The "Business" of Medicine

When I was young I knew I wanted to be a doctor. The picture I had in my head was that of the typical family doctor-- nice clinic, friendly secretary, breezing in and out of patient rooms with a smile. By the time I started medical school, the only specialty that I knew I didn't want to practice was family medicine. Okay, maybe not the ONLY one, but I definitely wasn't into it. Why? Because I don't want to run a business. Ever.

Family medicine is a business. As a family doctor, you are a small business owner. Regardless of what fee schedule you follow, you have to consider your overhead. This includes office rental, cost of permanent equipment (like examining tables, otoscopes, computers), cost of disposable equipment (urinalysis sticks, gloves, disposible speculums), office supplies, office staff (a medical receptionist/office manager and possibly a nurse)... I could go on, but you get the sitch.

A study done a few years back asked a few hundred Canadians what they thought their doctor got paid for an office visit. The answers were hugely variable... the average was around $100, but the guesses ranged from $50 to $500 and up. What does your doctor really get for an office visit? Well, if it was a typical visit that reviews two or more body systems and examined or reviews more than one problem, the doctor bills $29.20. Yup. That's it. And you wonder why you're rushed out of the office. If it was just for a single problem that was pretty straightforward (like a prescription refill) your doctor bills $17.75.

But your family doctor won't necessarily see that money. Claims are rejected for lots of reasons... if you forgot your health card, or didn't tell the doctor that you got a new card (the new one will have a different version code), the money doesn't come. If there is any missing or questionable information on the claim form (let's hope you have a really good billing company or secretary so this doesn't happen often) the claim is denied. If it's for a form or a WSIB injury, your doctor can't bill and has to get paid directly from the patient. Doctors aren't bill collectors-- many give up if the bill isn't paid promptly.

Now I'm getting boring, but these are all things that eat into the average doctor's salary. A recent article by The Walrus explored the rare breed of medical practitioner known as the family doctor:

Visit any medical school in Canada and ask, "Who plans to practise family medicine?" and too few hands will go up. Having competed with thousands to get into these prestigious schools, and already deeply in debt, most of these ambitious young adults feel they cannot afford to become family doctors in Canada. Without fringe benefits, and after the expenses of renting a clinic, paying for receptionists and nurses, and buying equipment and supplies, a family doctor working forty-hour weeks could expect to take home roughly the salary of a union plumber, auto worker, or skilled bricklayer (around $70,000). This, after at least 7 years of university, with medical school costing $15,000 a year in tuition alone.

Sad, isn't it?

PSA: It's Organ Donation Awareness Week!

Don't be so quick to break out the party hats. Organ donation in Canada isn't much to celebrate. The rates of donation are embarassingly low, and countless Canadians die waiting for organs.

This topic hits a little close to home these days. Just a few weeks ago, my fiance's uncle donated an organ to his sister's husband. The uncle in question, affectionately nicknamed TIB (which stands for 'Terminally Ill Bruce'... my in-laws have an interesting sense of humour) has polycystic kidney disease and has been on dialysis for 3-4 hours, 3 times a week for years. The survival rate for dialysis patients is NOT good. So when uncle Kenneth was found to be a match, it seemed to be a miracle. They weren't related by blood, so the odds were against them. But off they went down to London (Ontario's kidney transplant headquarters) where Bruce's new kidney pinked up before it was completely attached to his urinary system. Go, kidney! Living kidney donations have better success rates than cadaveric transplants, so we're all keeping our fingers firmly crossed.

Recently, there was a story in the paper about a guy who wanted to be considered as an unrelated donor in a liver transplant. The liver regenerates itself, so he wanted to give a section of it to a child on the transplant list. Everyone thought he was crazy to undergo a risky procedure for someone that he didn't even know. He had to undergo days of psychological testing-- apparently, the doctors were suspicious that this was some kind of misguided death wish.

But back to my point. You're dead. You no longer need your organs. Why not share them with someone who does? I'm not talking about donating your entire body to a medical school, for students to cut up and use decapitated arms to give each other high-fives when they managed to name all of the muscles of the forearm (not that that ever happens... really). I'm just talking about giving your corneas so that a blind person can see, your heart to give someone with a cardiomyopathy a second chance at life, your lungs so that someone with pulmonary fibrosis can breathe, your liver so that a child might experience life outside of the hospital... get the drift?

My personal opinion is that our health care system is going about organ donation ass-backwards. I think that rather than tell people to sign cards indicating that they'd like to donate, all organs should be harvested from eligible cadavers unless someone indicates otherwise.

Bottom line... if you DO want to donate your organs, you can sign all the cards you want and it doesn't count for crap. Your next-of-kin still makes the decision on your behalf. So talk to your family. Talk to your spouse. Make it clear that if they don't donate your organs, you'll haunt them from the grave for all eternity.

