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A doctor’s dilemma – Macleans.ca


Drip, drip, drip. I watch the saline flow through the plastic tubing into my arm. The baby gives a reassuring kick just before another contraction hits. There is concern for possible placenta accreta, a condition where the placenta, instead of implanting nicely against the uterine wall, sends its tendrils deep into the uterus like a murderous weed. My C-section is scheduled for tomorrow morning, but this baby—my fourth—clearly wants to put its own stamp of approval on its birthday, which has fallen in January of 2022, in the middle of British Columbia’s first Omicron surge. 

I don’t deliver babies myself, but as a family doctor, I learned how to do it in medical school and residency. I know that things don’t always turn out well. I glance at my husband, who’s catching a brief nap on the chair beside me. It’s been a tough few years, and the thought of something going wrong today, leaving him to explain things to our three little girls, makes me swallow hard before the next contraction comes. 

I work in a small town in British Columbia, the same town where I was born and grew up, where my dad was born, and where my mom’s dad was born, in a tent, before his family’s homesteader cabin was built almost a century ago. My two younger sisters and I grew up in a three-room cabin with no electricity or phone, as it was far too expensive to get hydro poles up the old logging road that was our driveway. We turned on the generator to operate our tiny black-and-white TV only on important occasions, like when the Canucks made a run for the Stanley Cup in ’94. Otherwise, we had books and the forest to keep us busy. My parents worked hard as a shipwright and a bookkeeper, but our weekends were always full of camping and hiking in the backcountry.

I applied to medical school after becoming interested in Médecins sans Frontières but I quickly realized that there was great need right here in British Columbia, and that family medicine was where I could make a real impact. Family medicine is the work of the generalist; the breadth of knowledge is wide, and the relationships run deep. One of the best things about my practice is that it can be anything, and it changes every day. You never know what will walk through the door next: a deep laceration from a hand vs. tool conflict, an insect in someone’s ear, or a person having a heart attack who needs stabilization until the ambulance arrives. In the span of a few hours, we may treat strep throat and tick bites, do flu shots and COVID swabs, diagnose cancer and heart failure, perform excisions and biopsies, and support a patient who is near the end of life or one struggling with thoughts of ending their life.

I love practising here. I love that I’m the doctor for the wonderful elementary school teacher who taught me, my sisters and my dad. I love to see the kids from my practice running around the schoolyard and soccer field when I’m there with my own family, and it makes me smile when a dad watching his children from the sideline shouts, “Hey, doc!” and shows me how much the baby strapped to his chest has grown. When I’m doing a home visit, a dying man pats my hand and tells me he worked with my grandpa 60 years ago. These relationships are what being a small-town family doctor is really about.

Herrling suffered two miscarriages during the pandemic. Then she got pregnant again. She gave birth to her fourth child in January.

Herrling suffered two miscarriages during the pandemic. Then she got pregnant again. She gave birth to her fourth child in January.

But things have changed, a lot. Nearly one in five British Columbians—close to a million people—are now without a family doctor. Some walk-in clinics, which previously provided a safety net to people who didn’t have a family doctor, have been shuttered, in part because there aren’t enough physicians to staff them, and also due to rising costs and a lack of government support. British Columbia’s descent into a primary care crisis is part of a larger trend across Canada; in 2019 there were approximately 4.6 million Canadians without regular health care providers. Although family medicine is the bedrock of our health care system, family doctors are among the lowest-paid physicians, and with the rapidly increasing costs of education and running a family practice, fewer and fewer can afford to choose this specialty.  

***

Drip, drip, drip. Raindrops slide down the hospital window, and the snow outside is turning to slush. If I were at home right now, I’d be catching a bit of sleep between logging off my work computer for the night and heading back to it in the morning.

A typical day for me starts around 6 a.m. My husband and I make lunches, and get our three daughters dressed, fed and through the daily battles of teeth and hair brushing. We give them goodbye kisses and eventually get them out the door for preschool and elementary school drop-offs. I’ll start seeing patients at 7:30 and continue until two or 2:30 p.m., sometimes making a quick run to the bathroom. I rarely have time to eat or to drink more than a sip or two of cold coffee. I see 30 to 40 patients a day. There are nearly always “fit-ins”—maybe a wound that requires immediate repair, a feverish toddler who really needs to be checked out, a mom with a UTI who is wrangling three kids, a patient with a mental health crisis who cannot wait. These are people I can help now and keep out of the emergency room. After I finish seeing patients, both virtually and in person, I start slogging through paperwork. 

