Medical School, Pt III

by Carl Nelson (June 2025)

When my wife and I watch TV, it’s often a detective series. When questioning a possible suspect, the detective will often play good cop, not letting on that the person is under consideration as a suspect until the person has played all of their cards. Then the detective will suddenly bring up an apparent “puzzling” contradiction—and then bore in harder and harder, to the suspects increasing discomfort as the bad cop proceeds.

I sigh to my wife that, “there is another profession I would be no good at.”

I remember a dermatology clinic where the students were asked to examine the rash on this one patient’s body. All did. And then afterwards, during the discussion the Attending asked, “did you all see it?”

I’d thought he was referring to the rash, which was an odd question I thought.

What he had actually been referring to was a button mushroom-sized basal carcinoma on the tip of the patient’s nose.

All agreed that it was remarkable, except for me who stayed silent.

I had done my best not to look at the thing, for fear of embarrassing the patient.

(There is an unconscious urge on the part of some patients not to face up to the problem which has driven them to the doctor to look into—and to force the conversation away. I was easily drawn into enabling this behavior. People who run away from fires probably shouldn’t be firemen.)

I had no great medical ambitions to advance in my profession. Practicing as a physician living some rural bucolic life, and learning about all the comings and goings of the community by patching up my neighbors seemed pleasant to me. Physicians seemed desired and held in some esteem by the small communities they nursed. But a couple externships in rural practices taught me some home truths.

The first was that if you were the doctor in one of these small town communities, you were responsible for all the medical care in that community—whenever it came and however it appeared. Without a few other doctors with whom to share the duties, you could easily be on call 24/7. And whatever presented itself, you would necessarily try to treat regardless if you had anything more than a clinic’s facilities. It could easily devolve into something like frontier medicine.

I did an externship in Browning Montana on the Blackfoot Indian Reservation where there was a small hospital with 3 or 4 doctors in residence. I loved the lilt to the words the Indians spoke. It had an embedded feminine quality, or perhaps expressed a humbleness towards existence. I was there in the winter when the living could get very harsh. Even on a sunny, cloudless day, the ten mile drive from Browning to East Glacier could be treacherous. The wind might suddenly kick up and drive snow across the flat plains until the blizzard conditions were such that you could drive right off the road or end up stalled in a sudden snowdrift. You could freeze to death left outside in that weather—and then the sun would come back out for a good viewing of your frozen carcass. The Indians didn’t seem to provide any shelter for their animals, either. I would see the horses standing in long wavering lines, tails to the wind, into the blowing snow. Somehow they endured.

When I arrived I can’t remember if they had provided me with accommodations. I don’t remember any, because I remember roaming about the small town where I happened upon the octangular (giving it a communal quality) Native retirement home. It had just been built and was only partly filled having just begun operations. I stopped in to look around and chatting about why I was there, asked if they might rent out one of their as-yet-unoccupied rooms? They were happy to oblige, letting me stay among the occupants for free. I thought that was very nice of them. Perhaps they liked having somebody of a medical background immediately on the premises.

It proved a very quiet residence though not entirely private. But I got used to attendants entering my room to get various supplies out of some of the cabinets now and then, at any time of the night—and then just as quietly leave. The big excitement happened when Harry Roundtree and Someone Water-Runs-Under-The-Bridge squared off in the hallway one day, crutches flying.

The reservation retirement center drew from a large region. These two had been feuding adversaries from an early age, but having moved to distant portions of the reservation from one another, hadn’t seen each other until infirmity had brought them together again. It only took a bit of time before the feud rekindled, disabilities be damned.

We treated the Indians as patients but didn’t mingle much. I imagine we didn’t fit into the Indian cultural events very well. We didn’t have kids, and we didn’t walk our pets, or live nearby for that matter. (That’s generally how people in my current neighborhood get to know one another.) So we mostly interacted at work. I remember hearing one rather successful Indian businessman who was from the reservation speak with a number of us one time. I can’t remember the occasion. He had tried to get a number of business ventures established on the reservation but with frustratingly little success. He had tried to establish a pencil factory. And for his efforts he was called an “Apple” (Indian on the outside, White inside.) An impression I drew was that there was a tendency to ostracize the successful on a reservation.

