Money vs Sanity

 Recently (only a few months into practice) I decided to decrease my work hours 2ndary to some increased stress at work. he stress was multifactorial and which I hope to have ameliorated the source of much of the stress, but a little extra time away seemed good for my psyche. 

On the flipside a good friend of mine is picking up every extra shift physically possible and working into weekends and nights, but somehow still fitting in shopping trips and new exercise classes. All this and my ever looming debt begins to make me wonder: am I just lazy? 

Is it overwork and burnout or laziness that's preventing me from getting through my workday properly? Am I really this mentally stressed after seeing so many patients that I can't do dinner or am I just too lazy to cook? 

I don't know the answer to that. I don't know if I want to know the answer to that. 

A related train of thought I've been having - would I be willing to trade some of these hours for a more physically active and less mentally demanding job? One where I'm not constantly worried about the effect of a new medication on someone's kidney function that's been on edge but who needs this medication so that they don't have a stroke and die but who also isn't sure if they really had a stroke and don't want the medication and why am I forcing them to take medications? Oh and they have this weird new bilateral numbness that may or may not be a pinched cervical nerve or cervical stenosis that may or may not need an urgent MRI or just general physiotherapy. 

I think my blood pressure went up 30 mmHg just writing that. 

I'm reasonably sure it would only take me a few hours of general labour work like drywalling or something before I scream with complaints of back pain and repetition boredom, but after a particularly mental taxing day and my pedometer only reading 1000 steps, I can't help but wish for something different. 

My partner thinks taking up gardening would be good for me. I say we're entering dead of winter in Canada and we don't have room for a Christmas tree this year because plants have already taken every available surface in our house...

But I digress. I'm taking some time away to do less work so that I don't spend all my monetary earnings on therapy. I've been trying to pick up my slack cooking again in this time. Believe it or not I used to cook elaborate meals to relax. You'd never know it by my instant ramen lunches. 

Lacking the drive to actually cook proper meals, I've taken to a cooking challenge I've seen some people do. 

So there's a game called Stardew Valley and it's all my fantasy impossible farmer/country living come to life. Having actually lived in a seaside small town, I can safely say the game is quite unrealistic in many aspects, mainly the part where people like outsides who move in...but that's beside the point. 

One part of the gameplay is cooking. It's not a huge part. You collect recipes, you collect ingredients, you hit cook, and you sell/eat/gift the dishes. But it has plenty of interesting enough foods that I'm keen to play around with them. Namely a bun, aptly named "strange bun" that includes some fish yet looks suspiciously like a meringue based dessert. 

I've started off easy. 

This waffle iron hashbrown isn't the prettiest thing I've made but it was tasty! My boyfriend who was already full up on several courses of dinner ate two of these average waffle sized potato creations. It take little other than a lot of shredding potatoes to thin, thin, thinner than julienne strings and crushing them in a searing hot waffle iron until it crispens. 

Apparently the trick is to squeeze out all the water. It may have taken entirely too many sheets of paper towel. 

https://www.seriouseats.com/waffle-iron-hash-browns-potato-recipe 

So the description for this roasted hazelnuts dish is that it tastes foresty...and it really did! It tasted like a coniferous forest after a mild autumn rain! Not that I've bitten many pine trees but I've taken plenty of walks and the air of this is reminiscent. 

I'm not usually a fan of hazelnuts but this turned out shockingly well. I'm not a fan of nuts period (they're too dry!) but this is easy to munch on. Sprinkled with some sugar and it takes on a light, aromatic and nutty flavour, sprinkle with olive oil and salt and it's delightfully umami and the natural sweetness of the nut pops more. Recipe and credit where it's due:

https://mayihavethatrecipe.com/how-to-roast-hazelnuts/

Next step: cookies. Ugh. I hate baking. Hate it with a passion. I'll labour over a carbonara or beef stroganoff all day. Leave the oven out of it. 

Shit stirring

 It wasn't that long ago that I looked down on the disdainfully termed SJWs - social justice warriors. The people who think we still need feminism or race equity or LGBTQ+ rights advocacy. I don't think it came from a place of malice - rather of privileged ignorance. And how privileged that ignorance is - to be a cis gendered "model" minority growing up in cosmopolitan cities with highly educated and cultured friends and family. 

