To the editor:
I graduated from family medicine pretty much a quarter of a century ago now. It was with hope and a prayer that I would love this career.
Like many careers, we have to guess and hope we get it right. I have had no regrets. I still love doing family medicine. I love the puzzle-solving in sorting out a new problem. I get to hear and be a part of people’s stories. And I have a job where I feel I can make a real difference in people’s lives. Not only that, but it's one of the few jobs where people take the time to give heartfelt thanks for the job we’ve done.
There are many jobs where people don’t get to hear that nearly often enough.
I came to North Bay as a family doctor because it had so much to offer me. The medical community was stocked with wonderful people who worked together and helped each other out. It has allowed me to participate in all sorts of fun and interesting medical care.
Family doctors in the north are often our specialty doctors too. We not only do family medicine but also work as operating room assistants, emergency doctors, palliative care doctors, walk-in doctors, addiction medicine doctors, stroke clinic doctors, foot care doctors, allergists, hospitalists (care of hospital patients), coroners, sports medicine doctors and more!
Most family doctors here provide several of these extra services to the community, beyond their family practice.
In our family doctors' offices, we also work at an intensive level.
In a big city, many of our patients would be followed by specialists. Here there isn’t the local manpower for that and it is often a big burden for people to travel for specialty follow-ups. So, much of the time we get a one-time specialist consult and then pick up the care from there. We are constantly picking up books, researching, being creative, and trying to keep up with all of these medical conditions. This is both wonderful to be able to do and at times very tiring.
I have found over the years that, despite constant recruiting, our numbers of medical practitioners of all sorts have remained relatively stable. We have basically been recruiting at the level that replaces retirements.
When I started here, there were 9,000 people with no family doctor. I don't expect this number has gotten any better. At the same time, the population has aged. We are taking care of a higher number of older patients that have high care needs. We have started joking that the new middle age is now the 60s and 70s. A huge number of the patients we are caring for are in their 80s and 90s. We have cheered when we have gotten extra beds in the hospital for patients and then been struck with the realization that we don’t actually have a larger number of people to care for them.
Medicine is also advancing.
Over the years there is more we CAN do for people to help them with their health. A heart attack used to be treated with pain medication and then we just had to watch and see how it all came out. Now we can clot bust, put stents in, do cardiac surgery, and have a raft of medications and lifestyle issues to help people with. This means that we put more time into people's health as we are able to do more.
The North Bay medical community has been incredible at making all this work.
I believe that we are one of the last places in Ontario where the hospital in-patients are taken care of by their family doctors. In the bigger communities, this is done by teams of internists. In the smaller communities, they are often flying in hospitalists for a week at a time.
North Bay doctors have managed to juggle doing this with our local doctors and have been proud to do so. We love being able to take care of our own patients in the hospital. For patients with no family doctor, we have all pitched in to take care of them through their hospital stays. We have been able to do this largely because we have such great teamwork across all of our doctors. We work hard to support each other and spare each other work so that we can all sleep and get time with family.
The emergency room docs often take care of patients overnight so that the family docs and critical care specialists don’t have to be woken up unless essential. We will often take over in the morning after a full night of sleep. In a small community of doctors, being able to get a bit more sleep at night is essential to sustain the ability to work long-term. The internists and the family doctors work together to spare each other unnecessary extra trips to the hospital when we can. It’s not that this doesn’t take a bit of negotiation at times as we all get tired, but so far, so good!
More recently (in the last decade), we have seen numbers of hospital in-patients climb with the same number of family doctors to take care of them. People’s medical problems are becoming more complex and we are often taking care of more acutely ill people. It’s at the point that there are days that are becoming near impossible to manage the workload. Once again, I’m seeing us step up for each other. I will look over at a doctor who looks like they are being mowed down that day and hear their colleague offer to take up some of the load.
I had my BEST BIRTHDAY PRESENT EVER the other day.
Normally, I start my day in the hospital by taking care of the most medically ill patients and the newly admitted ones. Then as the day goes on, I can move on to the less acutely ill patients. It’s always a bit of a juggle to decide who needs you most and I worry until I’ve worked my way through everyone who is potentially more ill.
I was on day five of a series of 12-hour days plus overnight on-call. I had started at 7 a.m. that day, it was 11:30 in the morning and I STILL hadn’t managed to see all my high-needs patients AND I had another 25 patients to see after that. It was one of those moments you just want to put your head down on the table and either cry or wave a white flag.
One of my colleagues came by to get some advice on one of their patients. It turned out that their workload was a little lower that day so they offered to take on one of the new patients I hadn’t managed to see yet. Did I mention, BEST BIRTHDAY PRESENT EVER?!!!
The other load on the system is that doctors have the same life problems as everyone else.
When I got sick with breast cancer, I was a little offended that being a doctor didn’t get me a “get out of jail free card”. We have to deal with all the same medical illnesses and family problems that everyone else does. We do our best to keep going when sick because we don’t want to load our colleagues. I’ve seen doctors work even while doing dialysis, cancer treatments, broken bones, and other illnesses.
At some point though, we have to start being smart and stop and just take care of ourselves. We need to take time off to heal, time off to play, and time off to recharge with family and friends. Because the problem is…that when we break, we can leave thousands of people with no family doctor.
There is just nowhere for patients without family doctors to go right now. Every family doctor I know is at or beyond capacity in their family practice.
When we take people, it's often because they have complicated medical needs and we can’t stand to send them back into the community with no care. But the more people you have overcapacity, the longer the wait time is for people to get in to see their doctor. Waiting 6-12 weeks to see your doctor starts to become more commonplace.
So, you know all those wonderful extra subspecialties that family physicians provide to the community? This is when the medical math gets really crappy. If you are overwhelmed with work, family doctors either have to give up these extra medical services they provide to the community or discharge patients from their practice to lighten the load.
You could say: “I’ll just discharge the medically well.” But how many medically well patients do you have to let go to equal one medically complicated person you want to keep. 5? 10? 20? My guess is between 15-20. So, if you want to lighten your load, you actually have to discharge the medically complicated patients.
Heartbreaker, right? Many family doctors give up these other services they provide the community rather than have to give up their patients. (Luckily we see some go the other way. Hard on those patients but sometimes essential for the overall community services.) So, who then serves the community in these other roles? Only two answers: more work by fewer people or no one at all.
In the old days when you were ready to retire, you could “sell” your family practice. The incoming doctor would buy your equipment and take over your practice.
These days, I’ve seen doctors work five or six years beyond when they wanted to retire just to be able to find someone to replace them. (Their hearts are big, and their will was strong.)
So what is the bottom line to all this?
One: We have a great community.
Two: As far as I can tell, there simply aren’t enough doctors. We simply need more people.
So, if you want to help, talk up our lovely community, help us recruit more doctors, and talk to our decision-makers about making more of us!
And don’t forget to be kind to the people around you. We are all essential workers whether we are doctors or not.
Dr. Sheryl Riley
Family doctor, walk-in doctor, hospitalist, preceptor in training new doctors, ex-emergency room doctor, ex-operating room assist
North Bay
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