As I sit indoors, babysitting a rambunctious toddler, confined to the house because we seem to be facing all the Horsemen of the Apocalypse and many of the Ten Plagues of Egypt, I reflect on the phenomenon of what I call “Geezering.”
This is the tendency for those of a certain age to believe things were so much better in the good old days.
We tend to believe that what we did back when we were trained, or we worked when we were in our prime, is obviously the right way. This leads to resisting any changes in the way things are done now.
That said, there are many things in medical practice and education that were, honestly, better back in the ‘80s when I started practice and teaching.
I began my practice working at the late, lamented, Queen Elizabeth Hospital. It was a tiny, McGill-affiliated community teaching hospital. As a family medicine staff physician I worked in the emergency room, and co-attended on the medicine wards along with an internist.
Every morning much of the staff would meet in the OR lounge, the GPs dropping in a few times a week to pick up our mail, but often drifting upstairs where we could be almost assured of finding the specialist we wanted to consult gossiping in the lounge. As we drank the amazing coffee created by Melvin, the OR orderly—his magical elixir that was rich, subtly spicy and came out of a giant urn—we would discuss cases all together.
Simple questions were dealt with then and there, more complex issues were prioritized. Surgeries could also be arranged. The surgeons at the Queen E were the kindest and most gentlemanly of men. It was easy to get things done. Everybody worked together. The atmosphere was collegial and supportive.
One of the best things in the old days was our ability to pick our consultants. Good consultants, who had the three As (ability, availability, and amiability) were sought after and made a better living than those who could only muster one out of the three qualities. We had bonds of trust and would work together on difficult cases. Now the Quebec, and other, governments see us all as interchangeable parts, demanding that we use a “fair and efficient” system that can often lead to impersonal and minimalist consults. If one doesn’t ever have to see the family doc who is sending the patient, and will possibly never work with them again, you have no skin in the game. There isn’t much incentive to truly do the best you can to unravel a difficult case, except your own intrinsic professionalism and intellectual curiosity.
The pandemic has worn all of us down, and telemedicine, for all its advantages, is a poor substitute for a face to face encounter. One of my friends has been failing, over the past three years. He has had several falls, could no longer ride his bike, and was having trouble swallowing. I thought he had Parkinson’s. His wife, a retired nurse, thought he had Parkinson’s. When he finally persuaded his family doc, who was one of a long string of residents, to send him for a neuro and GI consult, they were initially done over the phone. Only when he was finally examined in real life was the diagnosis made and treatment begun, three years later.
There are, however, advantages to the Brave New World we are in. Video and audio appointments, photo dermatology consults. Even remote surgery can help bring medicine quickly and efficiently to rural and remote areas without falling into the rabbit hole of transporting every patient all the time. While being there in-person may be the ideal, having family medicine doctors give chemo, birth babies, administer anesthesia and do minor surgeries with close links to remote consultants improves the health of these communities.
For this to work, however, we have to have family docs. Well trained, pluri-potential, family docs who are the Swiss Army Knives of the medical system. Years of government cuts and interference in practice, a widening pay gap and increasing administrative burdens have eroded the desirability of family medicine as a specialty choice. Those choosing family medicine are less likely to do ongoing care, because it is increasingly demanding.
There has been a great deal of backlash directed at the College of Family Physicians of Canada for their plan to introduce a three-year residency program. I’ve been hearing a lot of geezering.
“We went out to work after a year of rotating internship and we were OK.”
“Why are they teaching all that silly psycho-social stuff, they should just learn real medicine.”
Well, yes, nowadays our learners have less hands-on experience and this is a problem. They learn nothing of the business of medicine and this is a problem. They are not adequately learning that they are not the centre of this universe: the patient is.
However we are never going back to the days of one-in-two, one-in-three, 24-hour calls. I remember as a medical student doing pediatrics, there was a little boy admitted with hemophilia and anti-factor-eight antibodies. This little guy had fallen and bitten his tongue. ENT had declined to stitch it and now the oozing bleeding mess in his mouth was making him miserable. He was gagging and spitting blood every few minutes. I was assigned to give him tranexemic acid and factor-eight every hour. One had to be pushed and the other mixed immediately and hung as an IV infusion. I don’t know why the nurses were not allowed to mix and hang the meds, but they could not. At hour 22 of working flat out, I mixed them up. Nothing bad happened, but it was a bad error. I still remember how ashamed I was when my resident sent me to lie down.
There is a lot of literature about sleep deprivation and medical error. That’s why there are now working hours and call limits. It’s to protect the patient and promote learning.
So in order to make sure that our residents are getting the irreplaceable patient exposure they need, managing complex patients, doing procedures, working rurally, while still respecting patient safety, the residency needs to be extended. Most of our residents want this. Yes, you will still learn the most in your first year of practice, but perhaps you will feel more prepared to take on the more challenging parts of the practice.
The world is changing and we must change with it. As I look out the window at the orange haze caused by the wildfires, I realize that the environmental disasters we are facing are largely caused by people not wanting to believe that things need to be changed.