Paperwork is the bane of family doctors’ existence, slowly crushing us as it fills our inboxes day in and day out. This part of the workload disproportionately affects female physicians. American research analyzing the time spent by doctors on electronic medical records found that, regardless of the number of patients in their practices, female physicians receive approximately 25 per cent more messages from staff and patients, and have to spend at least 20 per cent more time dealing with their inboxes and notes. Most paperwork is uncompensated and includes all manner of tasks: charting patient visits, checking labs, reviewing imaging, requesting consults, reading specialist reports, filling out forms, researching unusual presentations, advocating for patients, answering pharmacist queries, speaking to home care nurses, and discussing cases that can’t wait with specialists. After two or three hours of paperwork, I wedge my family into my day. Dinner, bath time, brushing little teeth, a story, a lullaby, bed. Then it’s back to the computer at around 8 p.m. for another three to five hours. I know family doctors who are up until two or three in the morning or pulling all-nighters to deal with paperwork. 

In the span of a few hours, we may treat strep throat and tick bites, do flu shots and COVID swabs, and diagnose cancer and heart failure.

I’d rather have more time to spend with my patients, but it’s not really possible. I’d rather have more time to spend with my family, but it’s not really possible. The B.C. government pays family doctors $31.62 for the average visit. Depending on the practice, approximately one-third goes to overhead and one-third to deductions. The third that is left for us is the same whether we spend 10 minutes checking blood pressure and renewing prescriptions, or 45 minutes managing complex issues for a patient who has debilitating chronic pain, cancer and depression, as well as many medication interactions and tenuous housing. Again, this affects female family doctors even more: research published in the New England Journal of Medicine in 2020 found that female primary care physicians spend more than 15 per cent more time with their patients than their male counterparts do. While multiple studies have shown that patients of female doctors may have better outcomes, the extra time spent means female primary care physicians earn less. We all, female and male doctors alike, want to spend this time with our patients—these are our patients, we know them, we care about them, and our life’s work is helping them. And our patients deserve this time; they deserve our care. But our payment system—our government—does not prioritize spending time with patients; family doctors are working flat out not by choice, but by necessity. There just aren’t enough of us in family medicine, and there are always more patients than we can see. As it is, most family physicians care for at least 1,000 patients.

Fifty-two per cent of physicians in Canada are family doctors. But the vast majority of unfilled residency spots are in family medicine—of the 115 empty positions that weren’t taken by eligible new doctors in 2022, 86 per cent were in family medicine. B.C. graduates the most family doctors in Canada, and is tied with Alberta for having the third-highest number of family doctors per capita. And yet many of these family physicians are no longer choosing to work in traditional family practice.

Renée Fernandez, the executive director of BC Family Doctors, reports the concerning math that although British Columbia has 6,943 registered family doctors, only 3,145 are working in traditional family practice settings, providing ongoing care through all stages of life. Many family doctors pivot to paths that provide better compensation and allow them to put in their time and go home at the end of their shift, such as working as a hospitalist or in corporate telemedicine. Many family doctors go back to school to train in emergency medicine, addiction medicine or palliative care. They wanted to work in family practice—they trained and sacrificed for it—but they graduated to the stark realization that they simply can’t afford to.

There is also debt to be paid off—many doctors graduate with hundreds of thousands of dollars hanging over them. For doctors who take time out from their training to start a family, this debt can be truly staggering. Medical school and residency often conflict with one’s fertile years, and there is no easy choice—the practicalities of family life can be difficult to reconcile with the demands of medical training, and the evidence shows that many female physicians delay having children. Doctors don’t get medical or dental benefits, paid sick days, pensions or employment insurance, and when you take into consideration these expenses, plus huge debt, plus the minimum 10 years of post-secondary training required of all physicians before entering the workforce, managing on the remnants of that $31.62 for an average visit becomes a real crunch. The problem isn’t the fee-for-service system—the majority of doctors in B.C. are paid this way. The issue is the size of the fees paid to family doctors. Not all provinces publish these figures, but based on those that are available, it appears that family doctors in British Columbia have the second-lowest pay of all physicians across the country, and the gap between family doctors and specialists in B.C. is one of the widest, despite the high cost of living in the province. 