My Newest Patient

So in the town where I work, the hospital is GP-run. That means that all family doctors are the most responsible physician for their patients when they're admitted to hospital. If someone is admitted to hospital and doesn't have a family doc, or if their family doc doesn't have priviliges at our particular hospital, they get assigned to a family doc who will look after them while they're in hospital.

We got an assigned patient over the weekend. Well, we actually got about 5 of them. And she wasn't really ours... she was assigned to another family doctor in our call group. There are 4 physicians in our call group, so on the weekends the doctor on call rounds on everybody's patients. We ended up rounding on about 35 patients. It was a long weekend.

The patient I'm referring to was transferred from another larger hospital to us for rehabilitation. She had been admitted with respiratory failure, which in someone her age (in her early 50's, relatively young) usually means underlying asthma or COPD brought on by a lifetime of heavy smoking. But since I'm telling this story, it's obvious that it wasn't straightforward.

The patient in question was 650lbs. It required the fire department to transfer her from the big city hospital. She was being transfered to us rather than the hospital in the town where she lived because, quite simply, they didn't have the resources to manage her. She required a double-sized bed, which then required a two-person room to become a private room. The nursing staff required for her care was staggering... she is an EIGHT person transfer. Just to roll her over to change her position or put a bedpan under her required a call for assistance to be made to the two adjoining units. Nurses had to be pulled away from the care of their own patients to assist in the care of this one. The nurses told us that it took three of them to move one of her legs when she wanted to shift onto her side. The patient had to be kept on an incline as the pressure of her pannus (apron of abdominal fat that hangs down over the groin) against her diaphragm made her increasingly breathless.

Walking into the room, I struggled to keep my expression neutral. Her facial features were seemingly concentrated in the center of her face, dwarfed by a large roll of fat under her chin. I spoke to her, feeling overwhelming guilt at my own reaction. I'll admit it... I was disgusted. Her hygiene wasn't good... rashes were evident in the areas between skin folds and it was obvious that the extra flesh severely limited the range-of-motion in her arms and legs. All I could wonder was how on earth anyone could let themselves get this big. As someone who has battled their weight all of their life, I understand that is probably not a fair thing to assume-- that she had 'let herself' get that big. But she had no disability before she put on the weight (which was apparently put on gradually though her 20's and 30's, according to her medical record) and here she was, disabled by it now.

I know my reaction was wrong. And I made sure that I treated her the same way I treat everyone else. And I felt very uncomfortable when I overheard some of the nurses making comments about her afterwards-- not that I said anything to them about how inappropriate their harsh judgements of her were. But I knew that deep down, I agreed with them.

And for that, I still feel guilty.

An actual conversation that occurred between my preceptor and I during our weekend on call.

Me: We have a new admission to the ICU.

Preceptor: One of my patients, or an assigned?

Me: Assigned. Hmm.

Preceptor: What?

Me: His reason for admission.

Preceptor: An interesting case?

Me: Could be. His admitting diagnosis is 'asystole'. Doesn't that mean he's dead?

Preceptor: Yup.

Me: Hmm. So I guess we'll leave him for the end of rounds?

Preceptor: Yeah. Maybe he'll have decided is he's dead or not by that point.

The Best Intentions...

I had them. Really. And I have a whole bunch of topics that I've wanted to write about here over the past two weeks. But there was Easter, a trip to visit old friends, a trip to visit family, and this...

The latest addition to our family. Needless to say, now that furkid #1 is pretty self-sufficient (at a whopping 18 months old), furkid #2 was a quick reminder of how damn much work puppies can be.

So that's where I've been.

In addition to this, I'm still planning a wedding. Most recent things accomplished were ordering of bridesmaids dresses, purchasing of wedding rings and confirmation of floristy stuff.

I've also been trying to clean up my last 5 years of taxes, which were all inexplicably re-assessed in the past few months. This involved many meetings with accountants.

I am also trying to nail down the details of my schedule for next year. Life as a PGY-2. Sweet.

I am also trying to tie up the ends of my ill-fated involvement with my provincial union. It taught me a lot about administration and politics, but I can't WAIT to not be involved in this stuff anymore.

I have started running again, as I have come to accept the fact that as long as I am working one hour away from where I am living, I am lucky to make it to the gym twice a week. And that just isn't enough. Then I got plantar faciitis. So I stopped running. Then I felt better. So I started running. Then I got that stabbing pain in my heel for two days again. So I stopped. Well, you see where this is going.

And in the midst of all this, I am still a medical resident.

No wonder I'm so tired.

More from me soon. I promise.

