I spent my spring break on the Rosebud Reservation, in South Dakota, as part of a joint Stanford undergraduate and medical school class studying health disparities in a rural, reservation setting. For two days, I shadowed doctors and other health-care professionals at the local hospital, which is run by the Indian Health Service (IHS).
I myself am an enrolled Osage from the Osage reservation in Oklahoma. I'm a pre-medical student, and one of the reasons I want to go into medicine is to improve health in Indian Country. I knew the patient’s side of the IHS already, but I wanted to get a perspective from the provider’s side, which made this trip a no-brainer.
Healthcare at the hospital is free – paid for through the U.S. Federal Government’s discretionary budget – because of a long history of treaties in which Indian tribes exchanged land with the United States in return for food, education, and health care.
Being familiar with Stanford Hospital, I was amazed by the breadth of responsibility that IHS doctors had. The family physician I shadowed ran an outpatient clinic, managed the medical ward (which it seemed she took calls for almost every night), served as first assistant in some surgeries, and was about to also take shifts in the emergency room.
I wondered about the wisdom of this until the doctor reminded me that she was trained for everything she did. The legal pressure in mainstream America conditioned me into a mindset of medical specialization, but on a rural reservation there are no specialists. And, it soon dawned on me that my doctor’s wide scope of practice developed out of necessity. Poor equipment, an overload of seriously ill patients, and a lack of access to higher-level care demanded that the already short-staffed IHS doctors go above and beyond what is normally required.
When I asked the nurses how often they had to ‘MacGyver’ equipment, the answer was not just “sometimes” or “often” – ad hoc solutions were a way of life.
The complexity of patient cases that we saw was overwhelming. I have shadowed doctors on the East and West Coasts in the past, and those experiences dealt with cases that were either straightforward or non-life-threatening. But the patients at the IHS often had a laundry list of serious co-morbidities and home-life issues that made typical treatment difficult.
Add to this the isolation of the area – the nearest city was two hours by plane and planes can't always land in the winter due to blizzards – and some scary situations can develop. It seems to me that IHS doctors are by necessity the ‘cowboys’ of medicine, however ironic that is on a reservation.
I don't mean to paint such a dreary picture. In fact, I came away uplifted in two respects. First, the hospital produced remarkable results considering their limited resources and the illnesses they treated. Second, I saw that much could be learned both by medical students and by the medical community at large.
The Rosebud hospital – and IHS facilities like it – represent a world-class training resource for medical students. Nowhere else can a medical student do more – and thereby learn more (though I admit that much caution should be taken in giving medical students responsibility).
With health-care costs being a major concern for the nation, the IHS is a great example of how to do more with less – for instance, placing more emphasis on, and confidence in, the physical exam.
I don't approve of all the solutions that IHS personnel came up with, but I think the medical community can learn a thing or two from the IHS about getting back to the basics.
Layton Lamsam is a junior at Stanford. He recently visited the Rosebud Reservation in South Dakota as part of his Rural and American Indian Health Disparities class. The goal there was to learn about socioeconomic determinants of health through visits with various Indian Health Centers, community members, and tribal educational institutions.
Previously: Lessons from a reservation: Clinic provides insight on women’s health issues, Lessons from a reservation: South Dakota trip sheds light on a life in rural medicine and Lessons from a reservation: Visit to emergency department shows patient care challenges
Photo courtesy of Layton Lamsam