What I learned I should have asked/done in my first year of practice

If you are taking on someone else’s practice, you will also be taking on their mistakes and successes. It will take time for their patients to trust you.

Booking in Patients: Unfortunately, b/c the Ontario Government can’t get their heads out of their collective ass, you won’t have the luxury of “ramping up”.  Because the patients are going to be coming in at full speed, you will need to have a plan. I made a few hours every day my “meet and greets” where I would get families to come in to meet me and go through their health history to get me caught up. Priorities were patients with diabetes, using narcotics, with cancer, polypharmacy, etc. My staff helped flag them as they refilled their meds. 2 - 3 hours were for seeing acute patients/patients that were booked in over the past couple of weeks. At least one hour for labs, scripts and reports.

No general assessments for at least 6 months. If a patient is due for their pap, either divert to an NP or have them booked in for just a pap. Lots of your patients think they need a general assessment to see you. Have staff ask if a meet and greet will do what they want. 

Spend time with each patient’s chart updating it to fit the way you want to practice. It will save you lots of time in the future. 

Your access time in the first year is going to suck. Get over it. As long as you are treating your patients well when they come in, they will forgive you. 

Med Refills: They will be on meds that haven’t had the appropriate labs set up in ages. Set up standard labs and protocols for patients who are calling in for scripts and have your staff automatically order what you want (e.g. LFTs for statins, metabolic panel for antipsychotics, TSH for Li and synthroid…). 

Decide what your rules will be for certain drug classes (opioids, benzos, etc.). My rules were considered stringent by my patients in my first year. I was very clear about max amounts of morphine equivalents I was comfortable with (200). Anyone above that had to see the clinic pharmacist for a review and to see if there are changes that can be made, if the level of pain management is appropriate. Use the McMaster Pain Guidelines. Having the objective tool makes it easier to be firm. http://nationalpaincentre.mcmaster.ca/opioid/  I asked pain and bento patients to be in q4months. I wouldn’t renew scripts unless they came in. Drug testing was mandatory. 

Money: Get everything in writing. All the little bits and pieces that you are paying for in your overhead. Do any of your billings go directly to the clinic? Who is in charge of your billing? How often do they go for training? How do they deal with billings that get sent back? How is overhead split? Do you have to pay rent for the FHT staff or just your FHO staff? Who exactly contributes to the pot for your clinic? Is it the same people who are using the clinic? If you are working rurally - dose your ER billing go to the same billers? hospitalist? OB? 

Governance: How are budgeting decisions made? What makes a vote go through (i.e. is it majority or unanimous?) How are disagreements within the group managed? (ask for an example) What committees will you expected to be a part of? How many days vacation do you get? How does your team feel about you going on vacation? Are locums expected or will they cover your patients when you are not around? Does the team have a plan for mat/pat leave? How many hours are you expected to devote to in clinic time? Who manages your staff? How is that person evaluated? What sort of observation/probation does your team use?

What to expect in your first year of practice.

Every borderline personality patient will come out of the woodwork and want to be your patient. The kind things they will say, the flattery, the sob stories, oh, my, god, will they make you think you need to take them on. You do not. If they have a doctor, you are covered, so are they. Ask them to apply again in a few years when you are able to breath air again. 

You will see more cancer than you ever thought possible. The patients you are seeing either haven't seen a doctor in 20 years, or have not been followed as tightly as a new doc will. You will see the lumps and bumps that their previous physician missed, not because they are incompetent but because they are too familiar with their patient. 

The number of labs that you are ordering are going to be tsunamic. (Is that a word? It should be.) You think that you need to know everything about every patient. I sure did. I don't regret it. But it did mean that I needed significant amount of time to review it all, then do the follow up labs, investigate the things that went wrong...

You are going to want as much money as you can get as quickly as you can. I promise, it will come. Take an extra 6 months before expecting to pay down significant portions of your loans. Until then, take your time rostering patients. Taking on too many right away will make things impossibly hard and you don't need that. Taking on too many responsibilities (long term care, oncology, etc.) will put you under water too quickly. Don't do it. 

Keep in touch with friends. Everyone says to do it. No one does. Make actual dates and keep them. Spend time with people who are not your patients, employees, colleagues. Gossip about pop stars and athletes. 

Make dates for massage too. At least monthly. And with a therapist. Even if it's spent just getting to know each other initially, there will be times that you need an impartial person to call you out on your bullshit, remind you to complete your self care, to tell you whether or not this medical culture we call home is reasonable or not. They can help you will your relationships. Just get one. Seriously. 

Book all your vacations and conferences as soon as you can. Plan your whole year, don't let it get to the end of the year and you don't have time to get away. This way you can get locums if you want to cover you, get early bird deals, get the vacation you want. Use your maximum vacation and CME time. Do not use your time off to do paper work. That's not time off.

