I first met Jason ten years ago when he was a new and very stylishly dressed medical student; and I was a family physician in a small town eager to pass on my love for family medicine and the satisfaction this career can provide. Jason arrived early to clinic every day full of energy and charm with genuine excitement about the opportunity to learn medicine in a rural community. Jason put great effort into understanding the possibilities of a career in family medicine and trying to forecast his future career, interests, and family life.

Through the years I have watched Jason continue to impress and excel through medical school, family medicine residency, and into practice. I was not surprised to see that he set up a smooth-running practice surrounded by the family that is so important to him. No sooner had he entered practice than he joined McMaster faculty and began teaching, which is what he had been doing among his peers and juniors at every step along his training path. Jason’s strength in leadership and clear vision of successful medical education were evident from early days, and I was pleased to be involved in hiring him for his first junior leadership position at the medical school. Jason rapidly established himself firmly in a world where he was comfortable and talented, and he has climbed the ladder in medical education swiftly. As he has increased his influence over the teaching of future physicians, he has also increased his presence in leadership among his medical community and provincial organizations. When a difficult and contentious issue arises, I often find myself calling Jason to ask him about his opinion and understanding of the problem because I know he will be up to date, well informed, and decisive in his stand.

Jason’s very strengths are also sometimes his downfall. This dedicated doctor is too often popping in to the clinic to help out when he is on holidays or supposed to be away from the office. If you sit beside him in a meeting, you realize his phone never stops buzzing and he is usually carrying on at least four different text conversations, many related to patient care but also cute photo updates about his children that day, a few good-natured jabs at his brothers and sisters, and some checks in on sports scores from the many teams he follows. I have lost track of the number of times I have given him a lecture about setting boundaries, leaving the work to someone else, and walking away from the office from time to time. He tries to listen, he really does, but few other people will live up to the standards that Jason sets for himself, and so he continues to keep a close eye on so many of his projects.

In the Trenches is a brave and honest book as it provides a glimpse into the joys and challenges of medical school, family medicine, and the health-care system. Jason has never been one to make excuses for what does not work well in the system. He is usually the one shining a spotlight on the problem and then coming up with a creative way to address it. His opinions are strong and he is vocal; however, his advocacy comes from a place of genuinely wanting to leave the world, the health-care system, and each individual he encounters healthier from his presence. This book provides an inside look into one man’s path to choosing a career in medicine, some of the challenges he faced in training, and an honest and candid picture of the daily life of a doctor who seems to have it all. The sacrifices he makes, the rigor with which he lives his life, and the dedication he gives to everything from his exercise routine to his office set-up is evident as he allows us into his world.

By inviting Dr. Emily Dewhurst to collaborate on this project, Jason demonstrated the true teacher and student advocate that he is. We are fortunate that, through Emily’s writing, she allowed us in to the vulnerable, exciting, and terrifying places that medical students are required to inhabit. Through her recounting of stories, we see the transformation of a medical student from learner to professional, and see the struggles of being ushered into the health-care arena as a provider. She is bold and brave in exposing the challenges, the barriers, and both the excitement and heartache of medical school, and I hope her honesty allows us to improve the process and help future physicians learn from our experiences.

Jason’s honesty in the highs and lows of his career to date, the challenges he faces, the successes he has seen, and the room for improvements is unwavering. This is in complete harmony with who Jason is in all areas of his life. Devoted father, brother, husband, and son; committed teacher, administrator, and leader; dedicated physician, colleague, and employer. For all the good and the bad, those of us who are fortunate to care for patients, to teach future physicians, and to influence medical school directions are in a privileged position which we should not take for granted. Jason’s stories cause me to reflect on my career path, training experiences, and patient encounters that have profoundly shaped who I am today. I am thankful for these reminders and hope to never lose sight of the reasons I chose this road.

I was greatly touched when Jason approached me to write this foreword. It is a privilege to be a colleague of Jason’s and I have no doubt, as I watch his career grow and flourish, that the student has surpassed the teacher in knowledge and ability. As I have from the beginning, I continue to follow Jason’s career with joy, pride, and the optimism of knowing the world is a better place, and health care has a strong future because of physicians such as Dr. Jason Profetto.

