A Blog for Students of Rural and Remote Medicine in Canada

As our 10-passenger plane whirled into the air, its engine spluttered in the winds. I marveled at the tributaries like veins weaving through the lush greenery and watched the homes becoming mere specks. I imagined the wildlife that lived down there, appearing seemingly untouched by man, no semblance of concrete and glass I am so used to. Just soil, water and trees in its natural opulence. We were on our way to Kashechewan.

 

Keeshechewan, meaning “where the water flows fast” in Cree, is a Cree First Nation community located near James Bay. The community lies in a flood-prone area which becomes swallowed by the Albany River every spring. They are part of Treaty 9, an agreement first signed in 1905-1906 between Anishinaabe and Mushkegowuk Cree communities and the Crown. However, the circumstances around the treaty are still in question, promises left unfilled.

 

We were met by friendly faces on the tarmac. It was a herculean effort as we climbed on top the back of the pickup trucks, destined for the nearby nursing station. The back littered with empty water bottles, we packed ourselves like sardines. The unpaved roads tumbled our bodies around like ragdolls. The cold, crisp air made my cheeks burn; our hair whipped defeatedly in the wind. We shot each other looks of disbelief and childish amusement, the type of look when you are unsure if you are having fun or on the cusp of danger.

 

I never would have imagined myself in a small Indigenous community on the James Bay Coast – another unique opportunity that my medical training has afforded me. I was sent as part of a team from Weeneebayko Area Health Authority to provide support in the midst of a serious COVID-19 outbreak. The virus was spreading quickly through the intergenerational homes and patients left vulnerable by chronic disease and effects of colonization. As we tried to find calm in the chaos, I was assigned to see patients that were not query COVID.

 

C.W. came into the nursing station because his cast was too loose. A relatively benign, low acuity complaint – however, one that excites a medical learner enthusiastic to be hands-on at any given moment. I was eager to help wherever I could. As I awkwardly set up our supplies to recast his arm, he graciously offered me small talk.

 

He asked what year I am in and what I’m training to be. He says, “you must be really smart”, in a way that felt intimidating to me. I briefly held the weight of his words. Reflexively, I asked him what he does. He told me he is good with his hands, worked in carpentry, but that is how he hurt his arm. He grew up here in Keeshechewan, but went to school in a bigger city, an opportunity he acknowledged that not everyone has access to around here. He also tells me for a while he lost his language, but he was lucky to get it back after he returned to the community.

 

He spoke excitedly about his youth, his love for hockey and his achievements as a goalie. However, his love also led to a herniated disc that left him in chronic pain. And now with his hand in a cast, he could not do his other love, which was to write. He beamed with pride speaking about his beautiful cursive, the way he could string together letters in a fluid entanglement. He was even paid by friends to help write letters for their families, but he spoke about this in a trembling despair.

 

He was extremely polite – grateful – for what we did for him. He then tells me he remembers my preceptor, when he had first broken his arm in a work-related accident. He was extremely flustered, his father on the brink of death because of COVID-19 and may have acted inappropriately with the staff in Moose Factory. He told me he was thankful that they crossed paths again, because he sincerely wanted to apologize. I told him that I think she would really appreciate that. His eyes were filled with regret and his voice was soft. And I ponder what it means to hurt and be hurt. What it means to acknowledge our flaws and to right our wrongs. How insightful for him to see the harm he caused in light of his own suffering.

 

I cleaned up the plaster between his fingers meticulously and was proud of my work.

 

And then he wished me luck with my studies, and I wished him luck too. My work here was done. My brief interaction with him, also marked my brief time in Keeshechewan. I knew that I likely would not be back to see him again like two lines on diverging paths.

 

As my day ended, we were sent back on our charter plane to Moosonee. Another bumpy ride in the back of a pick-up truck, it was becoming routine. However, on our car ride back towards the airport I noticed something. The worn-down houses, that resembled portables more than homes, were splattered with signage saying…

 

“No Visitors.”

