Taking Back Her Life

By Patricia Thangaraj

The bravery of one Northern Ontario resident and Stage Three cancer patient is insurmountable as she has not only had to battle breast cancer, but also the Canada’s health care crisis. Yet, she has come out stronger on the other end, ensuring that she is taking back her life from the ravages of cancer. This is the fight story of Kittana Ruels.

Ruels was first diagnosed with cancer in 2018 while residing in Southern Ontario, where she had moved for work. Fortunately, doctors caught in the earlier stages and she had a lumpectomy. After this, she was then supposed to have a scan annually, but by that time she had moved back to Northern Ontario and it was here that her battles would begin.

This is because while there are walk-in clinics, all of them are tele-medicine. These clinics are led by nurse practitioners with a virtual doctor as there are no in-person doctors where she lives. She was supposed to have scans every April or May, but she did not receive one until September because of “the doctor shortage.”

After this scan, Ruels received no follow-up concerning her results, which she would find out later had some troubling conclusions.

“It was said in the results which I didn’t get until much later that it was highly suspicious and they wanted to follow-up and they recommended (a) biopsy or (a) surgical removal, which the doctor never called me. I never had a follow-up, so I had no idea.”

This first scan took place on September 22, 2022. She felt the lump again in June 2023 so she went back to the same walk-in clinic, but she didn’t get one until July because it was a different doctor. The scan took place on July 9^th and they did a biopsy immediately on the same day.

However, the same thing happened again, she said. “And then I never had a follow-up from those results either. No-one called me back. So I happened to be at the hospital for something else and that is when someone let me know that I could pick up my own results. So I did that and I read for myself that I had cancer again. And that was when I saw the previous scans’ concerns, which no-one had followed up on at that time.”

She continued, “So that led me to being diagnosed from the paper that I read. Not the best way to find out you have cancer again.”

Ruels believes that if the doctors or nurse practitioner had followed up then, her cancer could have been prevented. “I do believe that had they followed up then, this (breast cancer) could have been prevented. Maybe just a lumpectomy or something, I may not have needed chemotherapy. That is my believe. I would never be able to prove it.”

She said she is not aware of who is supposed to be doing the follow-ups, whether it be the nurse practitioner or the two virtual doctors, bur regardless none of them followed up with her in spite of the “suspicious” results.

After the biopsy in July, some friends of hers helped her find a doctor who could help her “get the ball rolling because you can’t navigate the health care system on your own.”

He took her on as one of his patients even though he didn’t have space in his practice and then another friend referred her to a family physician who took her on permanently.

She has a double mastectomy on September 8^th, 2023, she started chemotherapy on October 16^th. “There are six rounds in total every two weeks. So the first round three rounds are the FEC-D and then the last three rounds of docetaxel.”

Although she should have finished chemotherapy on January 29^th of this year, she has a pulmonary embolism, so they had to postpone that and she is now on another treatment plan  She is scheduled to have her last chemotherapy on February 7^th

Better Health Care Delivery in Southern Ontario

Originally from Kapuskasing, her first cancer diagnosis in 2018 would have been while she living in Southern Ontario, where she would have had easier access to a family physician. She said that her “cancer treatment was very quick down South,” especially since she was living a few minutes away from the Credit Valley Hospital at the time.

She said that before she made the decision to move back to Northern Ontario, she was not aware of the doctor shortages and the other health care challenges in this area of the province, saying that health care delivery – access to research, treatment and care – is much better in Southern Ontario than it is up North.

“It is much better. There are plenty of walk-in clinics that you can go to in-person. My experience has been that they follow-up with you. It is more readily available. There are no physicians here (Northern, rural and remote Ontario).”

In Northern Ontario, doctor shortages have led to an increase in wait times across the board and cancer is no different.

“When I went to the tele-health walk-in clinic here (Northern Ontario), the nurse practitioner there in-person told me that the wait time for a doctor was between five to 10 years. And then people keep getting bumped because when a baby is born, they have first access, so you get bumped down the wait list.”

Improving Health Care in Northern Ontario

As to what she feels can be done to improve health care services in Northern Ontario, she said she would firstly like to see more doctors moving to that area of the province to practice medicine and believes that this could start by policy makers offering more incentives for these doctors to move up North.

“The easy answer is more doctors, but I know that that is not that easy. I think better incentives for doctors to stay up North because I do know that there is easy answer…Having more physicians here, the ones that are retiring, half the time don’t even have anyone to replace them. We are as they call them, ‘orphaned patients.’” 

Ruels said that this move would not only help with physician shortages in the hospitals, but also in the walk-in clinics. Having an in-person doctor as opposed to a virtual one would be a welcoming one for Northern Ontario residents, she said.

“We need more doctors or you know, in-person walk-in clinics would be great, which still requires doctors though – full-time doctors.”

