By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Differentiate multiple roles a physician may play in the community and the potential for role conflict

The physician, like any other person, may play multiple roles in the community, and whenever anyone assumes any role, this may interact with how they perceive and engage in the world. This can create conflicts of interest. And this is a reality of life. Sometimes physicians can choose not to engage in certain roles because of the negative impact it may have on their ability to provide good care (ex: not taking financial incentives from pharmaceutical companies because it may unduly influence prescribing practices). Other times, the role of the physician is necessarily and unavoidably in conflict (ex: being both a care provider who spends resources to assist patients manage their health issues and also a steward of health care resources who attempts to limit the amount of health care resource expenditure). As I strive to be an ethical family doctor, it is morally imperative for me to reject the assumption of roles that may have a potentially negative impact on my ability to provide best patient care, all things considered, and where possible. When not possible, or when my risk-benefit perception is in favour of adopting a role that may potentially influence my provision of patient care, it is important that I attempt to be as transparent about this as possible, with patients and also with myself, which I believe requires honesty, humility, and curiosity. It requires that I reflect on the roles I assume and how they may influence how I interact with patients and make decisions in their care. It also requires that if I think a role is potentially impairing my ability to provide best care, to work to create a solution, by either abandoning or modifying the role, or worst case scenario, to no longer provide medical care if the care is no longer assuredly safe and sound. Above all else, my identity as a physician must strive to first do no harm. 

The JAMA Network published a simple but informative article titled "Conflict of Interest in Medicine" to help patients understand basic principles of physician conflicts of interest. Of all the Google hits I obtained from searching for articles on physician conflicts of interest, this seemed to be one of the most basic but also the most useful for an overall of understanding this phenomenon as it applies to physician conflicts of interest in general.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate the application of basic occupational disability prevention and management principles and practices in clinical settings
• Demonstrate an understanding of the impact of occupation on the health of an individual and the impact of health on work

Disability
Key Feature 7: Do not limit treatment of disabling conditions to a short-term disability leave (i.e., time off is only part of the plan).
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Every Canadian province has their own workers' compensation organization, so details of occupational disability management will vary between provinces. WorkSafeBC is the provincial workers' compensation organization in BC. Per the Doctors of BC/WorkSafeBC Agreement, WorkSafe BC "...has the authority to provide health care and rehabilitation services to workers who sustain injuries that arise out of and in the course of their employment." (Doctors of BC is a voluntary medical association that any physician practicing in BC can be a part of. Their mandate is to promote the interests of physicians working in BC.) The Physician Reference Guide for the Agreement explains, "Working with Physicians and Employers in this province, WorkSafeBC’s goal is to facilitate a safe, timely, and durable return to work for injured workers (...) When a person suffers a work-related injury or contracts a work-related disease, he or she can make a claim for compensation to WorkSafeBC." In BC, a claim would be submitted by a physician who assesses the patient and submits a Form 8 to WorkSafeBC. Further follow-up appointments ask the physician to submit a Form 11 to WorkSafe BC if the following conditions apply:

• There is a change in medical condition
• There is a change to the Worker’s treatment plan
• There is a change in Return to Work status
• It has been more than 4 weeks since the last Form 11 was sent, or
• A Form 11 is requested by a WorkSafeBC Officer

Of course, like any other injury, the physician doesn't have to address a patient's concerns through WorkSafeBC, and can treat the injury much as any other presenting complaint. However, there is in incentive for all parties, including physicians (receive better compensation for the office visit when submitting a claim through WorkSafeBC), patients (WorkSafeBC expedites investigations, specialist appointments, and treatments compared to the normal public healthcare processes, all important parts of the comprehensive rehabilitation process), and society (by holding employers accountable for the safety of their employees).

As a primary care physician working in BC or any other Canadian province, or any other region of the world, along with treating injuries and diseases, one of my main priorities is also to try to prevent patients from acquiring new injuries and diseases. When I am gathering my social history on patients in clinic, I ask about employment conditions and if there any possible hazards that could lead to injury or disability, which include the following types of hazards:

• Chemical hazards (ex: organic solvents, metals, asbestos, toxic gases) 
• Physical hazards (ex: noise, vibration, radiation) 
• Biological hazards (ex: blood or other body fluids, animal and bird droppings) 
• Ergonomic hazards (ex: awkward postures and movements, poor lighting) 
• Psychological and work organization hazards (ex: workplace stressors, workplace bullying) 

If hazards are identified, it is then part of my duties to try to work with the patient to create a plan to eliminate or mitigate harm from them.

