Up Down and Sideways

CRIMS - Community and Rural Internists: An Endangered Species

Bet you didn't realize that these once plentiful and admired people are on the endangered list. In British Columbia, the community/rural internist is the person who takes on every problem that is slippery and hard to grasp. Problems that might fall to a sub specialist also are taken on, since sub specialists tend to confine their activities to larger centres. The internists get patients ready for surgery, run the intensive care units, organize chemotherapy and do a host of other things that other specialists rely on. No internists and you may not have a surgical program.

Across the province hospitals are struggling as internists are unable to provide year 'round call coverage. According to HealthMatchBC, there are 29 permanent positions going begging today in British Columbia alone. The kicker is that last year we only graduated 38 general internists in the entire country.

That kind of arithmetic isn't encouraging. Unless we some up with some solutions, and soon, we will face a crisis of care. Here are some thoughts, and I'd welcome yours as well.

• Increase the supply of younger internists by:
  • Improving payment
  • Lobbying the provincial government to increase residency positions for general internists
  • Providing debt relief to general internists working in community hospitals
  • Providing the same debt relief to sub specialist internists who agree to work on call as generalists
  • Making subspecialty practice attractive to those who will work on call as generalists
  • Recruiting foreign medical graduates
  • Increasing the prestige of the discipline by providing leadership roles to general internists.
• Keep established internists practicing by:
  • Providing clinic space in or near the hospital at reduced rates
  • Providing enhance training opportunities to allow established internists to upgrade their skills
  • Training hospitalists to do many of the tasks presently covered by general internists at night - for example, ventilator management or insertion of lines
  • Enhanced use of telehealth technology which could provide centralized medical advice for remote intensive care units.

Keep in mind that new internists are going to take four years to train following medical school. We don't have time to procrastinate.

What are your thoughts?

Hello, I'm Jon and I'm a Recovering Paediatrician

The last day in the office has come and gone. After three years as a general practitioner and 17 years as a general consulting paediatrician, I am no longer in the office practice of medicine. I am on my way to becoming a full time medical bureaucrat. It's a big change, and it makes me nervous.

 

One of the nicest things about this past 17 years has been working with my wife in the office. She's a nurse; her insight and common sense have had an impact on almost every aspect of what we've done. We built two practices - first in Kamloops where we spent 11 years, then in Comox.

 

For the most part, it has been a happy practice. I think of my patients and how they've become a part of my life. The baby boy I resuscitated in 2004 gave my grand-daughter her first (non-family) kiss two years later. Then there's the mother of a baby with congenital chylothorax. I resuscitated her infant in the delivery room with high pressure ventilation and then with bilateral chest tubes. We sent the baby off to a tertiary center within hours of delivery. But she recognized me two years later in a donut shop and came over to say thank you.

 

I think of all the kids I saw with learning and behaviour problems. Some did well, others not so well. I remember attending the high school graduation of one of my cancer patients. Then there were the children who didn't do well. Kids with inoperable heart disease and metastatic cancer plus one lovely girl with polyarteritis. Their funerals taught me some humility. But they also taught me that medicine is rarely about curing and is always about caring. How we care, and how we show we care will be fodder for another post, but caring will always be the most important medical value for me.

 

It was a real mixed up day today. I felt as if I was abandoning my patients. One boy was in tears. So was another child's Mom. And then there were the good moments, with gifts received (chocolate, drawings) and memories exchanged. A girl who I had looked after with bronchiolitis as an infant presented today with psoriasis. A girl referred for ADHD looked as if she were more depressed than inattentive. Our receptionist left to get home before darkness fell - and that was a pretty choked up feeling.

 

Finally, the last patient went out the door - a lovely kid with CP. My wife and I were alone in the office with our thoughts and memories. We will miss this work. I know I will miss it a lot. I know that I will want to continue seeing babies, children and youth as part of my professional life. I've been doing it for so long that it's a part of my fabric. I'm Jon, and I'm a recovering paediatrician. I look forward to a few relapses.

 

Patient or Client?

KevinMD talks about how the nursing literature tends to use the word client, instead of patient. There is nothing more likely to provoke a reaction from a physician than the “c” word. Nurses believe that “client” implies a respect of the individual’s autonomy, while physicians believe that “patient” suggests a caring relationship.

The etymology of the two words may provide some insights. Client derives from the Latin cliens, meaning “to lean”. Thus you have inclinations, clinometers and clients. A client may be a consumer of a professional service, but it may also be one who is under the protection of another.

Patient derives from the Latin pati, meaning “to suffer”. So a patient is one who suffers and is therefore deserving of compassion and care.

Of course, whether one is deserving of compassion and care or under your protection may be a very fine point indeed. To that extent, the patient – client debate seems to be more about defining professional cultures than a real concern for the person at the centre of the discussion – patient or client depending on your point of view.