Ruels said that to get a further glimpse into exactly how dire the doctor shortages are in Northern, rural and remote parts of Ontario, during her chemotherapy she met another cancer patient who is also a doctor and he was still working during that time because “he had patients who needed him.”

The Northern Ontario resident said that cancer patients in that area of the province are suffering as a result.

“The first doctor who took me on said that it was very rare for me to fall through the cracks, but I have met many, many other patients who have said that they have fallen through the cracks. Several chemotherapy patients that I have spoken to also did not have a follow-up. One said his doctor was retiring and he never heard back from his doctor, so he didn’t know about his cancer.”

And she believes that the doctors too are struggling under the workload and doing their best to keep up with the increasing number of patients.

“So the doctors that you speak to, it is almost a little difficult for them to get right perspective because they are seeing their patients, they are following-up with their patients, you know. It is really difficult to say what you don’t know.”

Patient Care in Northern, Rural and Remote Ontario

When she was living in New Liskeard, which was before her cancer diagnosis, she did have a lump which required some scans, and they sent her to Sudbury for it, which was almost a three hour drive one way to get the scans to see the doctor and then she had to drive back to New Liskeard.

“They (New Liskeard) don’t have doctors in walk-in clinics either. So if you want to see a doctor, you have to go to the emergency department. When I went there to get a check on something, I waited eight hours to see the doctor.”

And the same situation is present in other rural and remote parts of Ontario and extends to other illnesses as well, said Ruels.

“Here (North Bay) it is just as bad. I mean my son hurt his ankle once and we went to the doctor to make sure it was okay and people had already been waiting for 14 hours. So we turned around and went back home and said we will wait to see our doctor.”

She said that there are more doctors in Southern Ontario, but in order to see one in Northern Ontario, you have to travel three or more hours and when her father had a stroke a few years ago, he had to drive from Kapuskasing to Thunder Bay – which is about a seven hour drive – to see the specialist. And now, her father needs surgery for a shoulder injury so he would have to travel a long distance again, this time from Kapuskasing to North Bay to access this service.

As for what can be done to improve doctor-patient relationships among the physicians that are working, Ruels said that she would like to see more accountability when it comes to medical professionals following-up with their patients.

“Incentives for doctors to stay, something to attract them to come up North, accountability for follow-up. I feel that both doctors who didn’t follow-up with me, there should be accountability there and I don’t know how to go about that. Accountability on them to do their job. I want to be realistic. I know that it is not that simple.”

They also need to recognize the differences between Southern Ontario and Northern Ontario and act accordingly.

“We need Northern Ontario to be treated differently because we are a lot more remote and a lot more spread out. So it has to be looked at differently, with a different lens,”

Not Just a Northern Ontario or Cancer Issue

However, while the situation in Northern Ontario is dire, she acknowledges that the health care crisis is across Canada.

“It is all around. There are many people without doctors…It is across Canada because I do hear a lot going on in the West as well.”

She stated that she had a friend who lived in Ottawa, who after hearing her story, prompted him to follow-up with his doctor because he had a heart condition and he waiting for his results and he didn’t even know that his doctor had been on vacation for a month.

With this being said, more needs to be done to improve access to much needed health care services in the North because the situation is worse.

Following-Up is Crucial

Ruels stated that back in September, she came to the conclusion that “no news is good news, but that is not the case. It was not my case”

Therefore, she is advising other cancer patients to ensure that they follow-up with their doctors. “At the time ask when you can expect results. When can you expect to follow-up and then give them the day that they say and if they haven’t followed-up on that day, the very next day call, follow-up because your life could depend on it. That is my big message. Had I not assumed no news was good news, I might have prevented chemotherapy, By the time they had caught my cancer, I had four tumours in my breast and I’m only 46 years old.”

She said that things could have turned out differently if she had follow-up from either the doctors or the nurse practitioner informing her of her “suspicious” results.

“So this could have been handled much sooner and it would have been a lot less detrimental. I am four months off work, you know. It is a lot. So follow-up like your life depends on it because it does.”

She said they found three tumours in one breast and a fourth tumour which has spread to the skin, which they called a “satellite tumour,” all of which were at Stage Three. Since then she has had a double mastectomy.

The Importance of Patient Self-Advocacy

Ruels also advised persons to push back if they are not satisfied with the how certain things are binge done like the dates that you are given for your appointments for various tests.

She said that the dates that they were giving her were so far away, there no way she could agree to that because she is a cancer patient and survivor. She said that there are a certain amount of appointments per day that are reserved for emergency situations in Northern Ontario hospitals and people can see if they can get one of these appointments.

“So they need to be able to move things around in the case of an emergency. I am not saying that we need to take spots away from an emergency patient, but I am saying that there is room and you need to push back. Don’t accept it just because they say that is what we have. Push back and say, ‘No I need something sooner because my life may depend on it.’”

