Clerkship began with sirens, followed by a bang on the door. Our next-door neighbour Bill was on the doorstep. Wide-eyed, his explanation tumbled out:
"People are heading to their muster stations! There's a fire at the plant!"
There was no time for questions before he was off with his dog Ruby in tow, his van squealing out of the empty lot. Robin, my roommate and a fellow med student, and I stared at each other: Where were we living? Were we supposed to be mustering? Should we be worried about the ominous smoke cloud drifting slowly towards us?
I had never been to the Kootenays when I signed up to do my entire third year clerkship in the small town of Trail, BC, so a visit a few months before the move seemed like a good idea. Driving down the steep icy hill, I started to second-guess my choice as the enormous lead smelter came into view. I was leaving the comparative metropolis of Prince George for this? As I walked through the grey streets to the dated hospital building, I questioned the whole "I want to be a rural GP" schtick I'd been so adamant about for years...
Despite these reservations, I was committed to doing my clinical training here and thus began a long and fruitless housing search. Our moving date was imminent when at last the local midwife agreed to rent her 111-year-old AirBnB investment property to us. In a little brown
one-and-a-half storey nestled between two nearly condemned pre-war houses on the edge of the Columbia river, we found ourselves living amidst some of Trail's more colourful characters. After transient years in apartments and residences across the country, I suddenly had a neighbourhood again.
On my second week in town, I met Henry, our 91-year-old neighbour from a few houses down. He had lost his license and seized on the prospect of new drivers to help him with his errands. His voicemails provided a daily dose of humour and normalcy during the turbulence of our first weeks of clerkship:
"Robin. I would like you to take me to Walmart. They have corn on for 37 cents and normally it’s a $1.37! I think I’ll buy a dozen. Or maybe two dozen. I can freeze them, you know.”
And then he forgot to hang up, so the voicemail continued for six minutes.
In addition to providing panic-inducing warnings about smelter fires, our neighbour Bill was always up for conversation, sharing wild stories about the town he'd lived in for over sixty years. Standing in the vacant front lot while our dogs played, he never failed to make us laugh:
"I was out last night at the burned out house up the hill doing security. Y’know, the one that blew up because they were making shatter? Anyways, the neighbours tell me it’s because a turkey exploded in the oven? ‘A turkey?’ I sez, ‘that musta been some turducken!’”
My knowledge of my neighbourhood expands in the months that follow, with a house call to drop off a compression sleeve to patients from family practice. They are an elderly Italian couple with limited mobility, and I find myself marvelling at how they must manage the steep staircases I ascended to reach their house in the upper levels of Trail's terraced streets. Unlike in a larger town, their landscape is my own, and the challenges they must face day-to-day are easier to identify when I see them again in clinic a few weeks later.
The crossover between patient and neighbour continues to blur. We had called Elderly Services a few months prior with neighbourly concerns about Henry's worsening dementia, but hadn't managed to prevent his fall and subsequent hospitalization. One day, I walk into a room for a consult and discover him in the adjacent bed, now my patient's new neighbour.
In December, I am in general surgery clinic assessing a patient for a nagging elective issue that has worsened dramatically since his last consult four year ago. He looks vaguely familiar, but so do a lot of patients. As he rises at the end of the appointment with the surgeon, he turns to me and asks "You live down on Brookview, right? With the little puppy?”. Suddenly it clicks-- he's Bill's friend, who sometimes collects our recycling. He hasn't had his procedure four years after his initial consult because after extensive personal tragedy, he ended up living in poverty in a fifth wheel down the river. It's one thing to accept the effects of social determinants of health intellectually, but to see it in your neighbours renews my passion for advocacy in new ways. At the same time, there are blind spots-- it's only after months of living side by side that we learn our neighbour Bill doesn't have running water.
In our orientation to medical school in Vancouver, we spend a lot of time learning about how to define boundaries. Never tell a patient where you live. Maintain professional distance at all times.
Rural clerkship has taught me how to redefine these boundaries. It would be inhumane to ignore the patient I met on the psych ward when he approaches me downtown. And just like I can't pretend not to know Henry when I see him at the hospital, I also have to acknowledge the existing relationship when I see my preceptor's child in the ED. After respecting the clearcut ethical standards (not acknowledging a patient in public if they don't acknowledge you, not caring for patients with whom you have a personal relationship), rural practice leaves you to navigate the grey zone of neighbour and patient as best you can.
Somehow, it works. And suddenly, halfway through my first year of clinical medicine, in a quintessential Canadian moment, I am at the local hockey game with a quarter of the town in attendance. I look around and spot patients and preceptors throughout the crowd. I’ve made a home here.
