The joy of family practice

When I opened my envelope on match day 1992 to find out I was matched to Family Practice at MUN in Newfoundland, I was ecstatic. What I know now is that I did not understand what family practice really meant and it would take me years to truly understand.

I ended up being one of the lucky ones. I have had the privilege of serving the same community for the most of the last 25 years. I have had the opportunity to work in the emergency department, labour and delivery, and in remote communities, all the while continuing with a core family practice.

Looking back over the years, I remember going in for so many ER shifts with my heart in my throat, just hoping I would do the right thing (or at least not the wrong thing). So many OB shifts - filled with dread, the sleepless nights both on call and not on call – just worrying about people – did I do the right thing? What am I missing? It is stunning the number of people and situations that I can still clearly remember - the person, what room we were in, who else was (or was not) there, sometimes what the view was out of the window – etched indelibly in my brain. What I realize is that despite the stress, and the seemingly endless difficulty, there was beauty.  It was all around me. Even, or maybe, especially in the darkest moments.

There is beauty in being allowed into people’s lives, in their most difficult moments.  It is easy to see joy in the delivery of a healthy child, or a newborn check-up.   The hard part is look after someone during a pregnancy loss, or in telling them they have a terminal illness. To do these things well takes skill and courage, but is ultimately the most rewarding part of the work. 

There is beauty in seeing people grow and evolve over time.  Seeing people who you looked after in their troubled teens, grow into accomplished professionals. People struggling with mental health move to a place of confidence and mastery in their lives.  People getting through a diagnosis and treatment of cancer and move to survivorship. Knowing that things will get better for them even if they can’t see it themselves.  

There is beauty in a relationship formed at 3 AM with a colleague, as you look after someone with a critical illness. 

There is beauty in the trust that allows a nurse to call you and just say “you need to come”, and you go. 

It is not until later that you realize the depth of these relationships. It is something that is difficult to replicate in a “normal” friendship.  That person with whom you have waded through the mud, you will be bonded to, in a way that does not fade.  

Over the years there are things that I wish I had known earlier, but that once I found them, these principles sustained me:

Know your “Why?” - Much is written about purpose, and for good reason.  There is now a lot of understanding about how having and knowing your purpose helps build resilience and compassion.  Not only remember why you went into medicine, but realize that the reasons will evolve, and become more nuanced.  Give yourself space and time - in whatever way is meaningful to you – to renew your purpose and have a way to remind yourself of it, even when things are tough. 

Find your ground - Again this might seem hokey. How can simply breathing and grounding help when all hell is breaking loose? I don’t have time! I have 20 people to see! Trust me – I have learned this the hard way. Stop, Breath, Find your feet, your ground. Have something that you automatically go to. You will be more effective, more efficient, and people will appreciate it. (Even when they don’t know you are doing it).  Sometimes finding your ground does not mean staying in the mud, but it will allow you to see when you should be saying no and stepping away.

The patient has the answer – People come with a multitude of undifferentiated, unusual, and puzzling symptoms. Our minds are desperate to find the answer, so we leap in and ask questions.  Over the years I have found myself talking less and less. I am in constant amazement that with a little space, people will come up with the answer.  Usually after a few pauses they will say “Do you think it could be ….?” and most often they have found something that was either on the tip of your tongue or that you had not even considered. Even more amazing, the more they experience finding their own answer, the more they will find their confidence and voice to speak it up front. 

You are human -Allow yourself to feel your emotions. Show you vulnerability.  I have cried, in front of colleagues and even in front of patients, and then realized that it was appreciated.  People want to be seen as human and want to see you as human.   

Have rituals - There will be loss.  Expected and unexpected.  Allow yourself to grieve - for your patients, and for yourself. Find a way to honour those whom you have cared for who die whether you knew them for 20 minutes or for 20 years. It does not need to be anything complicated. Just say their name, remember something about them, acknowledge the loss. 

Celebrate the seemingly small – The person who stopped smoking, or started walking a block a day, or found out that gardening is their best therapy. These are the victories that when collected allow us to see strength in people and awe in humanity.

Now I am leaving this community that has been my home for the past quarter century. As I slowly tell people I am leaving, the responses are all variations on a theme.  Disappointment that quickly turns into an expression of how happy they are for me and wishing me well in the future. And then a memory and an experience that we have shared.  It might be when we first met, of how they brought their family to me, of something I said, or of generally having been there through the multitudes of life’s ups and downs. 

And that is family practice.  Yes - it is about knowing a little bit about everything, it is about sorting through undifferentiated symptoms and presentations, making sure screening guidelines are offered and followed.  But more importantly it is about walking alongside a person or an entire family.  It is about knowing their history, values, context of their lives and weaving that knowledge into what we know of medicine, to find a path through whatever it is they are facing. 

Dr. Shireen Mansouri is a family physician who has lived and worked in Yellowknife NWT for most of the last 25 years.