 

As the wind began to catch under the wings of our little plane and the sun fell towards the horizon, I contemplated the weight of those words.

 

 ---------------------------------

A sincere thanks to all of the patients, preceptors, and locals who welcomed me to their community. Who trusted me with their care. Who shared time with me. Who allowed me to see a world, so different than my own.

 

And I hope we continue to reflect on our responsibility to Indigenous peoples that have been harmed; what are we but our words and commitment to each other? That we continue to reflect on how we are visitors to this land, and sometimes to our patient’s lives… in cross-section. And that we will never understand the harms and experiences in totality, we nonetheless have a commitment to work together and live in balance and harmony.

 

 

By Andrew Lee
Queen’s University – Class of 2022
alee@qmed.ca
Word count: 990

Winner of the SRPC Student Essay contest 2022

The first thing I noticed was his hand. I watched as his index finger swirled anxious circles around his thumb; tracing new paths through the deep grooves etched by the hardship, tenacity, and bricks of decades past. These were not the hardened hands of the farmers that normally passed through here. The nails were too soft, the cuticles too clean, and there was no dirt permanently sealed into the nailbed and palms, yet they still spoke of this land and were somehow more familiar to me. We locked hands and I think we knew. What I didn’t realize was what this connection would become – that we would become each other’s tether to the place we call home.

I remember the day that I first met Arthur. It was a couple of months into residency and I was debating whether I had made the right match. It was a Friday at the end of a long clinic day and he was my last patient. The autumn chill was creeping through the office and the sky had already tucked itself in for the night. I was feeling the pull of a weekend off as I turned the doorknob, but when I walked in I forgot about all of that. His defeated shoulders hung off of his small frame and I could tell he was nervous. I took an hour that evening to listen to his story. His soliloquy had me holding back tears that would later pour forth as I walked home.  I was the first person to suggest his diagnosis of Parkinson’s disease and I will never forget how those seconds of silence hung between us, so tangible that it seemed to quiet the world around us. I remember thinking that I would never again see such a textbook presentation of the disease, and certainly I was interested from an academic point of view. However, what has truly humbled me and made me relish my choice to pursue family medicine was the privilege of sitting with such a beautiful study of the human experience.

    After completing the mandatory portion of the appointment our conversation turned to the crux of the issue. I remember him telling me that the he doesn’t feel sorry for himself, but that he feels sorry for his partner because he has to take on the responsibility of his slow decline. “We are familiar with suffering” he told me “but this is new territory and we don’t know how to navigate this journey”. He told me stories about the fear of the 80s and the loss of friends to a disease steeped in stigma and unknowns. We silently commiserated on this topic, but the part that really gave me pause was how he described his relationship with his hometown.

He moved away from his hometown at the age of 20. He told me of the conflict he felt between the love for his hometown and the exclusion he felt by it’s inhabitants. Though he felt most connected to and wished to live in his hometown, he had fled for the comfort of chosen family in Toronto because the trauma of his childhood had built curtain walls that precluded him from penetrating its inner sanctuary. He had spent years attempting to scale the fortress that kept him away from his truth, and it wasn’t until memory had faded enough to keep him within a safe distance of harm that he was able to return to his home for his last chapter.

I spent a long time just listening to Arthur’s story that first day. Subsequent visits strengthened our relationship and understanding of one another’s life experiences. Being queer men, he opened up to me. We have not always belonged in those areas that we identify as home. This is what has been simmering within me for the past few months. I yearn to live and work in rural Canada for all of the amazing opportunities and privileges that is offers. Though the land itself is welcoming, our communities do not always echo the same message, which is why listening to Arthur’s journey helped me realize the importance of my role as a physician.

Though we have come a long way from the days of hurling bricks, we still need to create more space for those who have been marginalized throughout rural Canada. Now, whenever I clasp those resilient hands I am reminded of the duty to foster this environment, to hold my own space, and to shake the system to welcome in a more forgiving future where we do not only choose our home, but our home chooses us.