I recently started a note on my phone entitled ‘Musings,’ as inspired by a staff doctor in Goose Bay who has sent us several emails with this as the subject line. I love the word musing ‐ it is reflective, creative, and offers a window into someone’s inner psyche. It also makes me think of a small creature that I imagine would look somewhere between a lemming and a badger. A musing.
Etymology‐wise, musing in English is to be absorbed in thought. In Old French it was closer to the meaning of to meditate or to waste time. It actually wasn’t directly related to a muse (source of inspiration) and no, amusing is not a…musing (I was disappointed by that, come ON etymology!)
Wasting time was the definition that struck me. An emphasis on productivity, efficiency, and effectiveness is supreme in medicine. How many patients were you able to see during your Emergency shift? Did you stay on time in clinic? Being busy is glorified and accepted. What does that then mean for the act of musing if we are not wasting any time? Is medicine an anti‐musing profession? How could a job so centred on humanity not be full of musing and reflection? For me, it is typically in the middle of a long stare at a blank wall that I start to appreciate the nuances of a difficult day. Perhaps it is that musing is too easily pushed aside by our daily to do lists. We need to choose to muse, like we actively choose to do everything else in our lives. With that choice, we go against the grain of productivity. We accept, and cherish, that some of our time will not have an immediate tangible output.
There’s a man in the UK who started to count his sneezes in 2007 *1 as a way of documenting the mundane moments in life. All those moments in between the big ones. He thought sneezes were a good choice because they were banal, unremarkable, and often unwelcome. I was so taken by this idea when I learned about it that I started to count the times I spilled on myself – another (fairly frequent) involuntary act – and have noticed that it is a phenomenal way of remembering moments that are otherwise entirely forgettable.
I think this can be applied to our jobs and can certainly be applied to my experience as a resident so far. There are the big landmark moments: the first time you run a code, the first time you help deliver a baby, the first time (and every time) you have to tell someone their loved one has unexpectedly passed away. There are also a lot of forgotten moments in between that make up our days, and ultimately, will make up our careers. The man that counts sneezes says on his website that “the act of counting…..gives him a more profound understanding of the simple joy in the passing of time.” *2 Maybe it is an act of preservation to ascribe value to the in‐between moments. Not the ones that you make you smile all day. Just the ones that pass without you noticing. Or, maybe, ascribing value to the in‐between moments means that no moment is really in‐between at all. << Musing.
(*1) Fletcher, Peter. “Sneeze count – counting sneezes since July 2007” Retrieved from: http://sneezecount.joyfeed.com/
(*2) Fletcher, Peter. Date published unknown. “Reflections on the Counting of Sneezes.” Retrieved from: http://sneezecount.joyfeed.com/reflections‐on‐the‐counting‐of‐ sneezes/
Below are some excerpts from my ‘Musing’ note, recorded during the first few months of residency in Goose Bay and St. John’s. Some are quotes from other people that affected me and others are random thoughts from hour #15 of the drive between Labrador and Newfoundland. All were written down while I was wasting time:
Invention: A spray that will protect my clothing from all the pens that explode on me. Buying better pens honestly seems like a less realistic alternative.
“Be kind. Everyone has a story.” – C.E.
I feel insecure about the fact that I am playing a key role in people’s lives at the ripe age of 27. But I don’t think that insecurity is useful to anyone. Time to rise up to the responsibility?
Do I even like Tim Hortons? Why do I eat 3 times a week at a place I might not even like? Why don’t I know if I like it or not?
Always shocked by the things that make me cry at/after work. It’s not consistent and it’s not logical. Being present for the privacy of other people’s tragedies will probably never make sense.
Why do people only drink spicy clamato on airplanes? I have literally never had a spicy clamato juice on land.
“There’s no better reason to be late than a good laugh.” – Woman in St. John’s when I said I had to run for ward rounds. We had just finished having a hearty giggle about an older patient who had passed some gas in our elevator.
I’ve spent the majority of my life in big cities, until 6 months ago when I took a left turn and landed in Goose Bay (okay, it was a sharp left turn.) I’ve noticed that it is a self‐ selecting group that opts to challenge themselves in the way that rural medicine demands. Despite the reality that there is always more to learn and do, I have never met a group more willing to muse. I guess it logically makes sense that a profession in rural medicine, requiring unanticipated creativity and adaptability, would be well suited to people who take unconventional pause. From what I’ve witnessed, the patience to indulge in the odd thought experiment translates, quite directly, into the patience required for sustainable compassion.
