Story and myth in primary care

On a recent Sunday, I was on call for our group of 27 doctors (made up mostly of solo and small groups) sharing after hours and weekend call as part of our capitation contract with OHIP, called the Family Health Organization or FHO in Ontario. I myself run a solo practice in the GTA with a roster of 1,000 patients, and contracted part time help from an associate physician. During this Sunday on call session, Mr. Wang, a Mandarin speaking elderly gentleman in my practice, messaged me, “Doctor, I've had a fever for 5 days, can you prescribe something?” I replied that he ought to come in and see me, especially since I am on call in the office. Meanwhile . . . a solo colleague, Dr. Crosby, emailed me, a “check this out” link to a FHT (Family Health Team) in the GTA, promoting in its website blog, the:"Benefits of Choosing a Family Health Team Over a Solo Doctor"Curious, I read on what they boast: "Technology: Solo: varies Team: often more integrated EMR systems"Seriously? I doubt their EMR is superior to mine. Actually Mr. Wang got through to me using WhatsApp. He didn't have a computer, and had no data plan on his phone, but relied on the free WiFi from his low income apartment building. For him, messaging me in Chinese on WhatsApp, was a medical lifeline. After waiting an hour for his Sunday bus, somehow Mr. Wang made it to my office, but missed his destination stop, and had to walk back two blocks. Had I known he was so weak and ill, I would have offered a house call. His temperature measured 38.3°C, lungs were clear, but I was sure he had pneumonia, so I prescribed oral antibiotics, drove him to the pharmacy to pick up the antibiotics, and back to his apartment. Later in the day, I went back to read the article: "Continuity: Solo: risk of gaps when doctor is unavailable Team: ongoing support from team members"A couple of days later I messaged Mr. Wang, “are you doing better?” He responded, “whenever my Tylenol wears off, the fever returns.” Counting this as day seven of his fever, I decided he needed a visit to the ER. But how can he get there? Do I call 911? Mr. Wang is a tragic hero. He nursed his elderly wife, single handed, through many years of her debilitating dementia, the inability to communicate and a stroke that confined her to bed. Each and every day, he coaxed her to eat, turned her to prevent bed sores, and somehow managed to carry her to the washroom, disimpacting her if necessary. His devotion was admirable. Then she passed away last year. In his grief he stopped taking his own blood pressure medicines, precipitating a hemiplegic stroke himself. He waited a few days, then took the bus to my office, half limping. I called his only relative in town, but they don't want to get involved at all, even as he sat there with hemiplegia. So I drove him to the ER and left him with a letter to triage. But after he waited a few hours not getting seen, he left the ER and took the bus home. I was very upset with him. His reply? “I got hungry, and didn't know what they wanted to do with me.” So this time, I decided, I was going to be both his driver and his translator, to get him through triage and beyond. How would a Team have handled this? Perhaps a nurse, or social worker could have driven him. But they probably could not speak Mandarin. Nor could they have conveyed the seriousness to Mr. Wang, and his flight risk to the hospital staff. Nothing like showing up in person to show you mean business. Being there personally, with CPP medical record in hand, and personal knowledge of Mr. Wang in my head, I believe this eased subsequent care flow from admission to discharge. I only stayed for the triage, then headed back to resume my paperwork day at the office. And to read on about the benefits of a Team: "Service offered: Solo: general care Team: chronic care, mental health, diet, more"This Team promised “more,” but could it have done “more” for Mr. Wang? For him, this time the acute care mattered more. What he needed wasn't more information or counselling. He is an intelligent man who knew how to give good care to others, just not for himself. I wanted him to know that someone gave a damn about him, and will give him a hard time if he didn't follow through with his care. He didn't just need a ride . . . he needed ammunition . . . to fight and live another day. I don't relish being a “do-gooder”; I prefer efficiency. Between his stroke and this pneumonia I tried hard to find some volunteer to drive him, and to translate. But local Mandarin speaking volunteers are non-existent, since most seniors have at least one dedicated family or friend looking after them . . . just not Mr. Wang. Initially the internist was going to keep him for a full week. However, between his feisty character and the inpatient team's intel that his solo doctor was watching him, they decide three days was all that was needed for discharge, having settled his fever on IV antibiotics. He was happy to get out when I picked him up. I did so only because I don't trust him to pick up the continuation oral antibiotics from the pharmacy. I was taking no chances, leaving no room for a bounce back readmission. Having satisfied my mission, I returned to read, "Collaboration: Solo: minimal Team: high - team based decision making"They really made it sound like Teams are better positioned to tackle complex problems. But of course, they would have to wait until the next Team meeting. I imagined they would brainstorm ideas, compile meeting minutes, and assign responsibilities. On paper Teams are quite impressive. In contrast, a solo doctor sees complexity differently. A solo doctor knows complexity is not untangled through only a problem-solving approach, but work through personal knowledge of the patient, undiluted by shared care. If I need ideas and feedback, I'd post on the Solo Doctors WhatsApp chat and ask my 150 solo colleagues, who are supportive, collegial and full of great ideas. We not only collaborate daily, hourly and instantly, but colleagues such as Dr. Crosby help to mentor doctors who struggle with their patients and practices. But the blog on Team vs. Solo was right about one observation:"Type of care: Solo: one physician Team: multi-disciplinary team"Beyond a simple statement of fact, it hints at limitations, being solo. Yes, I am only one. I have limited time and limited energy. No, I will not attempt to out-compete, and out-deliver services to match that of a Team, for that would be self-defeating, and a recipe for burnout. I am going to judiciously sprinkle my care to patients in need, because I don't have the luxury of waste. Just because I helped Mr. Wang this time, I may not be able to help him next time. Nor do I have any illusion about being his forever guardian angel. But I made peace with my limit of one. I don't promise to be everything to everyone, only that I will take care of this one, this time, then move on to another one. I learned that commitment, action and tenacity galvanize, when you have the clarity to see the one person that matters. And in this I am like Mr. Wang, who cared for his wife, through so many enduring years, bringing her the best care any person could give. A team might be nice. But you have to have the one. Dr. Adam Chen runs a solo practice in Oakville, Ont. and is involved as an executive member with the OMA's Primary Care Solo Doctor MIG. To join this group, please email adamchen@live.ca

Story and myth in primary care

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