This week, Dr. Everett Fuller shares his narrative about his journey to Nova Scotia, Canada. In our next post, he will outline the process of licensure, finding a job, and immigrating to Canada.
This is the latest chapter in the life of a nomad. I grew up in a Navy family. I was born in Hawaii and lived in Okinawa, Japan and Maryland as a child. I went to “the dark side” and joined the Army (and my brother went to the Air Force), where I spent time in New York, Georgia, Germany, Macedonia, and Kosovo prior to heading back to Washington D.C. for medical school. I then moved to Texas and subsequently did two trips to Afghanistan, courtesy of Uncle Sam.
Once I hung up my uniform, we made the move to my then-wife’s hometown in eastern Canada. While we are no longer married, what I found here in Cape Breton, a good life, was still worth staying for. Hopefully sharing my experience might open the door for others to consider making the same move, minus the divorce, of course.
Fort Hood, Texas.
I take you back to the fall of 2011, Fort Hood, Texas. I was preparing for my fourth deployment, it was time to have a serious discussion with my then-wife. She had managed through multiple moves and career changes mandated by “big Army” but it was clear that she was not made for the military lifestyle. We also saw many other military families with significant issues stemming from deployment after deployment and decided it was time for a change.
Initially, I took a job at the local civilian ER, which allowed some degree of family stability by staying in the same neighborhood, schools, soccer teams, and friend networks. Eventually, the oldest started university at University of Texas at San Antonio. It was time for another conversation. When we got married, the agreement was that she’ll go wherever the Army sent us, but once I was out of uniform she gets to pick where we go. As good as Texas had been to us, she was always close with her extended family and missed them. She wanted to go home, to Cape Breton.
Cape Breton, Nova Scotia
Where is Cape Breton? It’s a tiny jewel of an island on the east coast of Nova Scotia. A little off the beaten path, with a relaxed pace of life and a close-knit family oriented community. But it’s Canada. We were in Texas. This was going to be a project, from finding a job, getting licensed, immigration, to buying a house.
Thankfully, we both had good jobs so we were able to take our time and work through the details over the course of a couple years. Her family still lived in Cape Breton so we used to visit every year. During one such trip, I was able to simply stroll into the ER to meet the department chief to ask about job prospects. The response was “We’re always hiring, how long do you need before you can take a job?” This was followed by an email about every six months “Just checking in to see if you’re still interested and what your timeframe is”. The critical first step: Find a job…check.
That moved us into the licensing and immigration process, figuring out our timeframe, and house-shopping. Licensing and immigration was slow and painful (it has apparently improved since then; more on the current status and process in the next post) and two years later we were ready to make the jump. We put our house in Texas on the market, we bought a house in Nova Scotia, and then we packed up a U-Haul (driven by in-laws who were willing to come help with the move). We loaded up two kids and six dogs into a minivan and a SUV, and set off on a grand road trip. Six long days of driving (plus a rest day visiting my folks in Maryland) later we were in Cape Breton!
Everyone Knows Everyone
Initially, it felt as though we had stepped into a time warp, and I was looking at my hometown in the 1980’s. Cape Breton had a small town feel with lots of smaller family businesses. There were only a couple gas stations and only some convenience stores were open all night. Even Walmart closes at night. The community is very friendly, like Gail the grocery store cashier, who tries to learn every regular customer’s name. Families stay close, and everyone knows everyone.
Downsides? We’re a bit remote, even for Nova Scotia. There is a small airport here, but often it is much cheaper to drive 4+ hours to catch a flight from Halifax. Nova Scotia is very Halifax-centric as it’s the only large city in the province. Want to shop at Costco or Ikea…drive to Halifax. Kids in competitive soccer…most of the league is in Halifax. Back to school shopping for teens who want the “cool” stuff…drive to Halifax. Want decent sushi? Yup…Halifax.
How about life in the ER, ER is just ER, right? For the most part, it is, at least when you’re at the bedside. That said, there’s also significant differences in the system. Some of that is the Canadian system, with both the advantages and disadvantages of universal healthcare. Some is more location-specific. And some aspects have even changed in the six years since I first moved here.
The Notable Difference
What were the most noticeable negative differences? Access and services. With universal healthcare, there’s access for all, but the criticism is that there’s a “rationing” of sorts. Hospitals aren’t in it for the profit, so you’re not going to get a CT, MRI, and cath lab in every hospital. In fact, the nearest cath lab, neurosurgeon, PICU are…you guessed it…in Halifax. A 4-5 hour transfer by ground, or a 2-hour (best case scenario) air transfer.