Everyone has their own way of working through the truths and contradictions of medicine. For me, it helps to have a note on my phone to record some in‐between thoughts – absurd or otherwise. Cheers to our own personal sneeze counts, whatever they may be.
Medical Resident Essay Contest
Names of individuals are used with permission.
My first rural experience was during my third year family medicine block. As a francophone medical student at the University of Ottawa, I had the opportunity to seek out a French-speaking preceptor anywhere in Canada. I was fortunate to have been matched with Dr. Coralie Boudreau, an inspiring female physician and graduate of the University of Ottawa working and living in Hay River, Northwest Territories. Hay River
– known as the “Hub of the North” – is a remote town of 3500 that is five hours south of Yellowknife.
Upon arrival, the medical staff at the hospital warmly welcomed me. I felt safe and supported in this new environment. I was encouraged to participate in winter sporting activities and community events during my rotation. I relished cross-country skiing at the Hay River Nordic Centre. I also had the chance to volunteer with the local girl guides. My Thursday evenings with this local club became a highlight of my experience and fostered a true sense of community during my stay.
Soon after my arrival I heard about a hospital unit clerk, Kathy Beaupre, who offered dog sledding opportunities. As is common in small communities, Kathy and I worked together in the ER a few short days later. Kathy spent many years living in Ottawa, my hometown. Kathy shared with me her dog sledding business card, which she had designed herself. Stapled to the back was a photo of a young girl. I immediately recognized her as Lily Beaupre, a precious child I had met at Roger Neilson House, a paediatric palliative care hospice in Ottawa where I volunteered for several years before medical school. As it turns out, Kathy was Lily’s grandmother.
Kathy shared with me that some of the profits from her dog sledding trips were donated to an organization supporting medical research on Niemann-Pick disease, the rare life- limiting illness that Lily had died from. I could hardly believe that I had flown thousands of miles from home to pursue my passion for rural family medicine and had stumbled upon the grandmother of one of the most influential people in my journey to becoming a medical student and, ultimately, a physician.
As a volunteer at Rogers House, I had been blessed to spend cherished time with Lily. She loved to be pushed around the facility in her stroller babbling to all who would listen. She passed away in 2013 surrounded by her loved ones shortly before her fourth birthday. Our local newspaper published a beautiful article with photos of Lily and her family. I cried at my kitchen table when I heard the news of her passing. A few months later, I was touched to learn my first-born niece was to be named Lily. For me, memories of Lily Beaupre have lived on through my niece’s happy smiles over the last five years.
Two years later, I was standing in front of her grandmother in a place that was 4500 kilometres away from my home. I was incredibly honoured when Kathy asked if I would
be willing to go out dogsledding with her to celebrate Lily’s life, or as she touchingly called it Lily’s “angelversary”. On March 31st of that year, I joined Kathy for my first dog sledding experience. I watched as Kathy got the dogs lined up and ready to go. As we started off down the white, snowy path with the sun rising over the lake I felt immense connections to both Kathy and Lily, but also to the land and the people in this small northern community. I understood the harmony of the north in a way that no words could describe.
A month later, I returned home to the tragedy of losing my newborn nephew, Jacob. He was honoured with a silver star mounted on the wall at Roger Neilson House, just as Lily had been 4 years earlier. This was one of the most difficult moments I have experienced, but thinking of my connection with Kathy during this time gave me strength. Even today, in those difficult moments when I grieve the loss of Jacob, I think of Lily, Kathy and her dogsledding team. I close my eyes and feel the brisk winter air on my cheeks, the pounding of the dog team on the snow and the presence of Kathy behind me – mourning, but also celebrating the life of a beautiful child, all without the exchange of a single word.
I have chosen to share this experience because just as the spirit of Lily lives on through the lives she has touched, so too does the spirit of the north. This encounter with Kathy reaffirmed to me the many reasons why I am pursuing a career in rural medicine. Time and time again, the rural north has provided me with a sense of community, with strong rural mentors and with a connection to the land and my own Indigenous roots that have been absent for most of my life. My rural experiences in Iqaluit, Nunavut; Yellowknife, Northwest Territories; Goose Bay, Labrador; and La Ronge, Saskatchewan have allowed me to train in the full scope of rural family practice with experiences in both hospital and community health settings. I am eager to spend four months in Inuvik, NWT in my PGY-2 year where I will continue to foster my skills in a rural setting while deepening my connection with our northern communities.
