A place to put pen to paper in an attempt to understand the culture of medicine and to document the stories that have been entrusted to me as a healer.

From the Ivory Tower to the Ranch and Back

This is an original essay documenting the challenges and joys of medical practice in rural Nevada. My intent is to show my deep respect for the rural physicians and the patients they serve and to express my gratitude to the University of Nevada professors and mentors who prepared me to meet those challenges. I hold a firm conviction that the University of Nevada Medical of School trains physicians to serve Nevadans. I was privileged to call myself a small town doctor and I have not forgotten the lessons of cooperation and the acceptance of my limitations that I learned there. I must acknowledge my greatest teacher, my father, who believed that all things are possible when you make more out of less. This essay was published in Doctoring in Nevada, Greasewood Press, University of Nevada School of Medicine, 2013

I grew up in rural Nevada and attended The University of Nevada School of Medicine. My father, an Irish Catholic with an 8th grade education climbed the ranks from cowboy to department manager in the casino industry. He worked two to three jobs at all times to keep food on the table and a roof, tin or otherwise over our heads. My mother, a waitress with a high school education, made ends meet in the early years by earning tips, with a weary smile every day. My parents were typical rural Nevadans, hardworking, uncomplicated people scraping by on casino or ranching wages, always hoping to improve the lives of their children. We went to church potlucks, helped neighbors less fortunate than ourselves, and worked. My parents always expected more and accepted less from life. These are the people I wanted to serve when I returned to Nevada after residency.

I accepted a position in a rural Nevada clinic as the third member of the ob/gyn department. The unmistakable allure of returning to my roots and my people was sweetened by the promise of my first real paycheck. My partners were seasoned physicians who were relieved and exhausted when I arrived, having lost their third partner to the allure of getting out of rural Nevada. Prior to my arrival, they had been on call every other week for two years. They were tired and ready for a break. I fully believed that I would ease into the practice of real medicine being nurtured by my senior partners. I envisioned a bucolic fifth year of residency with a fat paycheck. Many of my fellow classmates found that type of job in the big cities and the ivory towers of academia. They told stories of being mentored by their senior colleagues accepting a slow trickle of overflow patients and less difficult surgical cases. “Let’s give this simple hysterectomy to the new doc”. “Sure I’ll watch your first 10 surgeries”. I was no stranger to hard work and long hours having finished my residency training, where a 90 hour work week was not uncommon. What I could not have anticipated was the trial by fire first year I spent in rural Nevada. There is nothing like total immersion to teach you how to swim. I credit my professors at the University Of Nevada School Of Medicine and my colleagues at OHSU in Portland for giving me the foundation that kept me afloat that first year. Contrary to popular belief four years of medical school and four additional years of residency training do not make you a competent physician. You learn medicine by practicing medicine. I’m grateful for having had the opportunity to practice medicine with my people, who expected great things from me but had to accept less sometimes when my care was limited by geography and resources. My colleagues in the ivory towers never had to wait for anesthesia in an emergency, make a diagnosis without a radiologist around to read a CT scan, or turn a bladder scope into a uterine scope when the community hospital could only afford one scope. In truth, I fell back on my father’s philosophy; learn to do more with less.

I learned to be self sufficient in rural Nevada, much like the miner’s and rancher’s wives whom I served. I learned early on that I could never expect a back up obstetrician, even in an emergency. I never had a physician to assist in a complicated cesarean, rarely had a pediatrician residing in town to call upon for a distressed neonate and never had in house anesthesia. I had nightmares in the beginning that I would have to administer the anesthesia, do the cesarean and resuscitate the baby all by myself. A variation of those early nightmares became a reality midway through my first year. I was blind-sided by a distressed neonate with Apgars of 2 and 4. I left the new mother on the delivery table while I intubated her newborn, waiting for a nurse anesthetist to come from home. All the time feeling completely overwhelmed and incompetent when the oxygen saturations would not budge. Feeling anger that there was no pediatrician or physician anesthesiologist in town to help me. Feeling relief when the university transport team flew 300 miles to my rescue. I had been on the receiving team of rural transports many times in training but I had never been on the sending team so during my residency I could not have known the relief the transporting doctors felt every time they turned a complicated case over to me. Regrettably, I do remember the smug satisfaction I felt after saving the patients from their rural doctors. I was on the receiving end of that smugness the next morning when the junior neonatal resident called me from the university hospital to give me an update on the transported neonate. He expressed genuine surprise that we were able to stabilize and transfer this neonate suffering from Tetrology of Fallot, a rare life threatening heart defect. Despite the compliment he made sure I understood the error of my ways by saying, “this should have been picked up before delivery and in the future could we transfer the seriously ill babies in utero next time?” He asked if I would give an update to the pediatrician and anesthesiologist who made the save. Uh, that would be me and me again. I was too tired to point out to this punk that in rural Nevada I had no pediatrician or anesthesiologist much less a perinatologist for specialized prenatal diagnosis. Nights like these make every rural physician question their sanity and their choice to serve in rural communities. They often work with half the resources of urban hospitals and fight an uphill battle trying to explain to their colleagues how difficult their jobs are made by not having the resources that the urban and university physicians take for granted.