Recently, the B.C. government came forward with a contract offer to new medical school graduates. It provides a $25,000 signing bonus if they agree to work as family doctors in B.C., and includes debt forgiveness of up to $130,000. But the new contract misses the mark widely. It does not address the high costs of overhead or the reasons for burnout in family medicine, and it neglects those physicians already in practice. Attracting a small number of new doctors while losing those already here makes little sense. There is no single solution for this increasingly dangerous primary care crisis; the problem needs to be dealt with thoughtfully, rapidly, and in close consultation with family physicians who are on the front lines. The government should look at raising family doctors’ fees, subsidizing our overhead expenses and paying us for the many parts of the job that occur outside the exam room.

MORE: I’m a veteran ER doctor. I can’t believe what I’m seeing.

There is a lot of frustration among family doctors. We save the system a great deal of money. There is no comparison between the cost of seeing a family doctor—even if we were appropriately paid—and the cost of a patient ending up in the emergency room or a hospital bed, needing specialist care or far more intensive treatment. The data across many countries reveal that all these outcomes occur much more frequently among people without family doctors; a study in Hong Kong showed that these patients end up in the emergency room and are admitted to hospital at more than twice the rate of patients who have their own family physician. An American study showed that patients who have a family doctor rather than a non-physician primary care provider (such as a nurse practitioner) make fewer trips to the emergency room, are more satisfied with their care and incur much less cost to taxpayers, with fewer unnecessary tests or referrals to specialists.

Not only do family doctors save taxpayers money, they also save their lives. Canadian evidence shows that cancer screening occurs more frequently among people who have a family doctor. A lack of family physicians can negatively impact the care specialists provide. Daisy Dulay, a cardiologist in Victoria, has spoken about how the primary care crisis is affecting specialist physicians; for example, they must try to manage medical issues outside of their expertise when their patients don’t have a family physician. Family doctors feel terrible frustration at not being able to take on ill patients—our practices are full and there are no other family doctors to send patients to. It is morally injurious to have to turn away babies whose growth and development won’t otherwise be followed, dads who are suffering from depression that keeps them from playing with their children, isolated elders who have few points of contact, and people with serious illness who don’t know how to navigate the system. 

***

Drip, drip, drip. I think back to the delivery of my first baby, in 2012. I was in medical school, clerking at the same hospital I lie in now, pregnant through most of my third year. That’s when medical students leave the lecture halls and spend most of their time in the hospital. The family doctor who took care of me during that period was one of the people who made me want to be a family physician in the first place; I’d been placed with her for a rotation in my second year of medical school. Dr. M is the kind of doctor who hugs her patients warmly, jokes with them easily and makes her job look like the best in the world. She reassured me through my pregnancy—medical students can think of a lot of things that could go wrong!—and interrupted Thanksgiving dinner with her family to come and assess my labour when the baby was taking too long to arrive.

I trusted her and I knew I could depend on her. That’s a big part of being a family doctor. We see our patients for years and build up relationships. It’s terrifying to talk about the bleeding you’re worried might be the harbinger of cancer, but it’s a little easier to open up to someone you’ve spoken to many times before. It’s hard to finally share that your partner is abusing you, but if you trust your doctor, you may find yourself able to ask for help. You may be able to admit to your doctor that no, you haven’t been taking your medication—not because you can’t be bothered, but because you can’t afford it. As family doctors, we work with our patients to find solutions and support them through the difficult times.

Drip, drip, drip. These contractions don’t seem to be getting anywhere. The anesthetist comes in and tells me I’ll need an arterial line, which is a thin, flexible tube that’s threaded into an artery, usually in the wrist or groin. That is not at all a typical part of a C-section, but the possibility of accreta has the anesthetist worried about a catastrophic hemorrhage. I think about my daughters waiting at home with my parents. I can tell he’s trying to hide it, but my husband looks nervous.