To me, rural family medicine embodies camaraderie akin to that of a dogsled team. Although I have yet to be back on the dogsled, my time in the north reminds me of the strength of a community’s connection to the land and to each other. These bonds fill me with a powerful calm and a sense of well-being. They inspire me to continue to pursue my dream of becoming a rural physician.
Rural electives for undergraduate medical students has become more popular, and organizations such as the Society of Rural Physicians of Canada are to thank for increasing awareness amongst students. Students seeking rural electives may be undergoing “elective tourism”, seeking practical experiences, or even have aspirations to train for residency in a rural family medicine site. Despite their intentions to do a rural elective, I urge students to gain an appreciation for the diverse cultures that make up our rural and remote communities of Canada and the implications that culture may play on their health. I have had the opportunity to experience a variety of rural communities in Southern Alberta and Saskatchewan, as well as Northern Saskatchewan and learn about the cultures in these areas. I’d like to share how my desire to learn about the cultures I worked with allowed me to adequately care for my patients and impact how I will practice medicine in the future.
Growing up in Southern Saskatchewan, I was familiar with the Hutterite population. However, I was shocked to discover that my medical school colleagues from Ontario were unfamiliar with the culture. The Hutterite peoples are one of three Christian Anabaptist sectarian groups (the others are the Mennonites and the Amish). They are German speaking with origins in Eastern Europe, the United States and finally Canada. The colonies started settling in the Prairie Provinces in 1918. (1) Hutterites live in highly organized, self-sustaining communes that are agricultural based. My electives in Swift Current, Saskatchewan and Medicine Hat, Alberta allowed me to learn more about their culture, as well as appreciate their willingness to support local causes and infrastructure. While working in the emergency department in Swift Current, I searched for the name of one of my Hutterite patient’s on the provincial electronic medical record (EMR) database to aid in their care. I was soon overwhelmed with many individuals with the same name and birth year. I was informed by my preceptor to request his “wife’s name” as this would be filed as surrogate for his middle name. Aside from requesting a health number for searching patient’s files, I learned that the Hutterite culture adopts similar names due to their religious significance. When asking the patient for his surrogate name he spoke of obtaining services in a rural clinic using paper charts, which subsequently mistook his identity. This speaks to the importance of transitioning all clinics to EMR based programs. Rural locations are notably later to transition in medical processes and technology, which can result in obsolete care. Additionally, rural populations are more likely to travel across jurisdictions to obtain care, complicating information access. I’d like to advocate on behalf of rural populations for the universal use of office EMR systems. Furthermore, EMR systems should be able to freely communicate between platforms (and provinces).
While in Southern Saskatchewan, I also learned about the Mexican-Mennonite culture. As mentioned previously, the Mennonite culture is a Christian Anabaptist sectarian group as well. The Mennonite Community varies with regards to their adherence to tradition, religion, language and technology as practiced by their European ancestors. In the 1940s, a push by the Manitoba government for mandatory English lessons for elementary school students and a shift from church to government run schools was seen as an attempt to enforce secularism on conservative Mennonites known as “Old Colony Mennonites”. (2) Therefore, a collection of Old Colony Mennonites immigrated from their settlements in rural Manitoba and Saskatchewan to join a population of devote Mennonites in Mexico. Some of the population returned to communities previously settled in the prairies after years of drought
in Mexico in the 1950s. (3) I had the privilege of working with members of the Mexican-Mennonite community living in rural homesteads around Hague and Swift Current, Saskatchewan. During my experience, I discovered that physicians were required to offer advice in legal matters due to healthcare being their first contact for social crisis and a reluctance of the population to seek help from law- enforcement. Such distrust was instilled into the culture by their experience with corrupt police organizations in Mexico. Additionally, the population’s women are not fluent in English due to their desire to maintain their German dialect, which made medical visits difficult to conduct. My experience emphasised the need for healthcare professionals to familiarize themselves with local legal resources and translation services, both of which need to be remotely accessed in order to service our rural populations.
I had the opportunity to work in La Ronge, Saskatchewan in late November and attend Northern Saskatchewan fly-in clinics in Pinehouse and Southend, remote Metis and Aboriginal communities respectively. The communities were extremely welcoming. They made sure I was well fed, gave me a tour of the community, and provided me context into their reliance on community ties to survive. The communities were among the most grateful people to receive healthcare services that I have encountered, even waiting hours to see us despite our flight delays. This opportunity was positive for me since hearing an urban specialty physician once say, “Northern communities don’t care to attend medical appointments in the city”. This statement speaks to systemic racism in healthcare that exists against the indigenous peoples. Instead of blaming the population for missed appointments, we must ask ourselves why there are missed appointments. After speaking with patients myself, I now appreciate that we must address barriers to accessing health services in the north including personal phone access, reliable transportation, and opportunities for child minding and chaperones.
