enjoy being with my preceptors. I enjoy spending time with them in clinic as well as out of clinic. I feel like we share similar values and interests, professionally and personally. For instance, in the context of medicine, I feel we all value relationships, continuity of care, comprehensive care, and understading our patients as whole people (values shared by family medicine doctors both rural and urban it seems). More broadly, I identify with the emphasis these doctors place on community, at the clinic and in Baker as a whole.

To echo what I've stated previously, the old adage that "everyone knows everyone" in small towns rings true based on my experience in Baker. This has pros and cons of course, but I've found that the positive aspects of this phenomenon outweigh the negatives. Indeed, one of the most meaninful aspects of this experience has been the opportunity to get to know my preceptors, the rest of EOMA staff, and my patients so well since I see so many of them on a regular basis. A sense of community pervades EOMA and Baker as a whole.

I wonder sometimes if I am romanticizing the "small town" thing. My preceptors have been honest with me about some of the disadvantages of living in a small town, and I appreciate their candor. I feel it helps me paint a more complete picture. However, I've found that my experience in this rural community has been an overwhelmingly positive one. I feel that my preceptors' values and ideals resonate with me, and I share their love of this lifestyle and this beautiful land. It feels so good being able to just look out into infinity and be surrounded by mountains. Indeed, we are in the mountains. Baker's elevation is 3,451 feet afterall. It's so grounding being here, and I love that everyone is so close to the land. Side note: at the Kelleys a few weeks back, I was told that "everyone who moves to Baker eventually buys an animal or two. And dogs and cats don't count." We're talking horses, cattle, sheep, llamas, goats, pigs, chickens, and the like. :)

Another thing I've been thinking about is how progressive EOMA is. They are a patient-centered medical home, something we've learned a lot about from Dr. Saultz and others at OHSU. To see a PCMH in action is exciting. This innovative model is defined as follows: "The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner." Similarly, at EOMA, "Our philosophy is simply to treat you as we would want our family to be treated. From our receptionsists to our providers and management, we aim to provide the highest level of care we can with a sense of caring and compassion. In trying to achieve this goal, we have attempted to design the clinic and its flow to optimize efficiency and comfort. As you will see, this may mean encountering new ways of doing things that we are all going to have to adjust to. The changes we feel will help improve your access to the providers and our access to knowledge."

Dr. Schott really does embody that first phrase, and treats his patients as if they were family members. I can tell that his patients appreciate this and that he is well-loved and respected by his patients. Dr. Schott is incredibly hard-working, and several of his peers have recognized this as well. In fact, last night, I had a chance to meet Wanda, mother of Mercy (owner and landlord of my apartment and sister of one of Dr. Schott's best friends), and she shared glowing remarks about Dr. Schott, "Jon has always been so hardworking. I'm so happy that he became a doctor. Baker is so lucky to have him." It's not uncommon for me to hear comments like this from several of Dr. Schott's patients and friends. From what I can tell, it seems that the other physicians here are also greatly admired and respected by those in the Baker community, and it's an honor to be working with them.

Back to the PCMH, Jacque Cobb expressed, "What's great about EOMA is that we have doctors that have traditional values, like family and relationships, who are also really progressive when it comes to the way they practice medicine." Well said, Jacque. I've noticed that all of the docs here are incredibly up-to-date with regard to patient care. On more than one occasion, I've heard, "An article just came out a few months ago that says [this treatment] is better than [that treatment]..." or "A study published a few weeks ago indicated that a more effective treatment for [this condition] is [this lifestyle change] in combination with [this medication.]" In this way, their practice of medicine is truly evidence-based and cutting edge. It's wonderful to see this juxtaposition that Jacque described of traditional values and progressive practices. I think these doctors are providing excellent care, and their patients are happy to boot!

Baker Bangs

I wanted to go for the full immersion experience here in Baker, so I scheduled a haircut and style at Lavish Salon with Kelly, who was recommended by Angie. I showed up after clinic around 5:30 and left about two hours later with a totally new 'do! Here's before:

And after:
I wasn't sure what to expect since I was going to leave it up to Kelly to decide exactly what type of cut to do. All I knew was that I wanted some bangs. I've been thinking long and hard about this, and I think that if I used the right products and styled it just the right way, I could have a mullet. That'll be my project for when I get back to Portland. ;)

Anywho, thanks for the 'do, Kelly!