When I was in medical school, after our first daughter was born, my husband worked at the airport, on the ground crew. He’d go to work in the afternoon and come home an hour or so after the last flight arrived. Depending on weather and delays, sometimes that would be 3:30 or four in the morning. I’d be up at six, getting ready to head to the hospital, and our little girl would be up soon after, smothering my husband in toddler kisses and crawling all over him. He would try to stay awake until my mom arrived to watch our daughter, and then he’d go back to work. I’d come home and put our little girl to bed before hitting the textbooks. It was an exhausting time, but it was a means to an end. We thought that one day, when medical school and residency were over, there would be balance, and we would have time for our family and each other.

The year that my first daughter was born, we lost my grandmother and two of my uncles. They all died at home and they all received palliative care from family doctors. Caring for patients at the end of life is another part of family medicine that I love—the relief on a husband’s face when we get his wife’s nausea under control; the way breathing settles and tension eases from a person’s face when their pain is treated properly. We help people stay in their homes, with their families, until the end. We understand the challenges patients face, and we know which supports they need, because we’ve been with them along the way. But now, as family medicine itself struggles to stay alive, who will be there to take this journey with them?

When I finished medical school, we moved to a new town for my residency. When our second daughter arrived in 2015, at the start of my second year of residency, we were overjoyed. Despite pressure to take a shorter leave, I returned to work when my baby was 10 months old. After that, my husband left his job and stayed home with our girls.

It was the only option. Call shifts are unpredictable, ER shifts are late, it is a rare daycare that does evenings, weekends or overnights, and we had no family nearby. 

Medical culture still excretes toxicity toward trainees and women: sexual harassment, comments like “This is why women shouldn’t be in medicine” and expectations that maternity leave be limited to weeks or a few months. Camaraderie with your fellow residents can help, but when you’ve got small children and a partner waiting at home, you can’t easily justify heading out for a drink or meeting up for a hike. I was fortunate to find strong mentors in other doctors who are also moms, but without my husband at home, my training would have been impossible.

I completed my residency in 2017 and became an independent family doctor, starting my own practice a few weeks after finding out that we were expecting a third baby. When you have your own practice, there are huge overhead costs. Many people don’t realize that everything in a family doctor’s office comes out of the doctor’s pocket. They pay for the rent, the staff, the exam beds, the hand sanitizer and the toilet paper. They pay for the computers, the needles, the anesthetic, the sutures, the scissors and the gloves. These costs add up to many thousands of dollars each month—and the doctor must pay whether they are working or not. And when the doctor isn’t seeing a patient, the doctor isn’t being paid.

It can be overwhelming—the conflict between filling out reams of forms and soothing a feverish toddler.

The solution to this problem is a locum—a doctor who sees your patients when you’re unable to, and who pays a portion of their earnings to cover your overhead. When my third daughter was born, I was able to cobble together four months of coverage between three different locums. Unfortunately, family medicine locums are a dying breed, for the same reason that family doctors are. I know multiple family doctors who have been left with no alternative but to close their practices because they couldn’t find locums for their maternity leaves. One colleague is reconsidering having a second child because she knows she has very little chance of finding any maternity coverage. Without locums, already-burned-out family doctors have no respite from the emotional and physical exhaustion that weighs heavier every day. Sometimes the burden is too heavy; female physicians take their own lives at a rate of nearly one-and-a-half times that of other employed women. 

It can be overwhelming—the conflict between spending time with patients and being able to pay your staff; the conflict between filling out reams of forms and soothing your toddler who has woken with a fever. I have been fully qualified and working independently for just under five years, but already these conflicts have sometimes felt like too much. Still, like most of us, I care so much about my patients that it is hard to leave, and I hope, perhaps naively, that the value of family medicine will be recognized before we’ve been bled completely dry. So, for now, I stay.

***

Drip, drip, drip. It’s winter in British Columbia, very wet and very grey outside, and the night is slowly receding. Only a few more hours until I meet this baby, the baby who will complete our family. It has been a different pregnancy. This baby kicks like it’s already a soccer player, and I’m more tired, more sore and more worried. Part of it is that each pregnancy is a bit more uncomfortable. Part of it is being pregnant through the pandemic. Part of it is losing other babies.

