Winter 2020 (Volume 30, Number 4)

Hugh's Legacy
Reflections from the Northern Ontario Outreach Clinic

By Laurence Rubin, MD, FRCPC

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In October 1992, Hugh Little died suddenly. He was 58.

The previous spring, I had accepted the offer of Division Head, Rheumatology, at Women’s College Hospital. I had discussed this with him at length, and despite the impact it would have on the Sunnybrook Rheumatology Division, he strongly encouraged me to apply and supported my move. He was my mentor, my friend and an invaluable support during my post-doctoral years. He had recruited me to Sunnybrook, my first staff position. He was a leader, with a demanding academic and personal standard, but also a generous heart and an acute sense of humour

And while I had performed limited clinical activities in my years at Sunnybrook, one that I enjoyed immensely, was our semi-annual visit to Timmins for the Arthritis Clinic.

Hugh had started this program in the early 1970s as a travelling Arthritis Society program in Northeastern Ontario, with Timmins as the natural hub. In those days, rheumatoid arthritis (RA) management consisted of prescribing aspirin and injectable gold, along with the judicious use of steroids.

Many of the rheumatology residents who passed through Sunnybrook accompanied Hugh on these trips; a Thursday night arrival, check in and dinner at “The Senator,” the preferred (and really only) hotel in town, frequented by mining executives. The restaurant had a well-earned reputation for its menu and wine list. The dinner was both liquid and filling, but the next day at 7 a.m. it was time for a quick breakfast and heading, by foot, to clinic. The late Bill Bensen told me several times about the rigours of his frozen trudge up the hill to St Mary’s.

In the late 80s, Hugh asked if I would be willing to join him. The Sunnybrook rheumatology fellow at the time had a mortal fear of flying and refused the offer. I immediately said yes.

Following that visit, and at my request, I became a regular. Thus my 30-plus-year relationship with Timmins began.

When Hugh died suddenly, I was, by default, in charge. The hospital was grateful for my willingness to carry on and provide what they had felt was an important and critical service. This longstanding commitment and relationship has served us all well.

With a local population and catchment area totalling 60,000, and a focus on inflammatory rheumatic disease, predominantly RA, we developed an effective, efficient and sustained model of care. This has been the result of multiple contributions, and in particular our partnership with the Arthritis Society. After Timmins local and long-tenured Arthritis Society therapist Geraldine Carlier moved to Beirut, we were incredibly fortunate to recruit Mary Ellen Marcon from Sault Ste Marie. Mary Ellen was an inaugural graduate of the Advanced Arthritis Practitioner Program (developed by Rachel Shupak). I participated in the training program in Toronto; it was there that I met Mary. Both on site as well as through remote involvement, and with a deep first-hand knowledge of the region, she has been critical to our success over the years.

In 2000, Simon Carette joined the program. Simon had a very close association with Hugh Little during his training at Sunnybrook and beyond. In 1983, he co-authored a classic paper on the natural history of ankylosing spondylitis. Simon had participated in remote clinics while in Quebec City, and I knew him to be a skilled clinician with a keen sense of humour – an absolute requisite for Timmins, and he was fluent in French!

In 2000, we moved to the new Timmins and District Hospital (TADH). Over these past two decades, we have been extremely fortunate to have skilled clinic nurses, coordinators and volunteers, with whom we have established meaningful relationships, despite our intense quarterly two-day visits. We have sufficient space, the full spectrum of technologies and laboratory services, and all the needed pathways for excellent rheumatologic patient care in the 21st century. We have continuously engaged the primary care physician groups directly and through continuing medical education (CME). We even stayed for many years in an old mining executive house converted to a bed and breakfast, owned by one of the town’s longest serving family doctors. We have eaten at almost all the reputable, and some less so, dining establishments in town. Casey’s remains our diner of choice, as Simon can always count on his favourite peanut butter/brownie dessert!

In 2013, we began accepting patients from Kapuskasing, after the sudden departure of the previous visiting rheumatologist. Simon initially wanted to make separate day trips there, but I reminded him it was 150 km away, on a two-lane highway, and in the winter, we might encounter the occasional moose! We have also received referrals from remote Indigenous communities along James Bay, and met recently with the local ophthalmologist to collaborate on the management of uveitis.

Two and a half years ago, Simon and I agreed to offer an elective for rheumatology fellows in Timmins. With the support of the Rheumatology Disease Unit (RDU) Education Director, Dr. Dana Jerome, we brought our first senior trainees, Dr. Sahil Koppikar and then Dr. Bahar Moghaddam. In typical Timmins’ experience, we even celebrated Bahar’s birthday last December with champagne, “chilled” in the hospital parking lot snow drifts!

And now, we have both stepped away. My last visit was in June, virtually, of course, courtesy of the pandemic, but Simon made it up to Timmins in early October. Mary Ellen, after her more than two decades of dedicated service, retired in 2018. We were fortunate again, with the support of the Arthritis Society, to recruit Lynn Richards from Kingston, who has now been thoroughly inculcated in the “Timmins way.”

Sahil expressed a keen interest in the program and excelled from his first visit. I am very pleased that this past July, he assumed my role as Director of the TADH Arthritis program. Simon and I have every confidence in his skill and vision. He will also recruit to replace Simon’s position.

These thirty-plus years have passed quickly. I am very proud of what we have accomplished. We built and sustained a model of inflammatory arthritis care, expanding educational opportunities, and most importantly developing a viable succession plan in a remote Northern community. Sahil and his colleagues will undoubtedly evolve and improve this program, and I look forward to watching the changes.

We have been incredibly fortunate to be rheumatologists in this golden age of our specialty. The Timmins clinic is a microcosm and a living laboratory to effect and observe the results of these advances in a unique and grateful community.

And finally, thank you, Hugh, for asking me to join you; and thank you also to the anonymous resident whose fear of flying opened an incredible and gratifying life experience for me.

The Timmins team. Pictured from left to right: Drs. Laurence Rubin, Simon Carette, Bahar Moghaddam, Sahil Koppikar, and Lynn Richards.

Mary Ellen Marcon (on the left) and Denise Marin (on the right) from the Arthritis Society.

Laurence Rubin, MD, FRCPC
Staff Physician,
Department of Medicine,
St. Michael’s Hospital
Professor of Medicine,
University of Toronto
Toronto, Ontario

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