The home stretch: an away rotation in Toronto
Stefan Tarnawsky May 10, 2019
The asteroid (6478) Gault emits plumes as it begins to disintegrate from prolonged exposure to sunlight.
April was my last clinical rotation of medical school. I had set aside May for vacation/travel/moving to St Louis and I wanted to do something special for my last month: Radiation Oncology at Princess Margaret Cancer Centre in Toronto. I chose it for three reasons. First, I’ll be a medical oncologist and I want to learn more about the Rad Onc perspective. Second, I was a former patient of the Canadian healthcare system and I want to compare differences between the Canadian vs USA approaches.. Finally – and most importantly – my parents live in Toronto; and who’d pass up the opportunity for a month of home cooked meals?
I applied for the Toronto rotation through the AFMC Portal, which serves all of the Canadian medical schools. The application is straightforward, albeit it takes some legwork to collect proof of vaccinations and the cost of the rotation ($575 registration, $290 rotation, $80 international health insurance = $945CAD = $700USD) is not insignificant. Rotations do not have set start/stop dates; rather students may choose a duration (eg: 3wks) and a Monday of their choice as a start date. Applications open 6 months ahead of the start date; it’s wise to apply early. As for logistics within the city, Toronto is massive and I’d suggesting renting near the underground subway line (unless you have relatives nearby :D ). The underground is faster, easier, and cheaper than driving around the city and you’ll also use it to navigate Toronto’s niche neighbourhoods: Little Italy, Chinatown, Distillery District, etc.
I had a steep learning curve in the first week in the clinic. Toronto’s University Health Network (UHN) is equivalent to IUHealth and it uses a proprietary EMR that is most similar to the VA’s CPRS (read: antiquated). However, it does have an effective province-wide interhospital online record exchange akin to IHIE/CareWeb. Whereas I did interact with residents, I rarely worked with them in my outpatient clinics. Rather, I was mostly supervised by staff, and occasionally fellows — which in Canada are advanced training opportunities primarily occupied by IMGs, and are distinct from subspecialty residencies (which are most equivalent to US fellowships).
Given the high pace of Rad Onc clinics, encounter notes are usually dictated, not typed. As a student, I was expected to use the dictation services. The challenges were manifold. First, verbal dictation requires extensive planning: if you repeat the same phrase in your subjective, objective and assessment sections, then you’ll feel foolish and inefficient. Second, dictating in a busy team room is intimidating. For me, this led to a softening of my voice that made transcriptions less accurate. Finally, the content of my notes was different. My Canadian staff reminded me that the purpose of the EMR note is to communicate with other providers. Regurgitating the details of the radiology report or dictating a 14pt ROS is not helpful to any future caregiver. Rather, it is important to emphasize one’s recommendation and to justify that recommendation. This is a feature of the Canadian perspective that I hope to bring back with me to the US.
My last patient encounter as a medical student was a unique and memorable experience. I observed an assessment for MAID (Medical Assistance In Dying). This program followed the 2016 Canadian Supreme Court decision to permit patient-requested euthanasia in specific circumstances. Namely, for a fully competent and non-coerced patient with an incurable illness, who is suffering and is unwavering in their decision during a reflection period (min 10 days). The experience was eye-opening. Whereas I imagined patients seeking MAID to have intractable pain, the patient I saw appeared comfortable and was lucid. The dominant source of their suffering stemmed from a lack of control: knowing the pain, weakness, and fatigue would increase and that their family would suffer through their prolonged illness. The patient wanted, rather, to dictate the terms and timing of her death. Indeed, the patient’s hope in still having this one final choice, clearly provided them with incredible solace. Regardless of whether the US will adopt similar policies, this experience heightened my appreciation for the depth and variety of suffering in patients with incurable illnesses and will prompt me to seek to relieve this suffering through whatever treatments, conversations, or referrals I am able to offer.
Above and beyond the profound medical experience I had in Toronto, I equally had a blissful time deepening my ties to my family and re-exploring old relationships in my native town. When it comes time to choosing electives for the home stretch of MS4, I strongly encourage you, dear reader, to also consider something that will not only be professionally worthwhile, but will allow you to spend time with those you love.