A Blog for Students of Rural and Remote Medicine in Canada

GONE WITH AIR AND WITH WATER

“Do you feel ready?” I asked you.

“Oh, yes.”

There were many other things I wanted to ask you that I didn’t. I wondered how it felt to know that you would die, to have more than just some vague notion that your death was coming, but to prescribe it a date and time. How did it feel, I wondered, to decide to die on a Tuesday. I thought of the great stoics, they had conquered the idea of death, so they claimed, and yet when death’s time came —when death was no longer just an idea— many of them were reported to have been afraid. You didn’t seem afraid to me. You and death had established a time, and you didn’t seem afraid.

            You and I were different people. You were rugged. Your generation grew up with very little, and you, you grew up with next to nothing. You worked the fish plant, you played cards, you drank, you smoked; eventually, you had a family of your own, and you were proud. You loved your children as you did your grandchildren. Then, cancer.

I always thought that something happened when a person was diagnosed with cancer, something that irrevocably takes a “me” and makes it a “me and my body,” with the two then deemed forever at opposition with one another.

What cancer left for you was cruel, because you were no longer you, rather you were a man left alone in a body, scarcely able to get from your bed.

So, you chose medical assistance in dying. In the short time you had left, we became quite close. I never told you, but I set an early alarm each morning. I made sure that once I had rounded on my in-patients, before going to clinic, we had ample time to talk. On Thursday morning we got to discussing poker. “I was never much good,” you told me, “but, it was always a good time.” You used to wear goofy t-shirts to poker games, and your friends would laugh to the point of tears. I told you how I thought we all ought to live to the point of tears, and you agreed.

Monday morning you gifted me a t-shirt, at the sight of which you couldn’t contain your laughter. “It’s for you to wear at a poker game with your friends,” and you beckoned me to take it. I did. You had worn it yourself over the weekend at a poker game you hosted with your family and friends while on a pass from the hospital. You told me that your drink and smoke had never tasted so good, and you were happy that such was the case because “tomorrow is the day,” and you “couldn’t go out on a bad drink and smoke.”

Tomorrow, then, you would die, as you wanted. It was my first experience with medical assistance in dying. I felt like crying but, in some sense, it felt selfish, so I betrayed my own advice to you. I thought I ought to leave the tears to you and your family, so I refrained. In any case, you were happy.

It wasn’t long until the storm came. It was a Friday, and I was scheduled to be off for the weekend. I stayed up rather late, mixed a drink of gin, and continued to work on a short story I had been writing. It was a tumultuous night. At 3:00 a.m. the wind was steady drumming on the apartment like a reveille and scant gusts pushed their way through closed windows, a whistle that reminded me of a trumpet —nature’s call to action. I slept poorly.

Before 8:00 a.m. my phone rang, and I answered. Something about a code orange; “we need all the help we can get,” I was told, “there are houses being swept out to sea.” Hurricane Fiona had arrived at the coastal community of Port Aux Basques.

The main road was safe, but elsewhere water could be seen stretching up and over the streets. Some of the streets no longer existed. Many homes no longer existed. When one stepped outside, one felt him- or herself in a scene that was quite biblical, in the most terrifying sense.

The hospital had electricity. Some of the employees who had worked the previous nightshift elected to stay and help, some had no home to return to regardless. Many of those who arrived in the emergency department were brought by authorities for safe shelter, although some were hurt by debris, and one had survived being swept away while evacuating. I worked that day in a sort of sustained daydream, one that lacked the pleasantness of a reverie.

Things were different in the weeks afterward.

“My blood pressure has been out of control lately.” Then, in a sentence that followed, you’d tell me how you were living with family, or friends, because your home, and the perch it sat on, had disappeared. No wonder about your blood pressure, I would think.

“My sugars have been all over the place.” No wonder, I would think.

“I’ve been having headaches constantly.” No wonder, I would think.

“My shoulder has been bothering me.” Then you’d tell me how you had spent the last week laboring to clean up the debris around what was left of your home. Yes, well, no wonder, I would think.

“My anxiety has been torturing me lately.” No wonder.

I listened to stories that were nearly unbelievable in the weeks that followed. Unbelievable in the sense that they seemed too tragic to be real. There was often little else I could do, so I just listened. Eventually I left Port Aux Basques, having finished my rural family medicine rotation. It was my first ever clerkship rotation. Things were much different in the community when I left it than they were when I arrived. I was much different too.