Book an hour every day that is just for you to book. You can book it in advance, the day of, or not at all and use it for napping. Spend the time the way you want to. You may not know at the beginning how you want to spend that time, but eventually you will. 

Retaining your recently recruited rural doc

I. Make them feel welcome. Seems obvious, but encouraging all docs to individually welcome the new doc will make a difference. Honestly. Just do it.

II. Give them a list of things that they need to know about in town. Best place to buy groceries, list of housekeepers, electricians, plumbers, etc., restaurants, good place to go for a quick weekend with their partner, vets. Start the list now. Add to it as other ideas come up. These people are not in the yellow pages or local paper when you are in a small town.

III. Prepare a list of commonly used billing codes in your office, hospital, nursing home, wherever you tend to make your money. Each clinic has different common codes. Never assume new docs know them. They’re not taught in residency, and the codes they used elsewhere may not be appropriate. If your new recruit is making money to pay down the debt they have, they will be happier, promise.

IV. Check in frequently. Have someone who is their designated mentor that actually wants the job. Someone who will make sure they don’t feel like they are bothering the mentor. Knowing which docs to refer for what kind of issue is important. Knowing what to do when that doc then turns down all referrals is essential. Weirdness happens every day in the clinic.

V. Have regularly scheduled check ins. Both of you will be ready for the meetings and know that you are safe to say what you need to. If either of you have concerns, a regular meeting makes it easier for both of you to come up with solutions. If you just chat about a few cases, it will be time well spent.

VI. Be clear about numbers. How many days of vacation? How many months of free rent? How is overhead calculated? Everything needs to be in writing so that everyone knows the rules up front. That way when snide remarks like “but no one takes vacation in their first year” can be taken as the jokes they are meant to be.

VII. Make sure their new office and exam rooms are clean. Seriously. No one wants to work in someone else’s year’s of dust and outdated hand outs. That’s gross and indicates that your group doesn’t care about your new recruit.

VIII. Have a welcome dinner. Make spouses welcome. Spouses are the bomb for making new docs feel welcome. They know what their partners went through and will help make your new recruit feel like they belong. While you're at it, ask those spouses to add to this list.

IX. If you notice your new doc is not making it to the lunch room, it’s not a good sign. Check in to see what can be done to lighten the load. They will want to hear your advice.

X. Help them get a family doc. Know that they will NOT be comfortable with one of their colleagues doing their DRE or pap. Follow up to make sure that your friend actually took them on. You’d be surprised. It took my nurse begging a former colleague to get a doc for my partner and I.

XI. If your recruit comes to you with concerns, deal with it. While it’s true that things get better in 5 years (it’s OK to tell them that), it’s not enough. Help them through whatever is going on or you won’t see how much better they are in 5 years.

XII. Baby docs are just out of residency where they are taught that if they don’t have the answer to something, they’re useless. This will be a hard habit to break, but essential that they feel safe in stopping it. 

XIII. Consider a community meeting/doctor to introduce people in town to the new doc. Getting formally introduced may reduce assumptions and gossip that comes later, or at least keep it kind hearted. 

Why the Ontario MD funding cuts are a feminist issue (a rural focus)

There is a lot of talk among my colleagues on what to expect from the Ontario Liberal government with respect to our fee claw backs. The government’s hope is that by decreasing our fees, that we will work less and therefore the system will be charged less overall. They see lowering access to physicians by patients as the solution to their health care finance challenges. 

Sitting in my rural family medicine office, I see how these actions will spill out into my community. 

First of all, less work by the MDs in the office means less available salary and less work for our staff. Staff cutbacks always seem to be the first suggested when overall income decreases. In my office, and every other one I’ve worked in, this staff is comprised almost entirely of women. These women work full and part time in our office and obviously depend on their wages to keep their family in the black. Many of them live on farms and require the supplemental income.  

Female patients are interrupted more than male patients (1). If there is a push to decrease our time in the office, we will revert back to the one item per visit that was seen before the introduction of FHOs. Our female patients won’t get a chance to be heard. Their “door knob” questions will be left to the next visit, and likely the visit after that since many of our rural patients do not “want to be a bother”. Some of these “door knob” questions I have heard in the past two weeks have included: I was raped last week - can I get tested for HIV? I’m worried about my drinking, how can I cut down? There’s a growth on my back that seems to be getting bigger. I worry that these women will be shooed out the door too quickly to check in on what might have really brought them into the office.  