Hutterites, Mexican-Mennonites, Metis, and Aboriginals are among the extraordinary cultures
I’ve met on medical electives in rural Canada. These groups all possess obstacles to accessing healthcare resources unique to their culture including health information, remotely accessed services, and transportation. We must strive to understand these cultures, to in turn help heal them. One may not choose to practice in the rural communities they have sought an elective, but keep in mind we each have a voice as health practitioners with regards to allocating scarce health resources and creating health policy that impacts our rural cultures. Please sign up for a rural elective, enjoy the experience, and embrace the culture.
Some might describe the doctor-patient visit as a transaction: the patient comes with a problem and the physician gives her an answer. But does this fulfil the patient’s needs? Not always.
Asking the ICE (ideas, concerns, expectations) questions can help the doctor understand the patient’s point of view: ‘What do you think is going on?’ (Ideas), ‘What are you most worried about?’ (Concerns) and ‘What do you think I can do?’ (Expectations).
Mostly, the patient wants a two-way relationship with her physician. She wants to work with the doctor and actively contribute to her care.
The patient is not always forthcoming though, and sometimes the physician wishes she could tell her to be more clear. The doctor is not a mind reader. The patient is supposed to prepare, be concise and accurate. The physician expects her to describe the nature of her problem: When did it start? What makes it better or worse? What contributes to it?
But where does the responsibility lie?
Sometimes, the patient is reluctant to share information: she does not want to interrupt, she might defer to the doctor’s expertise, or she might not be asked.
The physician plays a critical role as an educator, but the patient can also inform the doctor by asking direct questions. These can be a starting point for informed collaboration on diagnosis, treatment and prognosis.
The patient’s health problem is the fact. The rest are her feelings. Those feelings need to be explored and acknowledged: What keeps her awake at night? What is she angry about? What does she fear? What is the best way to support her?
The physician ought to address these concerns because they are legitimate and must be recognized whether or not they are justified (in the doctor’s opinion).
Empathy is the physician’s ability to understand the patient’s experience and supportively communicate this to her.
A 2011 analysis of empathy published in The Canadian Medical Association Journal cited a study of oncologists who were filmed speaking with their patients. Moments when the patient expressed an emotion like, ‘I’ve got nothing to look forward to,’ were tracked. The oncologists responded in an empathetic way only 22 per cent of the time during these “empathic opportunities.”
Empathy is a clinical skill. It gives the doctor the information she needs to provide AND show care.
Attunement or agreement?
Expectations are complex because they differ depending on the patient. Each person’s unique makeup affects her attitudes around every aspect of her life, including health care.
Some expectations concern treatment and prognosis: ‘What will happen to me next?’ Others relate to what the patient hopes will happen. Still others revolve around how the patient wants to be involved in decisions about her care.
Asking the patient, ‘What are your expectations of me as your physician?’ is a valuable starting point. By listening to the answers, the doctor can confirm that she is on the same page as the patient. The physician provides the best care when she understands, respects and helps manage these expectations.
A lot has been written about the patient’s ideas, concerns and expectations. A 2009 study in The British Journal of General Practice looked at 36 family doctors in Belgium. It aimed to discover how often ideas, concerns and expectations came up at the physician- patient encounter, and to determine any correlation between these questions and prescriptions.
When ideas, concerns and expectations were addressed, medication was prescribed less frequently. As the authors write, “Identifying and eliciting ICE components are key competencies related to shared decision-making.”
Understanding the patient’s responses to ideas, concerns and expectations facilitates attunement over agreement. Asking these questions says, ‘I hear you, I understand you and I respect what you are saying.’
The doctor will not always agree with the patient’s ideas, share her concerns or meet her expectations, but these questions help the physician and the patient understand each other.
Of the Community
I spent last summer as medical student learning in small hospital at the edge of cottage country in Northern Ontario, a busy town in the summer with its many lakes, hills, and resorts. At the hospital, I rotated between the Emergency Department, the General Surgery team, and the Internal Medicine team, as if following the path of a patient’s experience through the hospital. When I went back to my classes in the fall, my classmates and I shared stories from our summer electives. But my experience as a medical student in this small town were far more than a checklist of presentations seen and procedures done. No, my elective taught me what it means to be a doctor.