Dr. Andrew O'Dea, BSc (Hons), MD St. John's, NL

On November 20 I came home to the news that the 10-day COVID-19 test positivity rate in Steinbach was a staggering 40%. Steinbach is a town of just over 15,000 people around one hour southeast of Winnipeg, and I was there for my family medicine rotation. The day before I arrived, a COVID-19 outbreak was declared at their regional hospital, and for the next month I had a glimpse of what life was like behind the 40%.

During my first ER shift, I was immersed in an atmosphere of stress and fear, as staff were already starting to feel the strain of the outbreak. All patients are screened as red, orange or green, meaning confirmed COVID, COVID suspect and no COVID symptoms, respectively. Although this labeling system works in theory, delays in testing led to many orange patients later becoming red once their test result would come back five days later. By that time, multiple healthcare workers would have already cared for that patient with inappropriate PPE. As a medical student I was mostly asked to see green patients, so I had a relatively normal ER shift. But listening to the conversations around me, it was clear that it was only the beginning.

By my second shift, this was all but confirmed. Two weeks after the outbreak began, the ER was essentially full of COVID red patients. I saw one orange patient whose test result had not come back yet. Around me, nurses were exhausted. Through cracks in the curtains, I saw patients struggling to breathe on 70L of oxygen. The anesthesiologist was on his way to do yet another intubation. Coughing was part of the constant background noise. I repeatedly refreshed the ER status board to see who was coming. Every single one was COVID red.

That weekend, a Hugs Over Masks rally occurred in Steinbach. Crowds of people gathered to listen to anti-mask rhetoric without any public health precautions. Honking trucks and cars lined up and blocked traffic down the main road for hours. I spotted signs that said, “Masks are child abuse”, “Freedom is essential”, “This is not North Korea”. All this occurred just two blocks down from a hospital buckling under the pressure of COVID-19. In clinic the following week, many patients were saddened by all the negative publicity the town received; most people who participated in the rally were not from Steinbach.

I spent a lot of time in clinic doing virtual visits due to COVID-19 restrictions. This is where I saw the reaches of the pandemic extending far deeper than just the hospital. Many patients were calling about the overwhelming stress of caring for their children at home because of school and daycare closures. Other patients who worked at schools and daycares were asking for work notes to protect their families at home. It wasn’t until I took a step back that I realized giving out more and more work notes to school staff would eventually make it more difficult for schools to stay open, which would simply exacerbate the childcare problem. How, then, do you advocate for both these patients when their needs contradict each other? A patient who worked at a personal care home with an outbreak asked for a work note due to their underlying health conditions. How do you advocate for this patient while also advocating for a healthcare system desperately in need of personal care home staff?

A young family came in one afternoon for a well-baby visit. After asking the standard questions, I asked how they were doing and found out that the couple was struggling financially. They were unstably employed even before the pandemic, making them ineligible for CERB. Now that the mom was prepared to work after giving birth, very few places were hiring. The social support services they had relied on previously were cancelled. Due to concern for their parents’ health, they were reluctant to have them help with childcare. Their first child had been taken away by Child and Family Services a few years ago. How do you tell them the same won’t happen again?

One afternoon I was with a doctor who had been practicing for many years at Steinbach Family Medical. At the end of the day, we talked about how COVID-19 was impacting the community. I saw him hold back tears as he talked about how difficult the last week had been for him. Multiple patients of his had died of COVID-19, patients he’d known for so long he thought of them as friends.

Every day we see the numbers. That day it was 40%. But there’s more to this pandemic than the numbers. There are people behind these numbers, and people that the numbers could never capture. And it’s important that we see them too.

By: Ms. Sara Wang, B.Sc. Winnipeg, MB

My first two years of medical school were a whirlwind of new experiences and learning, as I began to envision what my future as a physician could look like. I entered medical school with an interest in family medicine, but with a limited understanding of the breadth of what the specialty really encompasses–especially in a rural setting. It was a weeklong experience at the end of first year that was the spark that lit the match in my decision to pursue a career and life as a rural family doctor. I really believe that every medical student should be exposed to such an enlightening experience in rural medicine early on in their training.

