WHAT DO DOCTORS DO?
Here's an account of my average day as a family doctor and what we do. This day was cherry picked for having no unusual volume or unusual visits. I scrambled the initials of each patient by an algorithm known only to myself to protect their identities and confidence.
6:30 am: I'm up. "Holy, morning already?!". I exercise for fifteen minutes in my basement on a contraption called the Rack that resembles the two-wheeled walkers seniors use to prevent falling - but perhaps should be doing what I'm doing with them so they don't fall in the first place. The meal that will drive my morning brain activity consists of gluten free toast, an egg, and a fruit and spinach smoothie. Then I hit the shower and join the morning routine simultaneously occurring in all of the households on my street - a street full of overachievers.
8:35 am: Leave home and merge with traffic. Turn on an audiobook to pass the time while feeding my brain.
8:58 am: Arrive at destination. My first patient is always myself, treated with a tall cup coffee to light a fire under my bum.
9:00 am first patient of the day A: Crohn's, and chronic diarrhea since having a rotten segment of his small bowel surgically removed twenty years ago. Every month he seeks a solution to his intestinal hurry. Nothing works. He is like an amputee who keeps trying on an endless stream of prostheses each time believing that the next one will feel just like his original leg; an unattainable aim. But the truth is untenable for him and I don't have the heart to kill his hope. We will keep trying.
9:25 am patient B: Routine thyroid medication refill. Lab homework sent for shows that the replacement dose being given is like Goldilocks porridge, not too hot, not too cold, but just right.
9:30 am patient C: Glaucoma eye drop refill. Two ophthalmologists in the area just retired creating a famine for eye exams and eye prescription refills. Bummer.
9:35 am patient D: Another case of thyroid replacement therapy going well. Just needed a refill to keep their metabolism ticking right.
9:45 am patient E: Chronic fibromyalgia nerve pain and lower back pain after their vehicle ran off the road and abruptly came to a stop in a ditch wrenching them forward. Morbidly obese further torturing their spine. Nothing surgical to offer. Sympathy, weight loss encouragement and ongoing script for morphine.
9:50 am patient F: Another case of chronic pain. Having their left shoulder orthopedically fixed six months ago hasn’t helped. But they also disregarded the doctor’s orders to rest their shoulder for six weeks post-operatively. I suspect the rotator is re-torn. Script for morphine and referral back to the orthopedic surgeon, minus sympathy.
10:00 am patient G: An unusual case of postoperative pain. Six months ago I first saw this patient after a gallbladder removal which was a "success". But they’ve been left with severe pain at the outer edge of the healed incision. Tried topicals and local injection to numb the pain without lasting success. Script for pain killers and await a call back from the surgeon whodunnit.
10:10 am patient H: Classic story of pain in the soles of their feet, worse on first step down in the morning from bed. The arches from the heels to ball are tender. Classical plantar fasciitis. Prescription for Advil, physiotherapy and orthotic shoe inserts to correct the fallen arches.
10:25 am patient I: Yet another hacking cough and cold (there's a reason we call it the common cold). Advised decongestants and rest - let mother nature do her healing (then I take credit when they're better).
10:30 am patient J: Young guy with knee pain on squats and stairs. Impression - patellofemoral syndrome i.e. slack knee caps with tracking slippage. Sent for physiotherapy to strengthen and shorten his quad muscles to keep his patellae snug in their grooves.
10:35 am patient K: A medical mystery evolving over years with bizarre unrelated symptoms and unexpected responses to treatments e.g. intestinal "parasite" bloating that gets better with antifungals or antibiotics or a spectrum of naturopathy concoctions leading me to wonder if this is an insidious anxiety disorder called somatoform disorder. These people think themselves sick but are oblivious to their mind’s starring role in their illness. Stop their rumination by starting Prozac.
10:40 am patient L: New lung cancer. I begged them for seven years to quit smoking, including the visit just prior to this lung CT result they are here for today. Too late. Perhaps I should have been checking their ears for wax buildup all those wasted years.
11:31 am patient M: Deaf in the right ear. When I look in there's a swimming pool behind the eardrum. Diagnosis: serous otitis media. Oral and nasal decongestants advised for the next week.
12:40 am patient N: A surgical success!!! Suffering with bilateral lame shoulders for about two years, today they can do windmills on the left side since having the that rotator fixed six weeks ago. Elated. Now we just have to wait on the surgeon to work their magic on the right side, and hopefully sooner than another two years from now....
1:45 pm patient O: Skin lesions - and cancer anxiety. My impression: common age spots. Reassured and the cosmetically displeasing ones I blow torch away with a canister of liquid nitrogen. Fun.
1:55 pm patient P: Tingling running down arms. I couldn’t help notice as they walk in with their baby, their seat, and the diaper bag look almost as big as the bearer. On examination, she’s very slim with tender shoulders and arms, and tennis elbow soreness. Her bicep and tricep jerks are normal and her grip strength is good. Overuse is my impression. Referred for physiotherapy and advised to savagely downsize her travel kit.