The possibility of injury or disability from employment is not a rare phenomenon. According to the peer-reviewed article "Individual, occupational, and workplace correlates of occupational health and safety vulnerability in a sample of Canadian workers" by Lay et al. published in the American Journal of Industrial Medicine in October 2015, "Occupational injury, illness, and workplace fatalities are important public health concerns. Globally, 2.3 million deaths a year can be attributed to occupational injury or work‐related diseases, and many more millions suffer from non‐fatal work‐related injury and illness. Annually in Canada, an average of just under a million lost time occupational injury claims are accepted by provincial workers’ compensation agencies, representing one in 46 full‐time workers being compensated for an injury severe enough to miss one or more days of work. The consequences of work‐related injury and illness extend beyond individual workers, exacting important social and economic costs from families, businesses, and economies." The impact of occupation on the health of an individual and the impact of health on work is significant and common among the general population, and it is therefore under my purview as a family physician to consider how my patients and society may be impacted by and occupational injury and disability.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Analyze the communities or environments in which patients live and work with regards to their impact on patient health
• Prepare for a procedure by preparation of physical environment (ex: equipment, personal protection, aseptic technique) and by cognitive preparation (ex: mentally rehearse anatomic landmarks, technical steps and potential complications and their management)
• During performance of a procedure, keep the patient informed and ensure patient comfort and safety always
• Display commitment to societal and community well being

Like all days working with the Portland Hotel Society (PHS), I started my day with focused medical learning objectives (I read over all of my extensive notes on how to prepare for and perform the perfect Pap) and came away feeling a mixture of overwhelm, curiosity, and passion to continue to provide care to marginalised people. While running a Pap clinic today (I say that because there was no attending physician present, just me), I learned of one particular woman's history involving significant physical abuse and associated emotional trauma that occurred within the environment surrounding the PHS clinic. I think PHS is amazing in how it brings access to primary care to the people of the Downtown Eastside (DTES), but I hadn't thought about how patients who no longer live and work in the DTES may re-live trauma every time they return to the DTES for ongoing primary care. Needless to say, I was very intentional about obtaining informed consent before the Pap test, with extra sensitivity to explaining why we perform Pap tests, the details of the procedure, and associated risks (physically, potentially a bit of vaginal spotting and pelvic cramping). I also gave her the opportunity to ask any questions, and let her know that if ever during the procedure she was feeling uncomfortable, we could always stop. During the procedure, I kept her informed by explaining what I was doing as I was doing it, and continued to check in to ensure she was comfortable (as comfortable as a Pap test can be, anyhow). The first principle in medicine is First Do No Harm, and in patients with a history of trauma, taking precautions to prevent re-traumatization is an important aspect of providing patient-centered care. After the Pap smear was all done, we discussed the possible transfer of her primary care to another low-barrier clinic situated outside of the DTES, but this was mostly kept as a conversation for another day given the multitude of other things that took precedence at this visit. 

Recently (aka from 8 am yesterday to almost 4 in the morning - we had a deadline to meet), my resident colleague and I were working on a literature review on the risk factors, protective factors, barriers and facilitators to treatment, and recommendations to promote better care of refugee women with peripartum depression. I was over it when I went to bed in the wee hours last night, but it was at the same time such a good learning experience, and today I was prompted to look to the literature to see what has been published regarding trauma that women have experienced living in the DTES. I found this informative article entitled, "'Like a lots happened with my whole childhood': violence, trauma, and addiction in pregnant and postpartum women from Vancouver’s Downtown Eastside" by Torchalla et al. (2015) as published in the open access Harm Reduction Journal. If you are at all interested in the peripartum experience of marginalised women, I recommend reading it. It also drives home pretty well perfectly the reality of this learning objective and why it matters for primary healthcare providers to understand and critically analyze the environments within which all patients work and live. The social determinants are more powerful than the prescriptions I pen.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...

• Provide continuity of care to a patient population through coordination, advocacy, and interdisciplinary collaboration in a variety of settings
• Demonstrate an understanding of the process of repatriating a patient in one's practice after a referral process, including ongoing communications with the specialist(s) or institution(s) involved
• Demonstrate knowledge of disease processes including undifferentiated presentations, differential diagnoses, diagnostic confirmations, and management across the lifespan
• Demonstrate strategies to aid in the management of 'clinical uncertainty' and 'clinical dissonance'
• Distinguish between serious illness and minor medical concerns and take appropriate action including telephone triage, referring, and consulting