Community Week is a particularly unique opportunity that Queen’s provides where students are placed in a small community in Ontario to explore rural medicine. I was placed in Barry’s Bay, Ontario, and worked with an incredibly passionate community leader, Dr. Jason Malinowski. I saw and experienced firsthand how diverse and vital the role of community generalists are. Dr. Malinowski practices all types of medicine, is a key community advocate and leader, and most importantly, is committed to and deeply loves his community. The positive experiences I had in Barry’s Bay motivated me to pursue a rural medicine clerkship experience two years later.

At Queen’s, clerks are offered the opportunity to participate in a longitudinal integrated clerkship experience, where we complete Family Medicine, Pediatrics, and Psychiatry in a rural community over 12 weeks. Because of my experiences in Barry’s Bay, I knew that I wanted the ability to work with preceptors at length, to create space and opportunity to build meaningful professional relationships. I won the clerkship lottery when I was placed in Perth, Ontario, with three phenomenal preceptors: Dr. Anil Kuchinad, Dr. Dan Kruszelnicki and Dr. Bob Van Noppen.

Each of these physicians wear many different hats in Perth and practice a wide variety of clinical medicine. Over the 12 weeks, I gained exposure to a broad scope of clinical work, including office-based family medicine, inpatient hospitalist, obstetrics, emergency medicine, surgical assist and palliative care. Working in Perth and Barry’s Bay shone a light onto how diverse and rewarding rural family medicine can be, and the flexibility there is in molding your practice to fit your passions and interests. 

My preceptors invested the time in fostering confidence in my clinical knowledge and skills and encouraged me to take ownership of my patient’s management plans and follow up. One of my favourite parts about being in Perth over those three months, was that I had the ability to follow up on my patients’ admissions or visits to the Emergency Department, allowing for extended continuity of care. Working in a rural setting is unique in that it is not uncommon that you are the person to see the patient in the ED, admit them, round on them, discharge them, and even follow up with them in clinic days later. I learned an incredible amount from my preceptors, but also from patients who I grew to know well because of this continuity.

In Canada, we are sparsely populated geographically and there are major barriers to healthcare access that exist because of this. It is absolutely vital that undergraduate medical curricula engage their trainees in the importance of serving rural communities as a way to fulsomely serve all Canadian patients, ensuring access and equity. My exposure to rural medicine in Perth and Barry’s Bay was invaluable in demonstrating the reciprocal value in practicing in small underserved communities and was an absolute privilege to be a part of.

Marika Moskalyk 

MD Candidate | Class of 2022 

Queen’s University School of Medicine

 

Living the majority of my life in northern small towns with limited access to health services motivated me to attend medical school with the hopes of becoming a family doctor. For my first clerkship elective in February 2021, I had the opportunity to do two weeks of rural family medicine in Fergus and Elora, Ontario. The roles of rural family physicians are diverse, during this elective I experienced a broad scope of family practice by doing inpatient rounding in the hospital every morning followed by clinic in a primary care office. I also worked at the local hospital doing ER shifts, and assisted in the operating room. We delivered virtual and in person care, performed physical exams, investigated symptoms and discussed management plans. My main objectives for this elective were to help patients manage chronic diseases and to develop an approach to common dermatological complaints. These two objectives are important in rural family medicine because specialist services are not readily available. I was able to do skin biopsy, sutures and see various rashes in children and adults. Being a family doctor with the skills to interpret rashes and discern a concerning skin growth from a benign lesion is essential in rural settings. 

Overall, I had an amazing experience in these charming towns and was impressed by the broad scope of medicine practiced by my excellent preceptors. In May, I will be doing a second rural family medicine elective in Grand Erie Six Nations region. The work of rural family physicians is both rewarding and inspiring, there is a familiarity between patients and their physicians unique to rural settings. This allows physicians to support patients on an individual level while also helping to improve community health as a whole. 

