The Doctor Is Never In Or, How Micropractices Fail Patients with Mental Health Challenges

Key takeaway: Let’s get back the budget money and staff up again. Let’s pay our doctors whatever is competitive to retain the top talent and recruit new physicians. Let’s have a discussion with domestic violence serving organizations about how the hospital can be a safe place for someone in a triggered trauma state. We figured things out pretty well for palliative care. Now let’s tackle trauma.

Trigger warning: CSA, DV and GBV are mentioned briefly.

I am writing this to express my discontent with changes to the Alberta healthcare system under the United Conservative Party, NOT to critique a specific physician. If you are here for that, you may as well leave now because I’m not outing anyone here. If you know me and by some chance know the physician in question, please keep it under your hat (as they used to say for some reason I can’t be bothered to Google about). I mean it. Swear?

Some background important to this story is that I have Complex Post-Traumatic Stress Disorder and I have been off work since 2015 on a medical disability pension. This physician (Dr. Eau – not their name just what I happen to be drinking) took over my care prior to the pandemic but I don’t have the exact date. Shortly after (perhaps a year) my physician took a parental leave (nope – I’m not suggesting a woman).

Like many people, during the pandemic, my mental health took quite a downturn. I’ve been working on a piece (the hardest thing I have ever written!) called Inside My Breakdown about how this felt for me. Here’s a quote:

“the demon frees themself to wreak havoc in your mind. First, he turns your hypervigilance dial to 10, then cranks the cortisol tap wide open. He checks that the switches for catastrophic thinking, jumping to conclusions, and overgeneralization are all in the ON position.”

Inside My Breakdown, C. MacLeod

Yep, that’s pretty rough and raw. Back to the point…

Dr. Eau had carefully planned their leave and there was never a time that there was a gap in service, but I think I had to explain my entire trauma story and the current crisis to three different covering docs that year, which happened to be 2019. Of course, covering docs are to be expected sometimes in any physician’s career let alone during a pandemic. I would have just consider these things to be expected bumps along a very new road. And then came the war on doctors. And then the cuts to their billings. And then the cuts to healthcare staff. I’m not the best person to timeline this fuckery, so let’s go to a reputable source: Joe Ceci outlined the whole debacle in a 25-tweet thread. All the deets are there; go check it out.

Dr. Eau returned during the pandemic and was their usual, warm self. And then came what I believe to be the cause of all the difficulties to follow. A move to a micropractice office model. What’s that you ask? 

My opinion of this bridge

“Micropractice, or what some call an ideal medical clinic or medical home, believes primary care is best delivered in the context of a continuous and collaborative doctor – patient relationship, fostering comprehensive and personalised care. In the age of limited health care dollars and increasing clinical demands, meeting these competing agendas is difficult. However, micropractice is one way to bridge this gap. [emphasis and road sign added]. Unlike traditional medical offices, in a micropractice, staff, facilities and equipment are minimised, thereby allowing resources to be directed back to the patient and provider. Further, technology, such as an online scheduler and secure electronic messaging, removes third person disruptions, improves efficiency, access and communication for both parties. Think back to days gone by when a patient and doctor knew each other well. The major difference is the integration of technology and resource prioritisation to increase sustainability and longevity.”

(Source: https://www.willowfamilymedicine.ca/micropractice)

Yeah, I’m going to have to call bullshit on this whole model of medicine. Detailing all the reasons why excluding nurses and administrative staff from the primary healthcare team is harmful to patients isn’t a blog post, it’s a book and I believe it’s already been written by a nurse. To illustrate my point I’m going to simply cite the first relevant academic research article I found:

“In most countries, one of the main reasons for developing and implementing the nurse’s role is to improve access to healthcare, especially in those settings where medical resources are scarce [9]. Another equally important reason for developing nursing nurses’ roles is that this process is critical to further promote the quality of care by providing support to chronic patients through on-site follow-up activities, thereby reducing hospital admissions and readmissions [10].” [the numbers 9 and 10 refer to references in the article, which has 85 references]

Busca, E., Savatteri, A., Calafato, T.L. et al. Barriers and facilitators to the implementation of nurse’s role in primary care settings: an integrative review. BMC Nurs 20, 171 (2021). https://doi.org/10.1186/s12912-021-00696-y

The specific technology that I had experience using was by a company called Health Myself Inc. (Pomelo Health). Health Myself huh? Well, that was how it felt. It was on me to call together a team to get myself through a crisis. I was able to case manage my own care but I have 13 years of university, and 20 years of experience in health and human services, AND I worked directly with the online care planning tools during my stint in continuing care. I also have family and friends in the medical field. So how the actual fuck are people with fewer resources supposed to make it through the gauntlet to get appropriate mental health care? We all know the answer to that. They don’t.

