Enough is enough: An exasperated plea from family doctors

Enough is enough: An exasperated plea from family doctors

By: Dr Laura Sang

 

Access to primary care for patients without a family doctor is about to get even harder as of May 31 when the government is shutting down the program "Projet de loi 11". This program was instated in 2022, allowing family doctors to open walk-in appointments to the public for patients without a family doctor. During its operation over 900,000 patients (many of whom were vulnerable) were seen by family doctors participating in this program according to FMOQ statistics. Approximately 138,000 of them were individually rostered by a family doctor as a result. While this was not a perfect solution for patients and family doctors alike, it allowed for increased access to frontline care which ultimately decreased the number of non-urgent visits to the ER.

 

We are currently short of about 1200-1500 family doctors in Quebec and have about 100 less practicing in the public system compared to 2019 as per FMOQ statistics. What is the driving force of the exodus to the private system and early retirement? It mostly boils down to poor working conditions. Firstly, family doctors practicing in the public sector are highly regulated unlike anywhere else in the country. PREMs (regional physician resource plans) force physicians to practice predominantly in a specific region - i.e. 55% of your billing must be completed within that given region.  Inasmuch, family doctors are held to 12 hours of AMPs (specific medical activities) per week for the first 15 years of practice. A physician can change AMPs every 2 years and must select their AMPs from the list of available options, which can change every few weeks. Many physicians are obliged to work mixed AMPs meaning they are forced to work in multiple locations, which by default limits their availability for patient emergencies. Any failure to comply with the PREMs and AMPs results in a 30% cutback on physician billings to RAMQ. This is important as between licensure and overhead costs in office (family doctors must pay clinic rent to work) it costs about 50,000$ a year just to be a family doctor. There is no paid vacation, no paid sick days, no pension so we need to plan accordingly to secure our futures. We are subject to similar restrictions as would be a salaried government employee without any of the benefits. No wonder the private system may appear so attractive to many, especially to new family doctors fresh out of residency. 

 

However, throwing more money at family doctors isn't what is needed. Many people are leaving the public sector because they have no other choice as they can no longer cope with the demands in the public system. A national survey of physicians conducted by the CMA in 2021 showed that 48% of physicians tested positive on depression screening, 53% signaled high levels of professional burnout, 49% were planning on reducing their clinical hours or stopping working altogether over the next 2 years, and 79% had a low score for personal fulfilment. This is in part due to the increasing patient complexity and lack of support from allied resources. Wait times for imaging and specialist consultations are increasing. Many specialists now act as consultants to be able to see a higher volume of patients. This means that they cannot follow up their patients but instead will provide family doctors with a list of recommendations of investigations and treatments. Family doctors must then order imaging and trial medications before being able to refer to the specialist. Another burden faced by family physicians is the administrative burden, most of which is unpaid. Insurance forms, following up test results and other various administrative tasks amount on average to an extra 10 hours of work per week according to a recent CMA survey. 

 

We have known about this looming healthcare crisis for decades. It was never a question of if, only a question of when. Its arrival is merely hastened by the COVID-19 pandemic and a variety of other socio-political factors. It is time for action and accountability on the part of our government. Primary care is the backbone of our healthcare system. Without it, people will experience unnecessary morbidity and mortality, and our healthcare system will pay more for it. Let us treat and manage peoples' high cholesterol to prevent a future debilitating stroke. Let us diagnose and control peoples' diabetes to prevent a foot amputation thirty years down the road. 

 

The proposed changes would likely save the healthcare system money in the long run. We know what we need, but we are waiting for a government that is willing to listen. We need to do away with the PREM and AMP systems or at the very least be more flexible with them. We need financial incentives instead of fines. We need compensation for unpaid administrative tasks. We need safe workplace environments and reasonable work hours for physicians, nurses, and all other allied healthcare professionals to keep people from burning out. We need officials to stop making decisions for us without us.

 

References:

https://www.cma.ca/latest-stories/profession-under-pressure-results-cmas-2021-national-physician-health-survey

FMOQ

AMOLL

 

Do no harm - it's not as easy as it looks

This week was filled with sleepless nights, tossing and turning, the hamster wheel in my head whirling wondering what I could have possibly missed. One of my seemingly well patients came in asking for a routine treatment. I asked all the right questions, did the appropriate vital signs, and a complete physical exam. The treatment that I provided was reasonable, evidence-based and guideline-supported. And yet, I got a message the next morning that my patient deteriorated overnight and died suddenly the next day. I spoke to a family member asking what had happened and the death seemed unrelated to the care I provided. I poured over their chart reviewing past and current notes, bloodwork, imaging. Nothing. Nothing that I missed, nothing that could have clearly precipitated her death. I had caused no harm, it was simply her time to go.