Elisabeth Fortier, Class of 2022, McMaster MD program

I completed an 8-week rural family core clerkship rotation in Labrador as a third-year medical student. This was my first time visiting “The Big Land” and I was immediately drawn in by the breathtaking landscape. Early into day one, I joined a friend for a 12km trail snowshoe with the local Birch Brook ski club – getting a chance to meet new people, experience the tail end of the Labrador winter, and take in the beauty of the Mealy Mountains. I immediately felt at peace, knowing I had begun an experience I would never forget. 

The schedule for my first four weeks was filled with outpatient clinics, emergency room shifts, a week of inpatient care and a few OR assist shifts. My second month included a coastal visit to Hopedale and another to Rigolet – two excursions I was very much looking forward to. I was eager to meet the staff, the residents, the patients, and community members I had heard such good things about from learners before me. 

During a day in outpatient clinic, I saw an elderly man who had come for a checkup, accompanied by his wife. At the end of the visit, she explained how anxious her husband was about coming to the hospital and thanked me for making it such a comfortable and pleasant experience. This is just one of the many experiences that touched my heart and made me feel so welcomed and appreciated in Labrador. 

While my rotation was filled with inspiring and positive experiences, I was surprised by the continued lack of access and its association with communication or health literacy barriers. In particular, I recall one patient who had travelled from the coast to be seen in the ER for an infection, which may have been avoided or mitigated if not for the systemic limitations. The patient spoke little English yet nodded in agreement throughout our conversation. It was apparent that she was not entirely understanding of the minor procedure she had undergone just a few months prior and the follow-up care that was required as a result. Despite the communication, geographical, and cultural, and financial barriers faced, she remained polite and appreciative throughout the assessment. 

With each day, I was inspired by the gratuitous patients, welcoming healthcare team, encouraging mentors and incredible scenery. The connections that exist between staff and their associated coastal communities were like no other. My experience in Labrador showed me the value of emotional connections, the impact they have on people and places and, the reciprocal fulfilment they can provide. It reaffirmed my aptness for rural medicine and gave me a desire to return.

During my fourth, and final, year of medical school, I had the opportunity to return to Labrador for Memorial Universities Progression to Postgraduate (P2P) program – accounting for twelve weeks of selective clinical placements in a variety of fields, including hospitalist medicine, emergency medicine, general surgery, obstetrics, outpatient clinics, and indigenous health. After having spent a total in 5 months in Labrador, a vast part of my home province that I had previously never seen, I reflected on my unique experience.

With my phone to the window, I’m attempting to capture the beauty the is The Big Land. It was my first month in Labrador and I had the privilege of tagging along on a MedEvac to Hopedale to retrieve a child with suspected impetigo. We left the airstrip in Goose Bay just before sundown to incredible views of the Mealy Mountains. During my second trip to Labrador, I was fortunate enough to spend a week in Nain, the northernmost settlement in Labrador. Nain is serviced by a small runway which lacks lighting, thereby limiting the window through which planes can land – in addition to the occasional low ceilings and obscured visibility. Luckily, for my flight from Goose Bay to Nain the skies were clear, showcasing the spectacular land, so vast and untouched. At that point, I realized no picture could ever really capture the beauty of this land.

While in Nain a terminally ill patient presented to the clinic with a new GI bleed. The staff did an incredible job of managing him for several days while the weather was down – despite the clinic not being equipped for inpatients. Family and community members took turns visiting at all hours and even brought hot stew for the staff. This was truly an example of a community coming together, demonstrating how isolated and resource-limited settlements continue to thrive.  

On my last day in Labrador I shed tears knowing what I was leaving behind: an amazing three months of medical, cultural, and personal experience; incredible friendships; amazing mentors; and, so much more. As I drove away from town into what are arguably the most beautiful sunsets, upon a backdrop of the Mealy Mountains, I knew that this would not be my last visit to The Big Land.

Patricia Howse, M.D.

PGY1 Family Medicine

Queens University, Belleville, ON

For information on how you can experience Labrador during electives – check our MUN Family Medicine on the AFPC Portal or email ugme.electives@med.mun.ca for additional information.