I once worked with a physician author back in medical school. It was an interesting experience to pick his brain about how (and why) he practiced medicine and also wrote books. When I asked him how he did it he said it was simple, “Every day for six months I spent fifteen minutes early in the morning writing. Six months later, I had an unedited manuscript.”

I’ve always wanted to write a book and felt like I had much to share. So I tried it, and it worked. I committed fifteen minutes every morning at 4 a.m. to writing, and did this every single day (work days, weekends, vacations, every day) for four consecutive months. In the end, I held a manuscript of 50,000 words.

Through my teaching experiences to date, I’ve also encountered many medical learners, students, and residents of all levels and from all walks of life, people who I thought would make excellent contributions to the book. One lady in particular, Emily, is an individual whom I’ve worked with often, and realized that she was perfect for this endeavour. She shared with me many thought-provoking perspectives on life and medicine. She amazed me. I knew then that she had to contribute to the book.

Emily, now a resident doctor in family medicine, was a former student of mine in multiple settings. I taught her at all levels during her medical school experience at McMaster University. She had scars on her arms which presumably were from previous self-harm incidents, and when I asked her if they were, our conversation bloomed.

Emily is very insightful, intelligent, and reflective. She was able to engage in dialogue about some fairly difficult and dark times in her past. Initially I think this proposition scared her, but after some nudging she agreed. Emily provided me with ten compelling chapters, and I am so fortunate that she did. Her thoughts and views are well articulated and you will find her insights, from the perspective of a medical student, scattered throughout the coming pages.

This book is about family and academic medicine. It’s a memoir of sorts with story-telling and reflection, as well as a slice of life advice. The stories are true and accurate, with patients’ particulars omitted of course. I talk about both positive and negative experiences and how they contributed to my growth and learning as a person while winding my way through the medical system. Some chapters are concise, others more detailed.

I encourage medical and non-medical people to read this book. It’s my hope it will shed light into our profession, and what we actually encounter on a daily basis. I should clearly state how fortunate I am to be in medicine, at the same time acknowledging how challenging the daily grind can be.

The title is a metaphor to describe what it feels like sometimes to walk a day in the shoes of a family and academic physician. I hope not to be overly cynical but rather honest, not jaded but genuinely reflective, not a pessimist but a realistic optimistic.

And finally I wish to thank my publisher, Sheri and I C Publishing, for their fantastic support and wise guidance in producing this final product. Without writing, my thoughts are merely collections in my mind, and without my publisher my writing is merely scribbles on paper.

Before you indulge, please remember that success is not a destination to be chosen. Rather, we shall choose, without any guarantee, to endure and overcome the struggles and endeavours that may or may not lead us to success. Always enjoy the process, not just the destination.

A classmate of mine was the first to mention the concept of dark spots to me. We were discussing an ethical dilemma in medicine, and she raised some thoughts that made her feel uncomfortable. She emphasized the importance of bringing the dark spots into the light, forcing them to be seen, to allow us to learn from ourselves. For if we do not shine a light on the darkness of our minds, how then can we grow?

Living in a mind that is tarnished by depression has forced me to simultaneously live in a swirling wind of dark spots and become an expert at suppressing them. After all, patients don’t want a doctor that can’t handle her own emotions. And clinical instructors don’t want a student with anxiety or scars all over her arms.

When I met Dr. Profetto, and he asked so openly and unashamedly about my experiences with self-harm, I was surprised to feel so refreshed. To have a mentor that would not judge me for my struggles, but continue to teach and encourage me to grow as a clinician, was life altering. Dr. Profetto helped me to transform this darkness into a guiding light for patients struggling with similar issues.

At first, I was hesitant to write a contribution to this book. Once my chapters were written I even toyed with the idea of publishing anonymously. But then, who would I be? What would the purpose of these chapters be? We all have dark spots. I hope that reading about mine will crack open the cobwebbed doors of your mind and shed some light on yours.