From my first day in the ER to my last day with the internists, I saw how rural medicine is both for the community and of the community. Practicing rural medicine requires a certain level of intimacy with the community. The doctors and nurses in the town didn’t just treat patients. They were treating the person – their next-door neighbour, their friends, their children’s classmates, their hockey teammates. The physicians didn’t hide from their connections with the community. They embraced these out-of-hospital relationships, bringing comfort through familiarity. I learned that a history doesn’t always have to start with “When did the pain start?” but can begin with a “How is your wife doing?” or “Are you coming to the soccer game tonight?” or “What are you studying at university?”. A trip to the hospital can be foreign, scary, painful, and fraught with uncertainty. But I like to think this distress was remedied in part by the familiar faces of the staff at the hospital.
In addition to community member, another hat worn by the doctors in this town, more accurately, the many hats of the generalist. I remember seeing a finger-tip amputation in the Emergency Department, the child of the unfortunate coupling of power tool and soft extremity. The general surgeon was called down to manage the wound. Unabashedly, they brought down a textbook on hand injuries to the ED. They
were not a plastic surgeon, they were not an expert in hand injuries. What they did know was their limits, and their capabilities. Through a combination of humility, surgical expertise, and a couple peeks at their handy text, they dealt with the injury in front of them. Experiences like this were repeated many times over throughout my elective. The emergency medicine doc turned psychiatrist turned trauma team leader turned neurologist turned palliative care doc. The general surgeon turned oncologist turned obstetrician turned gastroenterologist. The general internist turned cardiologist turned intensivist turned endocrinologist. I was in awe of their breadth of knowledge and I admired the scope of their care. These were physicians who, alone, performed the jobs of many. They acted in response to the needs that arose, the rural doctor asking not “Who can treat that?” but “How can I learn to treat that?”. Even as staff physicians, they were students of medicine as much as I am a student of medicine. They embodied the never-ending education required to be a strong clinician.
And yet, my elective experience was not immune to the difficulties faced by rural medicine. A small hospital meant a small budget. Few staff meant lots of work. Patients had to come from far and wide to seek care. A single physician emergency department can be quickly overwhelmed, especially when the summer crowds come to Huntsville for the many lakes that dot the area. An on-call staff surgeon does not have an in-house resident to triage a patient with an acute abdomen. These are not issues unique to rural medicine but are ones amplified by paucities in funding and staffing. However, when up against the wall, when they were overwhelmed, when they were stressed and tired and at wit’s end, who did the physicians look to? Their medical community - the local group doctors and nurses, who at any time of day, were willing to come in and help see a few patients in the ED, or provide a second set of hands to help finish up a tough case in the OR. Being a part of a collective was what gave the doctors the strength when they needed it most, stronger as a team.
Looking back on my elective, I am grateful for all of the preceptors I taught me and shared their clinical wisdom. The doctors I learned from, most of all, showed me through action what it meant to be a doctor. To treat the problem but care for the
person. To never stop learning. And to remain humble and resilient in the face of adversity. And above all else, being there to help your community in times of need, because they will be there for you. Lessons I will take forward in my training and future practice. Reasons why I loved and love rural medicine.
The Jar of Beets
This is a story about a defining moment in my choice to pursue rural family medicine as a career. While I was doing an elective in Paradise, Newfoundland, there was a patient that came to the office on one of my first days. I was told to see her, so I went to call her from the waiting room. I could see that she was in tremendous pain from the moment she struggled to get up from the chair, and as she walked the short distance to the examination room. When she finally made it there and plopped herself down on the chair, I said: “Hello, my name is XXX and I’m the 4th year medical student that will be looking after you today. What can I do for you?” She immediately broke down into tears, begging me to help her. I was not familiar with her story, so I asked her to start from the beginning. She told me that she had slipped during the summer, and that she had injured her adductors. She had been following the physician’s orders and had been diligently going to her physiotherapy and massage therapy appointments. Despite this, she was still experiencing excruciating pain. But the pain she was describing to me was a different pain, now in the abductor region. As I asked more questions, her description made me think of polymyalgia rheumatica, which I had just discussed on my previous elective in Moncton, New‐ Brunswick. I quickly consulted UpToDate to confirm my suspicion, then went to discuss this peculiar case with my preceptor. He had been following her for this pain since the summer but I recounted the story from the start, from a new perspective. I told him I thought this was PMR, and which tests I would like to order. He was very doubtful, but agreed to order the tests. We gave the patient her requisition, and made an appointment for her to come back at the end of the week.
