Small Town Practices
The pleasures and pitfalls of practising medicine in small communities, remote regions
By Mark Sampson
Imagine you’re a physician who truly embraces the motto, “Variety is the spice of life.” Imagine you’re a general surgeon by speciality, but even that label doesn’t really encompass the breadth of work you do. In fact, on any given day in your practice, you might fix a hernia, clear a bowel obstruction, or perform surgery on a patient with skin or colon cancer. You might treat a stab wound to the heart or perform a Caesarean section. You might do skin flaps, vasectomies or an amputation. Maybe you’ll perform a mastectomy on a patient, then install the port-a-cath for her chemo and then, when all treatments have failed, be the presiding doctor over her medically-assisted death, holding her hand and being the last person to whom she ever speaks.
Dr. Roy Kirkpatrick, a general surgeon in Huntsville, ON (and member of CPSO Council as an academic appointment from NOSM University) doesn’t have to imagine this life — because it is his life and has been for more than 35 years. There is a term that he and other practitioners of rural medicine use to describe what it takes to do the breathtaking range of work they do, day in and day out: clinical courage.
“And I’m not talking about clinical cowboyism here,” he says. “You’re still operating within your scope of practice. But it’s about working safely outside your comfort zone. When a patient comes through the door with a life-threatening problem, you think: There is no one better to deal with this in the world than me, because I’m the one who’s here.” Indeed, Dr. Kirkpatrick likens himself to a kind of “Medical MacGyver,” problem-solving on the fly and jerry-rigging solutions with whatever resources he has on-hand. Most rural physicians in Ontario know this mentality of clinical courage to one degree or another: making do with what’s available, playing a supersized role in the health of their patients, and needing to show clinical judgment in situations they never could have imagined back in medical school. Rural doctors know what it means to play the long game with patients, a “continuity of care” in the truest sense — much of rural medicine is cradle-to-grave medicine. They also know the joys of the work can often feel indivisible from its challenges and its stresses. What gets you up in the morning is also what grinds you down and when you’re one of the few medical resources in a small place, you step up to help patients in any way you can. It’s just what you do.
One physician who knows this intimately is Dr. Sarah Newbery, a rural generalist family physician in Marathon, ON and Associate Dean of Physician Workforce Strategy at NOSM University. Dr. Newbery has worked in Marathon — a town she describes as “too small to have traffic lights” — for 26 years, having moved there with a group of fellow physicians she befriended during her medical training. It was a smart move. This tightknit group of clinicians were able to support one another, both professionally and socially, which in turn helped to integrate them into the community. Today, Marathon is resourced for six physicians but has eight on hand, which allows for flexibility and better work-life balance. Dr. Newbery and her colleagues do it all as a team: run busy family practices, staff the local emergency department 24/7/365, provide all the local inpatient care and, during the pandemic, administer the COVID-19 assessment centre. “We provide cradle-to-grave care for people here, including managing chronic illness, palliative care, chemotherapy,” she says. “We are deeply embedded into the fabric of this community.”
When working with medical trainees and extoling the values of rural medicine, Dr. Newbery stresses not only the importance of clinical competence, but of taking genuine joy in your work. Providing care in small communities or remote areas of the province can help physicians hit that three-pronged sweet spot that makes for a satisfying practice: deep, meaningful relationships with patients; rewarding connections with colleagues; and mastery over your own work. “I tell residents that they should start their careers in rural medicine,” she says. “It will maintain their breadth of skills and teach them the value of community, and that will serve them well no matter what they decide to do long term. Starting in rural practice will not limit you. It will make you a better clinician in the long run.”
Yet, after two and half years of the pandemic and its ravages on the health sector, many of the elements of rural medicine that engender that joy are facing new and unprecedented threats.
The celebrity at the supermarket
According to the not-for-profit organization Canadian Foundation for Healthcare Improvement, rural Canadians make up 22 percent of the population, and yet less than 10 percent of physicians and two percent of specialists work in these areas. Shortages abound throughout rural Ontario, made worse by the fallout from COVID-19.
A recent study in the Canadian Journal of Rural Medicine cited burnout, a lack of amenities, and physicians’ partners struggling to find work in their field among the major barriers to retention and recruitment.
Somebody with experience in the latter issue is family physician Dr. Steven Griffin. Fifteen years ago, he took what he thought would be a six-week summer locum in the small community of Bancroft, ON, but loved it so much that he ended up moving there permanently. This meant, however, that Dr. Griffin’s wife would have to sacrifice her teaching position at Queen’s University in Kingston. It was a big decision, but after a lot of soul-searching and back and forth, the couple decided to make the move. Dr. Griffin still remembers the night that clinched the deal.
“It was one of my last emergency department shifts, a really busy night,” he says. “I remember I had a patient having a heart attack in one room and a woman having a baby in another. It was intense, but I loved it. I was with the patient having a heart attack when the nurse called, ‘Doctor, you have to come now!’ So, I went across the hall and delivered the baby. That child is now in my family practice. I think that’s pretty cool.”
Like Dr. Newbery in Marathon, Dr. Griffin is fully integrated into his community in Bancroft. “My kids will sometimes ask me, ‘Dad, are you famous or something? Everybody at the supermarket knows who you are!’ ” He is deeply proud of the care he and his team provide to the community, even if the sheer breadth of it can seem daunting. “You have to be comfortable with being uncomfortable,” he says. “It’s a bit of a personality thing. If you’re not like that, you likely won’t succeed in a rural setting.”
Without a doubt, the pandemic has upped the ante of being uncomfortable. In terms of staffing and access to care, the summer of 2022 was the worst Dr. Griffin has ever seen with long, busy shifts, and lots of last-minute calls to cover and help out. “We were on the verge of falling apart as an emergency department,” he says, “but we managed to get through the whole summer without closing, even with two of us getting COVID.”
Helping the helpers
Drs. Kirkpatrick, Newbery and Griffin all agree on what needs to be done to strengthen rural care throughout Ontario. Number one is better locum support. The ability for substitute physicians to come in and provide much-needed breaks to clinicians working in remote or under-serviced areas is paramount to the system’s success.
But a close second is encouraging the next generation of medical students and residents to see rural medicine not just as a viable career option, but the pathway to a deeply rewarding life. “There is sometimes this mentality that, if you were truly great at what you do, you’d be working south of Bloor Street in downtown Toronto,” says Dr. Kirkpatrick, “and that’s just not true. In many ways, you have to be better at certain things than a big-city doctor.” Part of clinical courage, he says, means not always punting the football over to a specialist, even when you have the option to do so. Working outside your comfort zone will help keep your skills sharp for when there is an emergency and you have no choice but to step up.
And then there is working in a small community itself, where everybody knows everybody. Rural physicians often need their patients — who can be neighbours, acquaintances, friends — to understand the dynamic nature of injuries and disease, that unpredictable things can (and regularly do) happen. When they do, you as the physician can feel like you’re in the centre of that storm, responsible for people you’ve known for years during their lowest or most vulnerable moments … and, sometimes, you’re unable to help them. It’s the flip side of being the celebrity at the supermarket. Yet, even this is indivisible from the joys and rewards of rural practice: to bear witness to all manner of patient outcomes when those patients are also your neighbours.
“To seamlessly follow people through their whole health care experience is just incredible,” says Dr. Newbery. “It’s something that’s really hard to put into words, but rural practice can help us to live our fullest humanity as physicians. It may seem an odd thing, but I believe that if you start in rural medicine, you should stick with it long enough to have done something that you need to be forgiven for. There is something about that humbling experience of truly being in relationship with patients and community that is powerful.”