Not only are the physical resources limited but the human resources are limited as well. There were never enough doctors to serve my community. I stepped into the boots of a trauma surgeon one night. Trauma happens regardless of geography and despite the limited resources there is probably a physician in rural Nevada willing to help you when you need it most. The only general surgeon in town called upon me, the only other surgeon in town, to assist him with a gravely injured motor vehicle accident patient. It didn’t seem to matter to the general surgeon or to the man bleeding to death on the OR table that I was a gynecologist. After that surgery, my cowboy colleague, never called me little lady again. Apparently I had the right stuff, despite my gender, when the weeds were deep. That’s rural Nevada; you must earn her respect, sometimes over and over again.

Rural physicians are often maligned by urban doctors as being incompetent, under educated and out of date. I heard it said more than once during my tenure that physicians in rural Nevada can’t make it anywhere else. There is a misconception from rural patients as well that they can’t get decent care. I have dealt with far more incompetent and or unethical doctors in urban practice than rural practice. Rural doctors are always under the microscope and a bad doctor can’t hide behind the exam room door. There is no anonymity in your daily work or in your daily life. Everyone knows what happens at the hospital and the clinic in florid detail. You don’t have the luxury of being wrong under such scrutiny.

For all of the frustrations of rural practice there is the beauty of small towns as well. I found grace in the relationships I developed with my neighbors. In general, small town patients will criticize the entire medical system in their town as inadequate but will go to the mat for their personal physician who saved their wife and child, found the cancer that the big city doctor missed the prior year, held their dying grandma’s hand, admitted that they didn’t know what else to do and referred them to the university hospital. I received far more gratitude then from my small town patients than I receive now in my busy urban practice. There is no doubt that our cow counties are underserved and resources are limited; but for the right doctor with a cowboy up, can do spirit, there are no greater rewards than practicing there. You will be challenged and judged and sometimes hung out to dry but you will be a better physician because of that trial by fire. You will learn to look at the patient not the scan. You will just do what needs to be done. You will make more out of less. You will either earn the respect of your colleagues and patients or you won’t.

I eventually left rural Nevada for an urban practice. I was tired from so many uphill battles and the frustrations of small town life. My parents had been content in rural Nevada but I had had a taste of the city so they couldn’t keep me down on the ranch. I will never regret the time I spent in rural Nevada. I became a physician there. My friends who remained in the ivory towers and cities by comparison were still junior ob/gyn partners at the end of there first year, essentially completing a fifth year of residency with a larger paycheck. I had become out of necessity a neonatologist, a perinatologist, an anesthesiologist and a trauma surgeon in my first year. My greatest rewards came from helping my neighbors, who with their quiet strength and deep rural roots, let me become their physician.

Tracey Lane Delaplain, MD, FACOG

 

The torrent of medical education, sea glass or sand?
A second letter to my son, the medical student

By Tracey Delaplain, MD

Before you started your first year I cautioned you that “medical school will change you so you must guard the ideals you hold sacred”. I have watched you change in your first two years much like a piece of new glass thrown into the ocean being tumbled and polished by the torrent of medical academia. All first year students start out as a shiny piece of new glass, none of us knowing what will be left of us at the end of our training. I wonder if you will become a weathered, beautiful piece of sea glass or will nothing but sand remain of the original glass that is you. You study, you rant, and you test yourself against and with the currents. Sometimes you excel, sometimes you just endure. Sometimes the glass just drifts with the tide, sometimes it tumbles against the rocks. It’s surprising to me that you don’t always fight the current. You’ve learned a little bit about flowing with the tide yet I admire your conviction to stand firm against a prevailing current when you know you are right. The luster of you, the idealistic first year student has become duller but the promise of the finished sea glass washed up ashore at hooding is evident every time I see you with a patient. I see glimpses of who you are becoming and it looks very much like a physician. Not finished but exquisitely different, rough edged glass with a frosted patina starting to form.

