Reflections on the Rural Northern Initiative

Urban versus rural

Our small-town hospital paid lip service to the trappings of its bigger brothers; the beds, the drapes, and the charts were all the same, but the atmosphere was inexplicably different. In the emergency departments in downtown Toronto, doctor-patient confidentiality meant a conversation behind nothing more than a blue curtain, yet sensitive disclosures were wholly disregarded by the dozens of anonymous passers-by, nurses, and orderlies. In the small-town emergency department, the blue curtain possessed none of these magical properties. We wondered out loud whether a sexual history could be fully trusted when the same passers-by could easily be neighbours, colleagues, or even relatives.

In the short time that I was in town, I encountered patients in restaurants and stores who wanted to discuss their recently sutured fingers. In downtown Toronto, a curt nod would suffice in the unlikely happenstance of encountering a patient outside the clinic. Here, playing a round of golf with one’s physician was not only obligatory but in all likelihood unavoidable.

The rural on-call experience usually meant a few patients added to the end of our clinic schedule; however, a few trickled into the emergency department until the late evening. There was an implicitly neighbourly quality to the emergency department visits: just as one would never knock on a neighbour’s door at 2:00 AM to borrow a cup of sugar, conjunctivitis and coughs came reliably around midday, while hockey injuries, acute abdominal pain, and other items of necessity emerged unpredictably at night. The emergency department was the last line of defence. Failure meant calling the specialist in Thunder Bay—a far cry from calling the specialist upstairs, as was possible in the urban setting. Rural care was immediate and efficient, without a doubt, but whether it was definitive was entirely at the mercy of the physicians and nurses. There was no upstairs. Only Thunder Bay, located many kilometres across the empty wilderness of the Canadian Shield.

Ultimately, this led to a deliciously skewed view of the capabilities of the single regional tertiary care centre, based in a city that was an order of magnitude smaller than Toronto. Thunder Bay Regional Hospital—sight unseen—was the new ivory tower. It was not long before we wondered openly about referring our patients to its presumed pulmonary hypertension clinics. In an urban setting, the patient would be duly processed by the triage nurse, then by several medical students and residents. The wait could be long, the care uneven, and the demeanor aloof, but in the end, anything was possible if you waited long enough in the hallway gurney. The complicated, difficult patient would be shunted upstairs or discharged home to follow up with the histoplasmosis clinic several weeks later.

Undecided

The change from corporate medicine to a reliance on the comprehensive care model was refreshing. I had never considered the challenge and scope of rural practice. When I did, I found it compelling. For my adventurous side, it offered the opportunity to see a part of the country that I would otherwise never have visited. I remain undecided on whether I would permanently settle in a small town, but as a residency experience, rural practice is not to be missed.