The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Thursday, August 31, 2006

Making the Cut

Yet another family medicine group discussion gone awry.

One of the residents in the group is in the process of opening up his own family medicine practice. He has joined a group of family physicians in a small town just outside of our larger academic centre, one of many towns in our area desperate for family doctors. Good news, right?

He came to the group for suggestions a few weeks back. He had a very definite idea of how his practice should look. He didn't just want 'the rejects from all the other family doctors in town'. In fact, he also didn't want many elderly people. Or many sick people in general. He wanted a practice composed primarily of young families. In order to do this, he intended to provide intrapartum care (so he'd deliver babies) but he wanted to know how he could go about 'screening undesirables' out of his practice.

I was reminded of a recent patient I saw in emerg. He was a middle aged man, well dressed, who presented with the chief complaint 'requesting meds'. That's never a good sign. Either the person is a drug-seeker, or they're using the emergency room inappropriately. The way we usually deal with them is based on how urgent the need is. If the person is asking for narcotics, we pull all their old charts and, if it's during a weekday, we call their family doctor to see if they're legit. They're usually not.

One guy, though, was legit. He had injured his back and shoulders quite badly in a workplace accident several years before, and according to his medical file he had significant joint and nerve damage. And no family doctor.

This is a catch-22 for those of us working in the emerg. On one hand, ER policy has us explain to the person that the emerg is not the place to come to get prescription renewals. At most we should give them a script to cover them until the next business day, then go to their family doctor for ongoing care. If they don't have a family doctor, they are instructed to go to a walk-in clinic. Problem is, several of the walk-in clinics in this town have newly-posted "We Do Not Prescribe Narcotics" signs on their front doors. They're having as much trouble with the drug-seekers as we are.

So this guy was frustrated. Understandably. He had come into the emerg for his meds 6 times in the past month. Sometimes he'd leave with a script, sometimes not. His pain wasn't well controlled. The walk-in clinics refused to prescribe him narcotics. This was actually the second time I had seen him in the past two weeks. The last time I had offered him a three day script for Percocet (which he'd been on ever since his workplace accident) and a printed list of the family doctors in town who were accepting new patients. I asked him if he had called the doctors on the list.

"I called all of them."

I was suspicious. "All of them? There were over 20 doctors on that list."

"Yup," he answered, "Nine of them weren't taking new patients anymore. Two of them were more than a 30 minute walk from a bus line. Three of them I left messages with. Of the 6 I got a hold of, I got interviews with 4 of them. Two of them screened me by phone."

"Screened you?" I asked, knowing what was coming.

"The secretary asked my medical history and what meds I was on. After I got to 'chronic pain' from my accident, the doctor suddenly wasn't taking new patients anymore."

"And the ones you interviewed with?"

"I've had 2 so far. Neither one wanted me as a patient."

Sad, but true. Doctors are at such a premium around these parts that it has become common practice for a doctor accepting new patients to interview them first. In theory, these interviews are intended to help identify any fundamental differences in medical ideology between the family doctor and potential patient. For me, a big red flag would be parents who refuse to vaccinate their children and are unable to provide a valid reason why not. But that's another post.

So here I was, fresh from my experience with the frustrated patient, listening to one of my collegues ask us how he can best filter out these 'undesireable' patients. You can see where this discussion lead. Nowhere good.

My family medicine group now officially thinks I'm an argumentative troublemaker. My collegue's view was that it would benefit the community in which he practices more for him to build a sustainable practice, one that he enjoyed and wouldn't lead to burnout. I thought that was unrealistic-- we're not going to love every patient that walks in the door, but the ones he was excluding from his practice were the ones who needed a family doctor the most.

It might be a cliche, but if you're not part of the solution... you're part of the problem.

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18 Comments:

Blogger Sarah said...

I'm so naive. Why would no one want this poor man as a patient?

How could helping a man in pain by prescribing narcotics lead to burn out? Or is there some other reason I'm not getting?

I'm a little confused. And saddened.

Please continue to remain an argumentative troublemaker as you're a voice for people who actually need help!

9:06 PM

 
Blogger Medstudentgod said...

It is definitely troubling to have to take such measures, but I can sympathize with the resident's desires.

During a rotation I worked with an Internist who was beginning his own practice - only to get patients that no one else wanted. Many wouldn't keep appointments, were hard to interview and treat, or were simply "chronic pain" patients seeking meds.

He was frustrated already and thought aloud a few times if he shouldn't just hang it up and go back to the hospital.

It's a Catch-22 when starting a new practice. Realistically I don't believe this resident can "screen" too many patients if he wants to break even. Usually a doctor has to retire before a FD gets enough patients they can screen some out. At least that's how it is here.

Good to hear from you again.

9:41 AM

 
Blogger Couz said...

Sarah, the problem with chronic pain patients is that they tend to be difficult to treat. They come into the office frequently, and require higher and higher doses of narcotics. And you never really 'cure' them. It's difficult for the patient, of course, but it's also frustrating and disheartening for the treating physician.

If only it were simply a questions of 'prescribing narcotics'. Sigh.

