Earlier this year, I had the pleasure of going to Winchester – a small town close to Ottawa – to practice rural medicine. I was there for a month as part of my core surgical rotation.
My surgical preceptors at Winchester District Memorial Hospital (WDMH) were passionate about teaching. I was involved in every operating room (OR) case and was invited to scrub in to assist the surgeon. Among the many “firsts” that I encountered on this rotation were suturing, holding a laparoscope, removing the gallbladder with a grasper, anastomosing the small bowel, writing post-operative notes, and signing my first-ever prescription. I also got the opportunity to learn about other specialties, such as anesthesia, through managing a patient’s airway and administering anesthetic drugs. However, perhaps the highlight of my time at WDMH was following Mr. Smith— a gregarious older man who had metastatic small bowel cancer.
I initially met Mr. Smith during a consult in the chemotherapy clinic. I admitted him for a possible upper gastrointestinal bleed, in the context of his malignancy; his hemoglobin was 67 g/L. He was stabilized following blood transfusion and an unremarkable upper endoscopy and discharged home the next day with a prescription for proton-pump inhibitors. A few days later, he returned to the Emergency Department, this time with chest pain, worsening fatigue, and melena. To my dismay, his hemoglobin was even lower than before. A colonoscopy showed evidence of melena close to the small bowel. Still, the source of his bleeding was unclear.
I perused the literature that night and became convinced that the bleed likely originated from the small bowel, so I spoke with my preceptor about proceeding with a push enteroscopy – a scope that visualizes the anatomy of the small intestines. However, given that a push enteroscopy is only performed at some hospitals, Mr. Smith would have to be transferred to The Ottawa Hospital. I arranged for a bed at TOH and spoke with the on-call gastroenterologist who agreed with the plan.
When I visited Mr. Smith the next morning, his wife was at his bedside. As I discussed the plan with him and said my final goodbye, both he and his wife had tears in their eyes. He mentioned that he was grateful for all that I had done, from visiting him in the chemotherapy clinic initially to rounding on him multiple times a day and keeping him in the loop with all that was transpiring.
As I told him about the transfer and test, I recall Mr. Smith telling me, “Thank you for taking the time to listen to me. I have never seen a doctor like you. I think I am ready to go … to TOH.” At that moment, I felt a strong connection; it was as if he had become a part of my family within the course of only few days. Following Mr. Smith’s transfer to TOH, I thought I would never hear from him again.
A few days later, I learned that the gastroenterologist had successfully identified and clipped the small bowel bleed. Hearing this news brought great relief and joy; Mr. Smith was finally on the path to recovery. This had been a remarkable journey for me as well. The process of following a patient to recovery made me realize two important lessons.
Transfer of care does not necessarily mean letting go of your patients forever. A good physician is one who cares about their patients and will go out of their way to provide the best care possible. This includes referring patients to the right person in a timely and effective manner.
The second lesson was that communication is crucial to medicine. This includes updating the patient, their family, and everyone involved in the circle of care about the patient’s progress and working together to decide on a treatment plan. I constantly kept Mr. Smith in the loop about the next steps in his recovery process which, in the end, made his transfer to TOH much smoother as he knew exactly why he was being sent there.
Overall, my time at WDMH enabled me to envision what medical practice in a rural setting can be like. During my rotation, I learned to appreciate the medical complexity and cultural diversity that rural medicine has to offer, and I learned that that I must never forget to acknowledge the person behind the patient.
Acknowledgement: The author would like to acknowledge the contribution of Melissa Reed, MD Candidate at the University of Ottawa, for her feedback on this piece.
Editor’s note: This is a true story. The patient has given consent to its publication; however, his name has been changed.