I did walk about the town a bit, and one day visited with a high school student I met who was out shooting hoops. I considered dropping in the local bar for a look around, but decided it would not be prudent. None of the doctors went there. And after a few nights on call in the ER it was fairly clear why. One night I was awakened to treat a middle-aged fellow with a head laceration from a broken bottle. He was inebriated and garbling (or trying to) and thrashing excessively. I called the doctor on call for a bit of advice. I said that I had this guy here who I was having trouble treating because he was thrashing around too much. And he said, “That’s because he’s drunk.”

“Yeah,” I said. “But I’m a little worried because he looks okay (pupils and all) but he can’t talk.”

“That’s because he’s very drunk,” he said.

I asked my friend Jim, who was one of the practicing doctors there for the Indian Health Service how he handled patients like that. He said he would stitch their nose to the gurney mattress.

I don’t know if he were kidding me or not. Jim was the sort of guy who liked his practice wild and woolly. He was a tall, good looking blonde of Swedish extraction from Minnesota. He had a wild thatch of hair and a bristly mustache. He stood quite erect and projected incredible confidence. He seemed calmly in charge of whatever space he inhabited. People like him have always amazed me. How must it be, I’ve thought, to feel in such command of wherever you are? How relaxing!

I don’t know why he attached himself to me. I was told by someone that he thought that among the externs they got out there, I was a star. It felt good to hear, but I was quite surprised and can’t think of anything I did to glimmer. I remember finally getting a couple stitches into that drunk’s wound. I was reeeaaally tired and just wanted to go back to bed, but the older, wizened nun who was the nurse there kept on me. “Why don’t you try to get just one more?” So I did.

Isn’t it a wonderful thing that time eventually passes? I consider that a lot, even now, before I fall to sleep.

Jim was kind of addicted to outdoor gear. At the time, REI was the big outdoor co-op, making a name for itself from a large building in the Capital Hill area of Seattle. Whenever Jim was in the area he’d load up on equipment. When I visited his rental in Browning, I found he had one full bedroom filled with outdoor gear. And he had a Jeep. We regularly took his Jeep across the snowed prairie to the bar in East Glacier to smoke cigars, drink beer and shoot pool. I would slip in quarters and play my favorite country music tunes. Country music in an out of the way place like that in the deserted off season with a bar counter populated by a clutch of beer-sotted townies is just about perfect. Then, we’d drive back through the night, blast through a couple snow drifts (Yee-Haw!) and call it a day. We did some cross-country skiing and snow shoeing (This was after I broke a ski—his. Snow shoeing is a lot of work, and I didn’t enjoy it), and did some snow camping.

Jim had a very intuitive way of expressing himself. Sometimes his written note was kind of a cloud pattern. But I’ve always been comfortable with loose associations. I remember a schizophrenic patient I had who I presented one day to the Attending and others on the Psych Ward. They noted that he exhibited all the signs of Schizophrenia including the impenetrable loose associations (“word salads”), and I had to interject. “He makes good sense to me.”

They all laughed.

Once a week, or so, we’d take off in his Jeep to visit a clinic deep in the reservation. If it were anything serious they would likely make the drive into town. So the patients we saw were mostly follow-ups, medical maintenance, and largely colds, sore throats and the flu. Theodore Dalrymple noted in one of his essays, regarding his time spent at a rural clinic in Africa, that in a small isolated community, irritations which might dissipate in a large community can fester in their containment and develop into intense hatreds. I uncovered none of this in the small Browning community, but I did find that it would happen that not everyone held the doctors in high esteem. For example, if you had happened to treat a relation of someone who had a poor outcome, or left them unsatisfied, tongues could spread rumors damaging your reputation. Grudges could dig in and become abscesses. So it wasn’t as bucolic as I’d imagined. But what in life is?

Nevertheless, if I were looking for some medical sinecure with smooth sailing, rural medicine experienced some rough weather also. This is something I learned.

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Carl Nelson‘s latest book of poetry titled, Strays, Misfits, Renegades, and Maverick Poems (with additional Verses on Monetizations), has just been published. To have a look at this and more of his work please visit Magic Bean Books.

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