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.
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.
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.