Family and medicine in the North

Flying home from Attawapiskat, Ont, is both a miracle and still surprisingly difficult, depending on how you look at it. On the one hand, it is incredible that patients and nurses and physicians can get on a plane on the James Bay coast in Ontario and arrive in Timmins or Kingston or Ottawa before evening.

On the other hand, it is a roll of the dice. I am watching the snowy, gusty horizon for signs of the plane. Another plane has already gone around, judging it too risky to land. And as a result, some weary patients and families are getting back on their snow machines and back in their trucks and cars, hoping for better luck tomorrow. The dogs hang close to the hangar, seemingly used to observing this daily ritual.

I have just spent a few days working at the hospital here. It is essentially a nursing outpost, performing life-saving work with the most basic equipment. The sickest patients get medevaced out. Those needing less urgent tests or treatments wait by the tarmac, scanning the horizon.

Some things have improved over the past 25 years: we can now send an x-ray scan south in minutes and have a specialist join a consultation by video link. But life expectancy is still 10 years below the Canadian average, and maternal mortality several orders of magnitude higher than in the rest of the country.¹ Many women still travel south, alone, to deliver, for want of surgical services on the coast.

For a country so defined by geography, it is amazing how little we take it into account. Lack of access to health care in the North is an obvious example. But even in Ottawa I still have patients who have to drive in from outlying communities, not only Orléans and Kanata but also Cornwall and Prescott, the latter 2 more than an hour away. That cannot be good for their health. Ian McWhinney talked not of the 4 principles of family medicine² but of 9, including that family physicians should live in the community they serve.³ While this might seem antiquated, should we not focus on patients close to where we work?

It is hard to be choosy about access and continuity when the system requires at least 20% more of us as it reinvests in primary care.⁴ But as we redress the system, let us remember the difference between continuity of care and longitudinality.

Barbara Starfield called continuity the mechanism by which we gain knowledge. She called longitudinality the mechanism by which we achieve understanding.⁵ The way I look at it, longitudinality is continuity along the life course: in the Netherlands, family medicine is referred to as levensloopgeneeskunde, which literally translates to “life course medicine.” So, as we rebuild, let us make sure that we keep the “family” in family medicine. We share the understanding that many have come to reconnect with during the pandemic: family is everything. Family is medicine.

I am not naive: Canada is a huge country. And with the modern reality of both patient and physician mobility, any new models will have to be very flexible. Care in the Canadian North will require special solutions around access and transportation and it will have to be locally led. But there is no question that models of care that encourage local, human-scale access are preferred by patients⁴ and physicians⁶ alike.

Back at the airport, as the dice roll and the plane finally lands, I notice a young patient from morning clinic. He is still wearing his black hoodie and sunglasses and hardly interacting with anyone, his angst palpable despite his detached and strong projection. It was not hard to diagnose that he needed more help than we could provide in Attawapiskat. But, for now, it means leaving his family.

Later, in the air, it is possible to scan the endless taiga for signs of life. The landscape of bare tamarack trees and branching, sinuous rivers is only occasionally interrupted by what appears to be a hydro line, or maybe a winter road covered in early snow. Both my patient and I seem moved by this, but as we both doze off and think of what might be ahead, I wish we had more in common.

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