Not Quite The News

I have a love-hate relationship with the media. I love it in the sense that I have an addiction to information. I want to know what's going on. I read newspapers, watch the news on TV and listen to it on my car radio during my endless commute. I hate it when it comes to medical news. It is usually sensationalist and can pretty much be counted on to distort whatever new study has been deemed 'newsworthy' by some guy in an editing booth. It's frustrating.

And today is no exception. This news article describes the story of a woman who died after spending 3 days under observation in the hospital. The article goes on to describe the concept of the 'orphaned patient', and goes on to blame the fact that the doctors who take responsibility for orphaned patients have a maximum quota of 5 patients per day. Then Kevin, MD jumps on the bandwagon by posting the link to the article with his parting shot... "no wonder there's an access shortage up there".

Please. The issue of orphaned patients in GP-run hospitals is a little more complex than that. A bit of background for the lay-folk-- in many community hospitals, when patients are admitted it's their family doctor who assumes responsibility for their day-to-day care. If a patient is admitted who doesn't have a family doctor (or whose family doctor doesn't have privileges at the hospital admitting the patient) the patient is assigned a family doctor-- either a family doctor who takes on the care of these 'orphaned' patients, or a hospitalist, whose sole job is to manage the care of a large number of orphaned inpatients.

Family doctors have it tough when it comes to the care of inpatients in the hospital. It doesn't pay terribly well, and it's a difficult responsibility to balance with a full day of office. At my practice, a typical day has me coming in at 8am to begin rounding in the hospital. If I know we have more than 3-4 patients in at any time I'll come in earlier. If we had the misfortune of getting hit with an orphaned patient overnight, I was often faced with rounding on our inpatients as well as sorting out an often complex medical history and medication list for a patient I've never laid eyes on before. No easy task. One orphaned patient admission could easily take 45 minutes. Add that to the usual rota of patients in the hospital at any given time and rounding in the morning could stretch to 2 hours, starting the day's clinic 45-60 minutes late.

Last year our call group made the decision to stop accepting the assignment of orphaned patients. The workload had become unreasonable, and was only getting bigger as more physicians removed themselves from orphaned patient coverage. The hospital kept promising to hire hospitalists to help shoulder the load but none were forthcoming. So our group bailed.

Caring for inpatients means more than just stopping by to say hello on the way to clinic every morning. The five patient quota would still be a full house when you consider the time to round, write orders, put out fires, liaise with specialists and field phone calls throughout the day relating to the usual odds and ends that come up. And this is on top of the full day's office, minor procedures, house calls and paperwork that fill the typical family doctor's day.

Who is the Ottawa Sun (or Kevin MD, for that matter) to suggest that family doctors who limit their 'quota' to five patients are somehow slacking and shirking their responsibility to the health care system? Would it somehow be better for family doctors to double their inpatient quotas and cut their office hours in half? Family doctors are already putting in 12 hour days on any given workday-- something has to give.

The Clothes Make the Clinician

While stopping at a nearby Tim Horton's on the way to work, I saw a resident that I recognized. I smiled politely and waved while I struggled to remember her name-- or, at least, where I'd encountered her before. I studied her from my spot in line. It was 7:45am, so I knew she wasn't in surgery-- she would have been at the hospital long before now. She was nicely dressed, so she wasn't likely to be in anaesthesia. Anesthesiologists would either be wearing scrubs to work or dressed casually, intended to change once they got there. Couldn't be emergency medicine, or I'd know her. Family medicine and pediatrics were unlikely, as she was wearing a slim skirt and stylish sweater. Family and peds residents tend to dress more casually, as a general rule. Must be internal medicine. But wait... as she stepped away from the counter, I noticed her feet. Black heels that must have been 3 inches high. No way would an internist, or anyone in ward medicine for that matter, suffer through a 12-hour day in impractical shoes. Not to mention that running for codes would be next to impossible. By the time she greeted me I had it-- psychiatry. Stylish outfit, impractical shoes, lack of white coat (not that she'd be wearing it outside of the hospital, I'd hope)... it all added up.

It's amazing how much you can tell about someone by the way they dress. It's probably something that's true everywhere, and not just within the confines of the hospital. What we wear to work has been a topic of conversation since we started medical school. My medical school, as I've mentioned before, is a little on the traditional side. A little stuffy, a little old school. Initially, the only guidance we were given pertaining to dress code was: Men should be attired in dress pants, a dress shirt and tie. Women should aim to match this level of dress. Whatever the hell that means. Soon after trading in our classroom uniforms of jeans and t-shirts for the 'business casual attire' appropriate for patient encounters, it became clear that we needed more guidance than that. One of my classmates was reprimanded in third year for dyeing her hair pink. Another for wearing a midriff-bearing top (seriously... who thinks that is appropriate?). I can only imagine what other transgressions were unearthed as the year went on, since we seemed to get regular 'warnings' regarding our attire throughout clerkship.

There will always be those who just don't give a shit. One of my classmates, upon deciding that he wasn't going to go through the match but would rather travel the world and save it from a grassroots level, stopped 'playing the game'. He started coming to clinics and rounds unshaven, dressed in jeans (if it was a 'dressier' day) or some variation of workout clothing. He was reprimanded on more than one occasion and couldn't care less. When they have nothing to hold over your head, there's not much the 'powers that be' can do to make you dress better. Now he is a community medicine resident working on his Master's of Public Health and I have no doubt he WILL save the world someday... and he'll probably still be dressed like a bum.