The deepest chips around your edges have come not from the sleepless study nights or the pressure of your first boards but from the reality that everyone in medicine is not benevolent. I advised you two years ago, to “choose mentors who express the compassion and empathy that you feel now, the summer before medical school”. Many of your faculty have forgotten that teaching and healing are an honor and a privilege. I know this realization scrapes you but it shouldn’t touch your center. You will always be buffeted by physicians and fellow students whom you don’t respect or understand. It's even possible that you will become one of those physicians whom you see imperfections in now. Wisdom often shows us that not all differences are flaws. I am confident however that the empathy and compassion that is you will be protected at your core, while the surface will be battered and inevitably polished.

Physicians need to be receptive to change because many forces, like the tides, are out of our control. You will be transformed a little bit by each patient encounter. In my life these changes have been the best. Patients teach me every day and I never know whether an encounter will polish or chip me. Yet in some moments, we just need to drift untouched. You will learn how to drift in your third and fourth years. We drift when we are tired, frustrated or overwhelmed. Sometimes doing nothing is the right answer. Sometimes the glass just bounces along the bottom unscathed.

The art of medicine at its best is controlled chaos so you will spend most of your life being weathered by the currents. The sea glass is transformed by the tumult, to become a unique weathered piece of art. You must change to become a physician. The physician like the glass is always a work in progress. Always a student, always a teacher, always anticipating some turbulence. We hope for more polish than chips in our profession, so there is something of our core and not just sand left in the end. Learn to find balance between the tumult and the drift. Protect your clear center. Forgive the chips and flaws in your colleagues and yourself. Our profession is complex and wonderful. Physicians are just people with unique strengths and weaknesses. Remember that the most beautiful mosaics are formed from the oddest shapes and most diverse textures. Put your signature on the art of medicine but surround yourself with more sea glass than sand, more character than flaws.

Previously published in Blood and Thunder at The University of Oklahoma School of Medicine 2012 Edition.

This is the third in the series of letters to my son the medical student who grew into a surgeon. The letters have helped me renew my commitment to compassionate healthcare and medical education. It is too easy to lose your way as a physician when faced with the daily stress of real medicine. Spending time with the next generation of physicians gives me faith that we will always have a few doctors who stand out as not just competent, but caring healers.

My son is currently a surgical intern. The intern’s life is far from the glamorous stylized Grey’s Anatomy experience. It’s grueling and exhausting. I struggle as I watch him endure his chosen path. As a physician, I know exactly how he feels and I know that he will survive. As a mother, I want to smother him with love, make him sleep more and fix his schedule so that he can have two days off in a row to come home for Christmas. My husband reminds me when I hang up the phone in tears, “Keep the faith. He will be fine. You did it too and you survived.” I know in my heart that he will not only survive residency training but he will thrive. I hope you enjoy my letter and stay tuned for the next letter. “That Which Doesn’t Kill Us Makes Us Stronger or … Leaves Us Bitter and Broken. A Letter to My Son the Intern.”

A Chance to Cut
A Letter to My Son, the Surgeon
Published in Blood and Thunder 2014

University of Oklahoma School of Medicine

Tracey Lane Delaplain, MD

I envy you. I will never again feel the tumult and rush of surgical training. I’ll never feel the uncertainty of the first cut into human flesh, the adrenaline surge of a catastrophic bleed, the sickening grit of a malignancy in my hands, or the joy of knowing that in the moment my hands are the solution.

I envy your hands. I willingly retired my scalpel so passing the scalpel to you should be worthy of celebration and yet I feel grief. Ridiculous as it sounds, I envy your bone weary exhaustion; the exhaustion of endless learning and overwhelming uncertainty. I miss the burden of never knowing enough and the physical pain of sleep deprivation. These are the realities of post graduate education that I will never feel again. To say that I lament those days sounds absurd, even to me, but that angst is in a physician’s DNA. We wouldn’t be who we are without its influence.

