ACP Internist Blog

Friday, November 17, 2017

An American physician's experience working in Canada

A couple of weeks ago I visited Canada. It was my first visit in a very long time. We were in Ontario, spending most of the time in the Toronto area, and also getting to visit the majestic Niagara Falls for the day. I've heard so much over the years about the differences between neighbors America and Canada, and in even just a few days there, agreed that there are many significant ways in which the two countries differ (some ways in which Canada is better, worse, and just plain different).

Of course, with regards to their health care system—it could not be more different than her southern neighbor. Good timing with my visit, because the week before I left, a physician reader of my blog, who I had previously been corresponding with, emailed me to share his experiences after doing a stint working in Canada's healthcare system. His name is Steve, and he's a very experienced physician. He answered my questions about working over there. His answers are very interesting and insightful:

1. Tell us a little bit about yourself and your background?

I have 5 years in the Indian Health Service, 23 years in private practice in Sioux City, 1 year of locum tenens while my non-compete ticked off, 3 years Community Health, and locum tenens since 2014. Married since 1980, three grown children, one grandchild. I like writing, hunting, target archery, and learning new languages.

2. What made you want to try out working in Canada?

I got tired of hearing American doctors blasting the Canadian system, and American liberals championing it, while neither had any idea of what they were talking about. And I wanted to check out a place where I could hunt moose and my hunting buddy could hunt elk at the same time.

3. What's the first thing that struck you about Canada's health care system?

How happy the doctors are; they are far from burnout and have a great work-life balance.

4. How do bureaucratic requirements for doctors vary, especially with regards to electronic medical records and data entry, which is a huge cause for physician burnout in America?

Canada has one level of service, the U.S. has 5; so American doctors spend a lot of energy documenting a higher level of service, while Canadian doctors just document what's medically important. Meaningful use documentation is absent in Canada, and there are no incentives for excess documentation. The doctor faces no prior authorizations.

5. How was the collegiality among your physician colleagues?

This was the best physician group morale I've ever seen. Everyone valued everyone's input. I found no backstabbing or backbiting. And the group did well incorporating other locum tenens, residents, and students.

6. Was there any difference you perceived with Canadian versus American patients?

Canadians, in general, are more polite than Americans.

Because there's only one level of service, a lot of practices have a one problem per visit policy, so very few patients were surprised when I put a limit on the number of complaints.

Canadian patients are used to an under-resourced medical system; no one demanded an MRI because they knew the wait list stretched into 2018.

7. What are three things the USA could learn from Canada's health care system?

(1) Go to a single level of service. (2) Patient flow would go much better if the person who rooms the patient would just room the patient. (3) An EMR system should be for medical documentation; using it for billing and data mining ruin it for patient care.

8. What are three things we do better in the USA compared to Canada?

We don't have wait lists for joint replacements, MRIs, or tubal ligations. Strangely, we immunize adults better. We provide our Natives Americans with much more accessible health care.

9. Would you work in Canada full-time if you could?

This answer is far from simple. I'm in the last third of my career and I know the time will come when the social network I've been working on for the last 30 years will be more important than my work. Still, the quality of life and the quality of work is better in Canada. But medicine is full of moving targets, and you can't know if Canadian medicine will undergo the same deterioration that American medicine has since 2010. Nor can you know if the American system will improve.

Having said all that, it would be very easy for me to move to Canada to work full time if the children moved, which they might, depending on the next election.

10. Do you have any other message or advice for physicians practicing in the USA who want to try practicing abroad?

Go, by all means. You will make the memories of a lifetime. But correspond with physicians who have been there or who work there before you go.

11. How hard was it to get a license?

It was insane. It took 22 months, $7,000, hundreds of hours and thousands of emails. I would have given up long before except I didn't want to ever say I'd withdrawn an application for licensure. In the end, though, it was well worth it.

12. How well are Canadian doctors paid?

On average, a Canadian GP makes about 10% more than an American FP; I don't know about specialists. Office overhead runs between 15% and 30%. The cost of living, though, is very high.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site here.
Thursday, November 16, 2017

Why are you seeing a gastroenterologist?