The patient’s CRP came back very clearly positive. When she returned, I took the time to review the results with the physician before going to see her. My preceptor was still unconvinced by my diagnosis. He decided to phone the rheumatologist on call at the St. John’s hospital to ask for his opinion. After a lengthy discussion with the expert, they concluded that it was either PMR as I had suggested, or an uncommon presentation of ankylosing spondilitis. So my preceptor wrote up a prescription for high dose steroids and sent me to give it to the patient. As I left, he extended his hand for a “fist bump” saying: “Way to go, Doctor!” I gave the patient the news of the diagnosis and her prescription, and she left us a form to fill out for her insurance company. She made an appointment for the following week to pick it up.
When the patient arrived for her follow‐up appointment, she was smiling and walking much more normally. My preceptor and I saw her together. She told us she had immediately felt better after taking the steroids, and was improving every day. As she got up to leave, she pulled out a jar of homemade pickled beets to thank us. At that moment, I realized that family medicine allows you to create unique bonds with your patients, especially in rural settings where you become part of the community. Being finally able to experience the feeling of following a patient, diagnosing them and seeing their relief and appreciation after starting a treatment confirmed that I want to follow my patients from cradle to grave, as the saying goes. This elective, along with the other rural electives I have done, showed me how to collaborate
with physicians especially when resources are scarce. It was also the first time that my preceptors had treated me as a colleague rather than a learner, and it really made me want to be part of that work dynamic for my residency as well as for my future practice.
Off the Charts
The blades of the paddle dip into the cold, clear blue water of the pacific northwest, as the three of us set out on kayaks from the tip of the Alaskan panhandle. A white‐capping headwind is the consequence of our late start. The resistance from the wind reinforces the steadily growing realization that our journey along the Great Bear Rainforest to Vancouver Island is an ambitious undertaking. The surrounding snow‐capped mountains run straight down into the ocean, as if there was no sense in stopping to create a habitable shoreline in such a remote place. It is getting late and we are still paddling along the steep, rocky shore in search of a suitable spot to haul the kayaks out and pitch our tent. I am starting to understand the extent to which we are alone.
For years I have wanted to explore the coast of British Columbia and the opportunity finally presented itself between my first and second year of medical school. The vast majority of the 30‐day journey was spent isolated with no one to talk to except my two lifelong friends ‐ a testament to the remoteness and inaccessibility of our coastline. The exception was the occasional community we would paddle upon, where we invariably encountered overwhelming hospitality and enthusiasm for our trip. We were welcomed onto shores and into homes, where people eagerly shared food and stories of their lives and the land they inhabited. Although few
and far between, these interactions impressed upon me the immense reliance these communities have on their natural environment and the barriers to healthcare access that they face.
As a future physician, I was struck by the role the environment plays in the health of the individual and the community. Many of the coastal communities are primarily Indigenous and have been living for millennia with a close connection to the land and ocean. A poor harvest at sea not only results in an economic burden for many who rely financially on marine resources, but also a significant deficit in nutritional food. Traditional foods are a key source of essential nutrients, as well as a significant part of social and cultural well‐being.<1,2> Colonization led to a shift away from traditional foods and an increase in processed foods, leading to higher levels of obesity, type 2 diabetes, and cardiovascular disease among Indigenous peoples.<1,3> The exorbitant cost of processed foods in remote communities exacerbates the issue of food security. Furthermore, local and global sources of contamination from industrial activity threaten the safe consumption of locally harvested resources. Part of the solution to the growing problem of food insecurity involves promoting traditional foods, access to which relies heavily on maintaining a healthy environment. As healthcare providers, I encourage us to advocate for environmental protection; the outcomes have a substantial effect on the health of these rural communities.
Traveling by kayak, we shared a similar dependence on marine conditions as the people of the communities we visited. Entire days were spent huddled under a tarp, avoiding the
treacherous sea and relentless onslaught of wind and rain. Although I am familiar with the challenges many people face with respect to healthcare accessibility in rural Canada, I was astounded by the barriers confronting some coastal communities. One hardened, elderly man, a full‐time resident of Oona River, described needing to leave by boat two days before a medical appointment in the closest town. Other communities we passed through, such as Klemtu, rely on nursing stations to provide primary care, public health, and emergency care.
Locals must travel great distances to access a physician or specialized services, which entails transportation costs, child care, and time off work. Not to mention, the legitimate concern of a medical emergency exacerbated by a significant delay in accessing an appropriate level of care. It was unsettling to consider what urgent care would look like for us while we paddled through isolated channels.
