A day in a life of a family physician

There are many who think that family medicine is about simple infections, prescription renewals and providing referrals to specialists. I thought by sharing the exact details of a day in a life in family medicine, my colleagues can either substantiate or educate or commiserate with my experience. This is an exact play-by-play of my family medicine clinic day on a Tuesday this summer (2022): I arrive at my medical practice at 6:15 a.m. There is a note that the patient washroom has been clogged from the walk-in clinic last night. We cannot have this with patients coming in today, plus plumbers are expensive. I put on appropriate personal protective equipment, grab a bristle toilet cleaner, multiple rounds of Liquid Plummer, a very large plunger, and a smell-resistant mask. I finish at 6:45 a.m. This should have been managed the night before and I will have to talk with my staff. Read: A form letter that you can send to you patients to help them understand I spend the next 105 minutes reading the charts for the patients I am to see today. I have 42 patients booked from 9 a.m. to 8 p.m., with two one-hour breaks between 12-1 p.m. and 4-5 p.m. I like to make sure I have the necessary results, prepare the charts with ongoing action lists, see what results are pending, review any consultations and so on. I don’t need to do this and it takes extra time, but I find if I am prepared for patients, the appointments go more smoothly and patients cannot sidetrack me. Asking “What are you here for?” is not efficient. Plus, even when I am prepared, I often get dragged down new paths by patients and their families. In the morning, I try to deal with messages about prescription renewals, limited-use codes, early narcotics release, lost requisitions by patients, prescriptions for orthotics and other services covered by insurance. There are also record requests from lawyers, insurance companies, dentists, various therapists, failed referrals to specialists without any guidance, pharmacist’s questions or back-ordered medications, complaints from patients who want medications covered instead of those that will help their conditions, complaints from patients about long waits, special requests for specific specialists, requests from chiropractors, and physiotherapists and specialists for various test results. Then there are requests from specialists to take out stitches, arrange various testing, redirect referrals, send new referral requests since its been over a year, or specialists that are no longer looking after that condition or no longer accepting patients. And let's not forget complaints from parents for impossible mental health support, questions about various naturopathic medications, hundreds of work- related insurance forms, WSIB forms, MTO forms, EAP forms, VA forms, MOH forms and so on. This list is incomplete and will never end. Of course, many other similar requests will pile onto my desk while I try to deal with what I presently have. This will drain my soul At 8:30 a.m. my senior administrative staff member arrives. She knocks on my door to talk about patients who want to be seen earlier, have specific requests, want me to accept a family member, want to complain about my staff and clinic, and to discuss the clogged toilet. I find out that one of my secretaries wants to take a week off, as well as that one of my nurses is struggling with burnout and wants to reduce her hours, and so on. We struggle to get through her list. While we are talking an unexpected patient starts banging on the door. We ignore it for a while, but she persists. Somehow, she convinces the staff and eventually me to aspirate her traumatic olecranon bursitis and inject if with cortisone and then apply a pressure bandage. This puts us behind by seven minutes for my first patient at 9 a.m. Remember this is not unusual I start with a well-controlled diabetic and do the flow sheet. He needs all of his medications, blood work requisitions for future testing. He has heard about the Libre system and we discuss. He wants to do his MTO but we need to rebook; he needs his eyes checked so a form is produced and as I am ushering him out he shares his erectile dysfunction issue which we must deal with. So the first appointment from 9 a.m. to 9:20 a.m. starts at 9:07 a.m. and ends at 9:30 a.m. I am 10 minutes behind already. I bring in the 88-year-old lady with osteoporosis failing on bisphosphonates and moving on to denosumab. She is frail and moves slowly. She comes with her grand-daughter who is a nurse and wants to review all the bone density tests over the years and the t-spine x-rays. We talk about her grandmother's compression fractures and her pain when lying down. I go into my office to find a request for filling out a hearing aid form which I complete and give to the front staff. A patient in the waiting room called out for me to see their new baby and I had to play nice even though I was running behind. The 9:40 a.m. patient started at 9:55 a.m. Read: Why would anyone want to be a family doctor? This 44-year-old female has endometriosis, colitis, spastic bladder, depression, anxiety and sleep issues. She has been off work for a year on long-term disability as we sort this out. She finally saw the OBGYN, and recommended options are discussed. She did her own research. She brought in recommendations from her naturopath and chiropractor. This is a mixture of counselling, correcting false information, guidance, support, discussing insurance needs and hopefully moving her forward. I don’t know if I actually help her, but I do know we end at 10:30 a.m. Now I was 30 minute behind. I go on to a 78-year-old diabetic with severe stasis ulcers (needing home nursing care) and a left total hip replacement, then a two-month-old new baby needing a Rourke and vaccinations with a first-time mom who is struggling with baby blues not postpartum depression (thank goodness). Next is an 85-year-old who needs a health and medication review (hopefully deprescribing), is considering extra vaccinations and a MoCA. This takes time. She comes with her two sons and they want to talk about competency and whether she should go into a home. She is unwilling. It is now noon and I was an hour behind. No lunch again! Will I finish the last six people before my 1 p.m. patient? Why am I so nice? The day progresses with a skin biopsy, multiple joint injections, a travel medicine consult with a family going to Nigeria, a suspect chronic Lyme patient, a schizophrenic unwilling to take his antipsychotic medications, a corneal abrasion, poorly controlled COPD with unwillingness to stop smoking, an autistic young adult threatening his parents with violence, a sports medicine consult, a palliative care patient requiring CHF self-prescribing support, an obese patient with back problems wanting surgery but unwilling to do home exercises or lose weight, a chronic anxious patient with IBS wanting to stay off of work longer, and so on. Three patients do not show up despite two reminders for each of them. We actually have a patient come in around 3 p.m. yelling at staff that he wants to see me. It seems he ran out of this blood pressure medications months earlier. The pharmacist renewed it three times for a month each time for $15 each (robbery, he says) and told him to book an appointment with each renewal. He did not. Now he wants a renewal right away and is unwilling to book an appointment or wait to be seen at 8 p.m. at the end of walk-in clinic. He is threatening to complain to the CPSO. He leaves me his number to call him. I finally go to the washroom at 4:30 p.m. and have a late lunch/early supper. I manage to finish charting on half of my patients seen that day from 9 a.m. to 4:30 p.m. by 5 p.m. evening clinic start time. We have 12 booked patients and a few call-ins from the day that needed simple things (thank goodness). The staff leaves at 8 p.m. They have worked hard and dealt with many complaints, excessive demands and high expectations. I finish with patients at 8:45 p.m. I manage to deal with 10% of my messages and do some paperwork. I have about 20 charts to finish so stay until 9:30 p.m. to finish those off. The other 90% of paperwork will have to wait. My point: family medicine is challenging and complex. I hope that specialists read this and offer a day in a life of their medical lives, so we all understand that medicine is challenging and complex. We all work very hard and pointing fingers at each other will accomplish nothing. Dr. Alykhan Abdulla is a family doctor working in Manotick, Ont., past Chair of the Section of General and Family Practice and Lead for Longitudinal Leadership Curricula at UOttawa Undergraduate Medical Education. This item previously appeared in Healthy Debate. Read: Improve healthcare: More family doctors

A day in a life of a family physician

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