However, she stressed that they should only this if they have a life threatening illness. “I want to be clear though when I’m saying this, I am not saying it to everyone. I am saying that if you suspect you may have cancer, if you have found a lump, or if you have suspicion of something that could be life threatening, that is time sensitive, then push back. I mean if you just need a routine scan, then don’t take the spot of somebody who is more time-sensitive. But if you have a time-sensitive, life threatening (illness), then push back. Don’t just accept a date that is that far (away).”

When it comes to dealing with the physical and mental turmoil associated with having cancer, Ruels acknowledged that while this may not apply to all persons, she stated that it does get better.

“Just remember that it is temporary. Cancer isn’t always a death sentence anymore with the advances in medical science. I personally was terrified of chemotherapy. I thought I would spend the entire time sick in bed. They have such amazing medicines now to prevent nausea. I’ve haven’t yet to be sick.”

Navigating Canada’s  Health Care System

She also emphasized the importance of getting a doctor who would help you navigate Canada’s health care system and getting your results to see where you stand.

Cancer patients must also speak with their oncologist anytime they encounter any major issues like any side effects from medication and these clinicians would help with those issues.

She advised other cancer patients – and patients in general – to speak up and hopefully, this would lead other patients to speak up as well.

It is also imperative that physicians speak with their patients and given them an opportunity to ask any questions or to clarify any doubts because not every cancer patient knows how to advocate for themselves.

She said her doctor is great at doing this and she appreciates his efforts because there are cancer patients who may not have the courage to speak up and this is why it is essential for doctors, not just to follow-up with each patient, but also to leave enough room at the end of each appointment for patients to address any concerns.

“Follow-up. I would say that people don’t know what they don’t know So while it is impossible to go over every single detail of what might be, or to anticipate what the questions might be, lave that room at the end of your appointment to say ‘is there anything else that we can talk about. Do you have any other concerns. Ask those questions because not everybody knows how to speak up.

As for how physicians practicing in Southern Ontario can help their medical colleagues in Northern Ontario, Ruels said that while she can’t say how they can do this, following-up with their patients must be paramount. She said that her intention is not to anger or upset doctors, but to ensure that the patients who come to them, trust that they would provide that care to the best of their ability.

“I would say to those doing the tele-medicine, that they do have an ownership to follow-up. If you are taking on the role of being available as a doctor to people in Northern Ontario, then you are taking on that job. You need to do it completely. Just because it is not a permanent roaster station, doesn’t mean that you can allow it to slide through the cracks like that. You need to be on top of that. Do the job well or don’t do it at all.”

Advise to Ministry of Health Stakeholders Other Government Officials

As for policy makers, Ruels said that implementing solutions to address Canada’s health care crisis must be tailor-made to the complexities of the country’s diverse social communities and cultural differences.

“Recognize that Northern Ontario is very, very different from Southern Ontario. Recognize that it needs to be looked at with a different lens, you know. We are sparce. We are not as densely populated so there is a lot less available to us. So when you are doing your funding, keep that in mind.”

She highlighted an example where she had to go to Sudbury for her surgery because she couldn’t get it done in North Bay. Sudbury is nearly a two hour drive. There is a Northern Ontario Travel Grant available where they cover your mileage, and if you live a certain distance away, they would also cover hotel accommodation up to a certain amount for people.

Ruels said that while it is good that this exists, there could be more lenient with the restrictions. For example, she lives 10 kilometres too close to qualify for the overnight, but she still had to be there the day before because she had other appointments, so she had to pay for her own overnight hotel accommodation.

“Understand that if somebody is going to have surgery. They can’t drive to and back the same day. It’s just not possible. So give us a little bit more. We’re suffering here.”

The long travel distances to access cancer treatment and care is only one fraction of the problem There is also the case of sickness benefits, she said.

“This is a factor in my health process. So they want me to have radiation therapy, that would be 25 rounds of radiation, so it is five days a week. It is in Sudbury. I can’t afford more time off from work because you can have sickness benefits, but that only covers about 50 or 55% maximum of your salary. Well, I would loose my house, I’ll loose my car, you know I can’t feed my child, So 50 to 55 percent of my salary is not enough. I can’t afford to be off of work any longer. I have gone through my savings. I can’t drive back and forth to Sudbury because they won’t cover a hotel. So it is a two hour drive one way, plus the waiting time, then I get in for my appointment, then I have to drive back. That is half of a day. I would have to miss work five days a week.”

Her final treatment is in February, but she is “refusing it because I can’t afford to. I can’t afford to get radiation. Her options would be to stay in North Bay and hope for the best possible outcome.

“I am just going to have to be very diligent with my scans and you know, thankfully I now have a doctor to help me with that.”