This has become an issue discussed in the media as well... a recent American Journal of Medicine article actually tested the effect of a doctor's attire on the doctor-patient relationship. Not too surprisingly, when doctors were dressed casually their patients had less confidence in their clinical abilities and were less likely to share important medical information with them. What did surprise me a bit was the fact that the white coat won out over regular professional dress. The results are discussed in this article: When Young Doctors Strut Too Much of Their Stuff

This has been on my mind recently as well. When I switched into family medicine I soon adopted the uniform of khakis/cords on the bottom, sweater on the top. Comfortable, not TOO casual, and fairly effortless. Soon, however, I found myself reverting back to the slightly more formal dress pants, shirts with collars (although sometimes under sweaters), blazers and jackets... just generally more professional. I don't necessarily feel like I'm conforming to the mold, I just feel that professionalism comes more naturally when I'm dressed the part. It's like my 'uniform'. Part of it might be because I have so much working against me-- I'm female, and I look much younger than my age. Being female doesn't seem to matter much to anyone but the odd elderly male patient, but many of my patients have remarked that I 'don't look old enough to be a doctor'. I usually reply with a polite smile that I'm older than I look and leave it at that. But when I'm dressed more professionally, I don't seem to get the comments nearly as often. I know the piercing in my nose (a small, tasteful stud) doesn't help. So I do what I can.

Hey, in an ideal world we'd be judged based on only our clinical skills and ability to relate to our patients. But if my patients have more confidence in me when I'm wearing pants that are Dry Clean Only, it's a small price to pay.

Besides, in the emerg it's all scrubs, all the time. Heh.

Can I be Friends with my Patients?

I am putting this out there. Not only to fellow residents, physicians and medical students, but to the public at large. Is it possible to be friends with your patients?

It has happened a few times in the year I've been working in this community that I've just really hit it off with a patient. They're always my prenatal patients-- they're female, close to my age, and in many cases just damn cool people. I meet with them monthly during their early pregnancy, then every two weeks, then every week... you get to know a person pretty well when you spend that much time with them. Then, at the end of it all, I get to play a key role in one of the most important events in their lives. They like me. I like them. Often, I like their husbands too. And I'll find myself thinking of how much fun it would be for my husband and I to hang out with them. Last week, one of my prenatal patients who is nearing the end of her pregnancy joked that she'd buy me a beer when all this was over if I could get her through the birth without tearing. Meant as a joke, I know. But when you think about it, would it really be wrong? On one hand, I know things about my patients that I don't know about my friends (for example, I've never seen Vitamin K's va-jay-jay, even through she's been my best friend for years... and we like it that way). On the other, it's not like I'm thinking about people's embarrassing medical issues when I bump into them on the street.

My preceptor has some overlap between his friends and his patients. They were all friends first, though, if that makes a difference. Which I don't entirely understand. There is no way in hell I'd go to a friend to have my paps done, no matter how professional he or she was about it. In fact, Dr. Boss has even delivered the babies of his friends and coworkers. Again, too much information. But they have no problem with it.

Sigh. Can't wait to do emergency medicine full-time. This isn't an issue when you don't get to know your patients.

So Much More Than a Driver's License

I've recently been on both sides of a very sticky subject.

First of all, I'm convinced that the city in which I live is home to all of Canada's very worst drivers. People sit in the left hand lane driving 110 kph, oblivious to people trying to pass. No one thinks to actually indicate turns before they make them. Half of the drivers in town seem to be endlessly looking for an address. The worst, I'm sorry to say, seems to be the elderly. They crawl along city streets, braking for no apparent reason at random intervals. They come to a complete stop while merging into faster traffic. They seem to forget that you can turn right on red lights. They'll pull halfway into a lane from a parking lot and then stop when they see oncoming cars-- this subsequently blocks the lane as they don't seem to understand that the fact that half their car is already in the lane means that traffic can't proceed. It's aggravating, sure. And I admit that I am not the world's most patient driver. I've often voiced the opinion that it seems that many of the people on the road probably shouldn't be. Particularly those over 80 years old. In fact, I think that after the age of 75 drivers should have to pass a road test at least every two years to renew their licenses.

Now I know that age doesn't determine driving ability. There are shitty drivers of all ages. There are dangerous drivers of all ages. But when I see a car that appears to be driven by someone who can't see over the steering wheel, has an altered level of consciousness or some combination of the two-- well, more often than not the driver is of very advanced years. Although experience does improve driving ability, age does not. As a person gets older, reflexes slow, perception is decreased and judgment is gradually impaired. Sometimes these alterations are obvious, and sometimes not. Many elderly people have fairly good insight into their declining abilities-- they will stop driving at night, on the highway, in poor weather-- eventually, they give up their license entirely. For others, it's not a voluntary situation.

Last week one of my patients came in with his wife... he is in his early 70's, and although our communication has been a little hit-or-miss in the past I've never really doubted his judgment. The reason for his visit was difficult to tease out from his broken English, but it seemed that a few weeks after a routine visit to his ophthalmologist he had received a letter from the Ministry of Transport (DMV for my American readers) asking him to come in for a 'review'. The patient was, understandably, confused. He attended the 'review' as requested and was required to attend a seminar. After the seminar, he was provided with numerous forms and papers, some of which had to be completed by his family doctor. That's where I came in. As I figured it, the ophthalmologist probably notified the MOT that my patient shouldn't be driving. I think it was awfully unprofessional of him not to have given the patient himself a head's up as to his intentions to contact the Ministry, but knowing the problems I've had communicating with this guy in the past I wouldn't be surprised if he had explained everything and it just hadn't been understood.

It didn't take long for us to determine that there was no WAY this guy should be on the road. When the nurse tested his vision using the Snellen Eye Chart (at left), he was unable to see the chart from 3 meters away with his left eye. Or his right eye. Using both eyes, he was able only to correctly identify the "E" on the top line. And this was his corrected vision-- with his glasses. Scary.