Today I worked my last Saturday call shift of my first year of residency on the Family Practice Teaching Service at St Paul's Hospital. And it felt really good. It felt good because I felt like I was getting things done - I was working as a doctor. I got a list of all the patients who were admitted under the service, and I cared for them in full, as a real doctor is expected to do. I scanned patients' medical charts for pertinent information and reviewed any recent and/or relevant investigations and consultation notes. I then clinically assessed patients using history and physical examination skills. I addressed new symptoms or signs of disease that patients developed since they were previously assessed by the physician the day before, racking my brain for possible reasons for these new concerns, and I came up with plans to investigate and hopefully confirm what I thought were the most likely reasons for these problems*, to quantify their consequences, or to follow up with previous concerns as communicated by other members of the health care team. I  made referrals to specialists or allied health care professionals when I thought it was indicated, and I called them on the phone if they were already involved in patient care in order to address select issues more urgently if they fell under their purview. For less urgent concerns that specialists were involved in managing, I left notes for them to consider in the patient's chart. I made choices regarding patient management. I then summarised and communicated the information I gathered and the impression I formed with all of the facts available to me in a progress note in the patient's chart, finishing with orders to materialise my plans for treatment. I managed patients across the lifespan, from their early 20s all the way through to the 103 year old who I wrote a blog post about last week and who was still kicking. I received pages from nurses who were concerned about the patients under their care for various reasons, and decided if I could safely give an order over the phone, if instead only reassurance was needed, or if I needed to pay a visit to reassess the patient and gather more facts. Near the end of my day, a code blue indicating cardiac arrest was called for a patient in a nearby room, and being the first doctor at the beside, I asked the nurse next to me to start chest compressions and apparently started to run my first code. The ICU team did arrive only moments later, thank all the good lords, but I did start the process of what ended up resulting in a return of life. I was legit doctoring.

This may not sound as though I was participating in providing continuity of care considering I flew in for one shift this week to cover call for patients not under my care Monday through Friday. In some ways this is true. Or perhaps it instead reflects the fact that continuity of care exists on a continuum, and reflects the reality that the care of patients tend to happen in teams, as it ought to, and so long as information is being effectively communicated, it actually means more eyes, ideas, biases, perspectives, and possible solutions can participate in patient care. There does, however, need to be one most responsible physician who coordinates a given patient's care in order to be accountable to ensuring their needs are being met as much as is humanly practical. I can't wait to be the family physician who is held to this account.

The care of patients in hospital is very special to me in that this team-based care is front and centre. In private clinics, it tends to consist more of a physician-patient dyad, with allied health professionals and specialists recruited for particular concerns. This also works, and the degree of patient illness is also less acute and so tends to warrant less intensive interventions. Team based care requires more work, really, because it also means spending the time communicating information to different parties, and taking the time to consider other opinions and suggestions. But I really do believe this enhances patient care, and that although the degree of interdisciplinary involvement in a hospital is likely not warranted in outpatient care, that there is a balance that can be struck in having outpatient clinics that host an abbreviated interdisciplinary model. This is essentially the same this as The Patient Medical Home as advocated for by the CFPC. I almost certainly see myself working in a family practice office with these values and deliverances. At Three Bridges, the community clinic where I am currently working that serves marginalised populations, there is a host of interdisciplinary members of the care team who also work there and collaborate with the physicians or other professionals, sometimes skipping the need to involve a physician at all. There are psychologists, addictions counselors, nurses that range in skills from LPNs to practitioners, medical lab technicians, social workers, and project managers overseeing advocacy initiatives. And then there are the front-line staff and clinic managers keeping everything functioning. It is incredible work, is certainly enhancing patient care, and provides a strong sense of community that impacts the wellbeing of patients and health care workers beyond that which can happen from a set of orders on a piece of paper. 

*Admittedly, there were some things I was unsure about. But I coped. Strategies I used to aid in my management of clinical uncertainty included reviewing my own notes I have collated for different disease presentations, UpToDating how to work up a given lab finding, or using my pharmacopeia to confirm that a medication dose I was going to administer was safe for the patient in front of me. In other words, I used material references for support. I also made use of my team of human resources. I reviewed my plan of action with my attending physician if I had doubts about the balance of harm vs benefit for the patient, as well as the utility of an intervention for a given patient and whether it was a reasonable or unreasonable cost to the health care system. When there was clinical dissonance (aka the story and facts didn't add up), I made like a detective and dug deeper into patients' stories, and I asked patients' family members, nurses and other allied health professionals for their thoughts on the matter. I listened more intently with my stethoscope. I decided if there was a test I could run to provide clarity, or when the issue wasn't urgent, I communicated the uncertainty in my note to the next resident in my position and let the issue declare itself further (or dissipate in insignificance) with a tincture of time. Sometimes a trial of empiric medication with little harm but possibly great benefit was tried, and other times, when medications were possibly but not certainly causing more harm than benefit, a trial of cessation or decreasing the dose was employed. In these grey areas of medicine, of which there are so many, trial-and-error is the standard of care. I believe this is why the dogma of "First do no harm" is ever-relevant today and probably will be as long as physicians exist.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...