Kelly with her daughter, Savannah

It's midnight...

...and I'm going to get up in a few hours, but I feel the need to write. It was a wonderful day, and this evening, I had a chance to be involved in a very special delivery. All deliveries are incredibly special, but tonight's somehow had a profound impact on me. This was the mom's first baby. She's just shy of twenty and is a sweetheart. I first met this petite lady earlier in the day when she wasn't yet completely dilated. She had a long labor and almost went to C-section. In the end, she was able to deliver vaginally. I am so moved by each delivery I witness...there is so much emotion, magic, rawness, and beauty in these moments. I see women who are so courageous even in the face of the unknown, for a lot of them (though even for multip moms, each delivery is so different and unpredicitable). Something about tonight's delivery was especially powerful. I think it had a lot to do with the young lady giving birth. We broke down the foot of the bed, and her legs were being held up by her husband and mom. Dr. Smithson and I stood at the foot of the bed, watching baby slowly descend and eventually begin to show herself. Baby crowned for a long time and finally delivered a good 5 minutes after first crowning. During her contractions, mom kept looking at me since I was standing more centrally. Her husband and mom were on either side of her, her nurse was at her side, and Dr. Smithson and I were at her feet, and we were all yelling Push push push go go go that's the way! Just like that! Strong pushes! Good! I wondered for a split second what someone standing outside the room would think of our chorus of voices. What a unique time. A woman surrounded and supported by a group of people all waiting for a mini human to come out of her. I kept thinking of Dr. McKenna, my anthropology professor at Notre Dame, who always talked about the pelvis-and-head dilemma (how over eons of time, our brains kept growing, meaning babies' heads keep getting bigger but the pelvis does not!) I looked up briefly at everyone's face in the room. Mom had a look of fear and pain, dad had such a sweet earnest look of encouragement, grandma was fiercely supporting her own baby "Go baby girl! Get mad! You can do it!", nurse was solid and saying words of encouragement...I can't even find the words to describe the heightened sense of something in that moment. Somehow it feels right to describe it as a moment in which we were all so alive, so human, so authentic. Mom and I locked eyes several time. She seemed to have an expression like "Get this baby out of me!" Actually, she did say this aloud. But her eyes were full of urgency, vulnerability, desperation. Just making this eye contact somehow moved me. I looked right back at her and tried to affirm what she was doing...I nodded...you are doing it you are doing it, that's it, almost there, keep pushing...I felt the need to be grounded and strong. She was looking at us with desperation; indeed, for a long time she had been saying "Use the suction, I can't do this, get her out!!!" She'd say "I can't do this" over and over, and we'd all affirm her, Yes you can. Yes you are! She did it, she gave it all she had. She was utterly exhausted, but she did it. Baby came down and I got to catch her and lay her on mom's chest. That moment always chokes me up. Mom is always yelling because of the watermelon lemon thing and it's always fascinating to me when that scream of pain turns into a scream of delight and sheer joy and relief. Mom, partner, (and probably baby too!) always seem stunned. What a moment of pure connection and oneness. So beautiful. It's such a privilege to witness and take part in this magical event. I can't get over the beauty of birth and I don't think I ever will...tonight's whole experience seemed especially gratifying since her labor was so long and she almost went to section...in the end, everything turned out so well. We thought we'd have to use the vacuum or perform an episiotomy at the very least...but the universe had other plans. She did fabulously and fought through to the end.
I should get to bed. Sorry this blog has kind of been an ulfiltered, stream of consciousness type of thing. Thanks for bearing with me. But I just had to write. I've been wanting to write more about some of the deliveries I've seen...so now I finally am. Birth is just so beautiful! Well, off to bed. Alarm's set for 4 hours from now!

When in Rome...