 

 

Daniel Pearce, Torbay, NL

Please send us a self-reflection from your experience in rural medicine.

Note: I use fake names for patient confidentiality.

 

“Would you like to take an appointment with the Smith’s?” my preceptor asked.

“Sure! What is the appointment for?”

“They’re an older husband-wife couple. Ex-farmers. Mrs. Smith has terminal cancer. She has requested MAiD, so they’re here to talk about that.”

“Wow. Okay, I’ll let you know how it goes,” I said, my tone more somber than my chipper acceptance.

 

I call out in the waiting room for the Smiths and an older couple rises from their seats and walk towards me holding hands. We enter the assessment room, take a seat, and start getting to know each other. They both came from generations of farmers- they had “hay in their blood”, as Mr. Smith put it, winking at Mrs. Smith before having a chuckle. They told me stories of their life on the farm. They were dairy farmers with a large herd of cows, a fair-sized chicken coop, a small garden in the back, a couple of barn cats, and a Sheppard named Sam. “It wasn’t an easy life, but it was a good one,” said Bill, his arthritic joints a testament to the years of physical labour and hard work. They had an open-door policy: they loved to host neighbours, family and any sort of company that came to the farm. Their children would often have their friends over after school, likely in part attracted by the cookie jar that was always teaming with Mrs. Smith’s famous oatmeal chocolate chip cookies. As they reached retirement age, the farm work outpaced their capabilities, and they were forced to sell it as none of the children desired to carry on the family tradition. Flashforward to 2 months ago, when Mrs. Smith received an unfortunate diagnosis of metastatic cancer with a prognosis of roughly 6 months. During the appointment, she began to speak about her values and her decision to pursue MAiD. She didn’t want to burden Bill, or the healthcare system. She lived a good life, and she wanted to leave it on her own terms. She didn’t want to take more from this Earth, she said. She did her part supporting the community with their milk, and “now was her time”.

I listened and nodded, moved by the Smiths’ values, by the love they had for each other, for their family, their community, the Earth, and life. I probed about any symptoms that bothered Ms. Smith, trying to view things from a palliative lens to make her last days more comfortable. I asked about sleep, pain, bowels, and about anything and everything I could do to enhance comfort. She acknowledged my efforts but declined as she said she was comfortable and thanked me for my care.

 

About 1 month later, I was prepping my charts for clinic when I saw Bill Smith’s name. My preceptor asked to say hello before Bill left so he could offer his condolences. At the end of the appointment, Dr. J. entered the room, held Bill’s hands, looked him in the eyes and said, “I’m sorry for your loss.” Bill held on to Dr. J’s hands for what felt like 5 minutes as he talked about the final moments in Mrs. Smith’s life. Thank goodness for these N95’s and face shields because I was struggling to hold back tears. To see two grown men holding hands like that, to feel the energy in the room- Bill’s love for Mrs. Smith, Dr. J’s sincerity in his condolences- was one of the most moving experiences I’ve had in medicine.

 

Bill went on to ask about Dr. J’s kids and said he’d see him at the rink this weekend. Bill’s grandchildren played sports with my preceptor’s kids, and they all attended the same place of worship. It was evident that Dr. J had a genuine care for the Smiths that went deeper than the confines of the clinic walls. That’s a large reason why I chose rural medicine. The “everybody knows everybody” adds another layer that cannot be paralleled by the greater anonymity in urban medicine. Rural medicine is built on a sense of community; the emotion in the room that day was a testament to the community that connected my preceptor and his patients on another level.     

 

Sure, I could tell you more about how rural medicine allows me to practice as a true generalist,  how I’m learning what feels like everything under the sun; how I’m experiencing how to practice effectively (and creatively) in a resource-limited setting; how hard I laughed (afterwards, in private) when a patient called our facility a “country bumpkin hospital”. But, what stands out to me most is the sense of community that rural medicine is built on. The emotion in the room that day, watching Bill and Dr. J hold hands, observing their sincere interaction, THAT is what rural medicine is about. I love getting to experience it every day- the house calls where a patient insists I stay for a cup of tea, being able to stay late to squeeze in a patient for a last minute visit because I know their family circumstances and there is no walk-in clinic nearby, the conversations about the best Niagara peaches that turns into “You go to that farmstand for your peaches?! I went to public school with them!” To me, rural medicine is about community. And I cannot wait to keep building and connecting with my community through residency and beyond.