I never thought of myself as an advocate, one of those bitter folk always complaining about the state of the world. It took being thrown into the world of the underserved - one where people are incarcerated for untreated mental illnesses, where being Indigenous sentenced children to higher mortalities, where people choose between medicine for themselves or food, where a country must beg tourists for its oxygen cylinders returned after mountain expeditions, and where young people are casted out of their families for the "crime" of expressing their genders and sexualities. It took diving face first into this world to even scratch the surface of advocacy and what "check your privilege" really means. Has it made me bitter? Oh yeah. Do I regret it? Hell no. 

Anyways, that's the tangential background. Recently I was called by a shit-stirrer - by myself that is. At the first clinic where I'm working as staff physician (can you believe it?!?) I notice things. I notice my residents being worked into the ground and losing their love of family medicine. I notice patients who suffer large gaps in their care. I notice clerical staff who need sick days every month for their mental health. I should say I support mental health days but people shouldn't be so overworked they rely on these days to survive the work. 

By nature of the training of my past year, I've developed a habit of speaking. Speaking up and speaking loud and speaking often. There are 3 or 4 strands of emails and conversations I'm having with people on issues I've detected. I've emailed the clinic manager probably more than anyone should. And the nursing manager. And the physician manager. And I'm about to email the resident manager. 

Am I a shit-stirrer? Probably. Does shit need stirring? I think so. 

A strange homesickness

 A little over 3yrs ago I landed on the rocky shores of Newfoundland, fresh off the boat/ferry from my home of Hamilton. For the first very many months I was in a state of constant culture shock and homesickness for my old lifestyle in Ontario. I looked forward to the day of residency completion and leaving the island behind forever.

A year ago I moved to St. John's and found a new home. Walking out on the streets felt as comfortable as walking my backyard. I lived in a beautiful apartment with a beautiful view. My mentors there are the giants whose shoulders I stand upon now. I didn't get to spend a lot of time there. A lot of my time was flung on the road for electives and going to Labrador. Maybe as a result of that, it feels like I've only tantalizing been allowed to know St. John's. 

I thought a month ago when I finally came home to Ontario that I would feel, well, at home. It doesn't quite feel like that. Hamilton has changed from when I knew it. My friends have moved cross country. I've even changed boyfriends. This isn't the same home that I left behind. 

When I first got to Gander I longed for Hamilton. Now that I'm back home in Ontario, my heart yearns for the island. 

Since we turned into Quebec my chest has ached every time I think of the ocean. For almost the entirety of the drive back from St. John's we were never more than a breath away from the ocean - whether steep cliffs or rocky shores. Every so often a turn of the road opened up the vista of crystalline blue before us. It seems so ridiculously sentimental and silly to actually miss the ocean, but it's my personal belief that anyone who doesn't long for the ocean hasn't lived for long enough beside the ocean. 

I'm now so deep inland that the only waters are the great lakes. They're not much to complain about - the Group of Seven made lake scenery a cornerstone of their masterpieces - but it's just not the same. I miss the sharp crevasses that cut through the Newfoundland coast. I miss the casual whale sightings and pretending to be able to distinguish a humpback. I miss the rocky landscape that are a geologist's wild dreams (or at least job insurance). I miss a sky that seems to stretch forever when it's clear, but also temperamentally throws everything from hail to sun in a single afternoon at you. I definitely (in this oppressive humidity) miss the cool breeze that rolls off the ocean waves. 

I miss the ocean the most. 

A lake - even a Great Lake's - gentle lapping of waves that is stirred only by a passing yacht or heavy breeze does not pull me in as the Atlantic Ocean's raging turbulence. The ocean's roar seems to drown out all anxieties, fears, and generally tangled thoughts in a way that nothing else can. The crash of waves silences all else. I miss the hypnotic boil of the ocean that almost urges you to jump into its icy depths. I miss the white crests and the glittering blue under sunlight. I miss the dark blue depths and terrifying blackness in the night. I definitely miss its temperature like that of liquid ice on a hot day. 

Life on the island always seemed to be so turbulent. Life here back "home" is...calm. Civilized. Like tepid bath water after hot springs and arctic pool plunges. I can't say I'm uncomfortable, but tonight I miss the outcrop of St. John's as much as I once missed the inner city of Hamilton. 

Let it go

It's very hard to let things go, Disney songs notwithstanding. It's even harder to let go of a project that you conceived and completed, only to hand the reins over to someone else at the moment of completion. They say if you love something let it go, I'm not sure they were thinking of research projects but I guess there's a similar principle. 