We walk into the hospice. My Family Medicine preceptor invites me to meet a patient with a soft voice and lovely eyes. I can feel the bones in her hands when she reaches out to greet me. With her daughter beside her, she timidly voices her fears about dying: what she might miss, that she will be forgotten, and the pain she will leave behind with the people she loves. I marvel as my preceptor conjures words of kindness and listens patiently to her story, which at this moment I imagine offer equal comfort to the medical measures we are providing. One year later, I walk into the same rural hospice. This time, a familiar face occupies the space in that bed. The lady with the soft voice has gone, replaced with the lady who shaped my partner’s childhood; his grandmother. A different physician who joined her care in the hospital guides the family through a similar process of loss, but my role has shifted now. I not only hear the words that the physician says, but I feel their impact this time. When abstract experiences become firsthand immersions, and when emotion is added to education, that is when learning becomes understanding. This juxtaposition of patient illness experiences opened a window of insight for me, and influenced me to realize how physicians’ words and actions can impact patient and family care. I want to be a part of this frontline care, working across settings in the realm of stories, relationships, and community. I want to be a rural family doctor. 

Jodie Hooker

PGY-1, Rural Family Medicine

Collingwood Site, McMaster University

Collingwood, Ontario

The gifts of learning in a rural medicine setting are plentiful and rewarding. As a pre-clerkship one-month placement facilitated through ROMP as a NOSM learner in Owen Sound, I had my hands busy, mind full, and heart proud. I was granted opportunities to learn in various settings including family medicine, obstetrics, emergency medicine, and palliative care. I was typically the only learner alongside the preceptor – no long chain of command or “fighting” to perform a procedure (such as stitches, for example). As the primary learner in most settings, I feel like I was fully immersed in a learning environment and confident in my advancement in my medical training, which most of you know is often challenging and overwhelming. Outside of academia, this rural are offered many opportunities for community involvement and events such as farmer’s markets, local fundraisers, and a Saturday morning run club. Notably, it is important for me to have access to running and hiking trails, a view of the water (fortunately here it is the beautiful Georgian Bay!), and parks to wander with friends. It was easy to balance medical training and my personal life during my placement here because of the sense of community that is bonded together through the love of water, outdoors, and community engagement.

Anonymous

NOSM Learner

You spend your life like a buoy in medical school and residency; sitting atop the waves (perhaps getting submerged by a tall one or two) and letting the big ocean carry you wherever it does. It rolls and rolls, and the small line keeping you tethered stretches and sways, but there you sit.

You canvass a large academic hospital, middle of the day or late at night, and it's hard to feel at home. You rub your eyes, read the books, auscultate a heart and hear stories of those who suffer. You see someone far from home, the name of their hometown obscure. You don't recognize it, you don't know it. You pack up, move on to another service. See all new people with all new names, new language and new forms. That little tethering line feels so fragile. What connects you, what keeps you steady?

As I packed up my car to travel for an elective far away to Western Newfoundland, I felt a physical pain in my chest. Off I went, from my snug apartment, a beloved pet and people I knew of St. John's. Stretch, stretch. The tether, my tether, stretched to capacity.

Across barrens, through rock cuts, glaringly out of place Micky Ds signs and the reduced speed limit of national parks, I go. 800 or so kilometers. My headlights dim mid trip, and I seek solace in a deserted convenience store. It's something electrical, I'm told by a strapping young man who peers into the unknown (to me) parts of my ancient corolla. I'm left flustered. There's no near motel. I'm due to start my rotation tomorrow. "Depending now on who you belongs to, we might help ya", I hear from someone who in the end doesn't know who I belong to, but decides to help out anyhow. I end up sandwiched between the two trucks, and we make our way caravan style across the twisty remaining turns of the journey. I learn about a "triple triple" at a pit stop and notice that thanking those who believe their generosity is commonplace is harder than thought. The trucks salute joyful horns as they head towards the ferry once we've reached the end, and I turn in for town.