I went into the room to meet a very indignant Mr. E. He had no idea why the Ministry had contacted him in the first place, and didn't think there was any problem with his vision. He read the eye chart fine, he believed. Unfortunately, as in my last appointment with Mr. E., there was no reasoning with him. I explained that it wasn't my job (or the eye doctor's, for that matter) to determine his fitness to drive. All we did was evaluate his health, and report our findings to the MOT-- they did the rest. Which is exactly what I did. I filled out his forms-- I outlined his diabetic control (not good, but no hypoglycemic episodes that we were aware of), his cardiac status (afib, cardiomyopathy and CHF, all controlled with medication) and the results of his eye exam. I noted that although he did not show any overt signs of dementia, we were not able to complete formal testing due to language barriers and he did occasionally show signs of impaired judgment. I carefully documented that the patient has been advised not to drive. Which I did. Mr. E. was crushed.

"What am I gonna do?" he asked, looking at me imploringly, "how am I gonna get around?"

I turned to his wife, who seemed to be taking in the situation with resignation. This was not a surprise to her.

"Do you drive?" I asked her.

"Yes."

I looked back at Mr. E. In one visit, he had lost a good chunk of his independence and his freedom. Suddenly, he looked very old. Although I knew that he was honestly not safe to be on the roads, I felt awful for having to change his life so abruptly. He shuffled out the door, and his wife stayed behind to thank me. She had suspected as much for the past year or so, she said. But he didn't listen. She would take his car keys until the MOT officially revoked his license, she said.

I did what I had to do. But I still feel lousy.

Reflections of a Bad Day

As I sit here on the couch, wrapped in flannel and fleece and drowning a bottle of Cabernet Sauvignion (I never said I had good coping skills ALL the time) I'm thinking back to what made it bad. No one thing in particular, I guess. So here are some random musings on my day.

It started like any other day. Almost. The alarm went off at 6am-- I sleepily asked my husband to hit the snooze button to buy me another 7 minutes of sleep. The alarm clock is on his side of the bed. The alarm was silenced, and the next time I opened my eyes the clock read 6:21am. Damn.

I'm on the road by 7:30am for the commute out to the community where my family practice is located. The commute itself is a point of contention, as I've repeatedly asked the Department of Family Medicine to put me up in an apartment there (as they do for all of the other community-based residents) which they have inexplicably refused to do. I can't even get a call room in the community hospital. Our 'compromise' is that I am reimbursed $600 a month for travel expenses for a commute which is easily an hour each way. I hate my commute. Particularly on days like today, when a sudden drop of temperature coupled with the winter's first dusting of snow made for a long drive.

First stop-- community hospital, where I round on my inpatients while my preceptor plays hockey. After the death of our palliative patient the day before, our only remaining patient is an elderly demented gentleman who consistently believes he's in Ireland and the year is 1928. I stop in to say hello and write an order to hold his digoxin, as his heart rate is 42bpm.

Then I head across the street to the office. I am fully booked with an average of 4 patients an hour. It's already 9am, but my first patient is 20 minutes late. Not a great start to the day, as I see my second patient first and squeeze my first patient in when she finally arrives. She is an 83 year old woman whose second toe had inexplicably swelled to double its size the day before-- she's finding it difficult to walk as a result. It doesn't look like gout, doesn't seem painful to palpation, she doesn't remember any trauma to that foot... I'm puzzled. I send her for an x-ray and feel useless.

A few patients later, I'm greeted by a stonefaced woman and her 14-year-old daughter. She's angry that I'm not Dr. Boss (my preceptor). I explain that her appointment was made with me, not Dr. Boss, and that should have been clear at the time that she booked it. She's not interested in seeing me. She agrees (extremely reluctantly) too allow me to see them once she's made aware of the fact that seeing Dr. Boss would delay her appointment by another two weeks. The problem today is the fact that her daughter has been refusing to go to school. She has missed so much school this year that her mother is in danger of losing her government assistance payments. I wasn't aware that school had become optional for teenagers, but apparently I was expected to compensate for mom's lack of parenting skills. Needless to say, the visit did not go well.

Another few patients go by and I'm faced with an elderly gentleman with severe spinal stenosis. Imaging suggests that his case is surgical, but no one is willing to perform delicate spinal surgery on an elderly man with COPD and cardiomyopathy. But he's in pain. Shooting pain down his legs. And the medications he's regularly taking for pain aren't working anymore. What he needs is a medication specific for neuropathic pain, but none of them are covered on ODSP and him and his wife can't afford them. I load them up with samples and schedule follow-up in two weeks. I am half hoping that the new medication won't work so the problem doesn't boil down to one of finances alone.

I spend lunch writing notes, consult letters and answering phone messages from people demanding referrals that aren't warranted and investigations that aren't indicated. For the majority, I give in. I don't have the time or energy to argue, and I don't feel I can pass the buck to the office staff.

The afternoon started with a 20-year-old guy who had a 2 day history of gross hematuria. I must have asked a thousand questions trying to tease out some previous symptoms that would support my suspicion that this is a post-infectious glomerulonephritis, but came up with nothing. I sent him off for bloodwork and urinalysis and felt perplexed. Another swing and a miss.

The day was complete with a visit from a patient who was caught by the pharmacist a week ago trying to get a refill of narcotic three days after filling a prescription that should have lasted a month. When the truth came out she confessed to longstanding abuse of Percocet, Duragesic patches and Tylenol #3's. Now her liver enzymes are through the roof and I'm very suspicious that it can be blamed on the chronic acetaminophen abuse. What she really needs is a confirmation of the radiculopathy that caused the chronic pain to begin with, a referral to a hepatologist, a referral to the chronic pain clinic and some liver imaging (and maybe a liver biopsy). But these things take time. So we meet, go over her pain diary, review her meds use and wait for things to get done. It's frustrating how slowly things move sometimes.