I feel a sense of ownership over the completed product of this project. It came from a very impactful experience and from a very personal place as an immigrant to this country who once faced similar barriers. It was very many sleepless nights of trying to understand legal papers. 

All my training has been in the health sciences, and almost every paper I've needed to read since second year undergrad when I took Greek history for fun have been somewhere in the medical science realm. History of medicine might be as far as I've strayed. It was a real challenge to figure out where to even start with a social justice research project. Pubmed doesn't have anything, uptodate has no best practice guidelines and apparently Google scholar only gets you so far. Thank goodness for librarians! 

Even after accumulating the papers there was the hurdle of actually understanding them. The legal jargon was beyond me. I last read constitutions and human rights declarations in high school law class. The style of academic papers was foreign and so were the types of citations. How does one cite a declaration but not a UN declaration in APA? I still don't know if I did it correctly. 

After all of that and with no small amount of help from my literature-background partner, I presented a completed paper to the community partners that inspired this. I was and still am proud of the end product - double spaced and everything. And now I hand the paper over and it's fairly out of my hands. I can't carry it through to publication, see it into a journal, and others be able to use it as their research jumping off point. I can't even really be involved in the advocacy side of taking this paper to the powers that be and pushing for changes to happen based on it. For one thing, I'm leaving in a few weeks for a different province for work. For another, I'm not the right person to be advocating for this. There are people whose jobs it is to work in the environment that I've only written about, and who are in the know-hows of the politics and structures where the advocacy will happen. I won't be able to be dedicated to the degree needed since I'll be full time at my actual profession of family medicine. And despite the lengthy paper I only know this small aspect and not enough about everything else.

Admitting our limits is hard. Admitting that we have limited time and resources is hard. Admitting that we are not necessarily the right person for the job is hard. So for the best of the project, for the best outcome of the advocacy, for respect of the community partners who gave me this opportunity, I have handed the project over to them.

We had a handover meeting yesterday and we reviewed the paper and its goals. I hope to still be kept in the loop but have discussed my limitations with them, and they acknowledged the same. They will take the paper and run with it as far as they can with my recommendations. I've done my part so far, and the most important part now is making sure that I don't hold the project back. 

Everything under one roof

 I once worked rotated through a family medicine clinic that had a social worker, a psychotherapist, a clinical pharmacist, an occupational therapist, and a physiotherapist all under one roof. Because that was one of my first exposures to family medicine I took it for granted that that is what all clinics would be like, and what all patients would have access to. How naïve I was. 

Your average family physician is probably in solo clinics (just them and the admin staff), or maybe shares an office with a few other physicians. The privilege of multiple allied health professionals under one roof is a rare one, particularly here on the rock, I've noticed. I'm lucky to get a hold of someone to help with an in-clinic biopsy and suturing, let alone the family physician nurses and assistants that I once had access to as a learner. 

It is not an outrageous claim to say that patient health can only be improved by having multiple services under one roof. Think of it: you go see your family doctor, they say I think you can benefit from some counselling. Instead of waiting multiple weeks-months of waiting for counselling referrals through the local health authority or paying/being lucky enough to have insurance that covers private counselling but still needing to find a counsellor, they say go down the hall. There's a therapist who has access to my notes. 

While some may argue that patients can and should take some responsibility for their care such as finding their own physiotherapist or counsellor that suits them or booking a pharmacist consultation, isn't it just better to take that middle step out? Of course, everyone should have the option of going outside of the clinic, but I haven't heard too many people complain there are too FEW barriers in healthcare. Moreover, this kind of setup is exponentially more beneficial for the most vulnerable of our society. Do I tell a patient who can't afford the bus pass to get to clinic that they need to now go across town to the free counselling clinic with drop-in hours? What if I can tell them that there is a counsellor on-site? What about my patient who isn't suicidal enough (I've made a whole post on this but our mental health system is just sick care, it's not preventative care) to qualify for urgent services but who can really go for some qualified therapy that I don't have the time/ability to provide? Wouldn't it be nice to have that MH counsellor present? 

