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.