Functional problems rule the medical world, but what are they? Simple really … they arise out of a patient’s lifestyle (mainly) that is causing a concern. Think about an individual’s lifestyle; their patterns of sleep, nutrition, exercise level, stress, work or school schedules, family, etc. These are prominent pieces of our lives that affect us and how we feel. Not enough sleep? Too little exercise? Eating poorly? Arguments with your spouse? Foggy … Weight gain … Stress … They’re all functional problems.

Statistically, many individuals, especially those who are middle-aged or older, are more likely to have a functional problem, and that is exactly where I started; or at least where my mind started. I haven’t even described the point at which I started to speak to my patient, so I hope you appreciate just how complex the thought process is during an observation to determine why a patient initially comes in. That is why it’s paramount to first listen to an individual before a doctor begins to make deductions, with potential bias, cognitive distortion, and error.

After some further discussion I successfully determined that she was otherwise completely well; no respiratory, cardiac, gastrointestinal, or genitourinary signs or symptoms that would make me worry. We did blood work to look at the different medical causes of her fatigue, with normal results. I completed several physical exams; normal. She followed up to see me and repeat testing and blood work were carried out—again normal.

I advised her that the issues were mainly functional; she was stressed, sleeping poorly, not eating properly, and needed to start exercising more.

Three months later she returned to see me because now her right arm is tingling. The fatigue she noted was still there and perhaps worse. A neuron in the back of my brain was also tingling and a flag went up. Did I consider neurological causes? Nope.

One week later, a MRI of my patient’s brain showed multiple white matter lesions, suggestive of a demyelination problem. In this instance, it was MS. Even worse, I missed it. Let’s get this correct; I dismissed it.

What’s the point of such an incriminating story? Simple: It ain’t easy. This whole game of “playing doctor” is challenging and complex, especially as a front-line clinician. So why does one wish to get into this field to begin with? That is where we go next … back to the beginning.

The running joke in my family is that my mother is the brilliant one, and while my father is still quite smart, he is the beloved “donkey” because he is such a hard worker. I don’t think my mother has ever had her IQ tested, but I can quite confidently tell you that it’s at least two standard deviations above the mean, when compared to others in North America. I believe three standard deviations above the means is what constitutes a genius, and she is probably pretty close to that.

That said, I’ve always thought about being a doctor too. In elementary school, it was a far-stretched aspiration, but an aspiration nonetheless. It wasn’t until the latter part of high school though that my ambitions started to materialize. Then I really began to look at medicine more closely as a career and started to plan my road ahead. I think this is a valuable point to highlight; our future goals are never guarantees, yet reflect what we are capable of doing by putting in place the appropriate and logical steps in order to optimize our chances and create opportunities. Then, if and when an opportunity should arrive, it is at this point that we try to solidify our goals and successfully complete the application cycle.

As I neared the end of high school, I thought about the different potential undergraduate degrees I would pursue to facilitate my path to medicine. It was incredible really (and still is to the present day) how often poor advice is provided from those who have gone through university to those wishing to apply.

I was particularly interested in anatomy, human physiology, and sport. After a bit of research, the program which provided the most for these areas of science, in my opinion, was kinesiology. So I decided to pursue kinesiology as an undergraduate degree prior to applying to medicine.

I remember vividly the day that our high school class found out which university programs we were accepted to and would be pursuing in the following academic year. When I told my friend, Evelyn, that I would be entering kinesiology at McMaster, she looked disappointed and told me, to which I quote, “Ah Jason, kinesiology isn’t a good degree; you can’t do anything with it afterwards.”

For a moment I felt dejected, yet motivated simultaneously. Firstly, why would someone actually say that to me? I could never imagine saying that to someone else. Personally, I would rather be positive and encouraging. Secondly, I loved the comment and embraced the criticism. I thought to myself, finally, a chance to prove others wrong.

McMaster is innovative. It is the home of evidence-based medicine, problem-based and self-directed learning. We have limited exams and lectures and focus on newer, more creative ways to learn and retain information.

What I found more interesting about medical school though was not related to the academic rigor involved in doing well, but rather how complex and difficult some of my fellow student colleagues were. I witnessed first-hand the overly competitive, anti-altruistic, and at times, contemptuous manner with which students treated one another. How could we have worked so hard to come so far and yet even at this successful destination, we still didn’t truly appreciate the value and role of collegiality and collaboration?