• Describe the spectrum of institutions care options available

When I was in medical school, if I read "institutional care options" my mind would've reflexively jumped to geriatric residential care options. Although I was aware that there are other members of society who live in institutional care besides seniors, for lack of medical exposure to these other populations, the concept of geriatric living facilities was synonymous to me with institutional care facilities. But the breadth of institutional or residential care options is so much more than that. The website of the Government of British Columbia outlines the residential care options that are in operation in BC as follows:

It is more than likely that over my career I will support patients in finding institutional care facilities across the spectrum of needs for which a live-in facility would be indicated. However, unless I am working with a very niche population, my efforts to help patients find appropriate institutional living accommodation will still be overwhelmingly in the domain of seniors housing, particularly as I enter practice during the baby boomer exodus from older adulthood to geriatric stages of life. A resource I found to be helpful in navigating these senior housing options (across the spectrum and including those that are pre-residential level of care) is Seniors First BC. I encourage anyone who is or anticipates caring for a senior living in BC to check it out. And to find housing for any other domain of need, referring to the bc211 website is a great place to start (I just tried it for various demographics and was able to find options for all of the various residential care needs, woohoo!). 

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...

• Describe community-based care resources and rehabilitation services available
• Monitor and coordinate care of children with chronic illnesses, disabilities, or serious disease, using available community supports as necessary
• Identify mental health resources in the community and appropriately connect people to these resources
  
• Use referrals, support networks and community resources as part of a patient-centred management plan

Disability
Key Feature 1: Determine whether a specific decline in functioning (ex: social, physical, emotional) is a disability for that specific patient.
Skill: Patient Centered, Clinical Reasoning
Phase: Diagnosis

Today I spent the afternoon in my home family clinic. Within 3 hours of seeing patients, I had developed management plans that included referrals to at least 3 different allied health care professionals, which is pretty standard in a comprehensive family practice. Community resources and professional supports can be extensive in urban centres such as Vancouver, so it really is beneficial to ask patients about what sorts of limitations their medical issues are creating for them - be they social, physical, or emotional - in order to access an extensive network of supports that can make a world of difference. I have always been asking my preceptor whom I am working with if they have a go-to professional or community resource in the indicated area, but it's about time I start building my own database of community-based resources and rehabilitation services to refer patients to. Thanks to a formal lecture given to my cohort of residents near the start of residency, I have some excellent resources to get me headed down a path of less resistance in order to suffice and surpass my patient's allied health and community resource needs. The online resources that I find particularly glorious for (resident) physicians working in British Columbia:

No more excuses for me! Time to explore the options, find some health allies, and be resourceful in this province ripe with community support services. 

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Use a patient-centred approach to care of patients and families through exploration of both the disease and illness experience, understanding the whole person, and negotiating informed shared decision making regarding management
• Act in a caring and compassionate manner
• Initiate screening for mental health disorders in high-risk situations (ex: patients with cancer, chronic pain, war veterans, refugees, victims of domestic violence, etc.)
• Obtain a structured medication review including identification of potential drug-drug and drug-disease interactions (if appropriate, in consultation with a pharmacist)
  

Chronic Disease

​Key Feature 4: In patients with chronic disease, actively inquire about:

• The psychological impact of diagnosis and treatment
• Functional impairment
• Underlying depression or risk of suicide
• Underlying substance abuse

Skill: Patient Centered, Clinical Reasoning
Phase: History

Difficult Patient

Key Feature 3: In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times.
Skill: Patient Centered, Professionalism
Phase: Treatment, Follow-up

Key Feature 4: With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (ex: psychiatric patients, patients with chronic pain).
Skill: Selectivity
Phase: Hypothesis generation, Diagnosis

Disability

Key Feature 3: In patients with chronic physical problems (ex: arthritis, multiple sclerosis) or mental problems (ex: depression), assess for and diagnose disability when it is present.
Skill: Clinical Reasoning, Patient Centered
Phase: Diagnosis, Hypothesis generation

Key Feature 4: In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family).
Skill: Patient Centered
Phase: History

Key Feature 5: For disabled patients, offer a multi-faceted approach (ex: orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration.
Skill: Patient Centered, Professionalism
Phase: Treatment

Multiple Medical Problems

Key Feature 4: Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it.
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

Key Feature 5: Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to:

• Simplify their management (pharmacologic and other)
• Limit polypharmacy
• Minimize possible drug interactions
• Update therapeutic choices (ex because of changing guidelines or the patient’s situation)

Skill: Clinical Reasoning
Phase: Treatment, Follow-up

​Stress

Key Feature 1: In a patient presenting with a symptom that could be attributed to stress (ex: headache, fatigue, pain) consider and ask about stress as a cause or contributing factor.
Skill: Clinical Reasoning, Communication
Phase: Hypothesis generation, History