Some Actual Tales from the Emergency Room

So after bitching about my first shift in the community emergency room, I should be fair and rave about my subsequent three shifts. I spent two full 10 hour shifts in the emergency room since my preceptor had headed down to Windsor for the OMA hockey tournament. Ontario was a bad place to be sick last week... all the docs were in Windsor. Then I spent an additional afternoon in the ER which I'll be continuing to do on a weekly basis until the end of my family medicine rotation.

Small town emergency room? Not so much. This place was crazier than any academic centre I had ever worked in. With the possible exception of the Royal Alex in Edmonton, which is located smack in the middle of the seediest part of town and where the safest rule of thumb is to assume your patient is an alcoholic/addict until proven otherwise. Had I followed this rule of thumb I would have prevented one of my patients from going into DT's (alcohol withdrawl seizures) just seconds after I had nicely reduced his dislocated shoulder, promptly dislocating it again. But I'm getting a little tangential...

So here's a quick sampling of the good, the bad, and the completely bizarre that I was privy to over the course of 2 and a half shifts in my sleepy, small-town emergency room.

• 5 CVA's in 5 hours. Holy crap. I am now well-versed in the criteria for clotbusters.
• One child with the worst case of chicken pox I'd ever seen. She was admitted with varicella pneumonia, a complication of chicken pox. Poor kid. Someone should have taken her picture to show all of the parents who think having chicken pox is a natural part of childhood.
• An elderly guy who came in two days post-MVC with some impressive hematomas. The bags under his eyes were filled with blood, and looked like two purple testicles hanging off his face. Even more impressive was the hematoma on his head, which although it wasn't bruised, probably measured a good 15cm in length and protruded about 3cm from his head. A few days later he came in again-- the hematomas under his eyes had receeded, leaving nothing but bruising, but the scalp hematoma was unchanged. So I got to drain it. So... cool...
• Two cases of cellulitis secondary to IV drug use. I got to cut them open, debride them and pack them. Further confirmation that most doctors are the same kids who used to pick at scabs incessantly.
• A guy who came in with a 1L pop bottle stuck in his ass. The outline was plainly visible on x-ray. That wasn't even the best part... a hooker put it there, and he was desperate that his wife not find out about it. Consult surgery!!!
• A case of what was most likely THC-induced gastroenteritis. (I've been seeing a lot of young men with abdominal pain lasting 2-4 weeks, intermittent vomiting, some weight loss but no change in bowel habits (no bloody diarrhea, in particular). The one thing that they all had in common was that they smoked pot regularly. Normal bloodwork, normal abdo ultrasound... resolves if they lay off the pot. Diagnosis of exclusion, sure, but it seems to fit the bill.)
• A 35-year-old tall, thin guy with severe chest pain that radiated through to his back. If you work in any health-related field, you're probably thinking what we did. And it was. Marfan's syndrome! Chest pain! Dissecting aortic aneurysm! Holy crap! Confirmed by CT within minutes of his arrival, but was left hanging around in resus for nearly 4 hours as CritiCall desperately tried to find a centre with an available cardiothoracic surgeon and an ICU bed that could take this guy. Three 'no room at the inn' responses later, he was on his way to the nearest American centre. And our tax dollars paid for it. Sometimes, our health care system just sucks. But the whole thing was cool to see anyway.
• More 'rule out MI' than I care to think about. Ironically, though, the only person who was actually having an acute MI was the woman who sat quietly in the waiting room whose chief complaint was 'funny feeling'.
• Four nosebleeds, one in a guy with an INR of 7.2. He apparently thought that after he was stabilized on coumadin, he didn't need to monitor his INR anymore. I became very efficient at the use of Merocel (basically, nose tampons).
• A woman who was 2 weeks postpartum with calf pain. Sure enough, big honking DVT. Ouch.
• A 'found unresponsive' who never actually became responsive. After some creative detective work and the shotgun approach to the tox screen, it was ruled a TCA overdose.
• No really cool procedures, but I got three ABG's on my first try. Hey, those count too!

Sigh. I've REALLY missed emerg. I can't believe that for a minute there I was actually doubting my resolve to do that third year of training. Family medicine is good and all, but nothing makes time go by faster than the emergency room.

Back in the Saddle Again

So I've been spending some time (quite a bit of time) back where I belong. Or at least, where I thought I belonged. Not in an academic centre, but in a community emergency room-- the same community where I have been practicing family medicine for three months. A surprisingly busy community emergency room.

My first shift was less than stellar, however. My preceptor had nicely written the emerg docs a letter of introduction. I would like to introduce my resident, blah, blah, very competent, blah, blah, good technical skills, suturing in particular, blah, blah, please be nice to her. And the morning that I was to start in the emerg, he was even nice enough to go over and remind the doctor on dury that I was coming by to work that day. Apparently, the emerg doc wasn't really listening.