I was lucky enough to encounter such a multidisciplinary clinic again, although in a much different setting from the upper-middle-class-suburban/countryside-wanted-to-get-out-of-the-city area I once trained in. Downtown inner city, attached to an emergency overnight shelter and free meals. It required an amount of flexibility and "cowboy medicine" that I needed in remote rural work, too. One day a patient pulled an axe on the staff. Another day I crouched outside in the yard, acutely aware of 20 something people gathering around to listen, whilst I tried to convince a patient into a waiting ambulance. Some days I went to the kitchen begging for oil to dissolve earwax because the patient can't afford a $18 bottle of olive oil or a $50 ear syringing kit. Other days I commandeered a lounge to observe an at risk patient who refused ER transfer. I helped people get new mattresses, apply for bus passes, begged for extra patience from specialists and imaging departments when patients couldn't make it to the appointments. "I'm sorry but their social circumstances are extremely complex" x endless. What I really wanted to say was "Look b'y, their house was robbed the day before the appointment, they had bigger things to worry about." "No they can't make an x-ray across town in 20 mins because I can't give a taxi slip for this and the busses don't run that fast." 

But that's a detour for another day. The great thing about this clinic is the collaborative practice. Not only did the 3 nurses onsite act as everything from patient screener to wound care to emotional support, we had amazing social workers who doubled as counsellors. Case managers who could help get patients into a shelter or guide them through disability applications and housing and mental health top-ups and a hundred other things that I swear I've never heard of but wish I could have recommended and supplied to patients. Foot care specialists kept diabetic foot ulcers from springing up, or fungal nail growths (how is antifungal nail polish so %*^# expensive??) from exploding out of hand (or foot!). We kept running lists for when optometry clinics would pop-up. 

There were no average days at this clinic, and the only thing I could be sure of is that sooner or later I would be calling for the case managers or knocking on the door of the foot care clinic or texting the social workers. It felt very reassuring to know that I had these professionals backing me up - and I hope they also felt reassured by me being their healthcare backup! On a given morning I might start by taping closed some cuts a patient sustained during a fistfight just outside, then sit down with a case manager to discuss how a patient could qualify for more benefits. We talk about their encounters with the patient - much different from the usually more formal and directed medical appointments - compared to my clinical encounters and compare notes (literally on the EMR). They give context to the patient's life outside of medicine and I use that with their medical background to make a plea for solo housing support, for extra income benefits, for travel expense coverage. It might only be a few hours later before I call them urgently for a patient who has presented in a social crisis without stable housing or even knowing where their next meal is coming from. I swear it's almost magic how the case managers get the patient a hot meal, food to go home with, extra shoes, a shelter for the night, and a plan to get more permanent housing. All I had to offer was some medication and counselling for depression that stemmed from their situation - which they couldn't afford anyways until the case managers got them set up on the provincial medical support plan. 

I don't think there was a single day when I didn't page the social workers for one reason or another. Especially in the stresses of COVID, who didn't need counselling sessions? Time and again I called them and they called me. 

Me:

"There's a patient here who I've seen for diabetes but has some serious anxiety and isn't interested in medications, but wants to try counselling, can you see them?"

"There isn't a diagnosis yet but this patient has a lot of situational stress and wants to just talk to someone about it, are you available?"

"A patient has suicidal ideations, we need MH crisis services, please come back me up/help."

Or most commonly: "Help please!" 

SW:

"We're seeing someone for counselling who's expressing possible delusions and/or hallucinations, can you fit them in?"

"Someone who's here for social support is very depressed and interested in meds, bringing them over [to the medical clinic]". 

"Can you form/place someone under involuntary psychiatric hold for this?" 

It just always felt like a friendly environment. I could take a patient from the SWs and know that they can help me in turn. The case managers bailed me out more times than I can count for social and situational problems and I will dig through charts and write documents for them. Although I guess the more accurate thing is to say we were all helping each other and working together for the benefit of the patients, for the ultimate goal of providing them cohesive and comprehensive care. 

So why can't we have this everywhere? Why did I end up sending patients from regular family practices to this downtown institution just so they can get counselling and housing support? Why can't I go to the friendly next-door clinical pharmacist that we have in hospitals and consult them for maximizing diabetic therapies? Can I please have wound care specialists always close by so we can catch every early diabetic ulcer? Please? Please please please please please? 

Arggggghhhh

Okay that's my frustrations out. It's been that kind of a a day. The kind of day where even the sink in my clinic manages to break on me. The kind of day when the secretary asks me to leave before I cause an earthquake with my bad luck du jour.

The refugee health care is always the most challenging and rewarding part of my weeks. The horrors and trials and tribulations faced by the patients here are unimaginable in every sense of the word. How do I imagine being born into a country in violent conflict, escaping but leaving my whole family behind, spending 10+ years in an unfamiliar country without a home, a family or even an idea of a future, only to end up finally in a safe country, away from refugee camps, but all alone and unable to understand the language or the frankly alarming weather? (As I write it's single digits outside. It's July. C'mon, NL).