Key Feature 2:  In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress).
Skill: Patient Centered
Phase: History, Diagnosis

Key Feature 3: In patients not coping with stress, look for and diagnose, if present, mental illness (ex: depression, anxiety disorder).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 4a: In patients not coping with the stress in their lives: Clarify and acknowledge the factors contributing to the stress.
Skill: Patient Centered, Clinical Reasoning
Phase: History

The first patient I saw in clinic today was the first patient I saw in clinic at the same time last week, a 47 year old female who had an extensive relationship with chronic pain. Over the years, she had trialed a significant number of medications and alternative therapies to alleviate her pain, but her pain was tenacious. During my first visit with her last week, after confirming that her pain was indeed unchanged over the last many years, and after confirming for myself there weren't any "red flags" in her presentation suggestive of more ominous disease, I reviewed her current pain management strategies, including whether or not she was using any non-prescribed substances to cope. Her approach was as chaotic as the shopping bag she brought with the countless concoctions of over-the-counter supplements and herbal remedies, including some that appeared to not be sold on Canadian pharmaceutical shelves. She was speaking very quickly, wanting to tell me so very much about everything, and I think she was probably in anxious distress and having a hard time trying to cope. 

At the first visit, we reviewed the past history of her chronic pain - all of the previous investigations that were done and all of the specialists she had seen - and what the conclusions were. We then proceeded to clean up her pain medications and reduce them to the ones she felt confident were making a real difference in her pain. And then our time was well up. We ended this visit with an organized regimen of pain medications and a followup appointment to reassess how things were going in one week. And now here we were. She sat down in front of me and after a polite exchange of hellos she gently asked what we should do this week to modify her pain medications.

There is so much about chronic pain we have yet to understand. The pathophysiology is still highly theoretical. We are aware of its association with mood disorders and psychosocial stressors, but we do not understand at a level of utilitarian specificity as to why this is the case. Chicken, egg, or both? In any case, no matter how we arrive at chronic pain, we do know that it worsens mood and aggravates social stress, just as mood and psychosocial stress negatively modulate perception of pain. By extension, if I can do anything to improve mood and psychosocial stress, I may alleviate suffering, and the corollary argument also holds that if I alleviate pain I may improve mood and attenuate psychosocial stress, thereby enhancing quality of life. 

Knowing the connection between chronic pain, mood, and stress, and now that I had the medical facts straight, during this follow-up appointment I decided to explore what was going on in this patient's personal life. As for mood, although she did not think she was clinically depressed and denied active suicidal ideation, it was certainly suboptimal, compounded not only by her pain but by her debt of sleep secondary to her pain. As it turned out, she attributed her low mood to the stresses in her life: her father living overseas was currently admitted to hospital for life-threatening cardiac disease, and her husband was riddled with aneurysms from his aorta to his renal arteries and was awaiting urgent surgery to prevent sudden rupture and possible death. Wow. Suddenly her pain had context, and was only a part of what I felt was infringing on her quality of life. The focus of our conversation shifted entirely away from her pain at this point, and she opened up about her fears of living life without her most significant others as well as her concerns regarding return to work as she felt she needed to prepare for a future with less financial stability, which was already troublesome. I did not have any advice for her anymore, and instead I just sat there listening to her experience with ache in my heart. 

After she shared the most salient aspects of her personal life stressors and the impact they were having on her ability to function or create disability, we rerouted the conversation to some practical takeaways to manage things for now, with planned follow-up again in one week. We decided that what was best right now was probably not to make any significant changes to medications, and rather to first have follow-up counselling later this week with her psychologist whom she endorsed having a strong relationship with. At this time she was not interested in any support groups or other community supports, but she said she would consider it in the future depending on how things progressed. She had come to the clinic today asking what we should do to modify her pain medications, and she left saying she was happy we weren't making changes to her current medications and that we were instead focusing on other ways of modulating her pain (I think this must have been partly because she had so many futile experiences with inconsequential medication changes over the years and didn't have much faith that yet another medication change would be her solution). As she was getting up to leave the examining room she said, "I'm now leaving here with more hope, and it's what I really need right now." 

When I first encounter patients with very complicated medical histories, either because of the number or significance (ex: cancer) of the comorbidities, I find myself feeling stunned by the complexity, oftentimes not knowing where to begin or to what depth I should delve under the pressure of time constraints. Indeed, this is how I felt when I first met this patient.  In vain, I have felt personally overwhelmed by patients with multiple somatic complaints, serving only to increase my stress without making any difference in quality of patient care. Instead, these feelings ought to serve as internal cues to the fact that if I am feeling overwhelmed, it almost certainly means the patient is feeling this too, and likely with greater whelm. In that midst of overwhelming complexity, taking time to move beyond exploration of the disease process to exploring the illness experience, can, as this patient taught me, be the basis for a restoration of hope, alleviation of suffering, and improved quality of life. 