I write to you now from the west side of Cleveland in a coffee shop with my legs perched upon a chair. Just finished the last op-ed of interest in the New York Times. Do I sound relaxed?

I rounded this morning at both of the community hospitals that we serve. There is not a day that goes by that doesn't have blogworthy moments. If I had the time and the talent, I would post daily instead of weekly. Read on for yet another true medical insider's disclosure.

Gastroenterologists, as specialists, are called upon by other doctors to address digestive issues in their patients. For example, our daily office schedule is filled with patients sent by primary care physicians who want our advice or our technical testing skills to evaluate individuals with abdominal pain, bowel issues, heartburn, rectal bleeding, and various other symptoms. The same process occurs when we are called to see hospital patients. If a hospital admitting physician, who is usually a hospitalist, wants an opinion or a test that is beyond his knowledge or skill level, then we are called in to assist.

The highest quality referring physicians are those who ask us a specific question after they have given the issue considerable thought. Contrast the following three scenarios and decide which referring physician you would select as your own doctor.
• “Dr. Gastro. Just met this patient for the first time with a month of stomach aches. Please evaluate.”
• “Why did your doctor send you here?” queried Dr. Gastro to the patient. “No idea,” responded the patient.
• “Dr. Gastro, please evaluate my patient with upper abdominal pain. I thought it might be an ulcer, but the pain has not changed after a month of ulcer medication. The pain is not typical of the usual abdominal conditions we see. Do you think a CAT scan of the abdomen or a scope exam of the stomach would be the next step? Open to your suggestions.”

As readers can surmise, I favor primary care and referring physicians who give thought prior to consulting me. There are many reasons today why primary care physicians pull the specialty consult trigger quickly. Sometimes, busy internists simply don't have the time available to deeply contemplate patients' symptoms. Physicians have also referred patients to specialists with the hope of gaining litigation protection by passing the patient up the chain, although the medical malpractice crusade has eased over the past few years. Oftentimes, patients drive the specialty consultation process by asking to be sent to specialists.

More often than you would think, we see patients in our office or in the hospital when neither the patient nor I have a clue why they are there. This adds excitement to our task. In addition to being diagnosticians, we must also serve as detectives, divining the reason that the patient is before us!

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Ode to the bulletproof

I am a specialist in “preventive” medicine. My career has been all about leveraging the many means at our disposal to add years to lives and life to years; to prevent the frequently avoidable reasons for mourning. Instead of preventing mourning, I find myself mourning prevention.

The massacre in Las Vegas is almost too horrible to address; the utter carnage of a battlefield, transfiguring a scene of sweet recreation. The juxtaposition—one image in which we might easily picture ourselves with loved ones; the other fuming with the admixture of panic, dread, and trampled blood polluting the air—hits one almost with the force of a bullet.

Thankfully, though, we are bulletproof. Scenes of carnage just don't matter. Facts don't matter. Why should they? We have ideology. We have dogma. We have alternative facts, or at least, alternatives to facts.

These things work beautifully. They allow us to propagate conspiracy theories about vaccines, while enjoying freedom from the ghastly, historical scourges vaccines so reliably prevent. And then, they allow us to invoke other reasons when our children are once again vulnerable to diseases we might have spared them.

They allow us to keep finding reasons to extract fossil fuel from more places, despite our capacity to generate energy from sources that would not in turn help generate storms that utterly devastate our cities and island neighbors. What a boon it is to be spared such inconveniences.

They permit us to feign ignorance to the true liabilities of our diet and play instead at debating deep mysteries, even as the global reality hides in plain sight: everywhere our hyper-processed diet of foods that favor corporate profit over public health go, obesity and chronic disease follow. We will, I presume, throw in bulletproof coffee for the countries we are raping, but at the customary extra charge. No freebies!

We are bulletproof to the truth.

Perhaps it is the ascendancy of alternatives to truth that so polarizes us into the paralysis that always favors the way we are, however bereft of sense or hope, over any aspiration to how we might be. Perhaps it is our righteous minds that return again and again to their opposing corners, only to come out fighting.

