Solo saves a foot

Oakville, where I live and work, is perched on Lake Ontario. It has its boats and a marina, scenic parks and board walks, with a quaint and quiet downtown and surrounding neighbourhoods. A homeless patient paid a visit to my practice this week. This elderly man lost his home four months ago. He now sleeps outside in a small car with his family, with no rental prospects as winter arrives. He booked for a B12 shot, but the visit turned out to be more "dramatic." Our nurse practitioner gave him the B12 shot, weighed him, then prompted me saying, “He's lost weight, and he's got a swollen foot.” Swollen indeed. A foot poked out from the missing front part of a dirty sneaker, strangulated by the fabric lining, like a sausage finger trapped by a ring in the ER. Read: How I talk to patients requesting exemption letters I followed upstream and saw incontinence did not spare the pants either. I'm not sure how to describe the odour in words. He sat there looking glum with his head hung, having learned that in life, complaining doesn't get you far. I wanted to say, “See you next month for your B12 shot and Happy Holidays.” But in my mind I pictured amputation of a diabetic foot. Together the NP and I scissored away the tattered shoe fabric, wiggling and pulling to free the trapped foot, careful not to get poo flakes and droplets on ourselves. No wonder he was banned from the retail washrooms he used to frequent. He didn't move or say a thing. My mind raced to what we'd do next, problem-solving on the fly. Oh yes, pull the socks off and check the feet, acclimatizing to the odour. Thank goodness for gloves. Thank goodness for what appeared to be intact circulation and the absence of cuts and heel ulcers. No thanks for sharp dystrophic nails that are sock killers. Read: Scribble and doodle—for serious clinicians Now what? What is the “standard of care” in this scenario? I don't even bother ask, “Do you have a backup pair?” since his presence and plight already retorted, “Do I look like somebody who has a backup pair?” The only solution I could think of on the spot was to buy him a new pair. “Has to be the same one,” he chided. Not that he's choosy, but a size 13 wide is hard to find. I delegated other patients to my NP, and drove out to a nearby big box shoe store. After actually finding a size 13 wide, I also found sandals. “Gotta keep the feet dry,” I reminded myself. I was not so lucky in the sock department; size 12 will have to do. I returned from shopping triumphant. He was now sitting in the waiting room. My NP was seeing other patients for me, which is well worth the non-funded investment by a private practice. My Medical Office Assistant had already wiped down and mopped up my exam room, and bagged the discard pile. I am always thankful she makes everything and everyone better. Or less bad and sad. Now what? Do you put smelly feet into new socks and shoes? I retrieved a bucket, washed the feet, did what I could to file down the nails using a carpenter's file, dried the feet, then voila.... brandished the bright new shoes. The one foot was still too swollen from the strangulation. Good thing we have the sandals. He did not beam. He did not say “thank you,” nor have tears in his eyes as I walked him to the car. Nope. He just wanted to make sure we didn't forget to give him the brand new pair of white sneakers, as he walked out wearing sandals. Actually I think he was anxious to get out after two hours. It's not easy for anyone to subject themselves to being “helped” this way, while keeping their self respect intact. But I think we did good that day meeting a “standard of care." A diabetic man came in with wet feet and left with dry ones. Maybe we saved an untimely amputation. Maybe they will be wet again in a few days, a few hours. Maybe someone will steal the shoes. We won't know. And for now the wet pants are blocked out of my consciousness, for my own psychological well-being. Another battle for another day. I didn't tell this story so readers would go, “Aw, what a nice doctor.” I share this because afterwards, I tried to imagine what a big “primary care team” would do instead. The kind that visionaries feel are the answers to such needs. Perhaps the doctors would delegate the dirty foot work to nurses so everyone could “do best at what they are trained to do.” Perhaps a diabetic educator would tell him how to eat healthy among meagre food bank pickings, and set him up for diabetic foot care (an appointment I am certain he will miss). Perhaps a social worker would give him a printout of the rental opportunities in the GTA, all priced out of reach. Or perhaps our social safety net is so broken that homeless seniors like him just have to get by without easy access to washrooms, clean water, laundry, space to stretch and dry up, store things— not to mention food, clothing and other things that cheer the soul and infuse some sense of dignity and community. It's not easy even for “big teams” is it? Please, I am not arguing against big teams—a vision calling for huge investments to house many professionals under one roof, so they can collaborate to “strategize population health.” They have much support for their place and value in tomorrow's primary care. But I strongly disagree when these visionaries imply theirs is the best or only solution for tomorrow's needs that nobody can foresee. Especially when I hear them contrasting their vision against “solo” doctors like me, who allegedly have a narrow focus on care, doing high-volume, band-aid medicine, being isolated and backward in “modern collaborative approaches,” and ultimately delivering less. The reality is that many solo/small practice doctors do exactly what I did every day, meeting practical needs within a small office setting, working alongside loyal and dependable staff. Solos can give great care not in spite of being small, but because of it. We keep it simple and relevant, and don't need to have a meeting to get things done. We do extra because we know the patients, speak their language and say, “damn it, this one's on me, this person matters.” Would it be any surprise that one Alberta research study on collaborative care of 89,000 patients found “non-participating solo family practices scored higher than multi-physician clinic implementing teams did”? Some may argue I am not “solo” because I have an NP. But I am definitely not a “Patient Medical Home” and would dread working in one. (But if you like them, great!) Solo, I think, is a mentality that “small and personal matters,” and that “the buck stops with me.” One colleague who practises in a Family Health Team said to me, “but I am Solo too” . . . kudos to him! Against stereotype, we are neither alone nor isolated. There are more than 350 doctors in the Ontario Medical Association (OMA) who self identify as “Primary Care Solo” MIG (Medical Interest Group), and who regularly exchange practice tips and support one another against burnout. It was started by current OMA SGFP Chair Dr. Cathy Mastrogiacomo. If you are an Ontario family doctor working solo or in small groups and would like to join us, simply designate your affiliation in your OMA web account. To join our online discussion group email me at adamchen@live.ca, or text me at 289 772 9852. Solo brings cost-effective and good care, despite its humble existence, simple design and low maintenance. Grouping us all into big teams will be a huge loss to personalized care in our healthcare system. After all the novel healthcare ideas have been tried, Solo will still be around, doing good work quietly, helping patients one at a time. Adam Chen is a family doctor in Oakville and a member and executive of the Primary Care Solo MIG within the Ontario Medical Association.

Solo saves a foot

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