7. Going into Family Practice

I have written in installment VI about the decisions I faced in terms of going into residency and going through Family Practice. During my second year of that program, I became a licensed physician, as I made the choice of taking part in an aspect of the program which saw me going up north to federally run Medical Nursing Station outposts as a primary care practitioner. Since I would be on my own, this required me to be licensed. As I had already completed my first-year residency, equivalent to a rotating internship, which allowed one to gain a license, I was also eligible for that.

This program involved flying into a couple of communities in northeastern Manitoba, namely Bloodvein River and Little Grand Rapids on a six-weekly rotating basis. I would usually stay for a couple of nights, running clinics with the nurses during their office hours. These were both Indian and Métis communities, so I was enjoying re-connecting with the North, with the people of my growing-up years, and happy at being able to now provide them a vital service.

I was well aware of the possibility also of ‘moonlighting’ to get experience and earn money, although this was frowned upon. We were to devote our energies to working in the Family Practice Training Unit clinics and to her studies. The University and Department of Health were not exactly in favor of paying out more money either. However, early in my residency, an invitation was forwarded to me to relieve a rural physician by taking call for him on a weekend. This was approved by my preceptors and so one Friday afternoon found my new wife Anne and myself headed northwest to the small community of Gladstone. The doctor we were relieving, Waldemar Loewen, allowed us to live in the family home while they were away.

Ultimately, I spent several weekends during this over the course of the year. The doctor and hospital staff where obviously pleased with the services I provided and with myself. This was obviously helped by the fact that the Dr. and myself were both of Mennonite background, so we had a lot in common there. We also both enjoyed the outdoors. He was also very keen on working with the natives in the nearby reserve, which meshed well with my interests and experience. As a result, they invited me to join them in practice in this community. By this time, Anne and I had become quite familiar with community and were happy enough with the prospects.

This was in the 1970s when the New Democratic Party was solidifying its hold in government and attempting to make real some of its ideological ideas. One of these was to establish multidisciplinary Community Clinics as opposed to the typical scenario where physicians and all other disciplines worked separately, with very little interaction. They were also some attempts in this way to cut costs, as non-physicians, such as nurse-practitioners, were being educated to help do what Family Physicians generally did. This was further developed in the sense that physicians in these community clinics were placed on a salary, which capped their earnings, as opposed to the open-ended fee-for-service model, which was the accepted practice. This setup also appealed to rural communities that were perhaps smaller and less favored, as it allowed them to obtain and provide services that they were having difficulty maintaining.

I have already hinted in some of my previous postings that I was not averse to this kind of thinking myself. In that respect, I was a product of my time, as these ideas were shared by a number of my peers. Indeed, I was quite happy to work with different disciplines to share the load and serve our community more effectively and efficiently, at least in my opinion. Thus it was that I found myself working with nurse practitioners, community health nurses, visiting occupational and physical therapists, a social worker, a health educator and eventually even a dentist. There was one physician in the community who had started in the Community Health Center, but had gone private.

I believe I have written earlier before about my beliefs with respect to family and community. I thought at the time that this approach would help me learn even more about communities and becoming part of their fabric of life in service, and was not disappointed. Here, a whole small town, not to mention several outlying communities and a large Indian Reserve, Sandy Bay First Nation, were all part of my sphere of the work under the Seven Regions Health District and Center. I have always liked traveling, being on the road, and this allowed me to do quite a lot of that as I went out to meet patients in clinics set up in health centers in their communities, including the reserve, as opposed to making them all drive in. These centers were otherwise run by the nurse practitioners and community health nurses.

I was also happy to choose a rural practice because, with the experience I had already had working up north for two summers, and the education I had, I felt that I could use a lot more of my incipient skills in this environment than in the big city of Winnipeg, or some other larger center. In these places, other disciplines such as surgery were and obstetrics, and even emergency services which were becoming a specialty in their own right at this time, would be quick to take over some aspects of the practice. I felt that my professional life would be impoverished somewhat under such circumstances.

Obviously, my overall total upbringing and experience, living in rural areas and the farm, gave me a different perspective on life and what one can do and expect of oneself and those around one, then what might have been entertained as expected in more urban areas. You can't provide what is not available. Rural people understand this better, and are more accepting of such limitations. Sometimes, they were even benefits to this. One example that often comes to mind is obstetrics. In the "high-powered" ivory towers of specialized and academic practice, strategies such as increasingly technological intrapartum monitoring often led to attempts to augment, hasten and even end up providing surgical outcomes to the supposedly natural events of labor and delivery. However, when this was not readily available, I often found that just taking things more calmly and slowly, which one could do in the less pressured environment of the rural hospital, often resulted in a quite happy and satisfactory outcome in situations in which I suspected the results would not have been nearly as personable and patient-friendly as in a larger center. Perhaps God was helping look after us too, as I don't recall us losing a baby in the 7 1/2 years that I practiced there.

However, other forces began to surface and other dynamics developed that gradually drew to an end these happy years. More on that in the next installment.

