Query

I've agreed to cover a colleague's practice for a week. I said yes, thinking that we shared a similar outlook on life, had similar gripes about the ministry of health and the local hospital, similar frustrations with overbearing and demanding patients. We are around the same age and both have children. For some reason I imagined that all of this would mean we have similar practices, with similar demographics and a similar way of doing things. I guess I was hoping for an easy situation in which everything was where I wanted it, when I wanted it, how I wanted it, just like in my own practice.

Figure. Photo by: Fred Sebastian

Instead, I've walked into an entirely different scene. The average patient age must be 65; the oldest patient I've seen so far is 96. Patients come overloaded with medical problems; the average comorbidity factor is about five. And the patients have their own ideas about sameness: most want their old doctor back, asking Will Dr. Orser be back soon? and Why is Dr. Orser gone? and He's coming back, isn't he? I've gone from my young practice to a geriatric one, and I have whiplash … or would that be cervical osteoarthritis? I'm using medical muscles I thought had atrophied a long time ago, like managing chest pain in a patient with known angina and GERD, or titrating a dozen medications to maximal clinical effect while trying to avoid side effects, or wrestling with rheumatoid arthritis and diabetes and chronic opiate use for pain, or treating hypothyroidism with depression and myasthenia gravis. One patient had such a constellation of things wrong with her that I made four — to my mind legitimate — referrals for just one visit. I've ordered thyroid ultrasounds and peripheral arterial Doppler studies and EKGs and echocardiograms and umpteen blood tests in a mad dash to keep up with the diseases, which mount higher as I progress though my day sheet. I'm overwhelmed by the number of chief complaints.

The charts are sagas of woe. Twenty to thirty medications are listed; many are crossed off, re-entered, then crossed off again. Blood work and x-rays come by the pile; consultations by the raft. And nothing is how I want it, where I want it; instead the office is organized in a way different from what I'm used to, and after managing more complicated patients who take more time, I'm slowed down even more by the mountain of documentation I have to sift through to get the information I need.

I find I'm working harder and earning less: a quick visit is unheard of here. I'm forced to stop patients after a certain point, not because what they have to say is irrelevant, but because I need to move on to the next person with the next serious problem. I'm actually turning away pathology, deflecting it until the next visit.

I've called my friend, who is spending March break with his kids, and asked him why he does it, why he tends to such a population. He said that for him it's normal, that he's been dealing with these patients for several years, and that he likes practising „real” medicine as opposed to high-dose reassurance. He told me the trick is in knowing his patients; knowing what has been wrong with them in the past helps him interpret what's wrong with them now.

I knew that, of course, and felt a little like I was being talked down to, as if I were a medical student again. But I knew what he was trying to say: that knowing his patients saved him a lot of time, just like knowing his chart system saved him time. And working in an office designed to his specifications saved him time. The fact that neither the office nor the patients meet my specifications is, I'm not proud to say, frustrating for me. I'll even admit to being frustrated when a patient wanted to discuss another life-threatening problem. I've been seeing so many, after all.

In a few more days I'll be back at my practice. Safe, efficient, oversized, healthy, and where the patients are wondering, I hope, Where's Dr. Ursus? And where I'll be wondering, I hope I did all right while Dr. Orser was away.

— Dr. Ursus