From the Ivory Tower to the Ranch and Back

Bestowing my son Patrick’s hood at his graduation from the University of Nevada School of Medicine.

This essay was originally published in “Doctoring in Nevada” in the History of Medicine Series through Greasewood Press at the University of Nevada School of Medicine. You may have seen Jimmy Kimmel's monologue about his newborn son who suffered from Tetrology of Fallot. The newborn in this essay that challenged me 25 years ago, survived the same heart defect as Mr. Kimmel's son.

From the Ivory Tower to the Ranch and Back
by Tracey Delaplain, MD

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.