Family physician says she is not delivering the kind of care she wants to be providing
Dr. Sabra Gibbens says she has her dream job. As a family physician in a small town outside Kingston, she is working with people she enjoys, and doing work she loves and finds meaningful. But her spirit is uneasy — she knows she is not delivering the kind of care she wants to be providing to her patients and it is a source of ongoing pain.
“I feel like I am failing my patients. There is a real disconnect between why I went into medicine and my day-to-day reality,” says the family physician who works in Verona, a town of 2,000 people.
Dr. Gibbens’ reality is that she, like many family physicians across Ontario, is stretched far too thinly. (Please see the accompanying article, Family Medicine in Crisis.) Shortly before coming to Verona to replace a retiring physician, she learned the town’s other doctor was leaving to return to residency to pursue a specialist degree. She agreed to take on his patients on a “temporary” basis, expecting a replacement would appear shortly. But seven years on, she is still the town’s only doctor. With 2,500 patients in her roster — double the size of most family practices — she says she is completely and utterly overwhelmed.
“All I am doing is putting out fires,” says Dr. Gibbens, who works more than 65 hours a week and comes into the clinic on weekends to catch up on her paperwork. “I just don’t have the bandwidth to do anything else.”
She pays a nurse practitioner to come in three days a week and hires a locum one day a week. Because she is familiar with their medical histories, she sees the patients with complex needs, many of whom have multiple conditions.
“There is a real disconnect between why I went into medicine and my day-to-day reality.”
Dr. Gibbens runs a “cradle-to-grave” general practice. Most of her patients, however, are at the far end of life’s spectrum. Many suffer from chronic obstructive pulmonary disease, diabetes, heart failure, kidney disease, dementia and/or cancer. “And so, to do justice to any one of these patients, sometimes even 30 minutes isn’t long enough,” says Dr. Gibbens. The result is she may only see 18 to 20 patients a day, which is fewer patients than the Ministry of Health would like her to see.
She also receives periodic reports from the Ministry of Health on how she compares to other family doctors in her region and across Ontario on the delivery of colon-cancer screening, mammograms, flu shots and other preventative care services, and she is disheartened — but not surprised — to see that she falls below average on most metrics.
“It breaks my heart to know my patients are not getting the kind of care they need and deserve. I just hate that I don’t have the time to reach out.”
Throughout the day, her office phone rings constantly. Many of the calls are from people looking to be taken on as patients. In the vast majority of cases, the answer is a polite no. But many of the calls are her own patients asking to be seen on an urgent basis. Her staff members have been trained to triage the most serious cases, but she says too many of these patients are told they can’t be accommodated for several weeks.
“These are the phone calls that pain me. I would love to be able to squeeze them in. But I just don’t have the capacity to see them as soon as they want and need to be seen. So, they will hang up, clearly distressed, and then have to basically fend for themselves,” which may involve going to a Kingston-area emergency department for treatment, she says.
The language used to describe such clinician distress in health care is changing. Dr. Gibbens says the term “moral injury” resonates with her, because it more accurately identifies the root of her anguish in a way that “burnout” does not. Moral injury, originally used to describe the post-traumatic stress experienced by combat soldiers, is the feeling that one has participated in actions that transgress their deeply held moral beliefs, or the sense of being betrayed by an authority figure or system in a high-stakes situation, preventing one from doing the right thing.
“In the meantime, the patient is calling me repeatedly, worried they may have been overlooked. I honestly don’t know what to tell them.”
Dr. Gibbens, who is from the U.S., remembers a time she used to brag to her American friends about working in a universal health care system. Although she will remain in Canada, she’s not bragging now, she says. She is astonished at the length of the wait times to see a specialist — often as long as two years. It’s not much better in cases that she would describe as semi-urgent. “In the meantime, the patient is calling me repeatedly, worried they may have been overlooked. I honestly don’t know what to tell them,” she says. “But I don’t begrudge the specialists — I know they are struggling to keep up as well. Nobody is having an easy time.”
Perhaps her biggest challenges lie in accessing Child and Adolescent Psychiatry for her patients. Because she has very limited access to these specialists, she has had to extend her comfort zone in terms of diagnosing and treating children’s mental health and behaviour conditions.
It is challenging to differentiate between or recognize overlapping anxiety disorders, temperaments, attention deficit disorders, autism spectrum disorders, intellectual disabilities, and family or school environmental dynamics. Dr. Gibbens spends hours assessing the patient herself, collecting collateral information from parents and teachers, and factoring in what she knows about the child’s parents and siblings.
“I often have to make an educated guess as to which disorder is primary, initiate treatment, and then bring them back again and again to see what’s improving and what’s not,” she says. Many of these patients do well and never need specialist consultations. In those instances when she does need specialists’ help clarifying the diagnosis and/or guiding treatment, she is frustrated to learn the wait times are still 12 to 18 months. “I don’t know how else to help this child and their family while we wait. It’s painful,” she says.
Centralized referral programs have reduced the administrative burdens and wait times in some areas of care, for which she is thankful. But she would love to see it implemented for mental health services as well.
In the meantime, Dr. Gibbens says she will continue to do what is needed for her patients. “There are moments in each day when I do feel like I am making a real difference in people’s lives. And I say to myself, ‘Yes, I can definitely keep going.’”
