An eye-opening eight weeks
As the preceding narrative suggests, practicing family medicine in rural Alaska can be an eye-opening experience for medical students from the Lower 48. Although Native Alaskan villages are rich in cultural traditions, they usually are poor in resources and infrastructure. In many ways, they're more akin to a rural village in a third-world country than to the rest of the United States—even a small town in a remote area.
Places like Kururak often lack indoor plumbing, have weak economies, and are burdened by high rates of alcoholism, diabetes, and other illnesses—which is why Dartmouth has been sending medical students to Alaska since the late 1970s. Student interest in the 49th state grew quickly, and by 1991 a formal relationship had been established with a hospital in Bethel, Alaska. The hub of the 75,000-square-mile Yukon-Kuskokwim Delta region, Bethel has a population of about 6,000.
Now, each year, up to six third- and fourth-year medical students experience the family medicine clerkship based there. Working in Bethel and the region's 50-plus villages exposes students to a "public health perspective, prevention, community involvement, home visits—all of those things," explains Dr. Catherine Pipas, director of DMS's family medicine clerkship. It also gives students a chance to see a "more broad spectrum of what they can do with their skills in family medicine and primary care," she adds.
"My decision to choose primary care as a career was definitely
solidified in Bethel," says Dr. Emily Transue, DMS '96 and the author of the adjacent feature. "Sitting in a clinic in a big hospital, it was harder to feel that you could really impact someone's life, whereas doing a home visit in a village, [the patient's] needs and your potential to help are really clear.
"Being dropped into a village of a few hundred people," she continues, "you get a much clearer sense of the interactions between the community as a whole and the individual patient than you ever have in a larger place."
In addition to the Bethel clerkship, Dartmouth medical students can do their eight-week family medicine rotation on a Navajo reservation in Tuba City, Ariz.; in the Florida Keys; in Providence, R.I.; in two locations in rural Maine; and in multiple locations in Vermont and New Hampshire. Where thirdyear students end up for this required clerkship is based on a lottery system. In addition, fourth-year students interested in family medicine can do an elective rotation at many of these sites—including Alaska, Arizona, and Florida.
"The most important thing I took away" from Bethel, says Joan Hier, DC '01 and DMS '07, was "how to provide continuity of care with thoroughness and adaptation, given limited resources." Hier is not pursuing family medicine but is considering two other primary-care disciplines—internal medicine and obstetrics-gynecology. And, she adds, she'd like to work again in "a place like Bethel, even if only a few weeks a year."
Transue, a 1996 graduate of Dartmouth Medical School, is now an internist in Seattle, Wash. The incident she relates here took place when she was a third-year DMS student, during her family medicine clerkship in Bethel, Alaska. It is a true story, though identifying details have been changed to protect patient confidentiality. Transue began writing patient narratives while she was a student as a way to process the emotions of practicing medicine. Many have appeared in Dartmouth Medicine, and a collection of her pieces was published by St. Martin's Press in 2004 as a book—On Call: A Doctor's Days and Nights in Residency. She has been invited to speak about her writing at the annual meeting of the Association of American Medical Colleges in October.
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