Women in rural areas tend to be the caregivers for ailing relatives, elderly parents and neighbours, children (2). “Rural women caregivers are faced with such issues as limited access to adequate and appropriate healthcare serves, culturally incongruent health care, geographical distance from regionalized centers and health services, transportation challenges, and social/geographical isolation.” These women have several roles to fulfil - spouse, employee, parent, volunteer, caregiver. Decreased availability of physicians will put their own health at risk as well as that of those for whom they care. This increases the odds that the caregivers and their charges will end up in the Emergency Department and/or admitted to the hospital (where the real cost to the health care system begins). 

Less MDs in rural areas as they look for ways to make their practice lucrative enough to continue practicing will lead to less choice of an MD for families. Having a therapeutic relationship with your physician is essential to good health. As it is, those in my area are happy to get any physician let alone someone with similar ethics and values. Decreasing the supply of MDs will make it even harder for patients to advocate for themselves to get a physician they can connect with. Families need to keep their MDs to ensure that their children are vaccinated on time and will often stay with a doctor for years despite not feeling comfortable with them. I’ve met women who have suffered sexual assault who have gone more than 30 years without a pap because she was too scared to have her (previous) male physician perform it. Her cervical cancer treatment would have paid to have a female physician in their area for at least a year.  

Finally, and least importantly, female physicians spend more time with their patients (3). They are interrupted more than their male colleagues. This means that with the decrease in pay, that their time is worth less per hour than the men in their practice. Already we are dealing with no maternity or paternity leave for physicians. This is a step in the wrong direction, pushing women out of medicine. 

There are many concerns about physicians choosing to leave Ontario, not being available for their patients while they are here. My hope is that the OMA and the Ontario Government can work out an agreement to keep my patients, and all the rural female patients in Ontario, safe and well. 

(1) http://www.ncbi.nlm.nih.gov/pubmed/11456245

(2) Crosato, KE, Leipert, B.; Women caregivers in Canada; Rural and Remote Health; June 5, 2006

(3) West, C; When the Doctor is a “Lady”: Power, Status, and Gender in Physician - Patient Encounters; Symbolic Interaction; Spring 1984 

The MCCQE Part II has Placed a Cap on the First Round of Exams

Below is a rant from a friend in PGY1 of a specialty that diverges from the pack early in residency.

The more I think about the MCC imposing capacity limits for the fall MCCQE Part II, thereby forcing many first years to defer the exam until spring of 2016, the more angry I get. Here's why:

CAPACITY CAPS ARE INAPPROPRIATE

1. The MCC has had ample time to prepare for the high demand

The MCC cites two causes of the high demand this fall:

- No more harmonized exam for family med after 2015
- More candidates in general

The de-harmonization was announced over a year ago. Further, the exam was only harmonized 4 years ago, so the MCC already has experience with a larger volume of applicants.

As for the number of applicants in general, Canadian trained residents make up the majority of MCCQE test takers. The number of Canadian residency positions is easily accessible and is also known over a year in advance.

Despite so much warning, the MCC has only increased fall exam capacity by 7% over last year's fall administration.

2. The MCC's arguments for requiring capacity caps are not supported

The MCC says capacity caps were required to:

- Ensure the integrity of exam scores
- Keep costs down for residents

The MCC has not explained either argument.

Why not hire more people to mark the exam using the extra money from more exam fees? Why not delay releasing the results for a month or so until the scores' integrity has been assured? Why not split the exam into multiple sessions over a few weekends?

As for exam cost, no breakdown has been provided of where our exam fees go, nor how they would be influenced by an increased examinee pool. My impression is that the very steep exam fee of around $2300 should more than cover the cost of one administration. Of course more applicants increase cost (linearly), but they also increase income (also linearly).

3. The MCC is not offering any alternative within a reasonable time frame

The MCCQE is a mandated exam, and it is the MCC's obligation to ensure there are sufficient spots for eligible examinees to take it. This has always been the fall of 2nd year, and by capping spots, they are forcing examinees to wait an additional 6 months beyond that. A couple of weeks I could understand, but not a whole exam cycle.

HOW IS THIS UNFAIR TO RESIDENTS?

1. Many residency programs have a general first year, in part to prepare for the MCCQE.

Therefore, residents who have to defer the exam an additional 6 months are put at a disadvantage. For example, I will have been doing nothing but (specialty) rotations for almost a year before the exam, making it challenging to perform well in a general medicine OSCE.

2. The application process was biased.

An email without any notice was sent out, favouring those with immediate access to the internet and a credit card. Many residents working long hours that day were blindsided as by the time they returned home and checked their email, the exam was already at capacity. The same goes for residents that happened to be on vacation, or residents that needed time to assemble the $2300.00 fee. It also favoured residents on the East coast over the West coast, as signing up at the end of the fday in Halifax is hours earlier than the end of the day in Vancouver.