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Discuss the role of primary health care in Canada and globally as an essential too towards improving and maintaining the health of people locally and globally
• Demonstrate respect for colleagues and team members
  

Near the end of medical school I had the opportunity to hear Dr. Danielle Martin, a family doctor from Toronto, talk about her new book, "Better Now: Six Big Ideas to Improve Health Care for All Canadians." I learned about her and her book only when I received a faculty email advertising it, but as soon as I heard she was a family doctor who wrote a book with that title, I knew I had to be at that talk. And I wanted to come prepared, so I literally read her book in one and a half days, as that was the ETA until talk-time. Oh to be a family doctor who is passionate about advocating for system level changes and actually making a difference! *Insert heart-eyed emoji here*

When I read over the UBC learning objectives and thought about exploring the first one that is the focus of this blog post, I immediately thought of "Better Now," particularly since the first chapter is all about the "Return to Relationships" that epitomises primary care. I am moved by Dr. Martin's ideas and the way in which she exposes them to readers, and I want to share what I feel are some of the most compelling parts of her chapter on the significance of primary health care.

"Good primary care requires a broad knowledge base. It also requires humility, the ability to sit with the discomfort of uncertainty and help patients do the same, a profound respect for the role of specialists, and a deep confidence that a health care provider who knows the person is at least as important to her health as one who specializes in the disease.

And when it's well organized and supported, a primary care practice does much more than just take care of the individuals who come through the door. It serves as a connecting point for the entirety of a person's journey through the health care system, and it reaches beyond its walls to improve the health of the community it serves. A provider or group of providers can identify a population for whose health they are responsible and track that population using data, reaching out to engage in prevention and screening efforts. They can monitor and support patients with chronic diseases, and function as the hub for health and social services in the community.

When it works, it really works. That's the Big Idea in this section: relationship-based primary care for every Canadian. This means that every individual should have a relationship with a primary care doctor or nurse practitioner. It also means that every primary care group should have good relationships with the rest of the health care system, and with the community in which all are embedded."

I'm going to go on because my heart.

"In a society that fetishes specialisation and dramatic, life-saving measures, the value of generalism can be overlooked or minimised. This isn't just a Canadian phenomenon. From the United Kingdom to India to the United States, primary care is critically important and yet, paradoxically, often undervalued. There are lots of reasons for this, but one is that as medical technology advances, it can be hard for people to remember that treatment from specialists isn't always better than treatment from generalists. For many kinds of care, including prevention, screening, and the management of chronic disease, treatment from a generalist who knows you is nearly always your best bet. Relationship-based care from a generalist can and should be holistic: as British general practitioner and medical leader Dr. Iona Health has said, 'A death from a non-cardiac cause can be regarded as a triumph for a cardiologist, but all deaths fall within the remit of the GP.'

Primary care is also critical to ensuring that our health care system will be sustainable. Systems that focus on good primary care are more cost-effective, more equitable, and deliver higher quality care overall. A big part of the reason for this is that primary care is the best place to help people manage chronic disease. As medical science has enabled an increasing number of people to survive previously fatal problems like cardiovascular disease and cancers, people are living longer and developing more chronic conditions like high blood pressure, diabetes, and heart and lung disease. To have each of these diseases treated by a different specialist (...) is not only time-consuming and confusing for the patient but expensive for the system."

And then Dr. Martin ends this chapter with a compelling argument on how the scope of primary health care extends, as it should, beyond the realm of the family physician. 

"I focus on family medicine because the vast majority of primary care in Canada is delivered by family doctors, and that's likely to continue to be the case. Having said that, primary care is not the sole remit of doctors. Nurses, nurse practitioners, physician assistants, midwives, pharmacists, social workers, dietitians, and a wide range of other providers are increasingly the first point of contact  with the health care system. In some communities, people receive nearly all their primary care from nurses with advanced training. And in remote communities throughout Canada's vast north, where there are very few physicians or nurse practitioners, they may receive their primary care from community health workers. 

There is no magic to an MD degree that makes a doctor the only person suitable for providing high-quality primary care. Other providers play important roles in disease prevention, health promotion, and the treatment of illness. In the case of primary care nurse practitioners, their training enables them to perform work formerly thought of as "doctor" work. 

I'm not worried that a nurse practitioner or any other provider might do much (or even all) of what I do as a family physician. They're well-trained and capable, and when they bump up against the limits of their expertise, they bring a doctor into the mix - just as I seek other expertise when I hit my own limits. Frankly, there is more than enough work to go around.

