The Oregon Rural Scholars Program combines family medicine, rural medicine, and elective rotations to spend three months in rural Oregon. Third-year med student Rachel Seltzer wrote about her experiences during a recent rural rotation in John Day, Oregon.

As the only academic health center in the state, Oregon Health and Science University (OHSU) tends to train and/or hire many of Oregon's physicians. Most trainees are familiar with academic medicine. What about community hospitals? Do they really practice cowboy medicine? How is community medicine different than academic medicine? Is it?

As one of nine third-year medical students are the first to enjoy the opportunities of the Oregon Rural Scholars Program. We combine the family medicine, rural medicine, and elective rotations to spend three months in rural Oregon. I am at Blue Mountain Hospital (BMH) and the associated Strawberry Wilderness Community Clinic (SWCC) in John Day, OR, serving Grant County with 6,916 people. We are midway between Bend and Ontario, and between Pendleton and Burns.

So how up-to-date is medicine here? Well, I still use Up-to-date, OVID, the AMA Member Communications emails, Pharmacopoeia, and other resources just as often as I do at OHSU. BMH has regular training sessions for the staff; just before the holidays they ran a session on fetal heart monitor strips. BMH uses an electronic health record (EHR), and the SWCC has been utilizing an EHR since 2003.

The biggest lesson I have learned so far in John Day took two weeks. It is true that OHSU, and other hospitals in the Portland area, tend to see patients with more complicated conditions from across the state; that is the nature of having lots of specialists. But rural folk are made of the same stuff as city folk: they have the same medical problems. I have already seen a child who has had two kidney transplants, a gentleman with Wegener's granulomatosis, and two women who likely have CREST syndrome. I would argue, then, that community medicine is not less informed, and more simple, but is instead quite elegant, allowing family medicine physicians the responsibility of managing these patients with the help of specialists through phone consults and referrals.

Although the people of Grant County have similar medical issues to the general population, the socioeconomic situation is different than in Portland. John Day used to be a middle class town, with a lot of residents who worked for the timber industry and the national forestry service. As lawsuits between conservationists and the timber industry tie up the courts, even local, sustainable timber companies are out of work on temporary suspension. And as the national government has scaled back spending, forest services have contracted, and many of the ranger families in the area have moved or been laid off. Furthermore, two of the three mills have shut down. In the past ten years the principal of Grant Union High School has noticed an increase in the prevalence of distractability, misbehavior, teenage depression, and even teenage suicidality. Even so, my classmate, my attending physician and I were permitted the opportunity to speak to the majority of Grant Union's senior class about options after high school, which included living with Mom and Dad, getting a job, going to trade school, community college, or a four-year university, getting pregnant, or getting someone pregnant. Nevertheless, last year's senior class boasted a particularly scholarly group, sending 80% to some sort of post-secondary training or education. Bear in mind this is a county where (according to the U.S. Census Bureau) there are more people with a disability (19%) than there are with a bachelor's degree (16%), and the per capita income was $17,000 per year (In 2007. Before the economy tanked). Grant High School in Northeast Portland may not be happy with a statistic like this, but here at Grant Union, in light of the economic situation, and the accessibility of post-secondary education, I am quite impressed.

Now, to address the assumption that small town people are extremely friendly: they ARE! All the physician's I have worked with have invited me for dinner, at least on standing invitation. One of my patients invited me to dinner. Some ladies I met in line at a holiday Christmas tree benefit auction invited me to join their table for dinner. And then another invited me to their White Elephant gift exchange. There is something to be said for living in a town like this--it fosters a sense of community, so that few neighbors fall between the cracks. Also, while the majority of people here are from Eastern Oregon, and most of them from Grant County, I work with people from Illinois, New Jersey, Florida, California, New York, and Ohio. Additionally, a significant proportion of the healthcare professionals here trained elsewhere, many of them in Portland. So there is a breadth of perspective that I had not anticipated, and they are as inclusive and open-hearted as the locals.

A sense of community tends to be missing in a larger, more anonymous city like Portland. That Christmas tree auction? That was to benefit three different local agencies. Local businesses decorate Christmas trees to be auctioned off. Some people purchase a tree for their home, some will tell you the tree was purchased by the generosity of their business, and some will donate the tree they purchased to a needy family in Grant County. And the child who required two kidney transplants? His first donor match (the one his body ultimately rejected) came from a hospital employee.

As you can see, the people in Grant County take care of each other. The sense of community is overwhelming, inclusive, and encouraging. The physicians here attend at the nursing home. They sit on the school board. They do, on occasion, make house calls. And even when they can no longer take new patients, they share the new obstetrical patient load. They keep up with CMEs, they teach medical students and family medicine residents. They speak to students about options after high school, and to teachers about recognizing teenage depression. And a group of nurses goes to Ecuador for several weeks every year to provide healthcare services.

Does community medicine equate to cowboy medicine? My experiences suggest it does not. What it does equate to is medical and social services to the community--it defines the relationships these healthcare professionals have with their patients, while they still practice good evidence-based medicine.

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