Below is a post from Mandy during her away elective with the Indian Health Service. I’m looking forward to hearing more about it soon! James
The snow followed me here. Albuquerque broke a record for the amount of snowfall just last week. On the upside, sun-drenched snow covered mountains and rock formations are much prettier than slushy snow covered Boston streets. People here seemed much more excited about it as well, telling me about all of the pictures they took and their children’s excitement. Unfortunately, the weather also seemed to keep all but the sickest of the sick from coming into clinic.
Northern Navajo Medical Center in Shiprock, New Mexico has a separate walk-in clinic for patients who are already known to internal medicine primary care physicians, and sometimes for those who are sent by other specialties to establish care. It appears that when able, patients preferentially use this option over the emergency department or any available urgent care. They seem to appreciate the increased chance of continuity, and true enough if their primary care physician is anywhere to be found, they will often stop by and be involved in the visit. This model, however, can also increase the acuity of the patients seen in clinic.
On my first day of rotation, I was scheduled to work in walk-in for the morning session. By lunchtime I had taken care of a patient with acute cholecystitis, admitted one patient with severe acute alcoholic hepatitis and another with neutropenic fever. While I had taken care of patients with all of these diagnoses before, it had never been in the outpatient setting, and never while operating as the emergency department doctor, the primary care physician and the inpatient provider.
The saddest case was the young woman with acute alcoholic hepatitis. She divulged without hesitation that she had been drinking a fifth of liquor a day, almost everyday, for at least the past year. Unlike many Boston Medical Center patients in similar situations however, her family was still very supportive. Her husband accompanied her to her clinic visit, and there seemed to be no surprise or anger caused by her confession. While alcohol is illegal anywhere on the Navajo reservation, alcoholism remains one of the biggest contributors to morbidity and mortality among its inhabitants. Painfully, this patient also has a history of breast cancer, which was newly found to metastatic this admission after x-rays for a complaint of shoulder pain revealed innumerable lytic lesions.
All of my patients from that clinic morning were sicker than I anticipated, and I was encountering them in a different context of care than I expected. In addition, every patient I have taken care of as an inpatient likely would have had at least one consult service “on board” at any given large academic center; or would have been cared for primarily by a specialty service ward team. Even in my thus far limited experience here, I have really come to appreciate the broad expertise of the physicians I have encountered and the opportunity to take care of patients from presentation to discharge. I also greatly admire, and desire, the familiar relationships the primary care providers at Northern Navajo Medical Center have with their patients throughout every care encounter. I am very much looking forward to the next three weeks, and a chance to gain further experience in this traditional, yet novel, model of care.