What matters to me isn't who does the work, but that the work drives primary care to live up to its potential. This means that we can't just look to download tasks onto less costly providers at the expense of relationships, or add more providers to the team without a clear purpose and good evidence that their participation improves the health of the community, improves the patient's experience of care, and saves the system money - the Triple Aim. As a doctor and a citizen I want to know that every primary care provider is prepared to commit to three critical relationships: with patients, with other parts of the health care system, and with the broader population they serve."

I want to marry primary health care and live happily ever after with it as it cares for me and all my chronic diseases <3

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Discuss issues involved in relaying medical information to the extended family
• Respect​ privacy and confidentiality of patients
  

Today I was covering call for the Family Practice Teaching Service (aka the Family Medicine ward) at St Paul's Hospital. As I was rounding on a 103 year old female who was delirious and at the present moment, fast asleep, the granddaughter at the bedside shared with me how her grandma was doing that day and asked what we thought the prognosis was looking like. As I rounded on a 56 year old man with significant lethargy and paucity of words, his partner at the bedside began answering my questions on the patient's behalf; clearly he recognised his partner's significant weakness and wanted to be a voice of advocacy for him. As I rounded on a 92 year old Cantonese-only speaking female whom I had assessed on a previous call shift, I realised her family wasn't present as they usually are when I come by, which meant I wouldn't have my usual translators present.

What is and is not acceptable in the way of discussing patient health information with family and friends? I just got myself out of a major Google haze trying to find some answers. And you know when that happens either you weren't asking the right questions to get the answers you're looking for, or the information is really just not out there, which is kind of incredulous to believe as Google usually knows what's up. Maybe Google was just keeping things "confidential."

If you look up confidentiality, you can find a whole swath of information on the general ethical and medico-legal principles of confidentiality. However, to find guidance on the limits of just how much information sharing is acceptable and warranted when it comes to communicating with family members and other people in a patient's circle of care is apparently beyond my best Googling effort. If you're interested and have an incredible ability to focus on mundane reading, the Laws & Legislation webpage of the College of Physicians and Surgeons of British Columbia provides the legislation by which issues regarding confidentiality are interpreted in the courts, but again, there is little by way of detailed legislation regarding specifics of disclosure of patient information to family and other people involved in caring for a patient.  

The most informative sources I found for guidance in navigating patient confidentiality with respect to disclosing health information to family and friends are:

1. CMPA webpage: Privacy and Confidentiality: Breaches
2. Canadian Mental Health Association for British Columbia document: Best Practices for Service Providers: Privacy Sharing and Information Sharing

The second resource is only two pages and while still general, is as much reading as I can handle on this dry but certainly important subject. The first resource is much less informative but highly relevant as it has provided me with 2 questions I can ask myself in real-time to decide what I ought and ought not to disclose to family and friends with respect to patient information. These are as follows:

1. Do I need to share this information to provide care to this patient?
2. Do I have the patient's consent, implied or expressed, to share this information? 

It is my opinion that health care providers are much more competent at protecting patient confidentiality in the clinic as opposed to hospital environments. Unlike in clinics, in hospitals patients are often sharing rooms, such that patient information is discussed not behind closed doors, and patients also tend to be more vulnerable and thus may benefit more from the care of involved family and friends. But this is no excuse to be more lax when it comes to critically thinking about when and when not to breach patient confidentiality, and I think that I at least need to do better when it comes to making efforts to safeguard my patients' health information. Hopefully I will be able to use the 2 simple questions listed above to check-in before proceeding to discuss patient health information at the bedside, at the very least ensuring I've done my due diligence to consider how it may benefit or harm the patient and act in a more conscientious way for my own ethical, legal, and moral integrity.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate ​proficient assessment and management of patients using the patient-centered method
• Demonstrate proficient active listening, verbal and nonverbal skills, expression of empathy, unconditional positive regard, and genuineness
• Perform an appropriate assessment of patients using skilled interviewing and physical examination techniques in gathering clinical data
• Demonstrate proficiency in establishing a strong doctor-patient relationship and therapeutic alliance
• Demonstrate comfort with broaching discussions of gender, sex and sexuality, including lesbian, bisexual, heterosexual, and transgender women and girls
• Describe the wide range of development, attitudes, and experiences in sexual health

Disclaimer: Okay, so this post makes me feel like I'm tooting my own horn, really loudly. It feels unpalatable to be demonstrating the achievement of competencies that are pretty well synonymous with being a good person. It feels disingenuous, as though I've acted in a caring way toward someone and then turned around immediately to the person behind me and said, "See, I am a good person." But as part of this reflective blog that is mapped to my learning objectives, with the intent being that I will have exemplified proficiency of each one by the time I finish residency, a little horn-tooting is just my attempt to demonstrating this proficiency. 