Got a STEMI? They get lytics, then we call Halifax to request transfer (we actually have pre-hospital Tenectaplase with ER physician oversight as well). NSTEMI? Admit to the CCU here and then they wait sometimes for 10+ days before there’s a bed available in Halifax for their catheterization. A Lifeflight is very weather-dependent and based on Halifax, so transfer time includes weather checks as well as the 1-hour flight to Cape Breton and the 1-hour flight back.
The relationship between the ER and radiology was a bit of an adjustment as well. When I got here, I wasn’t aware that the radiologist functions in more of a UK-style gatekeeper role for advanced imagery. I was used to the US system…I order, you read, the clinical decision is purely mine.
First shift here…night shift single coverage remote/small ER. I think this patient needs a CT chest. Oh, Dr, you need to call radiology for that. Call radiology. Response “no, I don’t think that’s indicated.” My. Head. Exploded. After a lengthy discussion and a few choice words, radiology agreed to doing the CT in the morning (required transfer to the regional hospital as this local community hospital didn’t have a CT scanner). And if the patient decompensated and needs a CT more urgently, I made a very strong promise to wake said radiologist up at 3am to make it happen. Since then the process has shifted, so now we only call for approval after 5pm, and most of our radiologists are much more accommodating to the ER.
The Benefits of Working Here
What are the benefits of working here? First and foremost, I have the comfort of knowing that a patient and their family will *not* go bankrupt trying to pay medical bills if I make a catastrophic diagnosis. There’s no out-of-pocket cost, other than prescriptions (depending on their drug plan).
We don’t have the highly litigious environment of the US, so malpractice coverage is quite cheap. No Press-Gainey so we haven’t seen the pressure of patient satisfaction surveys driving clinical decisions. No having to fight with insurance for reimbursement or pre-approvals. And since the hospital isn’t profit-driven, we don’t have to fight the 30-day readmit rule or argue about whether the patient has a reimbursable admission diagnosis.
If grandma is weak and dizzy and not safe to go home but the workup didn’t find anything definitive, we can still talk to the hospitalist and admit based on common sense and patient safety. In short, it’s getting back to making medicine and patient care the priority instead of the “business of medicine”. And the patient population in general is much more appreciative of the care we provide than anywhere else I’ve ever worked.
COVID-19 and What Worked
Covid-19 also showed me how it’s different here. We’re remote, that’s already established. But that allowed us to see what was happening across the US and Canada so we could establish social distancing and proper precautions before it even got here. The majority of the population understood the dangers and complied with recommendations. Local businesses pitched in, with gift shops producing home-sewn masks and distilleries shifting production to hand sanitizer. Breweries started home deliveries (yes, that’s important here). With our large elderly population, COVID-19 could have been devastating, but at the time of writing, we have had just over 20 deaths across the entire island from Covid (estimated population of Cape Breton is approximately 137,000).
Even the administrative response to decreased patient volumes due to COVID-19 was commendable. I felt a lot of anger hearing about my colleagues in the US working with scant PPE, getting reduced pay and reduced hours, many even being fired because there wasn’t enough volume to maintain corporate driven profit margins at normal staffing levels.
In our ER’s we were able to maintain full coverage, full pay, and even got a scheduled raise despite the drop in ER patient volume. Specialties who had to shut down or drastically curtail their work received financial compensation to make up for a lot of the lost income. Nurses whose jobs were put on hold were re-deployed to other work areas rather than being laid off (one example is that OR nurses were shifted to the ER to assist with covid screening and donning/doffing of PPE by staff in the ED). We felt more supported and taken care of than what I was hearing from our peers south of the border.
Growth on the Horizon for Cape Breton
There’s also growth and reasons for excitement on the horizon here. The Cape Breton Regional Hospital recently obtained approval for a 3-year combined FM/EM residency program starting the summer of 2022. Emergency Medicine training in Canada has two pathways, the 5-year EM residencies (FRCP-EM) as well as 2 years of FM with an additional year of EM (CCFP-EM certification which is FM with additional competency in EM). This new program is just the second in Canada that does the combined FM/EM in an integrated 3-year residency.
We have also started construction on a hospital expansion dubbed the “critical care tower” that will include the new ER (twice the size of current), ICU, CCU, and with a little luck and political support possibly a cardiac catheterization lab. This is likely a 6-8-year construction project, but will help increase capacity and services at this hospital.
My Life Now
So…where am I now in life? Well-settled in here in Cape Breton, both professionally and personally. Currently transitioning into the Site Lead position (basically department chief but without authority over nursing or ancillary services) and taking a more active role in physician recruitment. I am also recently engaged, am coaching youth soccer (local high school and travel squads), and training to represent Team Canada’s “old guys squad” (over 45 team) at the World Medical Football Championships (i.e. Doctor’s World Cup), and enjoying life in the Maritimes.
Dr. Everett Fuller is an Emergency Medical physician, now residing in Cape Breton, Nova Scotia, Canada.