3. Anxiety
Every resident knows it's stressful to have a major exam looming over them. We had all expected to be done the MCCQE by the end of the year. We now face half a year of more waiting for the test than any group of residents before us.

4. This is the MCC's problem, not Canada's residents'.
I want the MCC to know that they are acting inappropriately. I believe they have failed to address the high demand for their exam properly and are bullying first year residents into accepting their mistakes.

Use of IO for IV Rad Contrast

In ATLS we are taught that anything that can go through an IV can go through an IO. This was questioned when we were unable to obtain a large enough gauge IV to give a patient the contrast solution he needed. Would an IO be safer than a PICC line? Would one less ambulance trip make more sense? Would this cause unnecessary damage to the patient?

At our small hospital, we don't have access to much, but we can do IOs. When all you have is a hammer.....

I had a quick look at my PubMed On Tap app and found 3 case studies of others who have done this successfully. No side effects are noted.

These are case studies, certainly not case controlled research. Hopefully someone will pursue this.

IO access appears to be safe but I don't see any studies comparing safety to a PICC line, likely because IOs are only used in emergency situations.

So, would I use an IO for a patient needing radiocontrast? I would advocate for it if IV was unavailable, it could avoid an admission to City Hospital, I was able to convince the radiologist on call to let me do it. It's just as invasive as a PICC. Truly though, I'm not sure of a situation when this might be the right choice given my current practice. If a patient is unwell enough that they do not have IV access, chances are good they should go to the City anyway.

Pocket Blockers for Atrial Fibrillation

This week during rounds, a question was raised about whether or not "pocket blockers" as recommended by the CCS for symptomatic paroxysmal atrial fibrillation will actually work or if they take too long to work. Cardiology is NOT my strongest area of practice.

The patient was an elderly man who was having occasional, upsetting episodes of palpitations that were caused by paroxysmal atrial fibrillation that lasted for several hours, especially at night. During the day, his heart rate was often too low to consider a beta blocker. I don't want to be the cause of a fall in one of my elderly patients. I decided, on the advice of another doc, to give him a beta blocker (bisoprolol) at bedtime only. I still worry though that his heart rate may drop when he doesn't need it and cause a fall on the way to the washroom at night. Would it be worth considering a pocket blocker for this guy?

"The choice of rhythmcontrol relates to AF characteristics. For patients with a lowburden of infrequent paroxysmal AF, pill-in-pocket antiarrhythmictherapy might be reasonable. For more frequentparoxysmal AF, daily maintenance antiarrhythmic therapymight be tried, followed by consideration of catheter ablationif the response is not adequate."

It seems unlikely to me that the CCS would make this recommendation, and a pretty graphic to go with it, if it wasn't going to work.

Now, to determine which beta blocker to choose, because, damn, there are a lot of beta blockers.
Let's go alphabetically. I've taken my info from Up To Date because it's the easiest for me to search through the blockers. I'm just looking at the Canadian types and oral delivery because that's all I care about for the patient we were discussing.
acebutalol: onset 1-2 hours, 1/2 life 12-24 hours
atenolol: onset 2-4 hours, 1/2 life 12-24 hours
bisoprolol: onset 1-2 hours, 1/2 life 9-12 hours
carvedilol: onset 30 min - 1 hour, 1/2 life 7- 10 hours
labetalol: onset 20 min - 1 hour, peak effectiveness in 1-4 hours, 1/2 life 6-8 hours
metoprolol: onset 1-2 hours, 1/2 life 3-4 hours
nadolol: no onset info given, 1/2 life 20-24 hours
nevibolobol: peak onset 1.5 hours, 1/2 life 12 hours
penbutolol: peak onset 1.5 hours, 1/2 life 5 hours
pindolol: peak onset 1 hour, 1/2 life 3-4 hours (up to 15 hours in the elderly)
propranolol: onset 1-2 hours, 1/2 life 3-6 hours
sotalol: onset 1-2 hours (or sooner), 1/2 life 12 hours
timolol: onset 15-60 minutes, 1/2 life 2-2.7 hours

OK, so 3 of these are appealing based on onset less than an hour - carvedilol, timolol and labetalol. They also have half lives less than 12 hours with timolol definitely winning. Most of these though are active by 1 hour. For most patients that are symptomatic during the day, any of these might be great. But I worry about this elderly man with low blood pressure, low heart rate during the day, and multiple medications.

 I think finding a cardio selective drug might be most helpful and decrease the risk of side effects. Those are metoprolol, acebutalol, atenolol and bisoprolol.

Of these, metoprolol has the shortest half life. I have a winner, and since my patient has side effects on the bisoprolol, it's worth changing.