I saw my last patient (thankfully, a relatively simple cough that seemed viral) just before 5pm and sat down to write my notes and tie up my loose ends. With any luck, I could be on the road at 6pm and home by 7pm. But it was not to be. One of my prenatal patients called just before the phone lines were transferred-- she thinks her water may have broken. And it's important to confirm it, because she's GBS positive and will need antibiotics if they have. I make arrangements to meet her at Labour and Delivery back across the street.

Thankfully, she shows up quickly. One sterile speculum exam, an AmnioStick and a quick look under the microscope, and I've confirmed that her membranes are intact. No amniotic fluid here. I reassure her and head out.

Another hour's drive home. There's nothing on the radio, and my iTrip can't find a free radio setting to broadcast from. It's a long hour. By the time I get home, I have about an hour until I'm off to bed. I can't believe I have to do this again tomorrow. Sigh.

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.

Some Patients Just Don't Get It.

A hypothetical conversation:

Random Person: The thing I hate most about my family doctor is that he's always running behind. I have to wait at least an hour every time I have an appointment. It's so inconsiderate.

Me: Yeah, that's rough. But people frequently come into their family doctor with 3 or 4 problems that they expect to have managed in one appointment, even if their appointment was just for a prescription refill. It's hard from the doctor's point of view as well.

Random Person: So then the asshole doctor just rushes the patient out the door. It's so rude.

Me: Which would you prefer... to have the doctor allow you as much time as you need to deal with all of your problems and not feel rushed, or run perfectly on time?

RP: I shouldn't have to choose. These doctors are only in it for the money. They schedule too many people. If they'd just schedule patients further apart, like every 20 minutes or so, they'd run on time and wouldn't rush me out the door. But they're too greedy, and want to make more money.

Me (trying to supress hysterical laughter): Actually, very few doctors in Canada (in urban centres, anyway) are still paid on a fee-for-service basis. So they get paid the same regardless of how many patients they see per hour. They're paid based on the number of people enrolled in their practice.

RP: See? So they SHOULD be booking less.

Me: How long does it take you to get in to see your doctor?

RP: If it's urgent, within a day or so. But for other stuff I have to wait 1-2 weeks. And for general physicals, sometimes I have to book a couple of months ahead. It's awful.

Me: (no longer able to avoid sarcasm) Well, when your doctor starts seeing half the number of patients a day so that you don't feel rushed and don't have to wait, I'm sure it will be much easier to get in to see him quickly.

Sigh.

Baa-Baa Black Sheep

In my family medicine group, I always seem to have the dissenting voice. And as those of you who are loyal blog-followers know, that voice isn't a quiet one. Recently, one of my co-residents shared a story about a friend of hers in BC who was refused a prescription for the birth control pill. Apparently this physician (not her regular family doctor but a locum while her doctor was on vacation) is Catholic, and prescribing the pill went against his values. She was asking the group if we'd ever heard of this before, and if it was legal.

Well, yes. It's legal. And many of us had heard of it, but more in the case of Plan B (aka the Morning After Pill) than the birth control pill. Quite a few physicans (and pharmacists, for that matter) have been known to refuse to prescribe or dispense the morning after pill under the premise that it aborts a fetus. For those who believe that life begins the moment that sperm meets egg (like that Eliza-bitch on The View... uh, the secret is out. I read celebrity gossip magazines at the gym.) prescribing or dispensing Plan B would be like being accessory to murder. But that's not what I want to talk about.

I know of a woman who was recently faced with a horrible choice. After receiving a high risk result on her maternal serum screen, she was faced with the very real dilemma of whether or not to undergo a second-trimester termination or continue with the pregnancy, knowing that she had a very good chance of giving birth to a baby with a severe developmental delay. She opted to have an amniocentesis, in spite of the 1% risk of miscarriage, to confirm whether or not baby actually had the chromosomal abnormality. Baby was fine. But that's not what I want to talk about either.

When this woman was weighing her options, she learned that a second trimester termination, regardless of the indication for it, wasn't available in her hometown. She doesn't exactly live in a rural area-- her town has a population of over 100k people, but she would have had to travel 3 hours to another centre. The reason that this procedure isn't available is because too many nurses had opted out of it. They found it "wrong". Even in the case of a severely deformed or damaged fetus that would be unlikely to survive more than a few hours after birth, these nurses have decided that it is wrong to abort a fetus after 12 weeks gestation and have been given the option to absent themselves from this aspect of their work. Once a critical number of nurses decided not to assist in this procedure, the hospital eventually was forced to stop offering this service altogether. So now this incredibly difficult and emotionally devastating process has to be done while she stays in a hotel in a strange city, away from her support system.

No one uses second trimester abortions as birth control. They are difficult procedures, both emotionally and physically. And like any termination (in my opinion, anyway) it isn't easy to perform. I've never taken any termination I've attended lightly, even the ones done at 10 weeks where the fetus is barely distinguishable from the other products of conception. But is it really ethical to take the choice away from women simply because nurses don't want to participate?

The other family medicine residents believed that it was perfectly within any health professional's rights to refuse to participate in a treatment or procedure that they find morally objectionable. I was, once again, the outlier. I believe that if our refusal to participate in said treatment compromises a patient's access to it (such as the case of the woman in need of the termination, less so for the woman requesting the birth control pill) that it then becomes immoral to abstain from providing it.

