Navigating the spectrum of medical practice resources

My early years as a physician in remote and northern communities in Ontario, Nunavut, and the Northwest Territories were unlike anything I anticipated. With extremely limited resources and often no access to specialists, I learned the true meaning of versatility and self-sufficiency in medicine.

After completing residency, I moved my family to Moose Factory, Ontario, a remote northern town where I worked as a full-time family physician in the fields of emergency medicine, obstetrics, pediatrics, in-patient and out-patient medicine, and substance use management. The role required me to juggle multiple disciplines in a resource-limited environment—a challenge that shaped my approach to medicine in ways I never could have predicted. I did this for 3 years, then spent a year transitioning to exclusively practising what is known as fly-in medicine, providing care in small towns and at nursing stations in Nunavut and the Northwest Territories. This was all done in very remote, resource-limited settings that constantly changed, much like the clinical environment. It was the perfect start to a satisfying medical career and to my personal development.

Those 4 years were a fascinating, exhilarating, sometimes traumatic, and life-encompassing experience. They taught me to always be industrious and open-minded in both life and my chosen art. For example, I once treated a young man in a very remote fly-in community of 200 people. While elucidating the mechanism of his injury, he struggled to find the words for a moment, then asked, “You know when you pick up a deer?” I nodded as if this was something I did routinely (I did not), imagining the physical anatomy involved.

I also co-authored a case report with a family medicine resident about necrotizing pancreatitis and the complicated, convoluted process of obtaining an abdominal computed tomography scan in an acutely ill patient.¹ It involved helicopters, fixed-wing aircraft medical evacuations, a stop at a nursing station due to inclement weather, and a return journey. The patient was eventually evacuated again to receive definitive treatment at another hospital down south. This example illustrates the multifaceted, complex medical work performed daily in similar practice settings.

As my career progressed, my medical journey shifted dramatically, eventually bringing me to the Mayo Clinic in Rochester, Minnesota. The contrast between the Mayo Clinic and Moose Factory was stark. Ironically, a large component of the hiring process centred on evaluating my interpersonal skills and problem-solving abilities, illustrating clinical decision-making examples and my procedural skill arsenal honed in northern Canada. At the Mayo Clinic, my practice still includes full-spectrum family medicine and obstetric care. I also receive referrals from colleagues specifically for my procedural skills—also developed in a setting where this was a basic prerequisite to function as a physician.

It has been stated that you cannot stub a toe without receiving magnetic resonance imaging in the current medical climate in the United States. While stated facetiously, there is some truth to this.² Working in the very structured, resource-rich environment of a large academic institution means guidelines and protocols routinely instruct us to perform imaging for simple presentations such as a typical knee strain or ganglion cyst. Imaging is required for all orthopedic referrals. Specialists often require multiple tests before accepting a referral. For example, a referral to a pulmonary specialist includes orders for a pulmonary function test, a chest x-ray scan, and an exhaled nitric oxide test, regardless of patient symptomatology or the clinical question posed. Patients are used to these rules and usually accept them as necessary to proceed with further care.

In the resource-rich environment of a large academic institution, specialty clinics are numerous and easily accessible, including a fibroid management clinic, a threatened early pregnancy loss clinic, a pediatric pelvic physical therapy team, and a home pulmonary rehabilitation program. As always, insurance coverage is a major decisive factor for patients. Overall, however, this seems luxurious from a clinician’s perspective.

The experience of being part of the labour and delivery team at the Mayo Clinic is the best example of how my career diverged from practising in northern Canadian communities. When working as part of the labour and delivery team, I am based in a single room for 12 hours, concurrently sitting with numerous nurses, residents, and staff physicians from family medicine, obstetrics, pediatrics, and neonatology, along with midwives and anesthetists. We have a pediatric nursery and a neonatal intensive care unit down the hall. Pregnant patients can request an elective labour induction for any reason starting at 39 weeks’ gestation.

On the unit, there are protocols and workflows for nearly every symptom and presentation. Individual management decisions are continually monitored and reviewed by other team members. A cervical examination requires a nurse to be in the room, even if there are already 2 physicians present. To say my current practice differs greatly from that of rural northern Canada would be an understatement. I reminisce about a morning working in a northern community after completing an overnight emergency shift where I was urgently flown to another nursing station for an unexpected labour and delivery. The labour course progressed normally, yet I figuratively held my breath, anticipating potential complications as the only clinician in town.

I often find myself questioning which method of medical care provision is correct, or best. Obviously, it is exceedingly difficult to work with limited resources and rare access to specialists, if any at all. Having access to every imaginable investigative and treatment modality also causes its own challenges, and raises questions relating to provider autonomy and broader implications for medical decision making. At what point do you refuse to place orders that are extraneous and unnecessary? What do you do with results based on someone else’s requested orders? When do you deem additional testing or interventional procedures unethical? As always, the answer is likely found somewhere in the middle.

Looking back, I see how my Canadian medical education shaped my approach to care, teaching me to rely on clinical skills over technology, and to make decisions in the context of available resources. Both approaches shaped who I am as a physician, and the balance between them remains at the heart of my practice today. I continue to be grateful to my previous preceptors, clinical colleagues, and patients during those developmental years up north.

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