I am proud of you. I suspect that I’m not alone in my mixed feelings of pride and jealousy. Every leader whether a monarch, an Olympic champion, the chairmen of the board, or a surgeon must without a doubt pass their power and burdens onto the next in line; the heir apparent, the younger athlete, the junior executive, the newly hooded surgeon. You bent a knee to accept the academic hood from me at graduation. I was overwhelmed with genuine pride, not just unconditional maternal love, but the deeply respectful pride of a mentor.

Take my scalpel. You’ve earned it but you have much to learn, my first born child. You have been given the chance to cut so make every cut a chance to cure. I will expect nothing short of excellence in the operating room from you but the time spent in the operating theatre is only a fraction of the time that you will give to your patients. The best surgeons know when not to operate. Be exceptional out of the operating room.

Draw strength and knowledge from your life’s lessons outside of the OR. I am a surgeon and your father is an exceptional helmsman. You are both. By his example, your father taught you how to be a great captain. You learned to set the course and inform your crew of the plan before you set sail, much as you will do during your pre-surgery time outs. He has shown you that every one on his boat is important and he always gives clear instructions when he needs their assistance. As the captain you learned to acknowledge all safety concerns expressed by your crew with a thank you, even if you had already seen the potential collision and adjusted your sails well in advance. The surgeon like the helmsman can’t see around every corner and has to rely on his crew to be alert and secure in the knowledge that they can voice their concerns to him at all times. The culture of medicine is changing but you will find surgeons who still believe that they don’t need to listen to their crew. I hope you teach those around you the importance of team work and courtesy on a safe journey. The surgeon takes the ultimate responsibility for the safety of his crew and the human vessel entrusted to his hands.

The helmsman can not control the wind or the tides but he can adjust his course. You, the surgeon, can’t change the circumstances that bring a patient to you. Your choice to serve or to set sail will have been made long before the crisis. When a patient enters the trauma bay or your office there’s no reason to spend any energy wishing it wasn’t so. What good ever came from shouting at the rain? You will curse more than once when your trauma pager goes off for the twentieth time in as many hours. You will feel real anger when your patient is drunk, high, foul mouthed, careless or ungrateful. You will wish that the patient had made better decisions, hadn’t waited so long to seek care or better yet that another surgeon was on call instead of you. Regardless of your feelings in the moment, take a deep breath and do your job. When you are truly in the moment you will find exactly what you need to carry on and all of the should haves and could haves will no longer matter. You can reef your mainsail or heave to and slow the forward progression of your vessel, but you can’t get off the boat in a storm. I hope you find the gift and perhaps the quiet divine guidance that allows you to realize that in the moment, you are the only one who can help that patient. At the darkest moments, adjust your course and engage the patient by saying, “I’m here to help.” There is no judgment in, “I will help you.” It will bring you and the patient into the moment where you can work together. Listen to the patient. What do they fear? What do they expect after surgery? Can you take the yoke from them and carry their fear for them? Can you align their expectations with the reality? Even an unconscious trauma patient needs to hear that you care and that you are there for them. Believe me; you will forget the surgery and eventually the patient too. The patient will never forget you or their surgery.

Allow yourself to feel uncertain. You will never know everything. You will feel less certain and occasionally fearful in uncharted waters. Is the injury beyond repair, will the bleeding never stop, will the Mets win again? Learn to say, “I’m sorry. I’m sorry you are in pain. I’m sorry you are dying. I’m sorry I couldn’t do more.” Forgive yourself for being imperfect because you will make many mistakes. It is arrogant to believe that you can save every patient so learn to say goodbye and when appropriate just get out of the way. It helps me to believe that there is a higher power to assist every patient at the end of their journey.

Learn to hesitate occasionally. Surgery is not always the best course of treatment. Do you need to change course, adjust your sail, or rethink the surgical plan? Don’t be afraid to question the dogma of surgical certainty; question the technique, the equipment, the motivation, and the efficacy of the old and the new.

You have been given the power and burden of the scalpel. Wield it with wisdom. Stay centered and focused. I once wrote to you, “All first year students start out as a shiny piece of new glass, none of us knowing what will be left of us at the end of our training. I wonder if you will become a weathered, beautiful piece of sea glass or will nothing but sand remain of the original glass that is you.” You have kept your clear center despite the torrent of medical education so don’t let your surgical training take that away from you. Stay true to your ideals and teach your colleagues how to be exceptional helmsmen. Be an outstanding mentor and pass on the scalpel when the time comes with envy and pride.