When in Baker, go belly dancing! Baker has a great place called Crossroads Art Center that "was established to aid, encourage, advise, and correlate activities to promote and sustain the creative and performing arts in Baker County andneighboring communities. [They] sponsor classes in drama, music, dance, oil painting, watercolor, sculpture, pottery, creative writing and other disciplines as well as adult and children's performances and visual art exhibits."

One of my patients had talked about a tribal belly dancing class she attended, so I thought I'd check it out. I attended the class tonight. Everyone was really friendly and welcome and tolerant of my lack of dancing abilities. These ladies are so good! I especially enjoyed watching Tymmera, the teacher (who, as it turns out, is the dental hygienist I had met before at the Halfway Pine Eagle Clinic!).

The regulars perfomed a "Basket Dance" they have been working on for quite some time. It's such a beautiful dance form! I feel inspired. :) I bought this album that Tymmera recommended: Migration by Gypsy Caravan. This the type of music we danced to tonight. It's hard not to move when you listen to it! Speaking of music and dance, check out this video called "The Musical Brain." It was shown on my United flight last month and is absolutely fascinating! Here's an interesting article on the same topic. Very cool! Reminds me discussions we had during my Anthropology of World Music class at ND with Stephan Fior. We humans are meant to make music and dance!

Various teaching styles

FYI if it's of interest, I thought I'd share a little bit how a typical day goes with my preceptors. Generally, we take a tag-team approach in how we see patients. I'll see a patient, interviewing and examining them to the best of my ability. While I'm with them, my preceptor will see a patient usually and then after he's done, I'll meet with him to discuss the patient I just saw. We'll then both see my patient. Then we'll repeat this process.

I appreciate the time my preceptors give me to meet with my patients. I have a chance to practice my interviewing and examination skills. Patients have been really tolerant and patient, letting a student interrogate, poke, and prod them. ;) I am forever grateful. I learn a lot this way: time alone with the patient is valuable, and time with patient + doctor is incredibly valuable as well.

I'd like to highlight another teaching technique, which I'll call the Lamb method. I worked with Dr. Lamb last week, and per usual, I met with one of the patients one on one first. We had a busy afternoon, so Dr. Lamb forewarned me that he'd come in and observe me interviewing some of the patients. So here I was interviewing a pleasant young lady with some suspicious skin lesions, and Dr. Lamb walked in. He said, "Don't mind me, I'll just be sitting here observing." The patient said lightheartedly, "You'll make her nervous!" Dr. Lamb then proceeded to briskly pull the curtain (that is usually used for patient privacy) in front of him, hiding him from view. So the view we had was of the drawn curtain with his legs still visible from below! (Mind you, he was in his typical garb: blue jeans and cowboy boots! I love it.) The patient and I cracked up, and I did my best to interview her. It got even better, though, because as I asked questions of the patient about her rash, Dr. Lamb would peek out from behind the curtain! I tried to maintain an air of professionalism and tried to continue asking her questions. At one point, I had to ask a question and asked to "consult the curtain." Permission was granted, and Dr. Lamb helped me out. :)

That's it for now...just a day in the life of a med student in Baker City! Man, I'm really getting attached to this place. Can I please do my pediatrics and internal medicine rotations here too, pretty please?

Dr. Lamb reveals himself :)

Some photos from around town

Pill Box Pharmacy where Dawn works

City Hall

Le Old Post Office

St. Francis one block away from my apartment

Historic Adler House Museum

D & B Supply, one of my favorite stores in Baker :)

Another one of my favorites :)

Earth & Vine

Super cute! Yummy food and local artwork

Traditions quilt shop

Sacre bleu!! Could it be?

Courthouse

Yum!

Inside Paizano's

One of Sue Orlaske's (local artist) batik pieces

Baker Tower (sorry about the power lines). This is where the Robbie Burns dinner was held.

Baker Tower from a different vantage point

Home Sweet Home: my apartment

Robert Burns Supper: Happy 251st birthday, Robbie!

Since I can't describe it any better :), here's a description from the Eastern Oregon Celtic Society's website:

2010 Robbie Burns Supper
Each January, Scottish/Celtic organizations from around the world gather over multi-course meals and traditional entertainment to celebrate the birthday of Scotland's most famous and infamous poet, Robbie Burns. This year, join the EOCS Saturday, Jan. 23, 2010 as we host Baker City's own celebration!

