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Canadian Family Physician•Le Médecin de famille canadien Vol 53: october • octobre 2007Exodus
Why I limited my scope of practice
Donna P. Manca
MD MClSc CCFP FCFPT
he millennium brought many changes for fam- ily physicians, including, in my case, a decision to limit my practice. The exodus of family doc- tors from the Edmonton hospital where I worked had started in the 1990s; we were like canaries in the mine, and our leaving was among the first signs that the system was sick.Better times
In the early 1980s I felt respected and valued. I could cope with the workload and the call was doable. I was up the occasional night but did not feel overwhelmed or unable to function. I could attend to my patients’ needs.
I met many specialist colleagues in the mornings dur- ing hospital rounds and felt supported and valued by them. My office was busy but I was not pressured to see more patients than I could han-
dle. The patients I saw were not so complex that I could not address their concerns within the time frame of a regular visit. The paperwork was man- ageable within the hours of a routine day at the office. After-hours coverage was shared among our group. I could
afford to attend the occasional medical conference or to take a couple weeks of holidays with my family. All of this was about to change.
As the decade progressed, so did medical care.
Captopril changed how I treated cardiac conditions.
New investigations were introduced and some, such as ultrasounds, were becoming routine. I was able to detect more conditions and had more in my black bag to offer. Medicine became more difficult, as patients had more and more conditions to be investigated and treated. Many patients who would once have died were now surviving with multiple complex problems; they were more difficult to manage in routine appointments.
Other patients presented to hospital with acute or chronic conditions that could not be managed at home.
The terrible 90s
The 1990s brought growing change with the loom- ing “health care crisis.” There were severe hospital bed shortages. With the aging population came increasing numbers of complex, frail, elderly patients who, once admitted to hospital, blocked the acute beds because the nursing homes and auxiliary hospitals were full.
Nursing home staff and auxiliary hospital staff were cut. I used to make rounds on my elderly patients with the nursing staff, but that changed and no one was available to discuss orders or concerns. The number of urgent calls increased, as did the urgent after-hours visits to the chronic care settings; many such calls were for conditions that would once have been addressed on weekly visits when there had been an adequate complement of nurses. I dreaded late-night calls; there were times I felt unsafe trying to get into facilities when the busy nurses on duty could not answer the door buzzer or my pages. I recall peering in windows in the dead of night trying to get a nurse’s attention.
The situation in the hospital was also critical.
Physicians were seen as causing the problems with “too many admissions.” There was a decision that all the family physicians’ admissions would be screened by specialists to reduce the number of “inappropriate admis- sions.” I remember one night I had a patient with severe heart failure whom I could no longer manage in the emer- gency hallway. It was about 3:00 AM and I needed the nursing staff on the ward to care for my patient. Admitting would not allow this without approval from the specialist on call. I woke a gastroenterologist who was kind enough to approve the admission for me so that I did not need to stay in the emergency department all night tending to my patient.
This policy added to the problem and was soon canceled.
The hospital nurses were overwhelmed and could not attend to my patients’ needs. I had to visit some of my patients 2 or 3 times a day (or night) to assess whether they were receiving the treatments I had ordered. I could not get access to the specialists, as they had their own inpatients to care for and urgent inpatient consultations sometimes took a week or more to arrange.
I recall the gross billings of a few physicians being published by newspapers, implying that the amounts were typical of what doctors lived on. Health care econ- omists and politicians indicated that a major problem was “too many doctors.” The solution: cut down on enrolment to medical schools.
The fee-for-service billings did not address the increased unpaid work. The paperwork escalated so that for every 2 hours I saw patients, I needed to spend 1 hour on paperwork. When I saw patients, I prescribed enough
We were like canaries in
the mine
Reflections
Vol 53: october • octobre 2007 Canadian Family Physician•Le Médecin de famille canadien
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Reflections
medication to last until the next time they needed to be reassessed. The number of prescription refill requests escalated, and some pharmacists and patients had the attitude that I was trying to make money by forcing my patients to come in for refills. Referral groups offset their clerical workloads onto us so that our office had extra work with referral procedures. The tremendous increase in unpaid work caused my take-home income to shrink;
I was not the rich doctor society imagined. I had trouble taking holidays, as any time away was prohibitive due to high overhead costs and the difficulty of finding phy- sicians willing to cover the practice. I could not afford to attend medical conferences, and continuing medical education was financially troublesome as well.
This was the scene in the 90s, which is why there was an exodus of family physicians from the hospital. I hung on longer than most.
Adapt to survive
For me, the straw that broke the camel’s back occurred on call when I was detained for a couple of hours dur- ing a difficult delivery. I was unable to answer my pager and the message centre was full; I recall there were more than 20 unanswered pages. The urgent messages included calls about an infant in emergency who needed admission; 2 patients on the wards who were rapidly deteriorating and needed assessment; a distressed patient in a palliative care unit that was a 15-minute drive away who needed tending; and patients in a nurs- ing home that was a 30-minute drive away who needed to be assessed immediately. I was completely over- whelmed and realized that I could no longer continue to provide that level of care.
I adapted and decided to become an academic family physician with a focus on research. My practice is now limited, as I no longer deliver babies or admit patients to nursing homes. In some ways I am busier; however, my patients are well cared for.
Although the 1990s were a dark time for me, I never regretted becoming a family physician. The problems I experienced were external to the profes- sion and symptoms of a failing system. There were tremendous advances in medicine, but the system did not adapt. Solutions were imposed by people who did not understand the problems. Uninformed decisions that affected practice were made without input from clinicians.
There is a need to evaluate and change the way we deliver medical care. To avoid repeating history, this should be done with the involvement and active partici- pation of all the groups potentially affected. We need to realize that blaming others for the problems and exclud- ing them from the solution does not work; everyone needs to be actively engaged if we are to solve the prob- lems we face. We need to stay involved and ensure our voices are at the table even when we feel overwhelmed.
We can learn from the past and improve the future for ourselves and others.
Dr Manca is an Assistant Professor and Research Director in the Department of Family Medicine at the University of Alberta in Edmonton and the Clinical Director of the Alberta Family Practice Research Network.
competing interests None declared