When I got there he nodded curtly and gestured for me to follow him into the patient's room. So I did. And listened patiently while he assessed her. When we emerged, he started the inevitable pimping.

"How do you diagnose the patient?"

I HATE the 'guess what I'm thinking' game. What is he asking me? Does he want me to explain what I'm looking for? What tests I should order? What my differential diagnosis is? What I had for breakfast this morning?

"What do you mean?" I ask.

"Through the HISTORY and PHYSICAL, of course!!!"

Um, sure. I thought he was referring to some revolutionary test he had recently invented to decipher 'weak and dizzy old lady' into a concrete diagnosis and treatment plan. Apparently not. So then he proceded to sit me down and write out exactly what the components of a good history and physical were. I had been pretty quiet until now, but I decided to speak up.

"Sir? I *have* done this before." I said jokingly.

Apparently, the wrong thing to say. He looked up at me, clearly offended.

"I am TRYING to teach you something here. This is the sort of thing that will be on your EXAMS."

Alrighty then. So I sat, quietly and patiently, while he explained how to take a history and physical. Then, how to palpate an abdomen. Then he decided to teach me an approach to reading ECG's. He told me how to assess a headache. He asked me what the ABC's of trauma were. He also continued to pimp me, asking me random questions about appendicits, long Q-T syndrome and the administration of TPA in stroke. So I answered his questions. For six hours, I followed the attending around like a big dumb sheep.

Finally, just before shift change, he was assessing a woman with abdominal pain and asked me what was the first thing I needed to know. Easy one.

"I'd want to know whether or not she was pregnant."

"Right," he replied, "and why is that?"

"Because I'd need to rule out an ectopic."

He stopped. And eyed me suspiciously.

"Have you done much emerg yet?"

Confused by his question, I started to babble. "Well, not since I was a clerk. See, I started off in the FRCP program, but then I switched to family medicine, but I never actually DID any emerg shifts as a resident, but I..."

He cut me off. "You're a first year RESIDENT?" he asked, incredulously. "I thought you were a first year MEDICAL STUDENT."

Um, thanks. You don't think it's odd that I know about long Q-T syndrome as a first year medical student, but knowing about freaking ectopic pregnancy tips you off? Not to mention the nametag I'm wearing that clearly identifies me as DR. Couz, Medical Resident? Or the fact that my preceptor introduced me to you TWICE??? Apparently, I am clearly the world's brightest and most knowledgeable first year medical student.

Somehow, this misunderstanding was my fault.

"If I had KNOWN you were a resident... well, you should have been writing ORDERS! You should be formulating TREATMENT PLANS!"

No kidding. Sigh.

Thankfully, I don't think I'm working with this bonehead again.

I AM a Specialist, for God's Sake!

In the old days, after medical school everyone did what was called a 'rotating internship'. After a year of rotating through various specialties, doctors were awarded a general license. They could either practice as a General Practitioner, or they could return to residency to specialize. Since everyone had a GP license after one year of residency, they could also moonlight for extra money through the rest of their residency.

Things are different today. They did away with the rotating internship years ago, and along with it went the concept of the General Practitioner. All areas of medicine required a unique residency-- two for family medicine, four for internal medicine and pediatrics, and five for most other areas of medicine.

Having recently switched from a five year program to a two year program, I've been on the receiving end of a special brand of elitism. Many doctors have the mistaken impression that family medicine is something that anyone can do. Many feel that they are somehow better clinicians than family doctors because they have specialized training. I didn't think I felt like this before I changed programs, but it still surprised me how much about family medicine I didn't know when I started. Most specialites know a lot about a narrow range of topics... family doctors are expected to know a little bit about everything. Sure, if you're working in a mid-to-large sized centre you can refer anything that you're not comfortable that you can manage effectively, but in many cases you're expected to know as much about prostate cancer as you do about chronic sinusitis.

So it's no surprise that I find it irritating when people declare themselves specialists as though it's something more impressive than family medicine. Family docs are more likely to really be making a difference in people's lives than the surgeon who took out your gallbladder, the dermatologist that fixed your rash or the radiologist who read your CT scan but has never actually seen your face. Not to bash any of these specialties, I just don't understand why family docs are seen as the generic version of the physician. Of course, the ability of your family doctor to actually make a difference in your life depends entirely on whether or not you've lucked into a good one. And at a time when over 4 million Canadians don't have ANY family doctor, even having a bad one is sometimes the lesser of two evils.

I do honestly believe that family doctors are underappreciated and underpaid. But that's another post.