We are indoctrinated from early on in our training to "do no harm" when caring for patients. However, as I progress through my career the definition of harm has changed. There are clear forms of harm like prescribing a medication that someone is allergic to. And then there are grey zones of harm that are much more challenging to navigate. Chemotherapy is an example that comes to mind. It's one of the mainstays of cancer treatment aimed at targeting rapidly dividing cancer cells to save a person's life. However, chemotherapy comes with many side effects to varying degrees that can deeply affect a person's physical and psychological wellbeing. We accept this harm to prevent a greater harm - death. 

While originally this concept of "do no harm" was developed for direct patient care, I'd like to argue that it can be applied to our healthcare system at large. Lack of access to primary and preventative care means more ER visits and longer patient wait times. Delays in colonoscopies and other investigative tools means progression of disease burden. Significant delays in access to specialists means more visits to the primary care providers, leaving less time to see other patients for minor emergencies and preventative care, which can in turn lead to more ER visits. Redistributing the responsibility of patient care increases the risk of healthcare provider burnout and further fueling this vicious cycle.

In my everyday patient interactions "do no harm" is always on my mind but not in the ways one might expect. Do no harm to the person in front of me. Do no harm by putting in safety nets for patients to prevent unnecessary ER visits. Do no harm by putting the time and detail into my consults to make sure that they are prioritized appropriately by patient needs. Do no harm by delegating tasks to colleagues (while simultaneously not overburdening them), and setting boundaries with myself to prevent burnout. Do no harm -it's not as easy as it looks.

Family Physicians: The Safety Net of our Healthcare System

"I'll take my chances at home; I'm not going back there. Last time when I had a stroke, they sent me home without catching it, and when I had a blood clot in my leg, I waited seventeen hours before being seen. I understand the risks, but I just don't feel safe going back there," she said solemnly. Her face was pale but her expression decisive. I looked down at the typed note in front of me - my clinical assessment strongly suggested a heart attack in progress, but I couldn't be certain without an electrocardiogram (ECG) and blood work. Instead of sending her to the emergency room (ER) as I felt to be medically necessary, I respected her wishes and via shared decision making devised a plan together to manage the situation as an outpatient. This mostly involved me arranging follow up with the pharmacist, urgent blood work, serial ECGs, an urgent cardiology consult, and frequent phone calls with the patient.

 

I never expected the Hippocratic oath I took all those years ago stating, "do no harm" to become "mitigate the harm done by our healthcare system". From the staggering wait times to medical errors/negligence, patients have become increasingly reticent to go to the ER. There was always some hesitancy, but it has only escalated since COVID. The fear of wait times, past negative experiences, and mistrust are all reasons patients have cited when I have advised them to seek emergency care.

 

In medicine we learned about something called "the Swiss cheese model". This model represents the various safety nets put in place to prevent adverse events from happening to patients. Like lining up slices of Swiss cheese, the ideal scenario involves the holes being staggered so that while an individual may pass through one or two holes, they will eventually be caught by another layer. Redundancy in a system is critical for safety. However, if the holes line up perfectly, a person may pass through all of them without being caught and something bad may happen. For example, imagine a medication error where a doctor prescribes an antibiotic that a patient is allergic to. Ideally this should be caught by the doctor re-reading their prescription. Yet if it is missed, the other barriers in place include the pharmacist reviewing the prescription, and the nurse cross-checking the medication before administration. On a more systemic level, slices would include accessible primary care/walk-in clinics, abundance of commonly used medications, and timely access to hospital care. Every time we cut corners, another hole is added to that slice of cheese. Forced overtime for nursing staff means more burnout and a higher number of patients assigned to one nurse. Insufficient PREMs (permits doctors need to practice in a given region in Quebec) in an area with high rates of doctors retiring means decreased access to primary care. Inadequate ward staffing means less beds open and longer wait times in the ER.

 

Not enough recognition is given to the critical role family medicine doctors and other frontline workers play in filling the holes of our Swiss cheese model. From catching a cancer on a scan that was missed while a patient was in hospital to frequent follows ups with the suicidal teen waiting to be seen in psychiatry despite repeated visits to the ER, sometimes we are the only slice preventing an adverse event - an overwhelming burden adding to the many reasons why primary care physicians are leaving the field altogether. 

 

The above scenarios do not reflect negligence or incompetence on the part of any individual, but simply exemplify the outcomes when healthcare professionals are overburdened and forced to care for more patients than they can reasonably handle. Instead of forcing primary care physicians to take on more patients or other band-aid solutions that look good on paper, we need our government to work with us at all levels of the healthcare system. Else the holes in our Swiss cheese will only continue to grow until there is nothing left.

