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.