I say that to preface the situation. But the frustration was real today and it took effort to keep in mind the challenges that many of these newcomers are facing. It absolutely sucked to call someone 6+ times throughout the day, dialing their entire family before reaching them, relying on an interpretation line each time. But they have a new baby and have no one else home to help them. They just couldn't come to the phone, and they were scared by the private number that all our cell phones are now blocked off as.

It sucked to not be able to communicate with a patient because they're illiterate in their own language to begin with, and I don't have their language available as a translation services because it's spoken by so few people. When I asked if their family could help, I was told matter of fact-ly that all their family was still in refugee camps or had died there/in the conflict. "Oh. Okay." I couldn't find another reply in that moment, and the patient did not want or need my automated "Oh I'm sorry to hear that" spiel. Their concern was the medication they ran out of. My concern turned out to be their medication is for HIV which I did not know about, and for which they have been out of pills for, oh, a month. Great. They didn't know my priorities and I didn't know theirs. Fortunately we came to a rapid agreement and a decision to book an advanced interpreter for this language.

It sucks to spend an extra 1.5hrs writing notes to the dentist, to the pharmacist, to anyone who will listen and might help to please, help this young person find floss and explain what it is. Please explain what the creams are help them find the cheapest one because not one is covered by the health plan. And please please be patient. They don't have a regularly translator available. They're just doing their best. And please excuse the fifth fax I've sent asking you to help someone with things probably above and beyond your scope of practice, but that's just what I'm trying to do, too. I can tell their patients to call their worker and find creams, or I can research the cream, fax the pharmacy, and make a plea for a cheaper available option.

But it really sucks to have someone not respect all that and hang up on you 3 times because they don't like the answer you're giving them, or you took too long answering while looking up their chart and pleaded for their patience (mine was certainly running out). I hope that it was misunderstanding, that they don't know that not all doctors work in hospitals, but after the 3rd hang up I had to just order the investigations and prescribe what needed to be done, and hope for the best for harm reduction purposes. Paternalistic? Definitely a touch. Necessary? Unfortunately so.

But I bought some bubble bath products and sat in the bath for 3hrs and read Harry Potter again, so that's always comforting. Now where's my wine?

*Originally written in July and forgot to publish it

I'm so reflective I may as well be a mirror by now

 Reflecting on reflections on reflected reflections. I'm living in a meta world of reflections. As my final year of training draws to a close, I also have to submit multiple reflections on my experiences. Normally, this isn't too hard. Narrative reflections are easy enough - I tell the story of what's happened and generally explore why this happened and how if impacted me. Critical reflection is so much harder. 

For example, on reflecting on my Indigenous Health rotation, I firstly needed to recognize and reconcile the intense experience and emotional upheaval associated with it. I needed to recognize why I was upset: I felt anger and injustice for the people of the local Indigenous community. Then what I did about it: made practice alterations and accommodations for culturally safe care. Then why I felt the need to be upset: colonialism's legacy and ongoing, chronic racism of Canada towards the Indigenous communities. Then why I felt the community needed me in their healthcare: they don't have anyone else, but does that mean I'm the best person to provide it? White (although I'm not white but I may as well be for my upbringing) savior industrial complex perhaps? Then what are my motivations for wanting to go back to the community: to serve the community as a healthcare provider. Why do I want to go back: perhaps guilt of not seeing more patients, or perhaps more of the savior complex, as if the community itself cannot rise to the challenge of low physician to patient ratio? 

At the end of the big round of reflections (which take several hours to days to reach, I might add), I've reached the pits of the colonialist, racist roots that being a settler has grown within me. It's scary. I like to think I know better. I thought I knew better. I have a background in Indigenous Health, I've supported smudging ceremonies, I've even analyzed literature written by Indigenous authors - way outside of the healthcare world. I'm also an ethnic minority who knows and has experienced the harms of racism. I would not have called myself racist before now, but turns out I am. Turns out we all are - depending on how far you dig and how far you're willing to dig. 