As health care providers, sometimes we have to put our personal feelings and judgements aside for the benefit of our patients. Am I judging the 16-year-old who is pregnant with her second child? Sure I am. But I'll treat her threatened miscarriage the same as the 29-year-old married woman who had been trying to conceive for 5 years. And the alcoholic who cracked his head on the sidewalk outside of the pub? He'll get the same suture job as the child who fell off her bike. Because even if I'm secretly thinking that the person I'm treating is a waste of oxygen, no one will ever know I'm thinking it.

So to these nurses who refuse to participate in second trimester abortions? You became a nurse. You chose obsterics and gynecology. You don't get to pick and choose the parts of your job that you enjoy and refuse to do the ones you don't. If that were the case, I'd spend my time in emerg treating actual illness and not the drug-seekers, the addicts and the drunks. Sure, second trimester abortions aren't pleasent. Neither are the early abortions, for that matter. But for women to have a choice, someone has to do it. And if we as health care providers keep passing the buck on the grounds of moral objection, that freedom of choice is in real danger.

The Things My Patients Teach Me

Today I was back in my family medicine clinic seeing patients for the afternoon. After the past few weeks of internal medicine it's hard not to think that their complaints are petty and insignificant sometimes. When I'm still thinking of the woman on the floor with end-stage COPD gasping for breath, it's hard to muster up sympathy for someone's itchy elbow.

But this nearly killed me. I have a patient whom I'll call Mr. E. Mr. E is an elderly guy whose first language is something eastern European that I most definitely do not speak. Mr. E is full of complex medical problems ranging from lichen planus (a skin condition-- see lovely picture to the left) to atrial fibrillation and everything in between. Currently we are battling Mr. E's high blood sugars (he is a poorly controlled diabetic) and his high cholesterol. This is complicated by communication problems-- the last time I asked him to check his sugars four times a day so that we could identify more specifically when they were high, he dutifully did so. When he brought me in his record book it was hard not to laugh when I saw that he had checked them at 7am, 8am, 9am and 10am. I had explained at the time that I actually meant to test upon waking and then before each meal, but he apparently hadn't entirely understood (in spite of assuring me many times that he did).

Today, Mr. E forgot his record book but was eager to tell me that his sugars were finally under good control. They had been steady all day, usually around 5 or 6. Lovely. I told him how glad I was that things were finally getting better-- his chronically high sugars had previously left him feeling nauseous and fatigued. He decided to share his secret with me. Salt and vinegar potato chips.

Um... pardon you?

Yup. Ladies and gentleman, the secret to diabetic control. Mr. E noticed one day that his sugars were good when he ate salt and vinegar chips after every meal. I asked him if such a high fat food was a good idea to be eating three times a day. Oh no, he informed me. No fat. Just salt and vinegar. Apparently, in the mind of Mr. E, they only put fat in the 'fat flavoured' chips. So he had decided to continue to eat the chips after every meal in order to keep his sugars down. I'm choosing to attribute the 'miracle' of normal blood sugars to the fact that we started him on Gluconorm at his next appointment.

I can't wait until his next cholesterol test. We may have to filter the fat globules out of his blood to test it. Sigh.

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?

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.

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.

Paternalism in Medicine

Today I had academic day, which is my only chance to sit around and compare notes with other residents. We frequently discuss cases, particularly ones that had a counselling/psychological/touchy-feely component that we were unsure about how to approach.

The case brought to the group today by one of my fellow residents was the story of a 19-year-old who came to see her seeking the birth control pill. Might have been straightforward, but she was also asking for a refill of Imitrex, a migraine medication. The birth control pill raises a woman's risk of blood clots, which will make her more likely to have a stroke. Have a certain kind of migraine (with aura, where you get visual and/or neurologic signs that preceed the headache) also raises the risk of stroke. To be taking both together raises your risk of stroke by more than either one alone.

The bottom line is that the Society of Obstetrics and Gynecologists of Canada says that migraines with aura are an 'absolute contraindication' to prescribing the birth control pill. So the group was saying that she shouldn't have prescribed the pill (she didn't in the end, but her preceptor ended up caving and giving it to her). I was the lone voice of dissention.

Don't get me wrong, I'm not in a big hurry to prescribe drugs with harmful interactions, but I wasn't sure if it was right to outright refuse the girl her prescription. I was of the opinion that if you are able to appreciate the consequences of your actions, you should be able to make the decision for yourself. For example, if I were to explain that the risk of stroke for a 20 year old woman on the birth control pill is 1 in 1000, and the risk of stroke for the same woman if she gets migraines with aura is 2 in 1000, but if you put the two together your risk of stroke goes up to 8 in 1000. (fictional statistics for emphasis)

Well, if that woman decides that the benefits of taking the birth control pill outweigh the 6 in 1000 risk of stroke, who is to say that it isn't her right to say so? The group shot me down-- lawsuits are stressful, it's ABSOLUTELY contraindicated (thanks, I got that the first time), her reasons for going on the pill were frivolous (who are we to judge her reasons?)...

I stood firm. She was an adult. If she understood the risks, I didn't see why we couldn't leave the decision in her hands. All appropriately documented, of course, to cover my ass in the event that she DID stroke out and I end up being sued.

So now my group probably thinks I'm negligent. I'll likely be voted 'most likely to be sued first' at our next dinner party.

This medicine stuff is complicated.

I am Woman... Does it Matter?

I think I'm lucky to have been born when I was. I'm way too contrary and stubborn to have been submissive and subservient, the way most women were expected to be in the past. And I was lucky to have been raised by parents who believed that women could do whatever men could do. The sky was the limit. I was never encouraged to go into any of the more traditionally female professions. At no point did anyone suggest that I become a nurse rather than a doctor, even after two unsuccessful applications to medical school.

