Community GIM

Can You Prepare? Rural Internal Medicine: My First 5 Years

Amy Hendricks, MD

About the Author

Amy Hendricks completed medical school and internal medicine residency at McGill, Montreal, Quebec. She has settled in Yellowknife, Northwest Territories, where she divides her time between rural internal medicine, classical music performance, and family life with a toddler.

Just over 5 years ago, I stepped off a plane and into an internal medicine practice north of the 60th parallel. My only colleague went on a sorely needed vacation just after I arrived, trusting that I was adequately prepared to cover his practice – the entire Northwest Territories and much of Nunavut.

On my first weekend, I was called to the emergency room to see a patient with atrial fibrillation. His corrections officer stood nearby. Although the patient was known to be a “frequent flyer,” there was clearly something new going on. His neck veins were distended, a soft precordial rub was audible, and he was uncomfortable lying down. His chest radiographs were concerning for a significant pericardial effusion, although I couldn’t identify any precipitating factors. The ultrasonography technician on call was not trained in echocardiography, so no further information was available. I had been informed of the usual costs of transfer: $10,000 for a medevac, plus a guard to accompany the patient for the duration of hospitalization in Edmonton. 

My first impulse was to review the consult with my staff (oh, that would be me). All right, the subspecialist (that would be me, too). I took a final look at the chest film and phoned Edmonton, where a cardiologist agreed to see him in the emergency room and admit him only if there was a significant pericardial effusion. Otherwise, the medevac would be a “hold-and-wait,” bringing the patient straight back to our emergency room the same day.

I heard nothing until a fax arrived on my desk informing me of the patient’s immediate pericardiocentesis for 1,200 cc of fluid. The fax was sent by a Northern Health Services Network nurse, whose sole job is to communicate news to northern facilities regarding the patients they have transfer south. I have learned to await these handwritten notes as the final word on whether my clinical instincts led to appropriate treatment or to an unnecessary medevac.

Until we filled our third full-time position this fall, the Stanton Internal Medicine Department relied heavily on locum physicians, some of whom have skills at echocardiography. As a resident, I often watched the echo technicians and cardiologists perform studies on my patients, but I had never imagined a general internist using the hallowed echo equipment – much less interpreting and acting upon the findings. 

The fluoroscopy room had also remained a mystery during residency. But on December 25, I found myself in a lead apron in front of a patient who was dependent on a transcutaneous pacemaker for his cardiac output. I called my colleague away from his Christmas dinner since I had never inserted a transvenous pacemaker – at my training institution, this was the territory of the cardiology fellows. And, gradually, one hallowed mystery after another turned into the familiar stomping ground of a country internist. Insulin pumps, dialysis units, tuberculosis management, home paracentesis for palliative patients, directing thrombolysis by phone based on a faxed EKG – these have gradually become expected parts of my practice, with subspecialist support available when my expertise and facility cannot adequately care for a patient.

Could I have been better prepared? I believe so. Internal medicine residency gave me a good knowledge base and clinical skills, but it did not give me the courage to use those skills to direct a patient’s care. As a rural internist, I am a consultant to a highly skilled cadre of family physicians who manage most of the inpatient and outpatient problems I dealt with as a resident. They consult internal medicine for the more complicated questions: Would this patient benefit from an insulin pump? Should this hyperthyroid patient be referred for radioactive iodine? Is this patient with hepatitis C a candidate for treatment? Should this patient undergo urgent coronary angiography? Subspecialty rotations during residency gave me the medical basis for working as a rural consulting internist, but I never saw internists working as consultants to family physicians until I began a rural rotation during my fellowship year.

Many voices within the CSIM have drawn attention to the severe understaffing of rural medical communities, particularly with “general specialists” such as general surgeons and general internists. I believe that part of this difficulty arises from the absence of primary care in many teaching hospitals. If there are no family physicians practising in a teaching hospital, to whom will an internist serve as consultant? How is internal medicine different from hospitalist duty, a function that is very competently filled by family physicians in many communities? Who guides a patient’s treatment plan – multiple consulting subspecialists, or an internist who has the training and confidence to manage the patient’s brittle diabetes, impaired renal function, and ischemic heart disease simultaneously? 

My time in a remote community has taught me that family physicians are truly the experts in primary care, and their care is often superior to my own for less complicated hospitalized patients. I forget about the patient’s depression; I don’t recognize the family dynamics contributing to illness; my discharge planning skills have declined as my consulting skills have improved; and I generally neglect to address contraception unless I am starting a teratogenic drug. But rural internists are not asked to do these things. We are asked to be resources of knowledge, procedural skills, and clinical wisdom to meet specific patient needs including critical care and many different subspecialty areas. We are asked to recognize a community’s health needs and address them through physician education, support of nurses, program development, and advocacy.

Advocacy … I don’t remember that being a part of residency training. But an established rural internist has a clinician’s eyes to notice gaps in care, and a community’s trust to address them in a practical way. My own interest in tuberculosis landed me recently at public health, meeting with Salvation Army staff to discuss the adequacy of ventilation at the homeless shelter. I offered to write to the minister of health regarding funding for some new air filters. This was not a political gesture; it was just part of the job. “This needs to be done, or my patients will suffer.” And if I don’t do it, who will?

Hendricks A. Can you prepare? Rural internal medicine: my first 5 years. Can J Gen Intern Med 2008;3(1):21–22.