Today was one of four days during my month-long rotation at Three Bridges where I was supposed to video-record my entire encounter with a patient, from introductions until the end of the visit. The point of this was so that I could review it with my attending physician that day and receive feedback on my clinical skills. I knew I needed to find a patient who would give consent to being the recorded patient, and that some patients would probably decline, so I knew it wouldn't be smart to wait until the end of the day to ask patients to help me out with this. Being the super nonprocrastinator that I am, I asked my very first patient, and to my surprise, they agreed for me to record our encounter! This patient was a 49 year old trans patient who identifies as non-binary and who prefers to go by "they/them" pronouns. They turned out to be lovely and probably the easiest person in Vancouver to get a taped interview with. 

The patient was coming in for follow-up regarding testosterone therapy. They started testosterone 3 months ago and had been gradually going up on their dose. Their goal was to have the appearance of an adolescent male, and they were well on their way. Prior to meeting this patient, I really had only explored management of testosterone therapy with patients who identified as male and who wanted to appear as masculine as they felt, without significant risks to their health that can accompany overzealous hormone therapy. This patient's hormone goals were not quite so polar. I had the opportunity to explore this with them, and much more. At times I almost (but not quite) forgot that the interview was being taped - I was enthralled in how they spent their time volunteering as part of a gay nuns advocacy group (aka the Sisters of Perpetual Indulgence) and how they had plans in the next year to cycle across Canada (one of the highest items on my bucket list). Although we did get somewhat derailed talking about The Great Trail, we also did  spend most of our time together talking about issues regarding their health. The interview flowed, and next thing I knew it was 30 minutes later and I was shutting off the video recorder. 

My attending physician sat down with me over our lunch break (we're even productive on our lunch breaks!) and reviewed the video with me. I felt vulnerable in anticipation of receiving feedback regarding how competent I was on the wannabe family doctor scale, which today was graded in 3 categories as either 1. Needs improvement, 2. Satisfactory, or 3. Effective. The observed areas on which I was assessed included

1. Subjective aspects of the visit (history-taking, eliciting appropriate information, awareness of important facts [cues], and problem solving abilities [making appropriate hypotheses]),
2. Objective aspects of the visit (skills of physical examination, ability to detect obvious signs, and appropriateness of exam),
3. Assessment components of the visit (the interaction of history and physical findings and rating the urgency of the problem),
4. Planning components of the visit (appropriate use of lab for investigations, therapeutic skills, use of other health personnel, and pattern of referral),
5. Doctor/patient relationship aspects (empathy, attitude, ethics, and interviewing skills), and
6. Efficiency (organisation, termination, and use of available time)

To retoot the horn that my attending surprisingly tooted for me this afternoon, I achieved an E for effective in the first 5 categories and I received an S for satisfactory in the area of Efficiency. I was given specific feedback as to why I earned an E for effective in 5 of the categories (such as demonstrating active listening, being patient-centered in my interview style, and by way of verbal and nonverbal skills expressing empathy, unconditional positive regard, and genuineness toward the patient). My preceptor felt that I only attained an S for satisfactory on the 6th category since I spent more time than indicated talking about the fun and interesting but not medically  relevant aspects of this patient's life. I felt this was a fair critique and that the interview would've certainly been more efficient by having a little less banter overall. As well, for critical but not corrective feedback I was told that I tend to have a very exuberant energy, and that while this was seemingly well-received by this patient and likely many others, it may be just too exuberant in some settings, and that it would be good for me to be aware of this if I wasn't already. I agree with this point of feedback and think it is important to be able to adjust body language and tone of voice to fit the context. I do think I am competent at recognising when it is time to pop the champagne bottle or instead to vent off most of the gas in my personality bubbles, letting things flatten out in those patient encounters that call for a bit more poise and solemnity. Perhaps my next video-recorded session will speak to my ability or inability to reflect this.

As a resident, it seems as though we are mostly learning what to do by learning from our mistakes, which can get a bit demoralising. And even when we receive positive feedback, having the perfectionist personalities that we do, we tend to focus on what we've done wrong rather than spend time acknowledging the accomplishments we've achieved. At the end of this interview, the patient asked me when I was going to graduate. I told her I have another year and a half of residency yet (thank goodness, I am so far from ready to practice independently). She then said that was disappointing as she was wanting to see if I could be her family doctor! I would say that meant I achieved competency in establishing a strong doctor-patient relationship and therapeutic alliance, which sort of means the world to me right now. So for now - and probably not for long - my horn is a-toot :)