Primary Care in Gallup, New Mexico

For months before arriving in Gallup, I had dreamed of canyons and Navajos. This rotation was to be a vacation of sorts, far from the fumes and cold March rains of Philadelphia. I was looking forward to exploring the Southwest, getting to know some of its people, and by the by, acquiring some medical knowledge as well. In addition, I was hoping to gain some personal insight into what kind of doctor I wanted to be; away from the pressure toward specialization, away from the mind set that academic medicine was the only medicine. I was not disappointed. The experience surpassed my clinical and personal expectations.

Whatever one desired for a medical experience, Gallup soon ushered forth an opportunity. The core experience as established by the schedule in alcoholism treatment, pediatrics, adult primary care, and emergency care provided an excellent starting point. Having had little outpatient pediatrics exposure at CHOP, I decided to spend extra time at the GIMC pediatrics clinic. The attendings were young, friendly, very bright, and all eager to teach. The satellite clinics at Tohatchi and Sanders presented a varied learning experience ranging from routine aches and pains to the management of complex diabetic problems. From the RMCH ER, I will always remember a woman coming in because an angry mare defending her colt bit her. An evening on the labor floor was notable for a no less knowledgeable, but lower-tech, lower-key approach than used at many East coast medical centers. In brief, whether or not the disease entity or the treatment differed from those encountered in Philadelphia, the setting made the experience unique.

I found Gallup particularly interesting as a lesson in rural health care. Though I am also pursuing a degree in health care management, I had very little insight into the workings of rural health care. The home visits with the public health nurses and the RMCH physical therapists yielded perspectives on health care delivery and living conditions on the Reservation. The experience also shed light on the Indian Health Service, showcasing its successes in such areas as vaccinations and prenatal care and exposing some of its financial and managerial difficulties. The model of health care for the rural poor provided an interesting contrast to the model of health care for the urban poor in Philadelphia. The practice of medicine was adapted to the geography, as the decision to treat with antibiotics was influenced by the patient's distance from the clinic and prospect for follow-up. For those of us contemplating a rural practice, the rotation constitutes an educational experience without parallel in the Philadelphia area.

Having worked with native people in South and Central America, I was eager for an introduction to Navajo culture. The week on substance abuse rehabilitation provided an intimate interface with the best and the worst of modem Navajo society. It was painfully evident that over a century of dispossession from land and culture was contributing to clients' substance abuse problems. At the House of Hope, I spoke with eleven-year-old drinkers and glue sniffers. On the other hand, former abusers were plying Navajo traditions to counsel clients at NCI and BHS. The sweat lodge and talking circle ceremonies were vibrant with a strong desire to recreate a broken whole. Not only was I able to see how these activities were integrated into the treatment plan, but also had the privilege of being a participant. The Friday lecture series on Navajo culture and mythology provided the framework for interpreting the many hours spent in contact with Navajos in and out of the health care setting. I gained the beginnings of an appreciation of what it means to be Navajo, and of course, was reminded of the importance of trying to comprehend the cultural background a patient brings to the physician-patient encounter.

The open-space tranquillity of the Southwest, in contrast to the more harried pace of the Northeast, afforded time for introspection. For perhaps the first time since applying to medical school, I paused to consider my reasons for becoming a physician. In the sweat lodge, I was surrounded by chanting Navajos, whose words I did not understand, but whose search for meaning rang universal. As instructed, I prayed for my past mistakes, for my family and friends, for my future, and for my ancestors whose hot breath was represented by the steam rising from the rocks glowing on the earthen floor. What did this experience have to do with medicine, other than exemplifying a more holistic view on healing? It began to loosen the grip of cynicism accumulated over one year in the clinics, and to reaffirm the ideal of caring for the human being over the pathology.

Thus, on many fronts, the Gallup experience proved incredibly enriching. I have and will continue to recommend the rotation to those peers who believe there is medicine away from the Mecca. Perhaps I improved my pediatric ear exam, furthered my understanding of managing outpatient diabetes, and witnessed new approaches to the treatment of alcoholism. More importantly though, I had the opportunity to sample a large variety of clinical options in a rural setting and learn more about my own interests in the process. Bruce Tempest and Herb Mosher have my deepest thanks for making this rotation possible and for bending over backwards to accommodate each student's interests and needs.