Family medicine has been in the news lately, with accounts of a shortage across the country and medical graduates shunning the practice. There are many who think that family medicine is about simple infections, prescription renewals and providing referrals to specialists. Perhaps by sharing the details of a day in a life in family medicine, then my colleagues can either substantiate, educate or commiserate with my experience.
This is a play-by-play of my family medicine clinic day on a random Tuesday this summer.
I arrive at my medical practice at 6:15 a.m. There is a note that the patient washroom has been clogged from use during the walk-in clinic last night. We cannot have that with the patients coming in today – and plumbers are expensive. Wearing appropriate personal protective equipment, I grab a bristle toilet cleaner, multiple rounds of Liquid-Plumr, a very large plunger, and a smell-resistant mask. It’s 6:45 a.m. by the time I am finished. This should have been managed the night before and I will have to have a talk with my staff.
I spend the next 105 minutes reading charts for the patients I am to see this day. I have 42 booked patients from 9 a.m. to 8 p.m. with two one-hour breaks at noon and at 4 p.m. I make sure I have the necessary results, see what results are pending, prepare the charts with ongoing action lists, review consultations and so on. I don’t need to do this, and it takes extra time but if I am prepared for patients, the appointments go more smoothly. Asking “What are you here for?” is not efficient. Plus, even when I am prepared, I often get taken down new paths by patients and their families.
In the morning, I try to deal with a slew of daily tasks: messages about prescription renewals; Limited Use codes; early narcotics release; lost requisitions by patients; prescriptions for orthotics and other services covered by insurance; record requests from lawyers, insurance companies, dentists and various therapists; failed referrals to specialists without any guidance; pharmacist’s questions or back-ordered medications; complaints from patients that they want medications that are covered instead of medications that will help their conditions; complaints from patients about long waits; special requests to see a specific specialists; requests from chiropractors, physiotherapists and specialists for various test results; requests from specialists to take out stitches or arrange various testing; redirect referrals; send new referral requests since it’s been a year or specialists are no longer caring for that condition or no longer accepting patients; complaints from parents for impossible mental health support; questions about various naturopathic medications; piles of work-related insurance forms, WSIB forms, MTO forms, EAP forms, VA forms, MOH forms and so on.
This list is incomplete and never ends. And of course, many more similar requests pile on my desk while I try to deal with what I already have.
This will drain my soul
At 8:30 a.m., my senior administrator arrives. She knocks on my door to talk about patients who want to be seen earlier, have specific requests, want me to accept a family member, want to complain about my staff and clinic, discuss the clogged toilet, report that one of my secretaries wants to take a week off, find out that one of my nurses is struggling with burnout and wants to reduce her hours, and so on. We struggle to get through her list.
While we are talking, an unexpected patient starts banging on the door. We ignore it for a while, but she persists. Somehow, she convinces the staff and eventually me to aspirate her traumatic olecranon bursitis and inject it with cortisone and then apply a pressure bandage. This puts us behind by seven minutes for my first patient at 9 a.m.
This is not unusual
I start with a well-controlled diabetic and do the flow sheet. The patient needs all his medications and blood work requisitions for future testing. He has heard about the Libre system, and we discuss it; he wants to do his MTO, but we need to rebook; he needs his eyes checked so a form is produced and as I am ushering him out, he shares an erectile dysfunction issue which we must deal with. So, the first appointment that was to last from 9 a.m. to 9:20 a.m. starts at 9:07 a.m. and ends at 9:30am. I am 10 minutes behind schedule already.
I bring in the 88-year-old lady with osteoporosis failing on bisphosphonates and moving on to denosumab. She is frail and moves slowly. She came with her granddaughter, who is a nurse and wants to review all the bone density tests over the years and the t-spine X-rays. We talk about her compression fractures and her pain when lying down.
I go into my office and find a request to fill out a hearing-aid form that I complete and give to the front staff. A patient in the waiting room calls out for me to see their new baby. I play nice even though I am running behind.
The 9:40 patient starts at 9:55. This 44-year-old female has endometriosis, colitis, spastic bladder, depression, anxiety and sleep issues. She has been off work for a year on long-term disability. She finally saw an OBGYN, and recommended options were discussed. She did her own research. She brought in recommendations from her naturopath and chiropractor. Our appointment was a mix of counselling, correcting false information, guidance, support, discussing insurance needs and, I hope, moving her forward. I don’t know if I actually helped, but I do know we ended at 10:30 a.m.
Now I am 30 minutes behind. I go on to a 78-year-old diabetic with severe stasis ulcers (needing home nursing care) and a total left hip replacement; then a 2-month-old baby needing a Rourke and vaccinations with a first-time mom who is struggling with baby blues, not postpartum depression (thank goodness); then an 85-year-old who needs a health-and-medication review (hopefully deprescribing), is considering extra vaccinations, and a MoCA. This takes time. She has come with her two sons and they want to talk about competency and whether she should go into a home. She was unwilling. It is now noon and I am an hour behind. No lunch again!
Will I finish the last 6 people before my 1 p.m. patient? Why am I so nice?
The day progresses busily: a skin biopsy; multiple joint injections; a travel medicine consult with a family going to Nigeria; a suspect chronic Lyme patient; a schizophrenic unwilling to take his antipsychotic medications; a corneal abrasion; a patient with poorly controlled COPD and an unwillingness to stop smoking; an autistic young adult threatening his parents with violence; a sports medicine consult; a palliative care patient requiring CHF self-prescribing support; an obese patient with back problems wanting surgery but unwilling to do home exercises or lose weight; a chronically anxious patient with IBS wanting to stay off of work longer; and so on. Three patients did not show despite two reminders for each of them.
At 3 p.m., a patient comes in yelling at the staff to see me. It seems he ran out of his blood pressure medications months earlier. The pharmacist had renewed it three times for a month each time (a $15 charge each time, robbery he says) and told him to book an appointment with each renewal. He did not. And now he wants a renewal right away and is unwilling to book an appointment or wait to be seen at 8 p.m. at the end of walk-in clinic. He threatens to complain to the CPSO. He leaves me his number to call him.
I finally get to go to the washroom at 4:30 p.m. and then grab a late lunch/early supper. I managed to finish charts on half of my patients seen that day between 9-4:30 by the 5 p.m. evening clinic start. We have 12 booked patients and a few call-ins that need simple things (thank goodness). The staff leaves at 8 p.m. They have worked hard and dealt with many complaints, excessive demands and high expectations. I finish with patients at 8:45. I manage to deal with 10 per cent of my messages and complete some paperwork. I have about 20 charts to finish off so I stay until 9:30 to finish them off. The remaining 90 per cent of paperwork will have to wait until tomorrow.
My point: family medicine is challenging and complex
I hope that specialists read this and offer a day in the life of their medical lives, so we all understand that medicine is challenging and complex. We all work very hard and pointing fingers at each other will accomplish nothing.