Ralph Bauer, MD
For this quarter’s resident corner, we will be talking with Dr. Paul Charlton and Dr. David Cheever from Gallup Indian Medical Center (GIMC). Dr. Charlton currently serves as the medical director of the GIMC ED and Dr. Cheever is a recent EM graduate a new addition to the GIMC team.
Tell us a little about yourself and how you found your way to GIMC?
I grew up in Washington and transitioned into medicine after a decade working as a Climbing Ranger for the National Park Service and in humanitarian relief in Pakistan. My wife (an IM hospitalist at GIMC) and I went to medical school at Dartmouth then residency in Seattle, with time in Washington, D.C. for a graduate degree in Conflict Resolution. Conflict management is my academic niche and I still research, publish, and teach on this topic for several universities.
My wife and I moved to Gallup 2 years ago with our young daughter. New Mexico definitely requires more sunscreen than Seattle!
I am relatively new to GIMC as I came on as a full time attending in August. I went to medical school at Georgetown before completing my EM training at the University of Washington/Harborview last June.
My main interest in residency was social emergency medicine and I am a big proponent of addressing social determinants of health from within the ED. Simply put, I enjoy working with underserved and indigent populations. For a long-time I felt that this meant that I should work internationally or in academics at a big public hospital. However, as I was finishing residency, I realized that none of these options were the right fit. I started to broaden my job search to include EDs that exclusively served an underserved population. The IHS seemed like a great fit, not only because the population fit my interests, but also because they were so underserved by EM physicians. Only about 15% of ED positions in IHS are filled by EM board certified/board eligible physicians, so I knew it was a place where I could contribute right away.
What do you enjoy most about working for GIMC?
GIMC is a wonderful place to practice medicine. For Gallup being a relatively small place, the acuity, pathology, volume, and cultural dimensions are fantastic. When you add in the strong sense of purpose in the work, the absolute prioritization of clinical care over financial reimbursement, the unique opportunities for really innovative interventions at the EM-public health interface, the exciting educational outreach we do with the IHS, and a welcoming community of patients and colleagues, I don’t think I could find a more rewarding place to practice EM in the US.
GIMC is a unique place for a couple of reasons. First, there is an amazing group of physicians throughout the hospital dedicated to our patient population. It’s a unique kind of provider who are attracted to working down here and that translates to a shared purpose throughout the hospital. Second, the clinical environment has been very exciting. We are unique among rural sites in that we are a level 3 trauma center and serve between 35,000 and 45,000 patients a year. This allows for diverse and interesting pathology which pushes you clinically.
What challenges or surprises have you come across since starting at GIMC?
My biggest surprise has been the cohort of exceptionally strong, well-trained physicians in the IHS and at GIMC, spanning multiple departments. That is increasingly a trend throughout the 638 IHS and tribal-run hospitals. We see more and more people who train at top-tier programs in the US and choose to leave academics to come work in these hospitals, as it allows well-trained physicians to challenge themselves by practicing full-spectrum emergency medicine in locations where their care makes a concrete positive impact. On a daily basis these emergency physicians know they make a difference.
Rural medicine has many unique challenges that I never experienced training at an urban academic center. It can be difficult to transfer patients, and I frequently speak with five or more hospitals before I am able to finally find an accepting facility for a patient. Inter-facility ground transportation is often non-existent, and flights are frequently delayed due to weather or no availability. I often care for critically ill patients for six or eight hours in our ED because there is no way to get them transferred to the receiving facility sooner. I had previously assumed that rural medicine might be slow and low volume. My personal experience at GIMC has been the opposite. There are a lot of sick patients here and I do more prolonged critical care with little to no backup than I ever experienced in an urban hospital.
For me, the challenges have been mostly clinical. Over the past six months, I have been exposed to a lot of patient situations that I had no exposure to in residency. For example, we often have to transfer out our sickest patients which, depending on weather and bed availability, means that we are doing a lot of ICU level care in the ED. What is the best way of handling the post-lytics arrhythmias in the STEMI patient? What about the stroke patient with the post-tPA bleed? Now that you have gotten ROSC in that post-arrest patient how do you effectively optimize them for transfer? These situations are pretty regular for us. However, these challenges are one of the most exciting things about working here.
What advice do you have for graduating residents?
Be willing to take a risk and practice in an environment that matches your values and sense of purpose and that sounds attractive to you. Obviously, that will look different for each of us, but sometimes it’s hard to realize how many different practice environments exist in EM if we aren’t exposed to them in training. I didn’t know much about the IHS before coming to Gallup, and it felt like I took a leap of faith stepping out of a traditional academic track. Because GIMC so closely aligns with my values and what I’m passionate about, I’ve been happier than I ever anticipated with my choice to enter medicine.
My main advice is to be open-minded in your search for a post-residency job. You have spent the last 7 or 8 years developing a very valuable set of skills and there are a multitude of ways to apply them. For me, at times in residency it felt like there are only two real paths in EM: community practice or academic medicine. However, in reality there are so many different career paths in EM as long as you are willing to be a little creative.