 

A day in the life of a family doctor

I roll out of bed at six am trying not to disturb my dreaming partner. After throwing on a hoodie from the pile of clean clothes I haven`t had time to put away, I fix myself a cup of tea and a bite to eat. As soon as that first drop of caffeine enters my bloodstream, I open my computer to review patient charts in preparation for my upcoming clinic. My inbox has about twenty messages from the day before, including one from a secretary stating that my patient -a single mother of two, recently diagnosed with breast cancer- was in distress as her insurance refused to cover her salary while she is off work undergoing chemotherapy treatments. I request that the patient be booked during yet another lunch break to see what can be done to help her out. Next, I print out a slew of drivers license renewal forms and insurance forms to complete as soon as possible. Each sip of tea is a guilty reminder that I meant to complete these days ago. After a brief good morning exchange with my partner, I drive to work to start my day of seeing patients. 

Bzz..bzzz...bzzz.... I silence my phone apologetically, ignoring the never-ending stream of emails about pandemic precautions, equipment shortage updates, and which personnel are out on sick leave as  a young eighteen year old sobs in my office. She is struggling to return back to school after being raped. Her appointment runs into part of my lunch break as I support her through the decision making process of whether or not she should take legal action against the perpetrator. The remainder of my lunch break is spent calling back patients with urgent lab results and speaking to the nurse from the rehab center I work at twice a week, trying to manage hyperglycemias and headaches at a distance.

While the last patient walks out my door at about five pm, my work day is far from over. I have a new pile of insurance forms, prescription renewals, and specialist referrals to complete. I spend the next two hours trying to finish charting all patient interactions. I spend extra time thoughtfully re-working yet another rejected insurance form so my patient with crippling depression after his son's suicide will continue to be paid while on work leave. I receive a result from a CT scan showing a brain tumor and ask around trying to figure out the fastest way to send the patient to neurosurgery and organize an appointment to discuss the result. After a brief dinner and an hour spent catching up with my partner at home, I skim through all the blood test results that accumulated throughout the day through fluttering sleepy eyelids to make sure there is nothing urgent before I  roll into bed to do the whole thing over the next day. And the next, and the next. By the time the weekend rolls around (and I am not scheduled to work) I stumble into bed and sleep for about 12 hours. 

I wish I could say that this scenario was unique to me, yet this reflects the reality of most family doctors in Quebec. Vacation and time off in our profession is hard to come by as family doctors in Quebec are considered entrepreneurs. This means that we pay rent to work in our family medicine clinics. We don't have paid sick days or paid vacation days, or pension. Any days of respite are unpaid. Inasmuch, we are only paid for patient interactions and next to none of the administrative tasks that take place after seeing patients. So we work and work until we burn out or leave the field all together because we simply can no longer bear the weight of our overburdened health care system. To make matters worse medical students and residents see our struggles and fewer are choosing to enter our specialty. 

Family medicine is an incredible specialty and I feel privileged to do the work that I do. Yet it stings every time I see news headlines stating "family doctors don't work hard enough". There is so much hidden labor that goes unacknowledged and simply asking family physicians to take on more patients won't necessarily improve access to and quality of care. The solution is far more complicated. Thus, the next time you feel frustrated as to why your family doctor has no availability, remember it's because we are working day in day out behind the scenes to fill out your forms, refer you to specialists, follow up your lab results, and manage emergencies when they come up. We are working for you even when we don't see you.

Sixth wave or not a sixth wave: Depends on the testing

 As we are at the cusp of loosening restrictions on masking and other public health mandates, there has already been a jump in cases. Many indicators suggest that this could be the start of the 6th wave, however without adequate testing we have no way of capturing if the rise in cases is beyond expected. 

Despite the theoretical availability of rapid testing kits at pharmacies and other locations, many people have been unable to acquire them. Since you are prohibited from taking public transit when symptomatic, PCR testing is then only accessible via drive-through. This is impractical for people who cannot drive, cannot afford taxis, or do not have access to cars. When trying to order home testing kits online, the average delivery time is 5-7 business days, which is too long of a window to accurately capture positive cases. In addition, several websites are out of stock anyway. Lastly, while private PCR testing is potentially more accessible it is unaffordable for many people.

So where do we go from here? The only way to understand the evolution of cases is to collect the data. Without access to testing, we could easily underestimate the number of cases circulating in the community until it is too late. I would like to advocate for the distribution of rapid testing kits to all households, systematic testing in high risk environments to capture asymptomatic cases, easy reporting of positive at home testing results, and clear public health guidelines on when/how long to isolate. 

A rise in cases with the ease of restrictions does not automatically indicate an impending 6th wave. Yet, we will never know the difference unless we look for it. 

Life on the wards with Omicron

 As I rummage through the N95 mask cabinet I finally find the one in my size...it's the last one. I hope when I have to change it in a few hours I'll be able to find the same one on another floor. That familiar sharp almost chemically grassy odor penetrates my senses as the mask is applied firmly to my face. I adjust it to seal tightly around my nose, trying to avoid applying maximum pressure to the bruised areas underneath. 