 

Dr. Evelyne Guay , Burlington, ON

A Privilege 

It was morning handover at 8AM on Sunday, November 21 and my 24-hour call shift was almost over, or so I thought. My preceptor and I were sitting with the incoming staff physician and resident as well as the emergency room nurse. Amid giving updates on the patients in the emergency department as well as those on the ward, we discussed the upcoming holiday parade, the latest guidelines of pneumothorax and chest tube insertion, and the new habitant of my preceptor’s birdhouse: a screech owl. As I am almost ready to leave and say good day (or for me, goodnight), “Code Blue 14 bed 3” calls overhead. There is no code team; stable patients in the emergency department and on the ward will have to wait. We need all hands-on deck.

The Code Blue is being called for the patient I admitted to hospital yesterday for an NSTEMI. I know this by the room number announced. We get to know all the inpatients, and their locations, through daily morning table rounds. Every patient who is admitted to hospital is discussed every morning. The nurse looking after the patient for that day takes the lead. We then have contributions from one or two individuals who specialize in home care, social work, geriatrics nursing, and physiotherapy. It is also a time that members of the team can ask others for advice. You never feel alone. We have less staff than our urban counterparts, though, we make up for it in our sense of community and our sense of responsibility to each other and to each other’s patients.

We arrive at the patient’s room; the nurses are attaching monitors, starting IVs, and performing CPR. We quickly don on, scrambling to put on our N95 masks, googles, gowns and gloves. We enter the room. My preceptor stays out because among the Code Blue, there is another patient in critical condition and my preceptor is waiting for a call back from CritiCall.

There is a patient in room 11 who is requiring increasing supplemental oxygen. He is a patient who has severe bilateral COVID-19 pneumonia. He is previously healthy, lives at home with his wife and children, has been a family practice patient of my preceptor for many years, and is unvaccinated against COVID-19. He presented to the emergency department yesterday requiring 1-2L/min of oxygen delivered by nasal prongs. I later received a call at 5AM that he was now on a non-rebreather mask with an oxygen saturation of only 89%. My preceptor and I phone CritiCall, a call centre in Ontario that provides support for urgent or emergently ill patients. We present this case to an ICU physician who replies that the patient is not ill enough yet for transfer. From our perspective of working in a rural hospital with one staff physician and access to only one mechanical ventilator, this quickly deteriorating patient is ill enough for transfer. However, we learn to respectfully accept one rejection, and continue to advocate until we receive the answer that gives our patient the appropriate care.

While my preceptor speaks with the next ICU physician available, the patient in 14 bed 3 experiences two rounds of CPR and then the algorithm for bradycardia with a pulse. He has been placed on an intravenous vasopressor infusion and intubated. One intubation done, one to go, because the patient with COVID-19 pneumonia has been accepted for transfer and needs to be intubated as well. Time to do some math: two patients intubated, one ventilator. To limit exposure of infection, it is decided that the mechanical ventilator will be used for the patient with COVID-19 pneumonia. That leaves 14 bed 3 with a human ventilator.

To summarize the last hour, we now have one physician intubating the patient in room 11, one physician now attending to the remaining inpatients and the emergency department, a resident phoning CritiCall for air transfer of the patient in 14 bed 3, and myself, bag-mask ventilating until the paramedics arrive.

The patient and I were left alone in the room. My hands were placed on the self-inflating bag. An eerie peacefulness rushed across me envisioning the chaos outside those doors. While two emergencies were occurring, there were still patients presenting to the emergency room needing triage and assessment, as well as inpatients waiting for their breakfast and morning medications. I can only imagine the ongoing endurance of the healthcare staff outside the room.

I stood there for three hours. “Squeeze, two, three, four, five, six. Squeeze, two, three, four, five, six.” My eyes moved from the monitor to the patient and back again. “Squeeze, two, three, four, five, six.” It was up to me to breathe for someone who could not on their own. An overwhelming sense of power and responsibility. When the paramedics arrived, they said in shock “no one switched out with you?” I laughed courteously as I thought to myself, “Who? Who could have? There was no one else available”.  It was not until I was relieved as a human ventilator that I realized the state of my body. I was working on one hour of sleep in the past 28 hours, my face squished by the N95 mask, my hands and forearms aching from squeezing the self-inflating bag 1800 times.

I walked with my preceptor down the hall as we finished our long, but life-changing shift. He said to me, “I hope you didn’t mind being the one to do that”. I stopped and looked at him and said, “It was an absolute privilege.” This is rural medicine.

Dr. Natalya O'Neill, Mount Forest, ON

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