So after growing up in an environment that taught me that I was just as good (if not better) than any man, I've often laboured under the mistaken impression that gender doesn't matter anymore. I had heard the stories about the glass ceiling, read the statistics regarding pay inequalities between men and women, but always explained them away. Glass ceiling? That's mostly in business. Unequal pay? Only because women still chose 'pink collar' jobs over higher-paying ones still dominated by men. But today gender doesn't matter. The inequality has lessened significantly over the past few decades, and will soon be history. Naive? You betcha.

Medicine is changing. The current crop of medical students in Canada is over 50% female. At my medical school (in the interest of remaining anonymous, I won't name it but it's safe to say that it's on the cutting edge of tradition) I was a member of the first medical class in the university's history where women outnumbered men. So the future is bright for women in medicine.

But we're not in the future. We're in the present. And women are still painfully underrepresented in medicine, particularly in academic medicine. Through the course of my medical career I've been interested in three specialties. I started off wanting to do reconstructive surgery. Then, my interests shifted to emergency medicine. Currently, I'm a family medicine resident. Interestingly, I started off in a male-dominated specialty and ended up in a female-dominated specialty.

Surgery often isn't an option for female medical students. The hours are long and hard, and it doesn't let up for the 5 years of residency. Even after residency, many surgeons complain that they don't fell that they're in control of the hours they work. And that's a lot of hours. On my surgical rotation it certainly wasn't unusual to see staff surgeons rounding on their own patients late into the evening or on weekends. And I'm talking about the weekends and evenings that they're NOT on call. I have yet to meet a female role model in surgery. The very few women surgeons I've encountered have either been workaholics or complete bitches, and I have yet to come across any of them that seem to have anything even remotely resembling a balanced life. Which then begs the question-- perhaps none of these 'balanced women surgeons' are around simply because such an animal does not exist.

Emergency medicine was a little better. Although the old guard was still primarily testosterone-driven, the spread of young doctors and residents is now close to 50/50. This is probably because of the 'lifestyle' aspect of the specialty-- if you're the kind of person who copes well with shift work, the idea of throwing your pager out the window for the rest of your career is awfully tempting.

Although family medicine is much more female-heavy than other specialties (with the possible exception of pediatrics and obs/gyn) it's not immune from some of the old school ideas. My preceptor, who isn't all that much older than me, actually said to me that "the problem with physician recruitment targets is the fact that they count women physicians as equivalent to men". Mind-blowing, isn't it?

His point was that women, because they have children, will work less over the course of their career. So if you're looking at replacing a retiring male physician, it would take more than one female physician to pick up his workload. I tried to point out that male physicians are also more interested in life beyond medicine, and are much less likely to subscribe to the 80-hour workweeks and 24/7 call that have traditionally been the hallmark of the family doctor. Many men today aren't content to make lots of money at the cost of their health and family life. What's the point of making lots of money if you don't have time to spend it? Your wife barely knows you, your kids hate you... it's just not worth it. My preceptor was unmoved.

"It's biology," he explained, "women have the children and act as primary caregiver. It's unlikely to change any time soon."

I was horrified, but bit my tongue. My soon-to-be-husband was brought up in a family where mom and dad split child rearing and household chores down the middle. There was no 'men's work' or 'women's work', it was just 'work' and it needed to get done. And it was. As a result, he and I are able to plan a future where we split our allowable parental leave down the middle, and share childrearing responsibilities equally. Maybe I'm underestimating the surge of maternal hormones that will make me want to give up medicine for diapers and Dora the Explorer, but this is the plan we've discussed at length. In fact, if anyone is going to do more than the other it will likely be him. Why don't people even consider this as a possible alternative?

I've started to worry that the assumption that my career will take a back seat the minute I procreate will make the legendary glass ceiling more real than I've ever believed.

Things I Would Like to Tell my Patients

1. Don't assume that every doctor in the world runs late. I rarely do. Please be on time.

2. Bring a list of your medications. If you don't have time to make a list, just throw them all in a bag and bring them with you. Please don't assume that I intuitively know what changes the specialists made to your medications, and please don't think that I'll be able to translate "you know, the white pill-- it's kind of round?" into meaningful information.

3. Don't freak out if you're in for a pap smear and you haven't trimmed your bikini line. I don't notice. I don't care.

4. Please don't bring two other members of your family with different problems and expect me to deal with them all. I like to run on time, and people who expect me to deal with their headaches, their son's asthma and their husband's depression in one time slot make this impossible.

5. If you come in with a problem and I perscribe something to fix it, don't expect the problem to resolve if you decide not to take the medication. And then don't come it two weeks later and tell me the medication 'didn't work'. It only works if you fill the perscription.

6. If you experience a minor side effect while taking a medication, call my office and let me know. Don't take yourself off of your medication so that when you come in 3 months later for follow up your previously controlled hypertension is 190/100 mmHg.

7. When you call the office and ask for an urgent appointment for a non-urgent problem, please don't reject all 3 appointment times offered and go to a walk-in clinic. We're trying to accomodate you. And when you come back in a week with the same complaint, we have no access to tests that have been done or what they tried to do for you.

8. No one is asking you to be a doctor, but PLEASE know a little something about your own medical history. Telling us that you had three operations in the past five years but you're not really sure what they were for doesn't help at all. And mentioning that they may have been for some kind of cancer doesn't really narrow the possibilities.

9. Be honest. I'm not here to judge your drinking/smoking/drug use/sexual practices, but they do affect your health care and how I approach your management. Don't lie to me. It only hurts you in the long run.