Our groups' annual Burns Supper will be held in the ballroom of the historic Baker Tower, with a social hour beginning at 5:30 p.m. and dinner beginning at 7 p.m. The event will include a cash bar, silent auction and door prizes. Proceeds from the auction go toward the sponsorship of the next Eastern Oregon Celtic Festival and Highland Games scheduled for August 28, 2010.

An amazing five-course Scottish meal will be served, featuring a host of delicious dishes - and of course, haggis! Guests will be treated to Celtic music, Burns poetry and songs, bagpipe performances and more. Guests will also learn more about Burns' life in a short tribute performed by Alan Johnston. By popular demand, Don McClure returns this year to give the Toast to the Lasses, and Amy Dunkak, the reply. A true character actor, Rick Forrester will recite a very entertaining "Address to a Haggis." Gary Keenan will sing a traditional Scottish song and recite a poem in Gaelic. Dutch Fahrney and Bob Nelson will perform the hilarious "The Origins of the Kilt."

Formal or semi-formal attire is encouraged but not required. Guests at the Supper will once again participate in the Guinness Book of World Records-making, Worldwide Toast to Robbie Burns. (http://www.worldwidetoasttorobertburns.com/.)

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Here's some background on Robbie Burns. What a fun night! I learned a lot about Robbie! For instance, did you know that he wrote Auld Lang Syne? He also was a big supporter of George Washington and our fight for independence.

Dinner was fabulous and consisted of haggis, Scotch eggs, creamy potato leek soup, roastit beef, rumble thumps, highland bread rolls, and tipsy laird!

Center: Haggis, Right: Scottish eggs

Roastit beef, rumble thumps

I sat next to a nice couple, Anne and Roger. Anne was a pharmacist for over 20 years at OHSU (Physician's Pavillion...less than 1/2 mile from my house!) and now works part time at Pill Box with Dawn Schott. Small world! But I've found that it's not uncommon to discover that you have mutual friends with most people you meet here.

One of the most memorable and embarrassing parts of the evening for me was when I took a picture with all the men in kilts (there were a lot of them!). I had asked Leanne, who works at EOMA and is on the executive committee of the Eastern Oregon Celtic Society, if I could take a picture with one or two of the the guys in kilts. The kilts and tartans were so beautiful and authentic, and I, as usual, wanted to take a picture. Little did I know that Leanne would tell Marna, one of the main organizers, who then proceeded to make an announcement to all 100+ guests that "We have a young lady here who's visiting and would like to take a picture with some men in kilts to send home. So if all men in kilts could gather in the side room that would be much appreciated. Where are you, Stephanie?" I just about died, but I couldn't back down at that point! Red as a beet with embarrassment, I walked into the side room and stood on the side. Someone said, "No, you get in the middle." All these Scots were gathered round and about 10 people were taking photos! That moment confirmed that fact that I don't like (and am actually quite afraid) of being in the spotlight! Still, I had to laugh. I had no idea that Leanne would tell Marna, and Leanne later told me that she had no idea that Marna would make the announcement.

And then the emcee said, "Okay, now let's have some of the throwers pick her up." Hmm...I'm heavier than I look...but they didn't listen and up I went. We took a few photos with me in the air. Back on solid ground, I thanked them all and walked back to my seat, simultaneously desiring to crawl into a hole and hide, giving silent thanks to Marna for this crazy opportunity, and laughing at the silliness of the whole situation.

Talking about the origins of the kilt

The fun continued, and two of the gents did a skit on the origin of the kilt. In summary, "We had to do everything opposite of the English, who wear black trousers, short black socks, underpants, and have pockets. So we wear multi-colored skirts, tall white hockey socks, have our [....] hanging out, and carry furry purses." All of this was recited in authentic Scottish accents. We were all rolling on the floor with laughter! Needless to say, it was a fun and entertaining evening--definitely a night to remember!