Believe me, it doesn't feel good during it. It's constantly interrogating one's self. Why? Why? Why? Why did I do this? Why do I think this? Why did I feel this? Someone pass me a creaky chair and dangling single light bulb on the ceiling please. I'm playing good cop bad cop with myself as the interrogators and the interrogated. The process of reflecting critically is challenging my feelings, my motivations, the drivers behind my motivations and tracing just how far back those threads go. I fear that, unlike Theseus, at the end of my spool of thread I will not find the exit to the maze but rather the minotaur. And I'll also be the minotaur in disguise. Turns out I'm also one of the monsters who eats the sacrificial children? Well, maybe not that far, but it can feel that disheartening questioning my real motivations on what seems surface level god and kind acts. 

Maybe there's a room for true altruism versus selfish and egotistic altruism here. 

I do think it's a necessary process. It is necessary to constantly challenge ourselves and evaluate our feelings and reactions. To be a truly self-aware and culturally safe provider, these are painful processes I must go through. But it doesn't make it any easier to be sitting here at 1AM chugging coffee and realizing on reflection that I'm not nearly so good a person as I'd like to think. 

"Canada is Nazi Germany"

So I don't know when Facebook went from a burgeoning social media upstart that was frequented by teenagers who migrated from MySpace (yeah, remember that?) to a platform of misinformation. It seems like one day it was just my classmates and I posting on each other's walls about homework, and the next I'm closing the browser because of people denying the existence of COVID, of residential schools, or even the Holocaust. 

Which leads me to the title of this post. Someone ungainly and enthusiastically accusing current Prime Minister Trudeau of being a Nazi and comparing present day Canada to Nazi Germany. I don't think this person appreciates the irony of their statements. 

The comment was made regarding reopening plans as the pandemic seems to finally be reaching its terminus (fingers crossed). If this comment was made on another recent news topic then it would have been very topical and perhaps even insightful. 

British Columbia recently announced the gristly discovery of 215 bodies of Indigenous children who died at the Kamloops Indian Residential School. 215 children who were missing up until now. 

I cannot deny that Canada, as a whole, has been a peaceful country for many people. Particularly sitting on the rock of Newfoundland, it feels like an isolated part even for an isolated country. It has been easy to live blissfully ignorant of the undercurrents and Canada's sordid history with the Indigenous people who lived on these lands, and whose unceded territory that I and many others have built our homes on. It has been more than easy to say, "oh we're not racist like the Americans", and being satisfied with that as a standard. Of course, in these words I reveal my own extensive privilege to say I have been able to live in ignorance. 

In 2009, Canada's then-Prime Minister Harper even told the world at the G20 "[Canada has] no history of colonialism..." We'll let that sink in for a moment. No colonialism? The Indigenous people all got up and left the land for the settlers perhaps? Or cordially invited displacement, resettlement and forced assimilation? 

This is not the Canada I have come to known in learning about the history of the Indigenous People in Canada. In 1910, Duncan Campbell Scott (the first topic when Googling him is his poetic prowess), the then Deputy Superintendent General of Indian Affairs, said that the deaths of children in residential schools will not deter from "the final solution" of the "Indian Problem". 30 years before the genocide of the Jewish people as "the final solution" of the "Jewish Question". We'll let that sink in for a moment, too. 

Scott got as far as acknowledging that Indigenous children died at much higher rates in the schools than in their communities (or "villages" in his terms) but did not see this as a deterrent. It's been calculated that Indigenous children died at the same rate as POW in Nazi Germany camps. Let's rephrase that: children in schools in Canada died at the same rate as prisoners of war in Nazi Germany. They died because they were born Indigenous. 

So, random person on Facebook, you are partially right in a way. We can certainly compare Canada's genocide of the Indigenous People to other genocides. You are even rather insightful, though not in the way you meant to be, when calling Canada Nazi Germany. 

So this is family medicine

 I always knew family medicine meant "cradle to grave care". It means seeing newborn babes at 10:45 and palliative care in an end stage dementia patient at 11:20. It means a day's patient list might include a blood pressure assessment, someone just discharged after a heart attack, someone suffering from severe depression seeking help, and a routine pregnancy visit. I have gone from an appointment that made me want to scream in frustration to another equally complicated but much different patient that takes every ounce of patience and gentleness I can muster. Of course, a variety of factors contribute to how the patient presents and my reactions to them, but not a single patient should receive subpar care or less emotionally nuanced support because I had a difficult encounter before them. Every patient deserves my reset and refresh in between. 

But some days it is really really hard. Just so hard. 

