Taking flight

There is just one rule – don’t touch the controls’. ‘I think I can follow that’. ‘Now pull the door closed firmly, turn the first latch, and then push the second across. You’re in the front so if we crash, you’ll need to do all that in the reverse order. Think you can manage it?’ ‘I certainly hope so!’ We set off to the end of the runway in the tiny single-engine Piper Comanche. Dr. Miles pushes the throttle in, pulls back on the yoke, and we accelerate rapidly. The wheels lift and we are airborne, climbing high over the Northern Alberta landscape. ‘Do you want to fly?’ ‘I thought I wasn’t supposed to touch the controls? But I mean, yes, absolutely!’ Dr. Miles just smirks. ‘With flying there are three axes – pitch, yaw, and roll. You must aim in this direction and try to keep the plane around 6500ft of altitude’. I grasp the yoke and try to adjust to the sensation of the additional altitude vector. Initially, I am too aggressive pulling back – ‘Did you intend to climb 500ft just now?’ The steering is sensitive but delayed – a slight adjustment tips the wings seconds later and I struggle to time my recovery. Gradually, it becomes more natural, until we hit an air current that rattles the plane and my confidence. Dr. Miles appears unbothered – he has his phone out and seems to be texting, though I know he is watching closely. The dynamic is much the same as in the OR, a delicate trust as I build my surgical independence but recognise when I need to ask for help. I wasn’t supposed to want to be a surgeon. My medical school years took place in smaller towns in accordance to my plan to become a rural GP. But when I discovered general surgeons could also live and work in such places, I found myself on a different path. Pursuing this came with sacrifices – longer training and having to complete this training in a city chief among them. In my 3rd year, a wonderful opportunity arose. I was permitted to complete a year of residency in the regional centre of Grande Prairie and learn from surgeons with the full-scope practice I hope to have. The surgeons here regularly spend time in other Northern Alberta communities, which is how I found myself flying a plane to High Level for our week of surgery and endoscopy there. ‘Pick it up by the snout! No, turn it the other way – no, the other other way’. I rotate the grasper and adjust my plane of dissection. ‘Better. Yes, continue, see how it is opening up?’ The ever-present frustration in surgical training is knowing that there is a person with you who can do everything you can twice as fast and with more finesse, but the surgeons in Grande Prairie allow me to safely fumble my way forward to competence. From 1 day to the next, I don’t notice a difference, but after a year, here I can finally see progress in my skills and confidence. Despite once telling me ‘the only emotion a surgeon has is impatience’, my mentors here have been endlessly patient while I learn. In the city, training is fragmented – you are shunted between hospitals and services on a near monthly basis. This exposure to different ideas and subspecialties is important, but your advancement is reliant on the trust of the surgeon supervising you, which can be harder to build on short rotations. In Grande Prairie, I find continuity, not only with my mentors, but with my patients. A patient I scoped comes back for their colectomy; someone I saw in the emergency department is on the elective slate for a cholecystectomy. One of the patients I have seen throughout my time here is admitted – with her consent, I attend her MAID provision. Complications also return. When my patient has a post-operative hematoma, I have to face them and help fix it. Each time I perform that procedure thereafter, I see their face. ‘Our hemostasis must be even more meticulous’, I tell the surgical assist while justifying my paranoia. Our landing is tenuous, the ground obscured with thick cloud cover. ‘Look down and tell me when you can see trees. There’s a factory somewhere near here – we must watch for that too’. We descend further, the altimeter approaching the 1109ft we set as the local elevation in the incongruously named town of High Level. Just when I think we will have to abort the landing, the tree tops and snowy ground below come into view: ‘I see it! I see the ground!’ Carefully, we make our way to the airstrip through the fog. After circling, we manage to maintain a view of the runway and Dr. Miles lands the plane. ‘Are you sure you still want to learn to fly after that?’ he asks me. ‘Without a doubt’. The week in High Level is busy as always – long days of surgeries or scoping followed by consults or the odd emergency department wound debridement. But the lively team potlucks and community dinners bring a camaraderie that is so different from urban practice. As I teach one of the local nurses how to apply the endoscopic banding device for a variceal bleed, I am struck by how much I have learned. A year ago, I was struggling through my first colonoscopies and needing help to reach the cecum. Now, with the support of a community and mentors, I have built a foundation of skills to take back to the city for my final year of training. The transition to staff life is still daunting, but my Grande Prairie mentors have trained me well to take the controls. My semi-rural surgical apprenticeship has strengthened my desire to practise in a small town, and to train future surgeons in such places as well. And perhaps 1 day, to teach some of them to fly too…. Acknowledgements: The author gratefully acknowledges the contributions of the general surgeons and all employees of the Grande Prairie Regional Hospital and the Northwest Health Centre to her education, as well as those of the University of Alberta General Surgery Programme and the University of Alberta Office of Rural and Regional Health in facilitating this experience. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.

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