University of Minnesota Medicine Global Health: Rosebud...continued.

Sharon and I have completed week 2 at Rosebud thus far. I think the initial impressions and settling in have been completed at this juncture, and some reflection is in order – especially from the vantage point of social medicine; but I’ll describe a bit about the clinical medicine experience we have been having as well. In regards to clinical work, it’s been great to see how medicine knowledge can be somewhat transferred to whatever setting you’re in (a basic example: 8 day old well child check—my brain remembers most of the things we should check for baby and mom, despite having no automated crutches present, wow I must have learned something in residency for the past 3 years!) – and we’ve been having the gamut of experiences from inpatient to outpatient, and the dual training that both Sharon and I have through Med-Peds has been pretty awesome and flexible in this remote/rural setting.

In regards to our clinical work, we spend the morning rounding on the inpatients, and it is like any typical day on the medicine wards back at home in Minnesota – pre-round, have multidisciplinary rounds, see the patients, orders, and then notes. The medical record system is a familiar VA style EMR (just imagine it as CPRS with fewer features) and I will begrudgingly admit that having training at the VA for residency has actually been helpful for adjusting to the medical record system here. The census has varied while we have been here and we have not had any inpatient pediatrics thus far (which is a good thing for the patients but not necessarily for clinical learning etc, but you get the point…). Regardless, a lot of the admissions of adults frequently have something to do with alcohol, unfortunately. Other things to note though, importantly, is that the hospital’s ability to care for high acuity patients is minimal; there is no subspecialty care, really (we do have a podiatrist on site, who has been very helpful!), and no surgical services. An important part of learning that seems to play a part here is triaging appropriately. If patients present with problems that we cannot adequately treat or potentially adequately treat, they have to be transferred out to a hospital in Rapid City or Sioux Falls (closest towns that are about 2-3 hour drives away and sometimes a medical flight evacuation is necessitated).

Going back to the day timeline: We take a lunch break to eat at home (5 minute walk, which is quite convenient)—and in reference to the literal food desert that Sharon mentioned we are in, we’ve been making all 3 of our meals for the past 2 weeks, and have been forced to cook things we want to eat; Sharon mostly takes the lead as head chef and I help chop and clean things and occasionally make things as well (lumpy pancakes?). After the lunch break, one of us goes to outpatient pediatric clinic and the other to medicine clinic.

A bulk of the medicine here seems to be primary care, and anyone interested in primary care I think would really enjoy practicing here – and not enjoyment in the sense that you’re in a system that has everything set up for you (it clearly is not), but I think I can imagine the providers finding a lot of meaning in the care that they provide for the clinic patients they see. Sharon’s clinic back at home is at CUHCC (a FQHC), and states that the clinic here actually may have a bit more resources than CUHCC, thus her experiences there have prepared for the dysfunction that can occur in the clinical setting (unlike my experience at a smooth, functional, well-funded clinic in the suburbs of Minnesota).

Either way, when we aren’t engaged with the clinical work, we’ve had opportunities to learn more about the Native American community (albeit limited in direct community interactions due to COVID). There have been good podcasts, lectures, book readings, academic articles, to try and learn more about the community we have been working with. In the back of my mind with any sort of rotation where we are outsiders, I try to believe that we aren’t committing medical voyeurism or tourism and I think we try our best not to be in that light. I always try to be cognizant of the fact that hopefully we aren’t committing those less than helpful acts, but intention doesn’t always matter if the reception of it is different. But anyway.

In general, I think the main serious reflection that I can offer hidden deep in this post is perhaps sadness about my own naiveite regarding Native American health. I think generally speaking for myself or my cohort of resident friends (fairly well educated, interested in health equity), we have all been well aware that IHS is underfunded, that the Native Americans were mistreated (broadly speaking) by colonizers/Americans/us when they first arrived in the U.S. many years ago, we’ve all heard about food deserts, underserved care, etc etc.

All of this is not news or new information to a lot of us (I presume). I think I knew this in my mind, perhaps theoretically. Maybe it is sad that it required me to physically be placed on a reservation, interacting with patients and community members to realize the severe inequity of care that these patients receive – almost similar to being in a foreign country, sadly, when they are actually in the United States – and the complete lack of interest (or maybe awareness, or discussion?) that most of the medical community, at least to my experience, possesses about the Native American community. Perhaps it is also the fact that I haven’t had much opportunity to work with the “rural” underserved; having lived in cities for most of my life, underserved communities in the inner cities are not new in my mind, but this rural poverty is definitely slightly different…(I’ll have to think more about how to unpack that …but I think the remoteness of everyone in the rural community doesn’t seem to help the situation.)

Now I know that this can be said of many topics (as in, you might be passionate about something that others are not!) but after having been here for 2 weeks, I truly feel that as a residency program and medical community, we don’t really talk about Native American health as much as we probably should. Again, maybe it requires one to suffer through actually being a food desert for 4 weeks, ie experience a personal inconvenience, to have empathy towards having poor access to nutritional food (food that you or I would want to eat on a daily basis -- and I personally would blame capitalism for this one -- making processed low quality food the cheapest thing and most accessible thing to be available for these patients). But I want to believe that to possess empathy, it doesn’t require you to actually experience something, I mean, that’s the definition of it, after all…(anyway, I’m trying to find reasons for my feelings and thoughts above).

The revisionist history that Americans are taught, about Native Americans, and the lack of detail perhaps about the atrocities/massacres that has happened in the past, and the rippling effects that this has had on native American communities << I personally learned more of this through this documentary which, I would recommend (resources provided by AmeriCorps Members here in the community, Caroline & Margaret!)>> is pretty bad. History is obviously recorded in a certain way (usually by way of the dominant (?)/colonizers / oppressors) in the world, but one thing that stuck out for me that was mentioned by the documentary was that, if we think of most Americans, we teach and learn a certain type of history about America through our U.S. public education system. If this "truth" is what the majority of Americans understand and have lived with, it sadly is not surprising that the Native American community is forgotten by us-- as the majority of functioning and active members of society mostly know only the public school's rendition of the telling of America's history.

There are a lot of further thoughts that I could expound upon regarding the above, but I think I’ll end it here. One of the doctors that come from the Mass Gen team mentioned this to me at clinic one day and she stated she hopes to “elevate the quality of care” that these patients receive. And they certainly do deserve this, as much as any one of us.