One day I received an urgent imaging result back. Metastatic cancer in a pediatric patient. Followed a few minutes later by an urgent call from the ER physician who also received the results. We conferred and I spent the rest of the morning and lunch calling up specialists, arranging appointments, transportations and, not the least of which, disclosing this terrible information to the patient and their family. Telling them the results of the imaging. Explain what metastatic means. Discuss the uncertainty of the prognosis. Encourage hope at least enough to go for urgent assessments by specialists. Console the family. Explain why it took so longer to get this diagnosis. Explain my own limitations and the need for other imaging and specialists before we can have a more specific answer. 

After several hours of this, to go and see someone who is acutely distressed about a single acne lesion was jarring. I wanted to just cancel clinic after this diagnosis to nurse my own shaken mental state, but I was needed and I wasn't SO badly disturbed that my medical skills would be affected. After seeing the next patient, I really wanted to brush them off. A comedone to a metastatic cancer? Come on. 

That is family medicine, however. And we can't go around comparing diagnoses. You can't compare suffering. 

So I held it together and examined the lesion and explained the treatments and empathized that yes, it does suck to have acne. By the way, it turns out the acne was only the leading question and once the patient was comfortable with me and reassured I would provide affirmative care, disclosed their more significant concerns. (That's family medicine, too. Sometimes complaints are only tips of the iceberg.)

Deal with it

 Uncertainty is a regular part of life, not just medicine. I'm finding it particularly hard pill to swallow this week. 

We're taught throughout medical school to not let a suicidal patient past us. That we must ensure safety of our patient from diseases, from our neglect, and from themselves. It was never said, but the general message I felt in med school was 'if a patient dies by suicide and you didn't stop them - you've failed'. Certainly I don't want a single patient to ever die prematurely, least of all if I have a chance to prevent it. 

Yet in residency, we once sat down to a teaching session with a well respected and beloved psychiatrist who told us for some people, suicide is the only end of their illness. That after all the counselling, hospitalization, medications, some patients will inevitably die. 

I recognize this in many other diseases: I can only throw so many diuretics and blood pressure medications before a congested heart eventually fails. No amount of insulin is going to save some patients from the ultimate MI caused by diabetes. I cannot stop a burr of growth from taking over healthy tissues and prevent the cancer from spreading like wildfire in the end. Why, then, when it comes to chronic mental health issues, is the idea that I cannot treat with intent to cure everyone that much harder to swallow? 

But I digress. I had a young patient whom I was meeting for the first time in a busy, fee for service clinic. By which to mean I expected to spend 15mins and move on to the next patient if I can. For anyone who is not familiar with the workings of many family medicine clinics - take note. This is one of the many reasons we're probably 30-60mins late when you're in a rush for your appointment. I run over for these patients, as I hope you know that if you ever need me like this, I will run over time for you, too. 

This young person presented with an innocuous complaint, calling in to say they need a "refill". That's almost anything from "I've been stable on this statin/cholesterol pill for 10 years" to "lorazepam for my wildly uncontrolled anxiety". During the encounter they revealed various stressors to me. Work stressors of losing their previous job due to the pandemic and being unable to find a job where they live now. Why don't they move? They can't afford the rentals here in the city and their family member requires on-site care and can't do without. They didn't qualify for social supports and services based on various statuses. They don't see a way out. They've been using alcohol to cope with the stresses and pain. They know they're drinking enough to risk serious morbidity and mortality. They have, several times, combined other sedating medications and drugs in dangerous ways. They won't call the mental health crisis line because the crisis workers can't help find a job or solve their debts. They're not actively suicidal this very second. 

That is one of the distinguishing features on a safety assessment. If someone states that they are actively suicidal (and of course various other questions/assessments I review), I must "form" them. I put them under a psychiatric hold for their own safety. Shockingly/un-shockingly, the system for mental health has quick service for the acutely suicidal, but service access is much more difficult when you're "just" very depressed. The entire discussion of how healthcare systems have gotten to be like this and are buckling under the added pressure of the pandemic is a different discussion. For now it suffices to say that we don't have enough resources, period. 

But this young person isn't actively suicidal. They're very likely to die by substance use, whether intentional or not. I can't form them. I offered to call the acute mental health response team but the patient declined, and they are not in a spot where I can sign a form to force them to have a psychiatric assessment. They are "just" in a spot that so many others are. Trapped by the economic factors of lack of job prospects, lack of social and community level support programs, and social factors of family circumstances and coping mechanisms. 

Do I give them medications that they might overdose on? Do I not give medications for their crippling panic attacks that they have and will continue to buy off the streets from a possibly dangerous source? What happens if they go home tonight and drink their usual amount of alcohol, take the benzos that they're requesting/have bought off the street already, and overdose? How do I live with that? How do I prevent that? 