Week 3

Me in one of the EOMA clinic rooms

Time flies when you're having fun! I can't believe it's already the end of Week Three. Technically, it's the end of Week 2.5 since I started my rotation here midweek. I have one and a half weeks left, and I'm already feeling nostalgic. Why must I always get so sentimental? ;)

It was a wonderful week. I learned a lot and saw such a variety of things. Dr. Schott was in Honduras on a medical mission trip, along with 10 other people (mostly from EOMA). I worked with Dr. Kelley, Dr. Mitzel, Dr. Lamb, and Dr. Irvine throughout the week. I delivered one baby and had a chance to watch another (first vacuum-assited delivery I've seen. Baby and mom are doing great). It's great how each doctor usually does the deliveries of his own patients. There's a doctor on OB call at all times, but more often then not, most deliver their own patients' babies. This continuity of care is quite impressive. The patients love it, and the doctors do too. The patients feel comfortable since they know the person delivering their baby, and I imagine that the doctors feel fortunate to be able to deliver the babies of their patients. It's wonderful, too, how after the delivery, both mom and baby will go back to EOMA for follow-up care. Does this epitomize continuity or what? :)

NST training session

This week, I also conducted my Non-stress Test training session for a few of the nurses at EOMA. Two days later, we had a mom come in for an NST--the timing couldn't have worked out better!

Performing our first NST (obtained pt's permission to take photo!)

I also joined Dr. Lamb in court where he spoke on behalf of one of his patients. It's amazing how much these doctors do in their communities. Dr. Lamb, I learned, is Deputy Medical Examiner, and Drs. Irvine and Kelley are also MEs.

This week also felt significant in that I saw several patients that I had already seen at previous visits. I appreciated this continuity and enjoyed seeing these patients again. I also saw one of the babies that I delivered last week. One of my most special patients has given me permission to include her in my blog. Her name is Joanne and she was the first patient that I admitted at the hospital. She was discharged after a few days and has returned to clinic twice. It has been so wonderful witnessing her steady improvement. I will have a chance to see her one more time before I return to Portland. People always talk about "patients you'll never forget," and she is one of those patients. And come to think of it, my time in Baker has been full of patients like this. I treasure the time I've been able to spend with them and am thankful for what they have taught me.

Joanne and me

I am also grateful for the time my preceptors take to teach me. All of them are incredibly busy, and yet they go out of their way to include me. I'm quite overwhelmed in a good way and feel I have learned so much from them. They've also been kind enough to advise me about the years ahead, in residency and in practice.

This week I also had a chance to attend a CHIP (Community Health Improvement Partnership) meeting. The CHIP program is a community-based decision-making program that empowers rural communities to improve health care and health systems at the local level. Paul McGinnis and Melinda Davis were there and shared a lot of insights about research at the community level. It's exciting to learn about Baker's projects and goals in this arena.

Overall, it was a great week with several interesting patients and learning opportunities. :) Tomorrow I will begin the day with a C-section at 7:30AM so I better get to bed. Goodnight and as always, thanks for reading!

Anthony Lakes: "Where powder is reality!"

Anthony Lakes certainly lives up to its motto. I experienced some of the best powder ever today at this ski resort, located about an hour from downtown Baker. Dr. Mitzel and his wife, Judit, were kind enough to let me join them on their adventure to Anthony Lakes. They went cross-country skiing, and I went snoboarding.

Dr. Mitzel in front of Anthony Lakes lodge

I'm told that Anthony Lakes was "packed." Mind you, there were about 10 people in line max! The quick lift line and lack of crowds was refreshing after the long lines at some of the Tahoe resorts. I'm told that today was one of the best days as far as snow conditions go since it was the first snow in a long while. There were 9+ inches of new snow at the top! Huzzah! Anthony Lakes has one lift, but the mountain feels huge! There are so many fabulous runs, I don't think I took the same path down more than once, even when I tried!

Little else compares to the feeling of boarding through fresh powder, and I almost giggled aloud with glee. The closest thing that comes to mind is meringue. Some of the doctors I work with have season passes. How awesome to have Anthony Lakes so close! What a treat it was to experience some of this perfect powder. :) I can see why some call Anthony Lakes this areas best-kept secret!