By the way... have any of my loyal blog readers noticed that I've finally mastered the spelling of the word 'prescription'? :-)

11:55 AM

 
Blogger where am i and why is my cat wearing a dress??? said...

i'm in that boat right now. i've lived in a north-central bc town for 5 years, and i still go see my gp in vancouver for routine (med refill/paps) care.

all i want is a good doc (in my opinion) that provides intrapartum care. and might be willing to take on my hubby (no, lasix 2mg sc is not normal, sir).

too picky? apparently. because i work on the family practice ward in town's hospital, i get to see how these docs work. and every one that i've asked who meets my criteria won't touch me with a 10 foot pole.

why? because i won't make them enough money. *sigh* apparently they want elderly, compliant patients. someone who needs some acne cream, nsaids and a pap isn't good enough.

i use the walk in clinic and it's the same routine every time. trying to farm me to a gp who i personally think is unsafe. i'll just drive the 9 hours to see my gp, thank you very much.

5:48 PM

 
Blogger Bardiac said...

Bravo for you!

So the resident wants all healthy young people... but if he gets them, he's going to be bored silly, isn't he?

9:18 PM

 
Blogger grass said...

i sound like a broken recrod, but wow - that is really sad... and probably violates human rights codes.

1:51 AM

 
Anonymous Charms said...

So much for every person in this country having access to medical care. So now docs can "screen" people out just because they don't want to treat them. What a luxury. I understand meeting with patients to ensure that you have the same philosophy and expectations of each other. I don't understand meeting with people to screen them out because they won't be easy or particularly rewarding patients. It infuriates me, actually. So what if people are "difficult patients"? Welcome to the real world. Every single person deals with "difficult people" in their jobs. Such is life.

If only we all got to pick the clients/patients/members of the public/etc that we must deal with through our jobs. Wouldn't that be nice? Just think, you'd never have a stressful day, everyone you talked to would be pleasant and respectful, and you would feel REALLY good because everyone you dealt with would be easily helped... there would be none of this frustrating bullshit that some poor people have to deal with.

What's wrong with this world?

Grrrr. Couz, I'm glad that you take a stand on these issues. People like you are the ones that really make a difference in this world.

12:28 PM

 
Anonymous Charms said...

So much for every person in this country having access to medical care. So now docs can "screen" people out just because they don't want to treat them. What a luxury. I understand meeting with patients to ensure that you have the same philosophy and expectations of each other. I don't understand meeting with people to screen them out because they won't be easy or particularly rewarding patients. It infuriates me, actually. So what if people are "difficult patients"? Welcome to the real world. Every single person deals with "difficult people" in their jobs. Such is life.

If only we all got to pick the clients/patients/members of the public/etc that we must deal with through our jobs. Wouldn't that be nice? Just think, you'd never have a stressful day, everyone you talked to would be pleasant and respectful, and you would feel REALLY good because everyone you dealt with would be easily helped... there would be none of this frustrating bullshit that some poor people have to deal with.

What's wrong with this world?

Grrrr. Couz, I'm glad that you take a stand on these issues. People like you are the ones that really make a difference in this world.

12:28 PM

 
Blogger Dr. Wannabe said...

Or...

If you're not part of the solution, then you're part of the percipitate.

*nerd*

5:19 PM

 
Anonymous Anonymous said...

Did nurse practitioners come up in the discussion at least once? Anyone?

9:12 PM

 
Anonymous Jen said...

Sorry, didn't mean to be anon. I'm Jen, I'm a nursing student.

9:14 PM

 
Blogger Couz said...

Hi Jen.

No exclusion intended, I assure you. Where I live and practice, NP's are a rare breed. In fact, I've only just met my first one on pediatrics. From what I've seen here in Canada, NP's mostly pick up the primary care slack in rural areas. I have yet to come across one in the mid-to-large centres in which I've been practicing.

I don't really understand why I don't see more of them.

9:27 PM

 
Anonymous Jen said...

Hey Couz,

I met a couple of NPs who work in downtown Vancouver in clinics. It was very cool how they integrated into the clinics with the docs and other professions there.

Back here in Ottawa, I recently used a the NP assoc. of Ontario website (linked from the Cdn NP initiative website) to find an NP in my area that's accepting new patients. She works in a clinic also so she'll be my primary care person and I'll get refered to the other professionals as needed (social work, dietician, doctor).

They're getting there....

Jen

1:05 PM

 
Anonymous JK said...

It's a frustrating scenario, but I am glad to see someone taking a stand.

I had a similar situation where a doctor refused to give me stitches. For no other reason than he didn't want to. It was a walk-in clinic, first thing in the morning, with not one single other patient, and I needed two stitches. I couldn't even comprehend how this could happen, let alone understand what a widespread issue it is.

People should not be forced to drive around a city bleeding, looking for someone willing to help. Or worse, when the total level of medical resources is limited from the beginning for people. Maybe I just don't understand.

2:27 PM

 
Blogger UptownGal said...

I am truly quite surprised at how "difficult" it is to find a family doc for some. 'Cos where i come from, u can just walk into any clinic and they have to treat u. GPs can't choose patients! That's like anti-selection! So everyone just finds a GP that they're comfortable with and there u have it! That's your family doc...

12:36 AM

 
Anonymous Anonymous said...

NP's usually can't presribe narcotics @ least not in the states

10:24 PM

 
Anonymous Anonymous said...

This comment has been removed by a blog administrator.

1:34 AM

 
Anonymous Percocet Prescription Information said...

My name is Monica Stone and i would like to show you my personal experience with Percocet.

I am 35 years old. Have been on Percocet for 7 days now. It did help the pain but the side effects weren't worth it. I'd rather have the pain.

I have experienced some of these side effects-
nausea, very itchy, racing heart, anxiety, flashing lights(almost hallucinogenic?), weird dreams, tiredness

I hope this information will be useful to others,
Monica Stone

1:04 PM

 

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