Even in such context, it is notably bizarre that the recurring butchery of gun violence is in defiance of the majority will for reasonable gun control measures. Defense against tyranny is invoked as the sacred basis for a Second Amendment yoked into a tyrannical act: majority will, denied by the concentrated power of few.

What needed to be said about Las Vegas has been said, any number of times. But we will conspire to ignore it. We will continue to prioritize the theoretical threats of morbid fantasies over any number of actual body bags filled with former loved ones. We will continue to let profits for the few prevail over the will of the many, and along the route of this endless parade of injury, suffer the insult of hearing that we are being tyrannized thus for the sake of defense against tyranny.

We are bulletproof to hypocrisy, too.

Einstein famously told us we should never expect to solve problems with the very methods that created them. One is tempted to think selling ever more weapons of mass destruction to deter mass destruction might qualify. But we are, it seems, bulletproof to Einstein's counsel.

We are bulletproof to Ben Franklin's counsel, too. An ounce of prevention is worth a pound of cure, except to those selling the cure at a mark-up. Except to those selling the causes, too, from bullets to bacon, soda to donuts, weapons of mass destruction to the conspiracy theories that invite us to use them. The better angels of our nature aren't buying, but they've long since left the building, leaving us to barter.

We are bulletproof to truth. But to the actual bullets that tear into our children, our sisters and brothers; to the climate that drowns and parches us; to the foods that fatten us; to the viruses that pock and ravage us; to the diets that degenerate us, alas, not so much.

My career has been devoted to preventive medicine, the art and science of assessing the vulnerabilities we have now to prevent the tragedy we need not encounter tomorrow. The preferred method these days is to deny the vulnerabilities, refute the message, repudiate the messenger, and find someone to blame for the tragedy when it happens. Find them, blame them, and maybe shoot them.

We seemingly have no interest in prevention, preferring to let horrible circumstance of every description we knew full well how to prevent happen, then finding a favored scapegoat. Our children, in line behind us, awaiting their turn to play, deserved better. Sorry, kids; meet the enemy, it is us. We are the Once-ler, and every other villain in every fable we ever read you.

There was much, all along, we might have done to prevent all this mourning. We may, instead, mourn prevention, and so, today, I do. Alas, preventive medicine.

We are bulletproof to the truth, and the truth is, we can never be bulletproof. We are all bleeding already. To stop the bleeding, we would actually have to stop shooting.

We are bulletproof to reality as vivid as a hemorrhage. Hemorrhage, though, is unaffected by our capacity not to notice.

Our solace, it seems, is one of the great truisms of medical education: eventually, all bleeding stops.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Monday, November 13, 2017

Physician burnout and suicide

Physician burnout and physician suicide has been getting more attention in the last several years. Suicide among physicians is horribly tragic, and maybe more so because of several factors. Suicide is the quintessentially most preventable fatal event. In order to prevent suicide, the person killing him or herself needs only not do it. To anyone who knows the victim/perpetrator it seems that if only the right words had been spoken, the right sentiment expressed, comfort offered, their death would not have happened. Among the family and friends of a suicide, this is one of the agonies that is added to the pain of loss. Physicians have a huge number of close contacts, patients and coworkers, who have a pretty intimate connection with them, all of whom mourn their loss and many of whom question whether they might have had something to do with it. Beside the emotional impact of the loss is the very real fact that physicians are responsible for some part of the care of potentially thousands of people who are left stranded by their abrupt departure. There is the very sad fact that someone whose job it was to help people was unable to get the help they needed.

It is not clear that physicians commit suicide at a higher rate than people in other professions, according to a report by the Centers for Disease Control and Prevention last summer, and although it is the number one cause of death among male medical residents per a study that was released this year, their suicide rate was lower than average for their age group. Although burnout is clearly increasing among physicians, I have not seen any data that shows that suicide is increasing.

