I am on call for my primary care clinic this week...

What does that mean?

A 🧵 about how
our fee for service (soon to be "group contract") clinic
of 16 clinicians, ~15,000 patients
delivers afterhours #BCPrimaryCare

@BCFamilyDoctors
Our MDs and NPs are on call for one week at a time.

Between 5pm-8am weekdays and all weekend,
we need to be ready to
support patients for
URGENT, not emergency issues
that cannot wait until the next business day

that means phone close by at all times
People call appropriately for:

e.g. sick baby with fever, to figure out does she need to go to emergency or can stay home

or

e.g. strained back shoveling snow and want to know what can do to alleviate pain

I can bill a "telehealth visit: 14x37"
~32$ for call + documentation
Sometimes people call hoping for:
✖️an appointment the next day, or
✖️something in their chart or
✖️renew a medication that is coming due in the next few weeks.

This is not what the service is for & this kind of request is why we have our fabulous admin staff.
I ask people to leave a voicemail with their name, contact and brief description of their issue.

I get to my computer, open up their chart and get a bit of background info about who they are, before I call them.

Emergencies should be calling 911, not me!
After I speak to the person & give advice
I write a detailed note
often with a direct message back to their usual MD
I might also need to print a prescription
find the pharmacy fax number
fax a prescription to the pharmacy &
make sure it gets there

Each call takes me ~30-60 min
I usually get 1-6 calls per day, a total of ~20 in a week.

This week is much busier

People are frantic, burnt out from the pandemic. Unsure about how to handle return to school, "typical cold symptoms", etc.
Myself,
I find the anticipation
of being called at any time
very taxing

while I only have to do it
3-5 weeks a year,
it adds a significant layer of stress to my work.

I wish that we could plan for those weeks and reduce or stop all other work, but that is not feasible
In our current #BCPrimaryCare setup,
we are all working flat out
doing the patient visits, virtual and in person

then we add on:
-pandemic response
-IT support
-HR/Lease mgt of office space and employees
-staying up to date on medical treatments
-being peer-reviewed by @CPSBC
Ideally, we would be able to describe all the necessary work to plan, deliver and improve #BCPrimaryCare, hire the best-qualified people, and ensure everyone has a sustainable, healthy work environment.
This would require clinic-based funding (instead of paying for everything via paid to MD fees).

Like how a school gets funds for its building, and operations and then based on the community needs, the teachers and support staff are hired.
The lack of this infrastructure is one reason for the persistent "family doctor shortage".

Imagine we graduated new teachers
& said, please go organize yourself
with other teachers
& start a school.
We will pay you per lesson delivered/child.

Bananas, right?
@BCFamilyDoctors
Providing after-hours care is a requirement of licensure to practice medicine in BC.

Some types of care, by some types of doctors have time paid for (plus billing per visit).

This is called "MOCAP", but it is not available to family doctors. www2.gov.bc.ca/gov/content/he…
I'm glad to speak to the patients
& when possible reassure them,
or avoid a trip to Emerg.

But I am not sure this model of care is sustainable, healthcare workers are getting BURNT OUT.
Real rest and breaks,
v. layering on more work is needed.

Maybe UPCCs are the answer.

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More from @DrRitaMc

Jan 26
Why is my family doctor running so far behind?

Another 🧵
to explore
the inner workings of
🇨🇦 care,
and
why the
#FamilyDoctorShortage
will not be fixed
by just hiring more family doctors.

@BCFamilyDoctors
There are two main reasons your doctor is running late:

1) undifferentiated illness
2) primary care service funding being stuck in 1985

#FamilyDoctorShortage
Let's start with undifferentiated illness.

You can show up at your family doctor's office looking for help for ANYTHING:

contraception
anxiety
drinking too much
sore knee
cough & fever
question about a drug ad you saw on TV
etc

#FamilyDoctorShortage
Read 17 tweets
Jan 24
What happens
when your
family doctor
orders
LAB TESTS
for you?

Another 🧵 about the inner workings of 🇨🇦 primary care (or how the sausage gets made), and how fixing the #familydoctorshortage is not just about hiring more doctors.

@BCFamilyDoctors
Let's say you go to your doctor,
after considering your story (= reason for your visit), your past medical history,
the possible diagnoses/treatments
for the issue,
she decides to order blood work (=evidence-based medicine),
& you agree with that (=shared decision making).
She creates a LAB REQUISITION (="req")
She selects the tests that she thinks will help understand/treat/monitor the issue.

This is based on what she learned in med school, what she learned staying up to date(=Continuing Medical Education) & sometimes, a specialist's advice
Read 11 tweets
Jan 20
I think Nurse Practitioners are a part of the solution to the #FamilyDoctorShortage in #BCPrimaryCare and the rest of 🇨🇦

👀
I expect to hear the following "buts"

1- see too few patients
2- spend too much time per pt, cost too much
3- have less training than FP's

And, I agree they are not 1:1 replaceable with FP's

But a "doctors only" fix to Primary Care is so 2019
Team-based primary care with other care providers:
nurse practitioners
nurses
OT/PT
counseling
SW
pharmacist
elders
patient navigators

This is what is going to address the shortages, in a meaningful and sustainable way.
Read 4 tweets
Jan 15
I am a generalist,
full-service family doctor,
working in a clinic
that provides
longitudinal primary care,
and I referred
a few patients
to specialists
this week...

here's how and why that happens 🧵 1/9

(#BCPrimaryCare)
When I see a patient, we talk about:

-the reason they needed the appointment today
-how life is going in general
-as needed, their other medical history

after I get hear the story
do a physical exam
review old information
We may decide that we need extra advice
2/9
Sometimes it is:
to confirm the diagnosis or
change treatment or
decide on tests or imaging
consider surgery
etc

I need to formulate a specific question & summarize the patient's condition, history and preferences. I do this both on the fly & after the appointment. 3/9
Read 11 tweets
Sep 28, 2019
@DocVan_Nostrand @MariaMichelleH Putting all the responsibility/money for all the things on family doctors, is not really working out:

❗️clinical care
❗️teaching learners
❗️running office
❗ transforming primary care
❗️Leading quality initiatives
❗️evaluating system change
❗️increasing access & capacity

🤔
@DocVan_Nostrand @MariaMichelleH What is the work that Family Doctors *must* have a leadership role in... ?

And what work could we rely on skilled professionals for?

(Analogy: if I was renovating my house, which bits would I want to be in charge of v. Get advice v. contract out completely)
@DocVan_Nostrand @MariaMichelleH I forgot

❗️cleaning data in your emr
❗️attending evening meetings about new fee codes &how to increase billing’s
❗️order the right amount of flu vaccine
❗️know all the non profit support services to refer your patients too in the lower mainland
❗️store &archive charts forever
Read 8 tweets
Sep 23, 2019
THREAD: Everyone gets a Family Doctor!

This new announcement by the @liberal_party recognizes the value of primary care. liberal.ca/liberals-move-…

And research shows us that access to primary care saves lives!
ncbi.nlm.nih.gov/pmc/articles/P…
Details in the Libs announcement are sparse, but to my BC ears, it sounds familiar ... GP for ME
straight.com/life/630116/gp…

Great idea, pay GP's a special incentive fee to take on more patients and ... everyone gets a GP, problem solved... right?
Except... it didn't work:
timescolonist.com/a-gp-for-me-do… (@cindyeharnett)

because...
Read 14 tweets

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