Reflections from My Rural Family Medicine Placement in Mistissini, Quebec
By Sam Amar
The most effective learning environment is one that pushes you beyond your comfort zone, yet provides the safety and support needed to explore and develop. Throughout medical school, I have strived to step outside of my habitual setting – both academically and culturally. This is why, for my mandatory rural family medicine rotation during my third year of medical school, I was excited about the opportunity to travel an hour north by plane from Montreal to Mistissini, Quebec. My month-long clinical rotation in Mistissini not only developed my clinical skills, but also taught me how to work in a resource-limited setting and the importance of cultural sensitivity in healthcare, particularly when working with vulnerable communities.
View from Mistissini Bridge
How I further developed my clinical skills
Mistissini is a Cree community located in the Eeyou Istchee territory. This territory covers a vast area of northern Quebec, primarily around the eastern side of James Bay and Hudson Bay, and is home to various James Bay Cree communities. My rotation took place at the Community Miyupimaatisiiun Centre, which roughly translates to “Centre for Health and Well-being.” The Centre provides multidisciplinary services including urgent care (where I spent most of my time), chronic disease management, and mental health services, including those for substance use disorder and social support. As my rotation progressed, I came to realize the importance of an interdisciplinary approach to care. Many patients had complex physical health issues that were often worsened by emotional or social difficulties. For example, I met a few patients who had difficulty managing their diabetes and other health conditions due to struggles with substance use disorder or significant financial barriers. It was inspiring to learn how the Centre’s comprehensive care team incorporates the local community’s holistic view of health – which includes physical, emotional, and spiritual elements, to help patients manage their health conditions. Central to this approach are the Primary Care Community Representatives: local community members trained to provide culturally relevant counseling on lifestyle modifications related to diabetes, hypertension, and other chronic diseases. These individuals also play a pivotal role in providing services for mental health and substance use disorder, social support, and spiritual care.
Interestingly, many of the reasons I enjoyed my experience in Mistissini were initially challenges and overcoming them helped me to develop skills that I plan to implement in my future career as a physician. Firstly, Mistissini – a resource-limited setting – was unlike any environment I had previously worked in. In Montreal, we have access to many, if not all, necessary diagnostic testing at our fingertips. In Mistissini, on the other hand, there is no CT scanner in the community. The available diagnostic testing includes basic laboratory investigations, an X-ray machine, and potentially the most important, but frequently overlooked tool: a good history and thorough physical examination. I often had to rely solely on my clinical skills to diagnose and treat – a challenging task that I worked to address by seeking feedback from my supervisors, intently observing new physical exam maneuvers, and practicing these techniques myself. For example, while assessing a patient with presumed benign vertigo, a complete neurological examination revealed significant right-sided weakness – a finding suggestive of a far more serious condition, such as a stroke. This physical exam finding allowed the medical team to expedite brain imaging for the patient. This experience not only improved my physical examination skills, but also emphasized the importance of performing a thorough clinical assessment in all patients – even when more advanced testing is available.
Compared to Montreal where family physicians can easily consult a specialist to promptly see a patient, in Mistissini, family doctors are the primary doctors present in the community and are involved to a much greater degree in the management of their patients since specialist doctors are few and far between, or not available at all. As such, there were times when patients presented with conditions my preceptors had never managed before, and we relied on available resources such as UpToDate and clinical guidelines to make evidence-based decisions. This experience taught me that adaptability, flexibility, and comfort with the unknown are key attributes that rural medicine physicians possess.
I also had the opportunity take on increased clinical responsibility compared to previous rotations. My preceptors would regularly involve me in procedures, writing prescriptions, and explaining management plans to my patients – all to a much higher degree of independence than I was used to. This increased responsibility was challenging at first, given that I only had limited experience with delivering diagnoses or determining correct medication dosages. This rotation therefore gave me ample opportunity to practice these key skills in a supportive learning environment. I was able to enter my subsequent rotations with more confidence in completing these essential tasks.
Recognizing the historical remnants of colonialism
On the first day of my rotation, my supervisor told me something that has stayed with me: “the Cree of Mistissini are a sick community.” Throughout my rotation, I learned that the James Bay Cree experience significant health disparities compared to the general population in Quebec and Canada, including higher rates of diabetes, cardiovascular disease, and mental health challenges. These inequities are deeply rooted in the impacts of colonialism, which disrupted traditional ways of life, displaced communities from their lands, and imposed residential schooling and systemic discrimination. Such historical trauma led to a loss of cultural continuity, reduced access to traditional foods, and instilled longstanding mistrust in health systems, which still exist today. I witnessed firsthand the lasting effects of this historical context on my patients’ health. The incidence of diabetes was far higher than what I had seen in Montreal. As of 2021, 31% of James Bay Cree adults are living with diabetes, compared to 9% in the rest of Quebec. Moreover, many patients are living with severe complications of diabetes, such as blindness, kidney disease, and limb amputations. It was deeply troubling to witness such high rates of complications, and to recognize that they stemmed largely from oppression within the very system I practice.
Prior to starting my rotation, I was admittedly nervous about building rapport with my patients given this historical context. I worried that my patients might be reluctant to discuss their health with me, not only because I was an outsider in their community, but also because, as a descendant of European settlers in Quebec, I represent the group that has historically oppressed their community. I recognize the injustices that the institutions I represent have committed against the Cree and other Indigenous peoples and how these injustices are still felt today. However, although I did have a few interactions where patients were more reserved, most patients were very willing to engage in meaningful conversations about their health with me. I believe what helped me foster these relationships with Cree patients was implementing cultural sensitivity into my approach.
Community Miyupimaatisiiun Centre in Mistissini
Culturally sensitive care entails recognizing and valuing patients’ cultural beliefs and healing practices as legitimate parts of their health and well-being. These practices and tools served as adjuncts to the allopathic approach to medicine that I have been trained in. For instance, I employed Cree greetings in my interactions with patients and learned Cree phrases for common symptoms such as pain and shortness of breath. A culturally sensitive approach also involves a high degree of shared decision-making—involving patients and their families in their care to determine the best approach for them together. For example, after diagnosing a patient with tennis elbow, I discussed standard treatment options, such as NSAIDs (pain medication), joint injections, and physical therapy, but also asked the patient how they wished to manage their pain. The patient expressed that they wished to alleviate their pain using a traditional medicinal herb alongside the standard treatment options. This culturally sensitive approach to care helped me foster these relationships, relationships grounded in mutual respect, humility, active listening, shared decision-making and the acknowledgement of the cultural and historical barriers that contribute to the disproportionate burden of disease that the Cree face.
Mishtamiikwehch ōō mishtamiikwe Ikwesini awâwâhahâch
(Thank you to the Cree Community of Mistissini)
My clinical rotation in Mistissini reshaped my understanding of healthcare for vulnerable communities and resource-limited settings and enabled me to develop exponentially as a future physician. I learned that practicing medicine in a resource-limited setting requires strong clinical skills and comfort with the unknown, and that a culturally sensitive approach is required for the effective delivery of healthcare. This experience both challenged me and provided me the support I needed to grow as a medical student that I will carry forward with me when caring for vulnerable populations. Mishtamiikwehch ōō mishtamiikwe Ikwesini awâwâhahâch!
Sam Amar
is a fourth-year medical student at McGill University. As a lifelong Quebecer, he is passionate about caring for the province's diverse and marginalized populations. He hopes to continue working with, and advocating for, the health of Indigenous communities in his future practice.