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.