They called it "mouse island", a tiny part of Port Aux Basques. A small apartment, two-bedroom. I was alone, front windows like dark eyes reflecting my headlights when I pulled in. I could feel the hum of wind as small snowflakes surrounded me as I pulled my meager belongings into the cold hallway. There was a bag of salt and a small shovel, heralding weather to come. Stretch, stretch, as I look at the desolate coves from my window and wonder how these two months will go.

I'm broken from my rather mournful reverie with a thump on the door. I imagine there aren't enough people in this place for there to be bad seeds on the prowl, so I open it. There's no one there. I do a cursory look, right to left. As I turn, a yeti appears. On closer inspection, a kind middle aged man with a beard covered in snow smiling from the dark. My inner fear must have betrayed me, as I hear "steady on, doc, just making sure you're making in alright". He holds an extra shovel, and asks if I have icers for my shoes, as the lady up the road fractured her wrist last week from a fall. To help, he tells me to park my car close to "the bridge".

I feel a bit chastised, not realizing my car was wrongly parked. I utter a thanks, mentally thinking of where this bridge might be, and I close my door. Look around at small sofa, clean kettle and sparse decor. Stretch, stretch. The unfamiliar hurts.

I become familiar with the nearest bridge, which is 10-minute walk. Although there appear parking lots along the way, some in front of abandoned buildings, I stay true to the advice. I put my icers on. I see a person twice in one week, in clinic and at the grocery store, and find myself wrapped in a hug as they proclaim to curious onlookers at Coleman's that I'm new here. At the pharmacy, I find myself helped with a hairspray (unsolicited) to "tame those frizzies in front" and someone loans me a quarter so I don't have to break a five dollar bill.

I've started to notice my heart doesn't hurt as much. The telephone calls home are still hard, and the loneliness seems worse in the night, but there is joy here. Something is happening. Tighten, tighten.

On a cold winters night, the snow tumbles down. It's stormy, and the wind puts me in the centre of a snow globe. The university is closed, us students are urged to use caution and proceed to work if safe. I get a call from the emergency, "are you coming?". It's busy, there's people to see. Taking the little shovel and bag of salt, out I go. After too much time, it's clear I'm stuck. The ol "put er in neutral and run at er" fails me. I call back, they understand. "Make it if you can". I rummage in my trunk, two clean snowshoes surprised to see me are pulled out. It's not a short journey to the health center, but it's do-able. I wade out into the snow, but it's blowing all around. Defeated.

Little orbs of yellow come down the road, and I peer into the snow. It's the RCMP making their way. Then it hits me. Why don't I just call the police and see if they could help me? I have the number of a kind officer, could he come fetch me? Not soon after, I hear the friendly beep of the cruiser and find myself in the back for the first (and so far, last) time. I'm asked why my car was so far away. I relate the bridge advice. The officer laughs as he explains that "bridge" means porch. Good to know several weeks in. Dropped off at the main doors of the hospital, I look around covertly. Imagine, the lady doctor dropped off at the door fresh out of the paddy wagon. Scandalous.

Inside, I meet sore throats, chest pain and delirium. See wet coats and snowy shoes, concerned faces and worry. See names I now recognize, from places I visited on my weekends off. One community of less than 100 I had flown into via helicopter for a clinic. The shared joy of knowing where one "belongs to" is a wondrous thing.

In the morning, the sky is clear and air is cold. I trot home lazily. Looking around at all the houses neatly tucked in in their beds of snow. Wave hello to everyone who is out shoveling, stopping briefly to offer a hand but it's declined on all counts, one claiming that "the day I can't shovel, take me away".

I look around at the beautiful place; once unfamiliar. No hurts in my heart. My tethers strong and firmly attached. I'll steady on.

