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 No one wants to work in someone else’s year’s of dust and outdated hand outs.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.

Using handheld devices in a patient centered way

Using handheld devices in a patient centered way

Why bother:

·       I’ve been told that patients don’t like when we use our smart phones in front of them, but my experience has been different. I tend to include the patient in my looking up resources and use the HHDs to teach my patients

What the lit review needs to show:

·       Appropriate size of focus groups

·       Survey methods for this type of study

·       How HHDs are being used in medicine

·       What do patients think about technology

·       Is there a difference in use of HHDs bw consultants and learners

What I’ve noticed in the literature so far:

·       All information on HHDs has come up in the past 2 years

·       It is all about what medical professionals think, there’s nothing about what patients think

·       We see lots of HHDs being used in the ER, that they are promoting patient safety and therefore are a technology we need to hang onto

Plan for the study

·       Start with parallel qualitative study on pts and providers

o   Patients:

§  What do patients think about learners with HHDs

§  What do patients think about consultants with HHDs

§  What do pts think HHDs are for

§  What aspects of use of HHDs do pts enjoy vs. wish we wouldn’t do

§  What do you use google for vs. what do you think your doc uses it for

§  Are you aware of resources accessible by hhds (google scholar, uptodate, apps)

o   Docs:

§  What do learners think about consultants using HHDs and vice versa

§  What do learners (consultants) think about their peers using HHDs

§  Do you use hhds with pts? How?

§  Are you comfortable suing HHds with pts, why? Why not?

§  What do you think that pts think of your HHDs

·       Follow up with large, multicentre surveys informed by qualitative results

o   Compare community, academic, rural settings

o   Survey patients and providers

                                   

Does Laughter Yoga provide benefit for participants with dementia?

Does Laughter Yoga provide benefit for participants with dementia?

A pilot study to test a method of quantifying benefit.

Why bother:

·       To this point, very little hard evidence for benefits of laughter yoga, mostly anecdotal

·       Those who run the program in MounForest have noted participants have increased engagement with staff and with each other through progression of the program, humour, remember staff, participants are happier and brighter and seem to be more playful

·       Laughter yoga is a program that is fairly easy to implement and low cost, if it is also beneficial to participants, we should increase the number of programs in rural Ontario.

·       The Day Out program offered by VON also provides welcome respite to caregivers. The majority of participants in the Mount Forest program live with family caregivers.

·       The percentage of elderly in rural Ontario is increasing, our FHT is looking for programs to serve them

Lit Review will include:

·       Has been shown to be useful for elderly depressed women when compared to another exercise program

·       Yoga decreases symptoms of anxiety depression, pain (poor evidence)

·       Yoga improves physical health but not mental health in patients with chronic disease

·       In patients waiting for organ transplant, laughter yoga shows immediate improvement in mood and heart rate variability

·       Some evidence for positive emotions having a positive effect on enhancement of well being

·       Humour therapy may be helpful for the treatment of patients with depression in late life

Lit Review highlights need for:

·       “a more convincing study would include mood measures before and after intervention”

·       Long term sustained research

·       Study of laughter yoga itself rather than humour or yoga separately

Purpose and Significance of this Study:

·       To prepare a testable and repeatable mixed methods review of Laughter Yoga to determine if the program provides benefit to the participants and their families with an eye on future Day Out programming at the VON.

·       To describe changes in wellbeing in participants of Laughter Yoga using validated measures pre and post intervention (MOCA, RAND vulnerable elders http://www.rand.org/content/dam/rand/www/external/health/projects/acove/docs/acove_ves13.pdf , functional testing performed at day out program by VON, GDS).

·       To describe impression of Laughter Yoga by the participants’ caregivers using open ended qualitative questions pre, during and post involvement in the LY program. To determine if those studying Laughter Yoga in demented participants are looking in the right places and inform future studies in this group.

Initial methodology proposed:

·       Prospective study on Laughter Yoga intervention in the Mount Forest Day Out program for those with dementia in the area.

·       Pre/post test study design of quantitative measures

o   MOCA, VES, Geriatric Depression score

o   VON functional testing

·       Qualitative parallel study of participants’ caregivers

o   Open ended questions about participants’ behaviours at home

o   Prompting questions about agitation, socialization, engagement in family activities

o   Phone interviews done pre intervention then q monthly following