A few months into the pandemic, I was pregnant—this baby would make us a family of six, just as we’d always hoped. My sister was due a few weeks before me, and we were delighted to expect our babies together. There was fear, working through the pandemic; pregnancy increased the risk of severe outcomes, and there was risk to the baby as well. Back then, we didn’t have enough PPE, but you can’t stop seeing your patients, especially in the middle of a pandemic. Doctors and some of our moms sewed shower curtains into isolation gowns. Fabric scraps became surgical caps. A local dentist and some community members dropped off masks. Several times a day, I would meticulously arrange my MacGyvered PPE, put my hand on my abdomen for a moment, pick up my stethoscope and a COVID swab, and head in to examine another scared patient.

RELATED: I’ve only been a nurse for eight months. The chaos is killing me.

My first-trimester ultrasound was delayed, and it wasn’t until I was getting close to my second trimester that I lay on the exam table, waiting to see the little heartbeat. It’s never a good sign when the tech says they’re going to go speak with the radiologist. The heartbeat wasn’t there. I started to miscarry on my birthday, in September of 2020. 

When there are no locums to be had, you keep seeing patients, you keep breaking bad news as gently as you can, you keep examining rashes, and you keep diagnosing other people’s pregnancies. When there is no space for your loss, you take some comfort in the fact that the face shield makes your eyes look a bit blurry anyway and you keep going. 

Then, a new hope: a positive pregnancy test soon after the miscarriage. This baby would be born in the summer. We didn’t tell our girls right away, but two ultrasounds confirmed that all was well, and on Christmas morning we shared the happy news. 

And then, two weeks later, another ultrasound tech went to get another radiologist. “I’m sorry,” the radiologist said, confirming our worst fear. “Your baby is exactly the right size for gestational age. It must have stopped growing yesterday, or maybe this morning.”  

I went back to work the next morning and found myself fighting back tears a few days later as I worried with a patient who was facing a possible pregnancy loss herself. Later, there was relief when it turned out her baby would live. Then I was fighting back tears as I talked to a young parent about their serious illness; fighting back tears as I watched a dying grandma say goodbye to her grandchild who wasn’t yet crawling. Sometimes the tears won.

And then, suddenly, there was concern that I may have cancer. Instead of hoping for a positive pregnancy test, we were hoping for negative results. Tests, scans, biopsies—not only was this scary, but I couldn’t take a break. My patients didn’t stop getting ill just because I got sick, too. Sometimes I had to reschedule half a day of appointments, or take care of patients over the phone when I got home from the hospital in the evening. I held my girls close when I read them their bedtime stories and tried not to let them see if a tear escaped. My parents helped out, as they always do, and I tried not to show them I was scared. Thankfully, the cancer investigations were negative and we could draw a breath of relief.

We found ourselves expecting again in the summer of 2021. We didn’t tell the girls for a long time. I searched for locums in every spare moment, but there were none to be found; I wouldn’t be able to afford more than a few weeks with my baby, maybe a month or two, and this meant asking the other doctors at my clinic, who were already overworked, to take on more work. There is no coverage from our government, our college or our health authorities when a doctor has a baby, or is seriously ill, or bereaved. The phone rang one night, a few weeks before Christmas; it was another doctor mom, calling with devastating news. A colleague’s perfect little baby had passed away during labour. I felt racked with terrible guilt that her locum could now give me some months at home with my baby.

***

Drip, drip, drip. A cup of ice melts on the hospital tray beside me. I’m out of the OR, and a brand-new baby snuggles cozily on my chest, a surprise boy. Everything went well; my excellent OB/GYN, the caring anesthetist and my lovely midwife brought us through. We take him home and show him to his excited sisters. They cuddle up, and one of them whispers, “Mommy, I’m so glad we have a new baby. Because now you will be home with us for a little while.” 


This article appears in print in the September 2022 issue of Maclean’s magazine. Subscribe to the monthly print magazine here, or buy the issue online here





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