P.S. The drive to and from Anthony Lakes was gorgeous. The drive goes through the cute town of Haines and is considered the Elkhorn Drive Scenic Byway. I asked the Mitzels what the main crop is in this area, and their reply: "Cattle." ;) We also saw three bald eagles! Apparently, there is a row of trees that several birds of prey like to frequent. We could see the dark bodies and bright white heads and tail feathers! I feel very American having seen our national bird. Three of them!

Excursion to Milton-Freewater & Walla Walla

This weekend I had a chance to visit Mike at his rural rotation site. He lives in Walla Walla and works at a clinic in Milton-Freewater with the one doctor in town. This doctor went to the same residency as Dr. Irvine and Dr. Kelley in Spokane.

The drive was beautiful; I hadn't yet seen that stretch of I-84 since the drive in was so foggy and the visibility had been so poor. I love these wide open spaces and looking out into infinity. Gorgeous. It seems that there are a lot more farms vs. ranches near Walla Walla, which is located northwest of Baker City. M-F and WW are also known for their vineyards and wineries, especially since 1984 when Walla Walla Valley was approved as an American Viticulture Area.

WW has about 30,000 people, and like Baker City, it is also very charming, with a cute downtown. I met with Mike and his parents, Dianne and Kip, who had driven out from Portland the night before. We walked around downtown and then had lunch at CreekTown Cafe. The food was absolutely delish! I got gnocchi with butternut squash and banana caremel pie.

After lunch, the four of us went to two wineries: Reininger Winery and Three Rivers Winery. Both were lovely with beautiful tasting rooms. As I am Asian and lightweight, I had but a few sips at both places. :) My favorite was the 2007 Biscuit Ridge Vineyard Late Harvest Gewurztraminer from Three Rivers.

Reininger tasting room

Three Rivers tasting room

Later we went on a Historic Homes Tour around the residential areas of Walla Walla. Mike drove and Kip read descriptions of the various homes. The houses were beautiful and several of them reminded us of southern style homes with their verandas and grand entrances.

Back at Mike's place, the four of us played Catch Phrase in the living, which Dianne and I feng shui'd to promote community and relationship. :) Catch Phrase was hilarious! If you haven't played it before, I highly recommend you give it a try if you have a chance!

Mike's feng shui'd living room

For dinner we went to an Italian restaurant located in downtown Walla Walla. The food was delicious, and I was totally unoriginal and ordered gnocchi again. Also with butternut squash. Both gnocchis were good, though my favorite was from CreekTown. The gnocchi there were like little fluffly pillows of potato-y goodness. Yum. :)

Gnocchi No. 2

The following day, we went to Clarette's for brunch. Clarette's is an adorable restaurant that was voted the Best Breakfast and Best Family Restaurant in Walla Walla. I got Eggs Clarette, a delicious variation of the Benedict. Instead of hollandaise sauce, Clarette's uses a tangy cheddar sauce. Also, their version includes hashbrowns. I still think breakfast is my favorite meal of the day. :)

Following lunch, Mike showed me around M-F, which I learned is affectionately called Muddy-Frogwater. There are carved wooden frogs in front of several businesses and the town hosts an annual Muddy-Frogwater Festival. Mike also showed me his clinic, which is located in Old Town.

Mike's clinic

One of Milton-Freewater's many carved frogs

I then headed back to Baker City, my home for these four weeks. Dr. Kelley and his wife, Jennifer, kindly invited a few of the other doctors and me over for dinner. The Kelleys (Kal, Jennifer, and little Ava), Irvines (Bill, Melissa, and little Alex), Mitzels (Jerrod and Judit), and I enjoyed a wonderful dinner cooked by Jennifer with contributions from the other guests. It was fun hanging out with everyone and watching Ava and Alex play. They are so precious! As are the Kelleys' two dachshunds Lola and Hans.

Mel, Alex, Ava, Jen

I am still so overwhelmed by and grateful for everyone's hospitality in Baker. Everyone has been so welcoming, and I am most appreciative! :)