9. Choosing Child Psychiatry

I had mentioned in V, Moving into Residency, that one choice I had considered was pediatrics because I liked being with children. At the time though, as I also explained further, my over-arching interest was in families and ultimately the communities they lived in. Therefore, I had reasoned that I could get my share of working with children in Family Practice, which is indeed the case. When it came to going into psychiatry, I really never thought about the Child and Adolescent subspecialty. All my experience had been with adults and even psychogeriatrics.

What really set the ball rolling in that direction was an interesting remark made by a friend who was a social worker for the Brandon School Division, Laura Crookshanks. She later became the head of their Student Support Services. I forget the circumstances under which we were meeting but in parting she remarked, and I could see the desire for this in her eyes and her smile, "Think about going into child psychiatry. We need help in that area," or words to that effect. She may have also mentioned, which was something I also probably already knew, that the only long-serving child psychiatrist in the community, Dr. Richard "Dick" Parker, was nearing retirement. Somehow, her request stuck in my mind and began to figure in my considerations as I moved forward.

The way the University of Manitoba Psychiatry Residency was structured at that time was that Child Psychiatry was something that one entered into in the second year. Thus it was, that the first six months of my second year found me in the Child Psychiatry Program at St. Boniface Hospital. If my memory serves me correctly, it was mostly an inpatient residency, which is what introductory residencies often were in those days (1991). When it came time for my mid-rotation evaluation, my preceptor really gave me quite a negative report, which was somewhat surprising. In retrospect, I have often wondered if this was somewhat intentional, because at the end of the six months, his report was entirely the opposite. Certainly, I may have worked harder at what I was doing, but I can hardly think that three months would have meant that much improvement over what he negatively reported on midway.

In any case, the final report was the important one. That, and my experience, was encouraging enough that I then began to look at choosing my electives to complete my residency with a major in Child Psychiatry. At that time, this subspecialty was not yet a recognized area with its own certification examinations and title. However, there was an understanding that one needed at least 18 months of residency in this area to be accepted as a practitioner in the field, so that was what I aimed for. I mentioned previously that I could have taken a year's credit for my Family Practice Residency and experience. Not having looked at that at all, I am not sure how that would have figured into the structure of my residency. It could have given me the extra year of child psychiatry training that could then have allowed me to pursue a full Fellowship in Child Psychiatry. However, as I had said then, I had elected not to do so, which decision was made before I began to move in the direction of child psychiatry, so that door was closed at the time.

I then took another six months of Outpatient Child Psychiatry, also at St. Boniface Hospital. Then I took an elective combination of Eating Disorders Consultation Service and Emergency Child Psychiatry Consultation concurrently, both at Winnipeg Health Sciences Center Children Center. Here I had the interesting experience of working with a classmate who had already become a child psychiatrist, Dr. Robert Steinberg. Finally, to get more experience with a wider range of child and adolescent programming, I set up an elective at the Manitoba Adolescent Treatment Center, which gave me exposure to inpatient psychiatry, outpatient psychiatry, groups and an on-site school. This was a new rotation which I had to set up with the help of mentors such as Dr. Eric Sigurdson, whom I had previously superficially known as a fellow family practitioner in Dauphin, a larger town to the northwest of where I had been practicing in Gladstone, but now in child psychiatry. Most interestingly, the preceptor I was assigned to was Dr. John Varsamis, the same sauve chain-smoking Egyptian Alexandrian Greek psychiatrist whom I had worked under as a medical student and who had encouraged me to go into child psychiatry. It was a privilege to share an office with him and be the recipient of much of the writing this advancing-in-years psychiatrist was doing, which was ahead of the times for his age, on his Apple computer. It was also interesting to see how, in spite of the fact that he always wore a suit and tie, he was so well-liked by his adolescent clients. It all pointed to the fact of how one related to them. We also worked on a project for identifying schizophrenia early, but never did complete that. Much of this involved looking at potential pre-morbid factors, as the earlier one can pick up warning signals, hopefully the more effective intervention at that stage would be.

So it was then, out of my four years of psychiatry residency, a full two years were in child psychiatry training as I recall. Perhaps the St. Boniface outpatients and Health Science Center rotations mentioned were only three months each, as my memory seems to tell me that I only had 18 months of child psychiatry, which was six months short of the requirement for being able to work towards a fellowship. In terms of learning therapy, instead of closing off training therapy sessions with children after completing the child rotations, as was the practice, I kept working with children with appropriate mentors, to support my overall direction. One of these mentors was Dr. Philip Katz, a prominent member of the department, whose son Lawrence Katz also became a child psychiatrist.

I had mentioned earlier the special circumstances under which I entered the residency which required me to return to rural Manitoba. As I said, I was intending to return to Brandon, which was considered rural still, at least as far as psychiatry was concerned, anyway. And there, a spot in the regional mental health program was just waiting for me. Some 50 or four weeks after completing my residency, I started working at the Brandon Mental Health Center as a Child Psychiatrist.