10. If you're convinced that all western medicine is evil and that all doctors are just out to medicalize everything and exploit your health problems for profit, maybe you should be seeing some other kind of health practitioner. It's a waste of my time and yours if you're just going to sit there and eye me suspiciously, then shoot down every suggestion I make with "I don't believe in taking medications/physiotherapy/lifestyle modifications". What are you hoping I can do for you?

It was a frustrating week.

Because "FAT" is a Four-Letter Word

For people carrying extra pounds, the word "fat" is often like the elephant in the room that everyone is pretending not to notice. In the case of medicine, this is a very bad thing. The fact is, being overweight (and I won't get mired down in the definition of overweight vs obese vs morbidly obese or whether or not BMI is an appropriate measurement instrument) is a medical condition. It is a significant risk factor for everything from heart disease to pregnancy complications. But no one wants to talk about it. And worse yet, people get offended when their doctor brings it up.

I have been known to spend time on a certain internet message board or two... the majority of the women on these boards are 20-35 years old and married, and are looking to start a family. A surprising number of those (as I mentioned in my last post) have had trouble conceiving. Of course, every healthy young person who wants to have a baby and can't get pregnant in a reasonable amount of time wants to know why. Fair enough.

What I'm seeing, though, are women who are coming back from their doctor's office steaming mad. Why? Because the doctor told them to lose weight, and in some cases, refused to perform invasive investigations until they did. They call their doctors 'insensitive', and 'ignorant' and insist that they know many women heavier than themselves who have gotten pregnant without problems. They demand hysterosalpingographs, exploratory laparoscopy and want to be put on drugs like Clomid. And they're very angry at the suggestion that their weight might be a contributing factor.

Part of the problem is that when someone, even a medical professional, suggests that someone is overweight (I prefer to use the terminology "carrying a few extra pounds"), women don't hear it as medical advice. It doesn't come out the same as 'your cholesterol is high' or 'your thyroid is low'. It comes out wrapped in a lifetime of insecurities and issues. It suddenly comes out in the voice of your mother, telling you at 6 years old that your sundress is 'slimming'. It comes out in the voice of your father, asking you at the age of 15 if you'd put on weight recently. If comes out in the voice of your ex-boyfriend, telling you that you'd have a 'rockin' bikini body' if you just lost a few more pounds. Worst of all, it comes out in the voice that has always shouted in the back of your head that you'd be prettier/happier/more successful if you were skinny. It's hard to separate the 'issue' from the 'issues'. And so the suggestion that losing weight is integral to your health comes out as a social judgement, rather than as medical advice.

Which is too bad. Medical research has shown that patients are more likely to lose weight if their doctor addresses the issue and supports their efforts. And in the situation I mentioned of trying to conceive, a weight loss of as little as 10% of your body weight may be enough to overcome the Unopposed Estrogen Syndrome that is most likely to be the root cause of anovulatory cycles and failure to conceive in women with a BMI over 30. And even if the problem is NOT as straightforward as losing a few pounds, wouldn't you want to try that before resorting to invasive measures that carry risks and side effects?

I wonder-- is the reluctance to accept this advice stemming from the fact that it suggests that it's the womans own fault that she can't conceive? Or is it even deeper than that? Is it because she feels that answer is "too easy" and wants medical intervention to feel that something is actually being done?

In a roundabout way, this leads us to the issue of PCOS (polycystic ovarian syndrome), a complex problem which encompasses benign ovarian cysts, irregular menstrual cycles and insulin resistance. More women are being diagnosed with this today than ever before. It's still unclear if being overweight predisposes you to developing PCOS or if PCOS causes obesity secondary to insulin resistance. But it's the same insulin resistance that is a precursor to adult-onset diabetes, a condition that is known to be caused in part by being overweight. Which came first... Chicken? Egg?

I'll get off my soapbox now. But I'm always hesitant to address the issue of weight with a patient, unless it's directly related to their reason for coming into the office (high cholesterol, knee trouble, diabetes). Maybe I'll get braver as time goes on, because I fear that continuing to ignore the elephant in the room isn't doing my patient any favours.

Sometimes, life just isn't fair.

There is a patient in the family practice where I work-- I'll call her Mary, since it's the most normal name I can think of right now. Her and her husband have been trying to get pregnant for several years. They are both in their early 30's.

(As an aside, I can't believe how many young, healthy people suffer from infertility these days... until about five years ago, I figured that anyone who pulled the goalie would inevitably get pregnant within a few months. Has getting pregnant gotten a lot harder in recent years or is this just another subject upon which I've apparently been burying my head in the sand?)

So back to my story. So Mary and her husband have been trying to get pregnant. A lot. They've both been investigated, and neither of them has any physical reason preventing them from conceiving. So they're still trying.

A few months ago, at a routine physical, Mary has an abnormal pap. Not "Oh-My-God" abnormal, just "Hmmm" abnormal. So she gets sent to the gynecologist for colposcopy (where they take a microscope of sorts and take a closer look at the pathology in question). She tells the gyne that they're trying to have a baby, and asks if they should put their efforts on hold while this whole cervix thing is being investigated. He poo-poo's her concerns, and tells her that 99.9% of the time this kind of thing turns out to be nothing.

Not so much.

Invasive cervical cancer. The good news? Largely curable with a cone biopsy of the cervix. But only if it's done right away, before the cancer has a chance to spread to the uterus. Because if it spreads, then she'd need a hysterectomy and any chance of biological kidlets would be gone. So pretty straightforward, eh? Send poor Mary for a cone biopsy!

But oops. Mary hasn't had her period since mid-December. Mary is pregnant with the desperately wanted baby that they've been trying so hard to conceive.