I have been a witness to the kinds of stresses that lead to suicide in physician colleagues. So far, knock on wood, none of the doctors who work closely with me have committed suicide. I have, however, been around some pretty spectacular cases of burnout. According to a Medscape poll, 40-60% of physicians show signs of burnout. Surprisingly, the major problem they complained about was the excessive bureaucratic tasks that they had to do. It was not the stress of making life or death decisions but the grinding demands of the computer, the paperwork, satisfying insurance companies, convincing organizations that monitor quality that they were delivering it. Other frequently mentioned complaints included extended work hours and feeling like they were just a “cog in a wheel.” My experience is that it takes more than a bad job to push a person over the edge, though. But life is pretty good at offering that little bit more. The breakdown of a marriage, a child with troubles, an illness can take a person who is competently holding on with her fingernails and plunge her into failure. Alcohol and drugs provide respite and destroy that last pretense of being able to do the work. The colleagues I've seen go through this usually step away from practice and may or may not return.

My worst times were early on in my career. During my first year in medical school, I comforted myself with the thought that if things got too bad I could just jump out of the tenth story window of my dorm. After a while I replaced that with deciding that I would just go live with my sister and cook for her. The first year was bad because there was just too much stuff to learn and if I stuffed my head full of it, as I needed to if I was going to pass my tests, I couldn't sleep. If I couldn't sleep I couldn't stuff more information into my head so I walked around gripped by fear of failing. Occasionally I was distracted from my misery by some of my really excellent teachers and was eventually saved by a prescription for sleeping pills. These I hoarded and doled out by the fragment so I wouldn't have to ask for more. A boyfriend and increasingly close friendships helped make the second year almost imperceptibly better. By the third year the opportunity to interact with real patients and be of use cured me. Training continued to be stressful, but there was always something rewarding that came back to me from grateful patients or collegial professors which gave me the joy I needed to make the process sustainable.

After completing my residency, I took some time off to find the right job. I got a house with the man who would eventually be my husband and a big yellow dog. The position I finally found was good, though demanding, and I enjoyed learning from other physicians at my work who had different skill sets than I did. I was able to keep up and felt I did a good job. Burnout threatened when my workload increased and I felt like I couldn't keep up. There was always more that I needed to do at work but home needed me too. Having a baby actually helped because the woman who we hired to help take care of her was wonderful and made me feel like home was well taken care of.

Six years ago I transitioned from a pretty sustainable to a very sustainable lifestyle, doing shift work as a hospitalist. My children have fledged and I no longer need to help them with their homework after work or worry about childcare if they get sick. I still do some outpatient medicine, but have not been sucked up into the complexity of documenting for merit based payment or pay for performance systems. I did go through the growing pains of adopting several computerized health records, both inpatient and outpatient, and have experienced firsthand how that can make everything seem impossible.

I can see that in a clinic system where an employer was pushing the physician to see more patients in an hour and patients were pushing back to get what they need, administrative tasks could be a big part of burnout. The recipe, I think, for burning out is one cup of impossible and maybe conflicting demands and several tablespoons of feeling like something terrible will happen if you don't meet those demands. When the demands are from both home and work, things get pretty grim pretty fast. If the work is not rewarding, as it would tend not to be when you can't do it properly, then there is no joy to counteract the stress.

Medical offices and hospitals right now are in a time of transition, which makes things particularly bad. We are moving toward making computers do the work that humans find tedious, but the interaction of computers and people is still awkward. We end up doing lots of the work that the computers eventually will be able to do themselves, keeping track of nearly endless and very complex data, remembering schedules invented and tweaked by organizations charged with optimal care for chronic diseases. We are wrestling with computers instead of doing the human job of reading people and helping them solve their problems.

It is not entirely our jobs which lead us to the brink of suicide and beyond. We are humans with sadness and stories and connections which can be difficult or even crushing. But we can make the job part of this much easier. We need to allow computers to do what they do best and have doctors do doctoring. We need to figure out how to unhook a doctor's monetary compensation from how many patients we see, so we can keep those patients healthy and out of our offices and hospitals where they belong. We need to not take on more than we can do well, even if that means saying “no” to the person who writes our paychecks.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.