The sheer beauty of the Canadian wilderness and the endless opportunities for adventure drew me to the far corners of this province. While I may never experience the coast by kayak again, the people I met and the wild country I saw have left a lasting impression on me and I will undoubtedly be back. This trip motivated me to promote environmental protection through a medical lens, as I witnessed how a healthy physical environment acts as a key determinant of health, particularly in a rural setting. Visiting these remote communities gave me a new perspective on healthcare accessibility in Canada, reinforcing the reasons I am drawn to rural medicine. The trip ended in smiles and sore backs; I was relieved to be finished, but compelled to return. Next time in a different capacity.
For a short video of this trip, go to: vimeo.com/232922619
Acknowledgements: The author thanks Malgorzata Kaminska for her help with this article. Competing interests: None declared.
1. Richmond CA, Ross NA. The determinants of First Nation and Inuit health: A critical population health approach. Health Place 2009;15:403‐11.
2. Chan HM, Fediuk K, Hamilton S, Rostas L, Caughey A, Kuhnlein H, Egeland G, Loring E. Food security in Nunavut, Canada: barriers and recommendations. Int J Circumpolar Health 2006;65:416‐31.
3. Anand SS, Yusuf S, Jacobs R, Davis AD, Yi Q, Gerstein H, Montague PA, Lonn E, SHARE‐AP Investigators. Risk factors, atherosclerosis, and cardiovascular disease among Aboriginal people in Canada: the Study of Health Assessment and Risk Evaluation in Aboriginal Peoples (SHARE‐AP). Lancet 2001;358:1147‐53.
Medical Students Writing CaRMS Getting Coffee
In my fourth year of medical school, I was fortunate to do an elective in emergency medicine in Whitehorse, Yukon, a community of 26000 people according to their population sign.
I had a favourite coffee shop in Whitehorse where I spent a great deal of time in between shifts in the ED. As it was mid-November, I often had my nose in my laptop, as putting off my residency application was no longer an option. In that time, nurses and physicians who had only known me for a few days would stop, pick up their coffee and wink at me on their way out the door "don't worry about CARMS, Lauren. Just be yourself." The advice is cliché, but no less true or genuine.
Often the place was so busy, I would share my table with locals of all ages who would usually respect my time to work, but often asked me what I was up to. After I told them, I'd usually get a question about a rash they’ve developed or if they should be worried that their 15-month-old isn't talking much yet. I once shut my laptop for over an hour listening to a delightful 85 year-old- man talk about his life as a prospector, a wilderness photographer, and before all that - a gratefully escaped German-Jewish immigrant over 60 years ago. He had been measuring his blood pressure daily and wanted to know the difference between the top number and the bottom number, so I did my best to explain. "How did I not know that after 84 years? ah ha ha". His laugh is reminiscent of the Count on Sesame street, and I felt my heart grow an extra size.
A different day I sat a toddler on my lap so his mom could deal with his fussing younger brother, only a few weeks old. We discussed his favourite Paw Patrol episode while I missed the cuddles and chattiness of my little boy (about the same age) who I left at home for this elective.
Another day the sister of a patient who passed away earlier that week, patted my shoulder on her way out the door. The memory of her identity didn't come right away, but her cologne helped stimulate the scene to replay in my mind - me passing her a tissue in the trauma room while her and her family wept. Sometimes when you're a clerk on your first day, all you can really do is pass the Kleenex. It was one of those cases where many of the ER staff texted their loved ones an extra "I love you" or "be safe today" (a ritual I often partake in when I too have seen something that hurts my insides). Her timid and sorrowful wave as she hurried out the door with a tray full of coffee took my breath away.
One time I exited the coffee shop and headed up the hill to the residence where I was staying. One of the ED docs ran by me at impressive speeds for such an icy day, barely recognizable through his winter gear by his giant, icicle-filled beard (that would give most lumber jacks an inferiority complex). We exchanged waves - and I threw him a thumbs up of encouragement, not fully understanding how people make themselves run for fun in sub-zero temperatures.
During my travels I had been reading a book of short stories called "The Surprising Lives of Small Town Doctors" - because I wondered if these writers could help me put into words how all these small town interactions affect a person. Dr. Kelly Anderson talks about community interconnectedness as an underrated resource in otherwise low resource places. Like her, I would not minimize nor have I personally faced the challenges low resource community members face.
I have never had to access a food bank with mouldy bread as the prize item, needed an echocardiogram that required an 8 hour flight, or sat in the back of a bumpy pick-up truck for 5 hours in unstable atrial fibrillation (and yes, those are real examples from my time in Whitehorse). That said, the connectedness of these communities is a hidden resource not to be underestimated.
The clock was ticking on CaRMS when I wrote these words, but for some reason, it seemed more important to put these thoughts down than it was to tweak my CV for the fourth time.