What the SRPC wants struggling new doctors to know

Two of my colleagues have had rough years. They asked the online forum available through the Society of Rural Physicians of Canada for help. This is an organized version of what was said by many wise voices. It's also a sanitized version to make sure nothing is identifiable because all of these folks allowed themselves to be vulnerable. I honour that and appreciate what they have shared. If anyone wants to be named and credited, I'll happily edit this post. 

Philosophy

• it's normal to feel like we don't know everything in our first year of practice
• lack of confidence is preferable to over confidence, and safer
• expect moments of doubt, feeling inadequate and incapable
• medical training focuses on the criticism of our skills, it makes it difficult for us to trust ourselves
• "It's family medicine, you don't need to have a diagnosis, you just need a plan."
• you can bring patients back if you need or keep them in the ER to observe them, rural medicine gives us that flexibility
• you have nothing to prove to anyone but yourself and your patients, it's not a competition any more
• even if you are the only female
• even if you are the only minority
• perfection is the enemy of good - done is better than perfect
• being a rural doc isn't easy, but it is amazing
• allowing ourselves to be human makes us strong doctors for our patients
• listen to your heart about where you should be spending your time
• "at 72 ... I would say I'm glad I worked less not more."
• evidence changes constantly, it's ok to give yourself a break on not having everything memorized
• rural docs expect to have to sacrifice themselves for their practice - our patients and colleagues don't

Generalism

• just because family medicine is flexible doesn't mean we have to do all the things to be a good family doctor
• skills can be relearned
• there will always be something that you think you could be adding to your practice or missing from your community, let it go
• we need hands in rural Canada, these may be full or part time hands
• it's more important you are able to help with what you can, even at a reduced rate, than to get into a situation where you can't do anything at all
• being a generalist can mean different things to different people; pick the way you want to go;  reprise it as needed
• generalism is a very flexible field
• doing less rather than stopping something, means that your skills will keep up
• "there is no proven evidence based minimum number of times you do a procedure to be competent"

Practice Advice

• a part time practice is OK
• if you don't need an MD to do it, delegate it
• stop the pieces of your practice that cause you too much trouble
• money will come, don't let it drive your practice
• sometimes the reason we come to hate what we are doing because we are doing too much of it, try scaling back
• adapting what is considered to be "the way things are" to suit your needs is reasonable
• covering your practice during times of illness (yours or your loved one; mental or physical) is important, but spending time with your family getting healthy is much more important
• in Ontario, when you need time away, call Health Force Ontario to arrange a locum

Building your Village

• find a supportive group of colleagues that you can ask for advice
• we end up knowing as much as our specialist colleagues
• others will have dealt with what you are dealing with and be able to offer advice on getting through it
• discuss emotional, philosophical topics in a non - judgemental atmosphere
• have a mentor who represents where you want to go in your practice, someone at the same level who will understand how much things suck sometimes, and a mentee or learner who will remind you how far you've come and why you went into this crazy business in the first place
• look for your mentor outside of your practice group so they are able to offer advice without being personally invested in your choices
• know that once you are through your hard times, you will be an amazing resource to your colleagues
• "There is a special place in hell for women who don't defend other women." Secretary Albright
• the SRPC is there for you

Self Care

• the first 6 months of any new job are the hardest and put you at highest risk for burnout
• the entire first year is brutal, be kind to yourself and each other
• we won't always be on our A game, it's OK for us to get the help we need
• get your own family doctor and use them
• use your PHP
• you are allowed to let others care for you
• what an honour and sign of respect to your colleagues to accept their help
• you are not your own doctor, don't self diagnose, don't self medicate
• self care isn't selfish, caring for yourself is important
• taking time away for your health is forgiveable
• follow  your own advice and stick to a schedule that includes exercise, eating well, mindfulness
• see a counsellor
• do the non-medical things that you love (hockey, reading, playing hopscotch...)
• rest is not a 4 letter word (going to have to beg to differ on that one, but the sentiment is strong)
• self forgiveness is essential for self healing; forgive yourself for not being everything for everyone
• once a week go out on a date with your partner sans children
• don't use alcohol to make the day better
• arrange your house so it's easier to live in - big baskets for your bits and pieces can help

Parenting

• maternity leave can be hard on us, talk to those who have done it about what you can expect
• check out www.mommd.com
• lack of sleep affects our brains (babies, stress, work); make sleep a priority
• post partum depression is a real thing, respect it and yourself enough to ask for help
• letting your partner parent can be a blessing
• check out positive parenting
• trust your parenting skills
• "Babies don't need a lot of things - they need carrying and feeding and sleeping and diaper changing. And extra attention when they are sick."

Resources

• it's OK to not know things and have to look them up
• First 5 years of practice Facebook groups  - one national and a whole lot of provincial
• Physician Health Program in your province
• Other MD mommas
• get an UpToDate subscription
• buy an Rx Files
• the Orange Book
• ask a colleague
• consider a small notebook or an app like Evernote to keep things you are always looking up

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.