“In an urban centre, you can define your scope. In a rural setting, the environment defines your scope. You do what is needed… It challenges you to consistently improve skills and get competencies in order to provide patients with the best possible care.”

Dr. Michael Kirlew on being a family physician in a remote setting

1. Profile: 
   1. Positions: Family Physician (Sioux Lookout for 12 years, now Moose Factory- Weeneebayko Area Health Authority); Academic Appointments (Northern Ontario School of Medicine, Queen’s University, University of Ottawa)
   2. Training: MD and Family Medicine Residency (Ottawa)
   3. Interests: rural, remote health care and Indigenous issues, raising awareness and dismantling systemic racism in healthcare; recently awarded the Jean-Pierre Despins Award from The Foundation for Advancing Family Medicine in recognition of his outstanding advocacy work
2. Pitch: An incredibly variable specialty where you get to meet so many amazing people and listen to their stories. You’re constantly challenged to become a better doctor!
3. Path: He was always interested in global health and Indigenous health and wanted to go into pediatrics initially. After an amazing elective with a rural family doc, he made the best decision of his life to choose rural family medicine!
4. Philosophy: Be open-minded to new experiences and be honest with yourself. Wherever you go, strive to be an advocate for your patients and to make the world a better place!

• “I think I have the greatest job in the entire world- every single day I learn something new!”
• He was always interested in rural and Indigenous health care- lots of opportunities for advocacy in rural setting
• Medicine is not only about content but also about context
  • Rural setting really allows you to learn about context of patients (impact of systemic racism and colonization on health care system and patient experience)
• Massive inequities in access to specialists and support structures between urban and rural settings
• He also loves longitudinal relationships with patients!
• In urban center, you can define your scope but in rural setting, it’s defined by your environment
• Constantly challenged to improve skills to provide patients with best possible care (life-long learning)

• In rural medicine, you always have to be willing to ask for help and know your limits (he works with an amazing group of colleagues)
• If you like being around people and constantly interacting, this is great for you!
• There is time to work but also time for laughs and jokes- important to recognize medicine is fundamentally an art and doctors are humans, too

• Rural family medicine has broad scope of practice but work and practical realities make it less lifestyle friendly
• Australian med students thought rural family med is associated with feelings of isolation 
• Dr. Kirlew’s response: 
  • It depends what type of person you are
    • He likes nature and the lakeside view as opposed to condos in Toronto!
    • Some people like city life and that’s ok, too
  • In rural area, you get to interact with amazing people and elders!
  • You have to do internal inventory and realize what you want to wake up to every day
  • It’s more about your mindset than the environment (you can make lifelong friends in rural area as well!)

Feldman et al. The difference between medical students interested in rural family medicine versus urban family or specialty medicine. Can J Rural Med 2009; 13 (2).

Isaac et al. Self-efficacy reduces the impact of social isolation on medical student’s rural career intent. BMC Medical Education 2018, 18 (42).

• He initially thought about neurosurgery but decided it wasn’t for him
• When he was a student, typically 75% of med students went into specialties and only 20% went to family medicine at his school
  • He liked working with youth and considered pediatrics for long time
• He always liked global health, Indigenous health care, and effects of colonization on the healthcare system, which drew him to rural medicine
  • He worked with great rural family doctor in elective, which totally changed his mind about family med!
  • He was torn between pediatrics and family medicine and was nuts the night before the CARMS match but he got into family med residency, and it was the best decision ever!
• It’s amazing how events can change the entire trajectory of your life, always be open-minded (you’re on a journey of discovery!)
  • Make sure you’re honest with yourself and let things influence you
• He loved working in Sioux Lookout with amazing patients and colleagues and now he loves Moose Factory
• The hidden curriculum in medicine can slant you to think in certain ways- understand that each rotation is one person’s way of working in that specialty (there’s a variety of options)
  • Ask yourself about your value system and what you want to do- let the experiences talk to your heart!
• Still get rural experiences if you like city- you will need understand the challenges that rural doctors face and that will make you a better (city) doctor

• Typical week is hard to define in rural medicine and he loves that! 
• Does a mix of hospitalist, emergency department, and family med clinic weeks. He also spends some weeks in even more remote communities.
• In hospitalist weeks, start at 8 am and see 13-20 patients a day (see patients similar to internal medicine at tertiary center- complications of diabetes, COPD, CHF for example)
  • You’re the internal med department, the RACE team, the ICU team
  • You only cover the days and emerg doctor covers nights!
  • Mix of rounding on inpatients, transferring patients out
• In emerg weeks, 2-3 shifts a week combined with some clinics
  • 8-12 hour shifts
  • In rural practice, not a huge volume of cases but more complex (don’t have the same specialist support as in urban center)
  • Handle coastal calls as well as telephone support for northern nursing stations at night
• In northern community, clinics in morning from 9-5:30 and also attend to critically ill patients at night
  • Weeks in a year spent in different areas depends on your contract
• Moose Factory is on an island so you may even take a helicopter to the mainland clinic (travel like Kanye!)
• You could be in Toronto (assisting medevac), northern community, clinic, or emerg department or elsewhere depending on the situation
  • rural medicine never gets boring, the environment is constantly changing!
• He’s met some very inspiring people with amazing resilience and stories (“absolutely phenomenal to share their stories”)
  • After four 12-year-old girls died by suicide in Sioux Lookout community, it was incredible to see the elders’ strength and hope
  • It’s incredibly powerful because Indigenous people’s lives are shaped by history of colonization and systemic racism

• When you train in an urban center receiving medevac, you usually don’t know how it started.
• If you have a critically unstable patient, Critical program in Ontario helps link rural sites with urban intensive care centres
  • Speak to intensivist on call and they might connect through telehealth (Virtual Critical Care in the north- like OTN for critical patients)
• The challenges are not only getting the patient to the right place but also weather and other factors- you may be managing the patient for quite a while!
• Work with Ornge Air Ambulance to transfer patient out. They’re triaged based on acuity, then flown out to care centre
• Sometimes, physician working in emerg might be flown out to northern site to put in a chest tube for example- help stabilize patient, then fly down to urban centre
• There’s a whole field of medicine devoted to how you do air medevac and all that!

“If you were in a Northern community [a few years ago], pregnant women would have to leave their community and home to deliver a baby. Health Canada would cover your travel but you had to deliver the baby by yourself. One of my patients was delivering a baby by herself, 600 km from home, and she didn’t have her partner or anyone else with her… Because that was a rule for so long, you just accept that that’s the way things are. You don’t even see the system for what it is anymore. And she said ‘why don’t I matter? I know that [other people have their partners with them, hugging the baby]. How come I don’t get that?’ That really challenged me. And I [realized] that this isn’t right. Why do we have systems in this country that triage people to inferior standards of care based exclusively on race? We never question what we’re doing until our patient [questions us]. That was a very powerful clinical encounter that day. We got the federal government to change that policy, just in 2018.”

Takeaway: Sometimes your patients can challenge you to question the system and be a better doctor.

Note: While we tried to keep these transcriptions as true to the speaker as possible, some dialogue is paraphrased and/or edited for easier reading.

• Pick a specialty that makes you happy
• Wherever you go, be an advocate for your patients- it’s super important in making the world a better and more equitable place!