It's Graduation Time!

The graduating class of 2011 is done!!  It seems absolutely unbelievable...I'm sure the reality of being finished internship will quickly set in as I begin to prepare for NPLEX and board exams, but right now I'm basking in the accomplishment.  And what a journey this has been...filled with a lot of ups and downs, the appearance of gray hairs and the skills to help improve health care in Canada.

One thing I was not prepared for this last month was saying goodbye and transferring the care of many patients I have got to know very well over the past year.  Although I'm sure their new intern will work as hard as I did, there was a sadness in not continuing along their health journey with them.  Well, I do not want to end on a note of sadness as this is a time for celebration.  So, congratulations to all the naturopathic medical students in North America who will be graduating this spring.  I wish everyone the greatest success.

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Christmas Break

Christmas is one of my favourite times of year.  Unfortunately, it is too often an exhausting, over-commercialized pressure to buy everyone that "perfect gift."  So, I try to ignore that extra stress!  For me, Christmas provides an opportunity to spend time with family and friends, time to relax and time to reflect on what is really important in life.  And, it cannot come soon enough!

I have to admit that I was naive about the energy required to consistently give my best to patients with chronic health care issues.  Burn-out can become a reality very quickly if not anticipated and prevented (The age old phrase, "Physician heal thyself" is so important).  I realize now that my expectations of being a naturopathic clinician were primarily based on my limited experiences as a patient.  As such, I projected much of how I thought being a clinician would be like by attempting to put myself in the health care professional's shoes so-to-speak.  But I am just one type of patient and I do not have any chronic debilitating conditions or diseases.  Needles to say, I have made some adjustments to the understanding of my job description.

For those of you interested in becoming a naturopathic doctor, as the style of practice varies substantially from one ND to another, do not base your expectations on one particular style of practice or patient group.  Although it is impossible to know exactly what to expect, and even what type of practice you want to have, getting as much experience with several different primary health care providers will also help you understand what it will be like to be an ND.

Have a refreshing holiday and Merry Christmas!

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Maintaining Mentorship

Most highly skilled professions have some framework of mentorship set in place to ensure that things which are not easily picked up in the classroom, or from reading a book, are taught in a practical setting. Naturopathic Medicine is no different. Mentorship maintained naturopathic medicine in the United States in the years following the 1910 Flexner Report when naturopathic schools could not afford to operate (the Flexner Report also shut down many "diploma mills" and substandard medical schools which was a positive outcome. Unfortunately though, the recommendations were to only fund schools with a pharmacological and technological focus).

Mentorship at CCNM begins in 1st year as new students are introduced to the teaching clinic with days spent shadowing their supervisor. Second and third year students get more involved with patients each year as clinical supervisors and 4th year interns take mentoring roles. There are certainly times where patients are surprised at the additional students that come into the treatment room and occasionally, the 4th year intern is inadvertently put in the hot-seat with all eyes on her or him. At these times, there is the potential for everyone involved to share an awkward moment.

My love for teaching and background in instructing usually dissolves my concerns about others watching me in clinic. Additionally, I recognize that I am not perfect at this yet and I may say the wrong thing or make a small mistake with someone else watching. However, as the mentor, it can still be an additional source of stress.

I wonder if this change in dynamic is currently making it very difficult for some students to fulfill another type of required mentorship called preceptorship. This is where students spend time with a ND, DC, MD or physiotherapist in their private practice (or hospital). If you are currently a student in naturopathic medicine, here are a few points to consider when being mentored:

1. Firstly, if at all possible, pick a mentor who's style of practice you like. This is very important for preceptoring and will eliminate many unforeseen disharmonies and make for a much more enjoyable day.
2. Recognize your mentor's strengths. Certainly there are times when you may learn how NOT to practice but try to glean the best of what the mentor is offering.
3. Show appreciation. This is so important in order to successfully continue a constructive and receptive attitude towards mentorship and maintain the philosophy of passing down knowledge to the betterment of the profession.

Residency is another type of mentorship offered to naturopathic graduates and I hope to write about this at a later date.

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The [CCNM] Hour

As an ND intern, I have the privilege to spend an hour visit with my patients. Initially, I thought this would allow ample time to ask all the pertinent questions, perform a relevant physical exam and ensure the proper care was provided for the patient by the end of the visit. Although this may be true in some straight forward cases, I have found that patients often see us as a last resort and have an extensive story and medical history to share. Furthermore, I think patients find some therapeutic value in just being able to freely tell me their story, in full, without me limiting their responses or cutting them off to one or two concerns per visit.