I'm fortunate enough to still be a resident and turned to my more experienced staff for help. Part of their answer is a hard pill that I have to swallow. Sometimes we just have to deal with that uncertainty. Sometimes in the brief time allotted in a family clinic encounter (we were now 90 minutes over time), we live with even more uncertainty. We've been told, time and again throughout training, you can't save everyone. I remember it as the mantra in medical school but didn't apply it to the mental health encounters. Sure, I can't save someone rolling through the ER with an aortic dissection (4/4 aortic dissection cases I've seen were fatal). But this person is alive, in front of me, and it feels like if I can't find the solution for them, they won't be alive for a next time. 

And I guess sometimes that's something we have to live with. A staff shared with me about a patient, ill with mental health issues, who did complete suicide under the staff's practice. But we really can't save everyone, we can only do our best by them. Underlying this is we still have other patients requiring our care in the rest of the clinic schedule, and we need to do our best by them, too. 

So I guess we just deal with the sometimes nightmare-inducing unknown and uncertainty. 

FYI this particular patient did seek and get help. They're doing all right, now. 

Food is my basis for everything

*So I originally started this post in November, but dealing with the mildest form of food insecurity now I'm revisiting this.

 I don't recall when the term "foodie" really entered the public vernacular, but I do recall identifying with it. Still do, in fact. For me this extends beyond taking delight in fanciful mushrooms or sampling cheese at a hip new restaurant (is hip still a thing?). Food is my basic comfort, my daily regimen and how I evaluate many things in life.

There's a Chinese phrase that translates loosely to "the common people sees food as the sky", as in food is the most important of all. Above the emperor (or premier these days), above the god/gods of religion, and above even the sky. Without food there is nothing.

I recently visited a correctional center and realized for the first time what food is like in the system. I always knew prison food was the stuff of mythological status poor quality, but didn't think heavily on them. Didn't actually have the fully formed thought that someone has to eat this day after day, month after month, perhaps year after year. 

How can you rehabilitate someone if you're not even going to feed them properly? Who can be rehabilitated, sit in therapy sessions, go to groups if they're living on lumps of potatoes with a sprig of carrots and practically doing intermittent fasting because of the schedules?

The slew of US prisons that have made news due to their terrible food - relying on margarine to meet calorie needs? What nutrition is in that? There's someone out there who's proud of pioneering this technique?

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That brings us to today, March 1st 2021. I'm somewhere in rural Labrador - where a Google streetcar has never been and it doesn't really know what roads are where. I've already been directed to turn off the highway and into some woods. Although even on mainland Newfoundland Google once tried to have me make a leap over a small valley to get onto the highway so...

I'm in sort of self-imposed isolation. Right as I was leaving, the metro area I live in suffered the worst outbreak of COVID we've had since the start of the pandemic. Fortunately I was on vacation and able to hide out at home for the worst of it. But Labrador does not have cases at the moment and I don't intend to be patient zero here. So I've received my day 0 swabs on landing (anyone else cry uncontrollably as a side effect?) and am staying in until my day 7 swabs are clear. There are no strict guidelines as I'm within the same province, but knowing that the most likely infectious source would be the airport I passed through, I'm trying to keep everyone safe by not relying on day 0 swabs. 

All that to say, I have almost no food. I got some groceries delivered on the day I landed, but my car was too full of luggage to get much more in the way of groceries. So I ordered them for today and the car didn't arrive all day. It's finally come now, bearing many many boxes of food (I think the delivery guys thought there would be a whole family here for how much food). 

For all of today I've been antsy, irritable (more than usual that is) and generally in a dower mood. It wasn't until I perked up with the food delivery that I realized. It was the effect of a near empty fridge and uncertainty of being able to receive food. As said above, it's probably the least insecure of food insecurities. I had packages of ramen. I'm not technically under real self-isolation and could have gone out to buy food. The grocery order was most likely coming. But just having the empty fridge was enough to drag my whole mood down. 

I imagine I'm a more sensitive case, but this leads me to think of my patients. My patients who rely on the community outreach for 3 meals a day. My patients who don't have housing let alone a fridge. My patients who choose between meds, rent and food. How do they function? How can I expect them to keep a headache diary or work on meditation when their minds (I presume) are weighed by uncertainty of what their next meal is? How well can I possibly treat their medical concerns when I can't treat the root problem of food insecurity?