2:40 pm patient Q: Hypertension refill. Used to run systolics of 180’s to low 200’s when we first met. Still recalls the scare I gave them when I said they were a “stroke waiting to happen”. Heeded my warning and faithfully takes their antihypertensive pill each day. Systolics now idle in the low 140’s. Guess the fear ploy worked. Sometime you gotta hurt ‘em to heal ‘em.
3:05 pm patient R: Another knee sprain. I don’t think a day passes that I do not see one of these (or an ankle sprain). Almost always explainable. Almost always extinguishable with rest, ice and ibuprofen, compression bandage, and elevation - we call it the ‘RICE’ treatment.
3:10 pm patient S: Swollen lump like a golf ball at the back of the elbow. Tender and slightly pink and my otoscope light applied to the side of it shines right through. Stereotypical bursitis. Often caused by banging your elbow against a wall or leaning against your chin for too long on a tabletop - like while reading this entry. Treatment is aspiration of the straw colored viscous fluid with a large bore needle, replacement by some cortisone as an anti inflammatory, and a tensor wrap for 24 hours.
3:50 pm patient T: Fixing a shelf not anchored to the wall, it let loose and fell forward scraping open their L chest. There is a clean vertical cut above the pectoral running down about 3 inches. Yikes. Cleaned. Sterilized. And Sutured with ethilon 3/0 caliber nylon in four spots along its length. (Did you notice the floating ‘L’ stand in for “‘left’ chest” up there? That’s one notation shorthand I used in my real chart note for this visit).
3:53 pm patient U: Back for annual lab results. Two years ago I gave them a scare when the blood sugar started meandering away from normal. Seems to have taken my sermon on a low sugar, low carb diet seriously as their numbers today are right on point. Yeah.
4:15 pm patient V: Follow up visit from the ER for excruciating headaches. Turns out they were sinus headaches. The CT scan of their head, showed the normally hollow sinuses were filled with pus. Placed on antibiotics and today doing much better. But I know this patient. Everytime I see them they sound nasally congested, snort during the interview, and speak with a Donald Duck voice. I know that the patch done by the ER doctors is not going to hold. I start them on a day to day preventative allergy prescription.
4:35 pm patient W: Au revoir - my final patient of the day. But my day isn't over yet. Many people think that after patients leave doctors are done. Far from it. The patient visit is the tip of an iceberg. Not visible after you leave is the heavy lifting of recording the details of the your visit, prescriptions and rationale - these actions can take as much time as the physical encounter - and every visit also spins off x rays, lab tests, referrals, insurance forms and more that need to be reviewed each day. So my next 'to do' is review the day's urgent labs that came in and respond to numerous paper requests for clarifications or refills from pharmacists. Then, I sign off.
6:00 pm: Leave my office, remember to set the clinic alarm on my way out. Remember to pick up 3% milk on the way home for my toddler.
8:30 pm: Supper was yummy in my tummy. Kids in bed. Down to basement office to finish low priority labs and complete writing up day's chart notes.
10:30 pm: slink into bed after brushing my teeth and watch part of a Netflix serial on my phone until my eyelids get too heavy... then pass out.
Next day: do it again.
As you examine my timeline, you might notice there is no mention of a lunch break. That’s because for most doctors lunch breaks are as real as rainbow unicorns. While my schedule promises one everyday, there are always time overruns that gobble it up. Most days I get 5 minutes to eat plus some pee breaks. And that’s generous in our line of work. I’ve known of doctors holding their wee-wee almost to bladder breaking point before breaking down and running to the bathroom. Weekends are also interrupted for me. That’s when I catch up on insurance and disability forms, and complete charting more complex visits of the week.
And remember when I said I chose this day to highlight because it wasn't unusual? Well unusual is actually the usual within our schedules. I haven't included covering clinics for other docs for headache, common cold, family emergency etc. at the last minute. Or left field hits to my off time anticipated schedule for sudden house calls after work weekdays, bank holidays and weekends - including this one as I'm writing.
So this is what doctors do in a 'typical' day in family practice. For those who aspire to be doctors, be careful what you wish for ;)
How Much Time do Doctors Spend doing Forms for Patients?
Two thirds of Family Doctors report doing up to 3 hours a week, one fifth spent three to five hours, one twentieth up to eight hours, and two out of twenty-five spent more than 8 hours per week filling out forms and other paperwork for their patients.
People often have no concept of how much paperwork we do. When you visit your doctor, you are seeing the tip of a huge submerged iceberg. When you leave, we have to enter details of your visit into our record, review it, and sign off that it is correct. That usually runs me about five minutes per patient and frequently longer. Then at the end of my day, there is a screenful of top to bottom labs, x ray and CT reports, plus specialist reports to review and sign off on. Some of these reports will require follow up, so recalls notices have to be sent out to our clerical staff to bring these patients in for their dose of bad news. Then we have our physical mail slots filled to the brim each day with more reports, insurance requests, pharmacy clarification requests, medical journals and junk mail (indistinguishable when you're tired). You probably remember the childhood stories of little happy elves that come in overnight and tidy your room to your delight when you wake. We are those elves working out of sight late at night and often grumpy.