Looking at the one-story entrance, the building appeared too small to be hospital. To get there, I drove down a neighborhood street. Tall trees lined the final stretch up the hill and then there were several small buildings with several small parking lots. Tall trees stood between the industrial features. The whole hospital was about the size of a city clinic. Tiny but mighty – people could get CT images, surgery, and life-saving medications within the hospital’s walls. There weren’t many specialists available and none on the weekends, but the basics were strong. There was “Emergency Department” in glowing letters on one side and there were hospital beds for patients who needed to be admitted. Though not meeting criteria to be a critical access hospital, this hospital in the forest was the only access to healthcare some people had. It was not as remote as the most desolate places in New Mexico, but the hospital in the forest illustrated the scale of healthcare available to many (most?) rural Americans.

The patients were brave and grateful for care. A large portion of the patients were also frustrating because they didn’t see doctors and didn’t take medications outside of emergencies – thanks to the stoicism of rural people and a lack of access to health resources. The full-time workers at the hospital were a blend of devotion and mediocrity – strengthened by being the only healthcare around while limited by the hospital’s small infrastructure and many slow days on the job. I found myself out of place on one hand, having come from a hospital almost 30 times this hospital’s size. While feeling at home on the other hand, having grown up in rural America.

The hospital also reminded me of the hospitals and clinics of Paraguay. The scale was more in-line with the hospitals of the world. The limited access to specialists also reflected my experiences in Latin America and growing up in rural Vermont. I found myself more interested in the functioning of the hospital in the forest than I thought I would be. When I applied to residency, I limited my search to programs at hospital that had 350 or more beds; this hospital had about 30 beds (a critical access hospital has 25 or less). At larger hospitals there are more patients, more specialists (including medical specialties and surgeons), and more treatment options. In a small hospital like the one in the forest, there is some access to cutting-edge technology but more than anything there is creativity because one must find solutions for problems with fewer resources.

As I settled into taking care of patients at the hospital in the forest, I found myself challenged in a different way than when I was at the large hospital where I spent most of my time. Caring for patients in a low-resource hospital forced me to use the full range of my training. If patients started to decompensate it was on me to figure out why and to what to do about it. If the hospital in the forest didn’t have the treatment that my patient needed, then it was my job to pitch their story and get them accepted to a bigger hospital with more capabilities. If I couldn’t transfer a patient who needed something I didn’t have to a hospital that had what they needed, they’d get worse and maybe die. So, while most days at the hospital in the forest were filled with the bread and butter of medicine (the basic, simple cases), complicated cases required more thought than they did at a large hospital where any treatment my patients needed was at my fingertips.

I felt the ebb and flow of the hospital in the forest. Many days were calm and straight forward. Those days I had so much extra time I progressed rapidly through my non-work to-do list. These lulls made up for the days of insanity when the patient list grew with lightening speed (admission after admission) and my patients were all trying to die at once. The flow was more like that of my days in the emergency room – boomeranging between busy and slow.

When my time at the hospital in the forest ended, I was grateful for the experience. Perhaps the greatest lesson was realizing that I could be happy working at a small hospital. While such a realization may seem trivial, a willingness to work at a small hospital opens the door of possibility. There are so many small hospitals in the US and the world. Knowing rural medicine is interesting to me means that there are now 1000s of miles where I could live that I couldn’t live if I wanted to work at a hospital with 350 beds or more. What a funny thing that I spent years jostling to train in an urban center to realize that rural life has its own set of challenges and joys. I can see myself being happy in either setting in the future. Big, busy hospitals are ideal for learning but now I know they aren’t the only interesting places to work in medicine. As I think about the next steps, the hospital in the forest sits laughing in my mind. It’s laughing because life has a way of sending me to places that I never expected to go.