I gown up with my mask, googles, and face shield to start rounding on my patients one by one. After seeing them I review their labs - another two are now COVID positive. That explains why Ms. C was so sleepy this morning and her toast sat untouched by her bedside. One patient who was admitted for an upper GI bleed is due to go for a special test today...provided they are COVID negative. When I called the gastroenterologist in charge to organize the test, I was told I was lucky that I only needed it now; they were unable to do it a few weeks ago because all the personnel were out with COVID and there were not enough staff available to complete the test. I hoped my patient's repeat COVID test would be negative so we can understand why they have been bleeding and can be discharged home safely. 

One of my other patients - admitted for a bacteremia (bacterial infection in the blood) - needed a repeat cardiac echo (an ultrasound that looks at the movement of the heart, how the valves are working, etc.) to make sure there was no damage done to the heart. We had tried the procedure from the outside (transthoracic echo) but the image quality was poor. This patient needed something called a transesophageal echo. This is a procedure where an ultrasound probe is inserted down the esophagus to visualize the heart from the inside. However, this patient was on a ward with an active COVID outbreak. After much discussion with the cardiologist we all decided that the safest thing for everyone would be to postpone it till COVID had calmed down. The procedure can be associated with a lot of coughing and would increase the risk of COVID spread to the staff. 

My evening shift in ICU started with a printout of the COVID protocol and signover for the many patients admitted to the ward - over half were there for COVID. A patient's worried daughter called asking for an update; I told her we would call her back. All the staff were in said patient's room, flipping them over for the night. Putting these ICU COVID patients on their stomach seems to help with oxygenation. I was instructed to follow up on bloodwork for this same patient that came back with concerning results. However I didn't get the chance to call my staff as a new transfer arrived with a deteriorating respiratory status from one of the wards. I read the chart "severe COVID pneumonia, patient unvaccinated". I scrambled to assess to be able to call for help early if intubation was required, having to remind myself  to step out soon to call back the blaring alarms of my pager - I was being called from other areas of the hospital. 

This wave feels different than the previous ones. People are less sick generally speaking due to vaccination and the properties of this new variant. However, because it is so contagious the sheer volume of people who are sick is that much more. While most will be mild cases, a small proportion - especially if unvaccinated - will end up in hospital/ICU.  The issue is that when you have a huge portion of the population sick with COVID, in absolute number of severe infections still translates to more hospitalizations than during previous waves. Even more challenging are the staffing shortages created by the healthcare workers who are infected and having to stay home to prevent further spread. This impacts EVERYONE's ability to get medical care of any kind. THIS is why public health measures are necessary to curb infection rates. Our system is overwhelmed, our workers are overwhelmed, we all are overwhelmed. So please I urge you to find that strength inside you to continue to follow public health guidelines. Mask up, stay home, stay safe, stay strong. 

A Thankless Thanksgiving

Thanksgiving feels different this year. The once vibrant autumn leaves seem dulled, the days more cloudy, the pumpkin spice lattes less festive. Oh yeah, that's what burnout feels like. Approaching the two year mark into this pandemic, I'm not the same person I was before. 

I used to tell everyone that I loved people, that I was a people person. I used to easily find the good in everyone and cherish the little moments of humanity shared with my patients. I used to feel a sense of devotion and calling to sacrifice myself to try to fill the cracks of our broken healthcare system. I haven't seen that person in a while.

At the start of this pandemic, we as healthcare workers rolled up our sleeves, hugged our families, and threw ourselves head-first into the frightening unknown of this virus. I personally sacrificed my health and ended up hospitalized with COVID-19 during the first wave while trying to care for complete strangers. The patients who once thanked me for my service now roll their eyes when I ask them to put on their masks so I can examine them. Every nose out of a mask in the metro is like a punch in the face. Every maskless person on the bus is a kick to the gut. Every anti-vax person is a painful reminder of how I could have easily lost my life to this virus.

The conspiracy theories run rampant and we continue to see vaccine hesitancy brought about by false claims and poorly disseminated health information. I feel like science rejecters and myself live on completely different planes of existence, with a framework of reality so different from mine I can't even begin to understand their perspectives. When I examine their newborns in the nursery, I feel a sense of longing and a twinge of jealousy; they are so pure and innocent, not yet hurt by the world. People care about them, want to help them, want to love them. Their cries pierce my soul because instead of the joy of new life I see flashbacks to young mothers on ventilators barely pulling through.

So while I recognize my privilege in life and in this field, I also continue to live and breathe the collective trauma that many have now left behind. While I am thankful for the development of these life-saving vaccines, it is a thankless thanksgiving to have to watch so many die simply because they refuse to take it.