As such, I have already listened to (while carefully charting) some extremely complicated cases and the hour flies by before unearthing all the potential contributing factors to the person's current state. And, I still need to remember to at least take the person's blood pressure! However, when I review the patients case, I recognize the tremendous value of the information I gathered to point me towards treatment options and areas where I need to research. Furthermore, I have realized that most patients with complicated cases (that have stumped other health professionals) do not expect me to have an exact solution by the end of one hour. Although that would be nice, my assurance that a health improvement - at the very least - in the near future is possible is more important.

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Meet the New Naturopathic Interns

Come on down to the Canadian College of Naturopathic Medicine (click for directions) on Monday June 14th at noon to meet the new interns. After 4 years of university and 3 years of naturopathic medical education, we are now entering our 12 month internship and are accepting patients. CCNM has one of the largest naturopathic teaching clinics in North America which has over 26, 000 patients visits per year.

During the event there will be an opportunity for everyone to learn more about naturopathic medicine through several short presentations including:

1) Brief intro to naturopathic medicine
2) Overview of services offered at RSNC
3) Pediatrics overview
4) Sports medicine overview
5) Adjunctive Cancer Care

Also, there are information tables and interns will be available to answer your questions.

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The first clinical impression

Keeping in mind that my first impressions of clinic are highly influenced by the kinds of health care issues the patients I have seen thus far have presented with, my first thoughts traveling home after my clinic shifts were much more melancholy than I was expecting. Some people are really in need of a significant amount of help. Another realization I have been continually reminded of is the critical state of our current health care system and the luxury naturopathic doctors have to spend sufficient time with their patients. We have the time to ask the detailed questions and actually listen to the answer (I truly believe that most family doctors do not prefer to spend so little time with their patients but are forced to do so in order to survive under the provincial health care billing system).

So far, my aspirations of the valiant hero who swoops in with the naturopathic coup de grace and instantly changes the person's health future have been shifted, I believe positively, to recognize that pacing myself will be critical. This is a learning process - it is called a "practice" for a reason! Even if I do have all the answers in a particular case, delivering those answers in a way in which patients will comply is an art in of itself. There are so many new realities now in clinic and it is a very steep learning curve. As such, the first couple of weeks have been somewhat overwhelming.

However, we do have a great amount of support at the teaching clinic. Each intern has at least 4 different supervisors, and is therefore exposed to 4 different styles of practice and patient case management. Additionally, we have a variety of health professionals available for consultation on site at the clinic including Laboratory Technicians, ND's, Chiropractors and a Psychologist. So, there is help when we need it.

This was just a first impression and is subject to change!

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A New Leaf

Today we completed the first of two days of clinic orientation. While biking to school this morning, the routine was so familiar, and our final exam marathon still so fresh in my mind, that I did not feel ready to be back at school. However, after the morning introductions, I realized that although the setting was the same, everything was different now. We are not only students, we are now health care providers. In fact, we were informed that 44% of the patients that visit the clinic here at CCNM reported that their ND intern was their primary health care provider. What a phenomenal responsibility!

We are turing over a brand new leaf in our journey. I understand that we are forever students and our next step is a 12 month long internship with 1035 clinical hours, case management documents, competency checks, more assignments, and still a few required classes. Even so, our focus has now shifted from excelling in class and passing exams to getting people to feel better. And, they do! We were shown some encouraging data that CCNM is accumulating, which reinforces what we all have known to be true: naturopathic medicine helps many people.

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OSCE Follow-up

What an experience! If it wasn't for the nearly crippling anticipatory anxiety, I could almost say it was fun - the kind of exhilaration that happens during an important performance. Being sequestered in a meeting room for an hour, in a group of nine, prior to the official start of the exams did not help. However, I heard many other groups used much better coping tactics than mine did and they were able to laugh off some of the tension. I will never forget the walk down the stairs to the clinic. Our group walked in silence and I felt like I was in the movie Gladiator right at the scene where they were waiting to get rushed out into the Colosseum.

However, once I entered the first room and began talking to the patient, things began to flow more naturally. All the hours of preparation and studying pathologies, redflags for life threatening conditions and physical exams was integrated into somewhat of a smooth patient experience.

The OSCE's at CCNM consist of 3 patient visits that are each 18 minutes long. Then following each case we have 5 minutes to write up how the case would be appropriately managed and answer questions on our understanding of the patient's condition. Although 18 minutes is certainly not enough time to investigate the root cause of many diseases, it is sufficient time to rule out whether the patient has an emergency situation. As the first principle in our oath is, "First do no harm," having the ability to quickly evaluate the severity of a patient's symptoms and provide a medical diagnosis (Primary Care responsibility) and management plan is essential to every ND's training.

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