HCMC physician residents gain northern exposure to rural medicine

Dr. Alison Raffman had only arrived in Bemidji two days earlier, with three boxes of stuff and two cats, and already she was hustling around the emergency department at Sanford Bemidji Medical Center.

The medical resident was treating dizziness in a newly diagnosed cancer patient, an infection in a nervous pregnant woman, and an irregular heartbeat in an elderly man struggling amid hearing loss and dementia to describe his symptoms.

And then there was Sandy Helberg in room 16, a 75-year-old who couldn’t stop her nosebleed. Raffman used her mobile phone’s flashlight to look up Helberg’s right nostril and throat.

“We’ll get a plan set in place to see what we can do to stop that bleeding, OK?” she assured her patient.

Raffman rotated to Sanford Bemidji for one month as part of a new effort by Hennepin Healthcare in Minneapolis to broaden the training of its residents — doctors fresh out of medical school who practice under supervision for three to four years before they can treat patients independently. The approach could be catching on nationally as hospitals try to solve the looming shortage of rural physicians.

Hennepin provides one of the nation’s premier residency programs for emergency medicine at HCMC in downtown Minneapolis, because few other hospitals can offer so much exposure to everything from traumatic injuries and drug overdoses to heart attacks and frostbite.

But while the training readies doctors to work in large trauma centers with every resource and specialist on hand, program leaders found it didn’t necessarily prepare doctors to serve in smaller ERs where they might need to do more on their own and stabilize patients for treatment elsewhere.

“My residency trained me to be an urban doctor,” said Dr. Meghan Walsh, director of HCMC’s residency programs. “The ability to stabilize a patient, and all that goes into that, is a very different practice pattern.”

Hennepin found a willing partner in Sanford Health, which operates 11 hospitals in western Minnesota and is trying to get ahead of the physician shortage. The median age of rural doctors is 60, compared to a median of 48 for urban doctors, according to a recent Minnesota Department of Health report, meaning that a retirement bubble is about to burst for outstate hospitals.

Many young doctors dismiss rural medicine as a career option without trying it, said Dr. Daniel Hoody, a former HCMC physician who was recruited to Sanford Bemidji two years ago to serve as its chief medical officer. One month in Sanford Bemidji can surprise them, he said, because the hospital draws patients with complex health problems from across northwest Minnesota and three Native American reservations.

“We’re changing the decision to not practice in a rural area from a passive decision to an active decision,” he said. “You come up here, you experience it, and if you still want to practice in an urban area, OK then, great.”

A profusely bloody nose is hardly new to Raffman, a Virginia native who graduated from medical school in Maryland. She chose HCMC for residency because it offered a rare combination of training in emergency and internal medicine. The 31-year-old is in her fourth year.

“I really love emergency medicine,” she said. “I love the people, I love how busy it is. I love how you get to see a little bit of everything.”

Raffman conferred on a treatment plan for Helberg with Dr. Andrea Patten, the attending physician who supervises the Sanford ER residents. Other doctors tried a day earlier to stop the nosebleed with medication and gauze, but it didn’t work. Raffman and Patten decided to start over by cleaning out the patient’s nostrils and clamping them closed for a half hour.

The doctors donned gowns and face shields and returned to Helberg’s bedside. The patient flinched as Raffman reached a tweezers into her nose and pulled out 1, 2, then 3 inches of clotted blood and gauze.

“Keep breathing. Slow breaths,” she said calmly. “That’s gonna feel good to get that out of there, huh?”

Raffman worked in hospitals for two years as a medical scribe after four years of college, taking notes for physicians before enrolling in medical school. Her second day on that job thrust her in front of a gunshot victim while surgeons opened his chest. She learned that day that blood didn’t bother her.

The doctor said her dream career is being a hospitalist, treating inpatient cases, and volunteering on the side at a poison control center. That would be difficult to achieve in a rural area, but she is keeping an open mind. It was subzero on Feb. 12, her second day in Bemidji. At least the cold hadn’t put her off.

“I have my huge jacket,” she said.

Residency programs create their own “gravity,” because most doctors end up practicing within 100 miles of their training sites, said Dr. Stephen Rith-Najarian, Sanford Bemidji’s director of medical education. Creating its own residency program would be redundant and costly, so Sanford Bemidji instead hopes its partnership with HCMC entices a few doctors to come back, he said.

“If we’re rotating 15 or 20 people up here [each year] and we get one or two of them, that’s huge,” said Rith-Najarian, who meets the residents at the townhouse Sanford provides and gives a tour of Bemidji that includes the famed Paul Bunyan statue.

HCMC and Sanford started the program in May when a Boston native, Dr. Max Goder-Reiser, spent a month in Bemidji. He returned with glowing reports, including his first experience using Sanford’s removal kit to take a fishhook out of a patient’s palm.

“I still have the fishhook,” he said.

Since then, doctors have lined up for the opportunity. HCMC has expanded to send psychiatry residents up north, and Sanford is looking to partner with other residency programs on monthly rotations.

The program might be on the leading edge of a national movement. The Accreditation Council for Graduate Medical Education has proposed an overhaul this year that requires all U.S. emergency medicine residences to rotate students to ERs in rural or underserved areas for at least four weeks of training.

And the program worked, sort of. Goder-Reiser said the rotation convinced him that he wants to practice in a rural area and help Native American communities struggling with drug addiction and domestic violence. But he is probably headed to New Mexico.

It was just after 3 p.m. when Raffman returned to her desk to find a lunchtime bowl of tomato soup. She slurped four spoonfuls before Patten called her over to check on the next patient.

Jack Stomberg, 90, had surging blood pressure and headaches, but also hearing loss and dementia. Raffman struggled to get information from him during her exam.

“Do you have any pain in your chest right now?” Raffman asked.

Stomberg looked back blankly before turning to his daughter for help.

“Pain in your chest, RIGHT NOW?” the daughter repeated, loudly.

Nurse Christopher Rahn whispered to Raffman to try speaking in a different register to see if it helped her patient hear her questions: “Not your volume. Just the pitch.”

Sanford’s concern at the start of the program was that new residents every month would be underprepared and pester busy nurses with basic needs. Hoody said that hasn’t been the case: HCMC’s residents have been ready on day one, and the nurses enjoy working with them.

Raffman’s next case down the hall was Rosaleen Rapisarda, 85, who’d just learned she had an aggressive cancer. She scowled when told she would be moved to an intensive care bed overnight for tests. Now was the time to revisit her wishes over lifesaving care and make sure they were specified in hospital records.

“If you were to get sicker … and you would need a breathing tube to help breathe for you, would you be accepting?” Raffman asked.

“I don’t think so, no,” the patient replied.

“OK, we always want to make sure we’re doing things for you,” Raffman said.

“I know. I understand that. No, I don’t want to,” the patient replied.

Raffman returned to her desk. The soup was still waiting, along with a copy of a heart scan, which confirmed an irregularity in Stomberg’s heartbeat. How to address that would be the day’s next challenge.

It was just after 4 p.m. Raffman’s 10-hour shift was almost halfway done.