September 09, 2003 Volume 39 Issue 32 (Medical Post)

SPIRIT OF MEDICINE

Family practice has worn me out

Needless to say, there was no lunch for my staff or me that day. We all went home feeling utterly exhausted

I cannot sign this article because I don't want my patients to know I am worn out by this job and actively searching for an alternative.

After much discussion with fellow physicians, it seems there are many family docs as tired as I. Expectations from patients are increasing exponentially, the volume of difficult patients is so high and the financially non-compensated paperwork so bountiful, I find myself utterly spent at the end of the day. Doctors are pursuing all sorts of alternatives to full family practice, and I'm not sure where the replacements are going to come from. Even for a percentage split, which means I am significantly subsidizing someone to work in my office, I certainly can't find anyone willing to do a locum. I don't dare to hope I will find someone to continue to care for my patients once I find a way out.

Most family physicians I know book a patient every 10 minutes, with more time set aside for physicals and pre-booked "talks." If you book in a more leisurely fashion, it is impossible to make a living. Long ago, when I first started, this was plenty of time to adequately assess and treat many complaints. The quick visits made up for the difficult cases and the longer, unexpected problems that will walk in every day. It was fine to spend 45 minutes sorting out a difficult case for minimal compensation, because there was enough leeway built into the system to allow this. It allowed me to feel I was practising good medicine. This is no longer the case.

A recent day in the office convinced me I have to find something to do that will allow me to feel I have made a medical contribution, frustrate me less, pay me an adequate wage and allow me to go home at night and not worry about all the things I wasn't able to get to. My day went from worrisome to worse as the list went on and I got further and further behind, despite having booked elderly patients for extra time.

The first patient of the day forgot to mention to the secretary the reason he wanted to be squeezed in today was not just because he had run out of meds. The chest pain he had last night, and was having on and off this morning, was quite worse than his last heart attack.

Now 20 minutes behind, my very next patient, who told the secretary she thought she had a yeast infection (fairly quick and easy even with the swab), didn't really think that at all. What she thought was she might take all the prescription meds she had in her house that night because she just couldn't cope anymore. I sorted out what to do; deciding if she needed to be "formed," or would consent to urgent psychiatric assessment.

In our area, urgent means anything from a one-day to one-month wait. These are big decisions for me. I would worry about that one all night long. I would be completely confused as to how I was supposed to bill for something like this these days. She wasn't booked as a "long appointment," but I had spent considerable time sorting everything out and sending her on her way. Was I going to be audited for billing two "K" codes when that's not what the bookings would show? I am utterly confused about what is appropriate billing these days and what is going to get me into trouble. Often I end up just billing a routine visit so I don't have to worry about a billing error as well as worrying about the patient. How many times can I do that and still pay my staff?

There were a few patients next with fairly routine family practice complaints, and seeing a member of a four-generation family who are all my patients helped me remember why I used to love my job. Then the bottom fell out of the office again. One of my favourite 87-year-old patients came in with florid heart failure, then an elderly insulin-dependent diabetic with Parkinson's, COPD, hypertension, hypothyroidism, B12 deficiency, peripheral vascular disease, previous colon cancer with a colostomy and osteoarthritis presented with a full bag of all her medications. Each one, it seemed, was set to run out at different times, some with two different pills put in the same bottle, some needing special Ontario Drug Benefit forms filled out.

Unfortunately, the specialist had initially given her these pills and I had no idea what code to use to allow her to qualify to continue on these previously prescribed medications. The amount of time needed to sort out even a fraction of her complaints was mind-boggling. I used every technique I had ever learned at every conference about how to cope in family practice, and still I was at it forever. Next was a chronic complainer who booked appointments on a biweekly basis to bring in his lists of all the things that had gone wrong with his body in the intervening time. I have tried to deal with his anxieties in an appropriate way, doing all the things I learned to help anxious hypochondriacal patients without referring them for a lot of unnecessary tests, but today I just about lost it. My frustrations are going to get me in trouble.

Just as I was beginning to sort out the next few patients and feel I had a handle on the morning, a very demanding father came in with his teenage daughter, wanting me to sort out "whatever the hell it was that was wrong with her." He demanded to be in the office during the consultation (a request that was refused), and made it known to my secretary I had better get her in to see a specialist today because he had had it "up to here" with her. I'm not sure I could even get myself in to see a specialist today.

Needless to say, there was no lunch for my staff or me that day. We all went home feeling utterly exhausted. I don't enjoy not sleeping well at night because I'm worried about what didn't get done well. I don't like waking up in the morning and not wanting to go to work. I enjoy the often demanding medical and psychological part of my job, but I am exhausted worrying about how I can do a good job and continue to cover expenses. I used to look forward to going to work. This is the very saddest part of my conundrum.

This was an unusual morning in the office with such an extreme number of demanding cases, but the problem is that most days have more and more difficult problems to sort out. Some of this is our own fault; with the proliferation of walk-in clinics, the bread and butter of true family practice is lost. I do not know what the solution is for family practice, but I do know I am not an isolated case. I think my frustrations speak to the problems that need to be addressed if we are going to have a physician population that wants to get up and go to work each day. I fear for the future of general practice.