Dr. Laura Downing - Dartmouth, NS

I’m just a medical student – what can I do? I thought to myself as I was taking another history with a patient in the small Emergency Department of Louise Marshall Hospital in Mount Forest, Ontario. It was my first clinical experience in a rural setting as well as my first week of clerkship and the patient in front of me was worried about breast cancer. They also confided in me about some stressors they were experiencing at home for the past year. This patient looked at me with anxious yet trusting eyes and I wanted to help them, but I felt severely unqualified and worried about making things worse.

I still remember making the hour and a half long drive up to Mount Forest, to live for two weeks in a small town where I knew no one, and I could not stop anxious thoughts from crossing my mind. What if I disappointed my preceptor or made a mistake with a patient? And what if I did not belong there at all? Was I just a “big city” person with no place thinking I could fit in a rural town?

This was my second time coming to Mount Forest. I had been there once before for “Rural Skills Day” – a one-day event organized by the doctors to introduce medical students to rural medicine. Prior to that event I had never seriously thought about rural medicine as a career, mostly because I knew almost nothing about it. I am still surprised at how much one day can change everything. At Rural Skills Day, not only was I introduced to suturing, casting, intubating and interpreting chest x-rays for the first time, but I was also introduced to a rural community. The physicians were so kind and generous with their time, staying longer after lunch to answer my many, eager questions. They described how happy they felt there, able to work with a wide scope of practice, often with fewer resources than bigger centers have access to. And they told me how warm and welcoming a small town can be.

Suddenly, I was transported back to Ukraine, where I was born and grew up for six years in Zalishchyky – my grandmother’s village. It did not have fancy restaurants, highways, or even a Walmart, but it had large, green fields full of the tallest sunflowers I had ever seen and orchards with cherry, apple and apricot trees. It was the place where the neighbors would come over almost every day, giving no warning except our dog barking at the gate. My grandmother would always have tea brewing in the afternoon and some biscuits ready just in case they would come. It was the place where you would have a fire roaring most evenings and sit together with your family telling stories. I have often thought of that village since then and how much I missed its calm and peaceful atmosphere so different from living in Toronto for the next 17 years of my life.

Mount Forest, although bigger than my village, gave me the same feeling of warmth that day and I promised myself that I would come back there for a clerkship elective to experience rural medicine and decide if it is the right career path for me. Although I was incredibly nervous, I also felt excitement for how much I would see and learn over the next two weeks. I was fortunate enough to be staying with one of the residents and she was encouraging and helpful, guiding me through the next few days as I got settled in. I was surprised at how kind everyone was and I did not feel like an outsider at all. My preceptor checked in with me frequently, asking if I was feeling overwhelmed or what else I would like to be doing to achieve my learning objectives. Truthfully, it was better than I ever could have hoped for my first two weeks as a clerk.

I also continued to develop my passion for rural medicine. I have always loved variety and I got my fill at Louise Marshall Hospital. We saw inpatients every morning, went to the nursing home to see patients one day, then worked at the family medicine clinic other days and even worked at the emergency department. I was able to suture, perform joint injections and other procedures which I really enjoy. I was also lucky enough to have seen a patient discharged from the ward come back for follow up at the clinic – it was an incredible feeling to be part of such continuity of care and to get to know patients so well. I started to build confidence and would take histories independently.

It was on my second emergency shift that I was to see the patient worried about breast cancer. I took a few deep breaths before entering the room and then introduced myself and proceeded with asking the usual questions around symptoms, protective factors, past medical history and family history. However, medicine is both a science and an art and although I was still very inexperienced, I could sense that right now this patient needed my skills in the art aspect of medicine. I thought of the cases I had seen with my preceptor over the last week and let my experience guide me. I put my clipboard on the table in the room and took a seat beside the patient. I told them that it is normal to feel scared and overwhelmed at times and that we were there to help. I also assured them that it’s okay to take a break and look after yourself and then I invited them to discuss their stressors in more detail and listened intently. At the end of the visit, the patient smiled and thanked me. Although it was not much, I was able to help them feel a little better. And although I may be just a medical student, I learned that there is always something I can do.

By:  Ms. Anastasiya Lezhanska  - Hamilton, ON