What a horrible situation. She could still opt for the cone biopsy ASAP, knowing that it could compromise the integrity of her cervix and put the pregnancy at risk. Or, she could hold off until after the risky first 12-15 weeks (when most miscarriages occur) and have the cone biopsy done then, knowing that there's no way to tell if the cancer would have spread to the uterus in that time frame. Or, she could opt not to have it treated at all until she gave birth, but the pathology showed a cell type aggressive enough to think that this option may put both her life AND the baby at risk.

My heart was breaking for Mary and the decision that she had to make.

In the end, she opted for what I would have done under the same circumstances. She opted for the cone biopsy. She had it done two weeks ago. So far, so good. But when I saw her today and asked her about her pregnancy, she said she hadn't thought about it... she was scared to death to grow attached to the little being inside of her, knowing that there was a good chance it would never see the light of day.

I don't know about you, but I'm crossing all of my fingers for her.

Ah-CHOO!

At the family practice where I work, my preceptor books patients every 15 minutes with a few last-minute emergencies squeezed in. I, on the other hand, see patients every half hour to allow for the fact that I'm still learning. Not to mention the fact that I'm still sneaking out of the examining room to look up drug dosages, fumbling though the sample closet for ages to find what I want and occasionally waiting for my preceptor to finish with his patient to confirm my treatment plan with him. So I take longer.

All in all, I'm seeing about 12 patients a day. Par for the course, according to my impromptu discussions with fellow residents during our academic half days. Out of those 12, at least 2-3 are coming in with a cold. Every single day.

Why on earth would anyone see their family doctor for a cold? I really don't get it. You have a stuffy nose, a cough and you generally feel like crap. And it's been going on for three days. What on earth do you think that seeing your family doctor is going to do? If there was a magic pill that cured the common cold, don't you think you would have heard about it by now?

So now I have a "spiel"-- I explain all the things that I can rule out based on the physical exam. No swollen tonsils with white crud on them? Not strep throat. Ears look fine? No ear infection. Lungs sound clear? Not a pneumonia. Then I go on to tell them that since there is nothing going on that we can treat with antibiotics, they just have to let the virus run its course. Usually people are okay with that, and if they seem to want more I'll perscribe a cough suppressant with slightly more codeine in it then you can get over the counter. Or a swish-and-spit mouthwash that is only slightly better than placebo at helping a sore throat. But it makes people happy.

My preceptor, after 10 years as a family physician, is slightly more accomodating. If people honestly think they need an antibiotic, he'll occasionally give it to them even if it goes against evidence-based medicine. I can understand the urge to keep your patients happy, but I also don't think that patients should dictate their own treatment. It may sound paternalistic of me, but that's why we train for so damn many years... so that we have to knowledge and the tools to make treatment decisions for them. Otherwise, ALL drugs would be available over the counter. My preceptor good-naturedly refers to me as The Antibiotic Nazi. At least, I'm hoping it's good natured.

But back to the point. Why do people come in with a cold? Do they honestly think it's something worse? Even if everyone in their family has a cold, they've had a cold in the past and there's nothing new and interesting about this particular bug? I can understand in the case of a child, because parents always err on the side of caution when a kid has a sniffle. And kids are much more likely to have strep throat or ear infections. But when a healthy 35-year-old comes into the office with a two day history of stuffy nose, cough and fatigue, I have to be honest and say that I'm rolling my eyes in my head...

Sigh. But that's what a family doc is there for, right?

Paging Dr. Hypocrite...

As a family doctor (or in my case, a reasonable facimile) a big part of my job is preventive medicine. The idea behind this is that by taking care of the 'big picture' of our patient's health, we'll prevent larger problems down the road. The fee schedule that my preceptor works under actually encourages this... in place of a fee-for-service model that encourages assembly-line medicine and rewards procedures over counselling, under this new model a family physician is paid a monthly fee for every patient enrolled under his care. Regardless of how many times or for what reason each patient actually comes into the office. This isn't quite as wacky as it sounds. The monthly fee for an elderly woman, for instance, is substantially higher than a young adult. Young adult males, who traditionally are the lowest users of the medical system, are worth the lowest monthly fee... unless they have a serious mental illness, which makes the fee higher. Get the idea?

So anyway, this alternative funding system lets us spend time doing things like helping patients stop smoking, improve their diet, cope with their stress and other things often deemed 'touchy-feely' but that pay off in the long run. The problem is, the medical system makes it pretty damn hard to practice what you preach.

Before medical school, had a pretty healthy lifestyle. I ate well, I managed stress in a constructive manner, and I was pretty active. I hit the gym 4-5 times a week, and picked up a new sport every year-- most recently I had learned to row, play touch football and golf. And I maintained a weight, which although I was always unhappy with, translated to a healthy BMI. All in all, I was doing okay. Then came clerkship.

The hours got longer and the gym visits got fewer and further between. Healthy meals gave way to take-out on more evenings than I care to admit. Sleep became a valuable commodity, and I wasn't getting nearly enough of it. And the stress grew. Some people coped... some didn't cope so well. I did okay, mostly thanks to a kick-ass support system in the form of two close friends and an amazing significant other. But many of my healthy habits went right out the window.

So here I am, 25 lbs heavier than I was before I started medical school. Before this week, I haven't seen the inside of my gym more than once in the past month. I'm relying less on take-out thanks to the joint efforts of myself, my fiance and our slow-cooker, but diet alone isn't enough to undo the damage. And that makes me a hypocrite. What are people thinking as this overweight, overtired doctor advises them on improving their diet and finding time to exercise? How can they take me seriously when I can't take me seriously?