As for Health Myself, the usability is of very low quality in my opinion as a patient user and a person with a Ph.D. thesis entitled: Reducing Informational Barriers to Human Service Utilization through Community Information Websites. The primary finding in my research was that the information needs to be easily accessible in a way that makes sense to the users. The Pomelo portal isn’t user-friendly, in my opinion. Upon entry to the home page, there is a small white text menu with items like About and Contact. Below this in large, bold, white, all-caps-lock text on a navy background screams to the user to choose one of two options: sign in as a new user or book an appointment.

If you think to click on Contact and scroll down to the bottom of the page the physicians’ phone and fax numbers are listed in regular font size (again white text which is not the most readable choice). Easy enough to fumble your way through for most people perhaps. However, for anyone in a crisis whose brain has run straight to fight, flight or flee, the type of complex thinking you need to remember where to find your doctor’s phone number will not be accessible.

I’m going to stick to my own direct experience now if I can. I tend to drift into what my cousin Yvonne dubbed TedTalk mode. So here goes some rather painful sharing. Through an unfortunate combination of circumstances, I was hit by both deep, unresolved grief and a repressed memory of sexual abuse that occurred when I was under 5 years old. The memory surfaced around the 36th anniversary of my Mom’s death. The double whammy completely destabilized me. I couldn’t sleep, could barely eat, and worst of all I lost track of whether or not I had taken my medications and began to miss doses. I was filled with rage. And then just with sadness. And finally hope. Hope that this was the final piece to heal with EMDR. I wrote a short blog about it, which you may want to read. Go ahead, I’ll wait.

When the crisis hit hardest I was home alone with my daughter and trying hard not to scare the hell out of her. I called 911 for a Wellness Check on myself three times: July 23, 24 and 25. On the 25th I was taken to the hospital because I could not sleep and that was getting dangerous as it had been days since I had any sleep and weeks since I had a good sleep. They kept me at Rockyview overnight in an incredibly crowded area where we all had reclining chairs instead of beds. There was a wall on one side of me and a solid divider to my left. I assume it was a domestic violence bed as I had been very clear self-advocating with the first responders that I was not comfortable around men.

Me at Rockyview, morning July 26

The nurses’ station was only a few feet from the ends of the recliners. Single lane traffic only going in and out. The night nurse was kind and warm and I believe her name was Katherine. In the morning I was assessed by a woman whose credentials I wasn’t able to verify. She was slight in stature with an impressive mane of salt-and-pepper hair. I thought she said she was a psychiatrist but after the follow-up call with the outreach team, it seems likely she was an experienced and amazing nurse named Vivienne. They gave me quite a few Ativan on the ride in the ambulance and more through the night so details are a little foggy. Thank you wise woman of whatever healing profession you claim as yours.

I also have nothing but good things to say about the first responders: the women took charge and the men gave me the space I asked for. I don’t have everyone’s name, but I’d like to thank The Power Couple and the 2 male RCMP officers out of Three Hills (July 23), Brittany the RCMP officer and the male EMT from July 24, and Katrina from the ride to Rockyview on the 25th. You guys all rocked it!

So what is my problem you ask? Well 3 different EMT teams told me that the hospital was not a good place for me to be. A woman who has had multiple sexual traumas and is in acute distress, can’t manage her medications independently and needs 24 hr supervision for a few days to ensure hydration, nutrition and medications all happen on schedule. I think it should be the role of a hospital to provide a safe, quiet place for people who have suffered illness or trauma to rest and recover. Our hospitals can not manage that level of service with the current resources, particularly after the UCP gouged the healthcare budget.

I pulled together my own ad-hoc multidisciplinary team of friends and family members and they got me through those few days. But not everyone has a cousin who is a physician and another who is an occupational therapist as well as a local pharmacist willing to make a house call and refill sedatives as permitted by the College of Pharmacists.

Dr. Eau was aware of my mental health condition, that I was suffering severe insomnia and that I was processing trauma with my amazing therapist (hey S). The hospital assured me that my family doctor would get my discharge paperwork the day I left Rockyview. I kind of assumed that my primary care doctor would call to check in on me after a major crisis like this. The first mental health crisis I have had resulting in an ambulance trip to the hospital.

I did not get a call so a few days later on July 29 I went onto the Health Myself system to book an appointment and try to reach them to discuss the sedatives I was taking and the crisis in general. The “Send Message” icon was disabled and there was no visible number to reach the clinic. Of course, if I had not been in crisis, I would have remembered where to find the phone number but that would only have gotten me to Dr. Eau’s voicemail. I opted to make the first booking I could and write a note about the situation in the booking notes, hoping they might see that.

Our appointment was Aug 9 (15 days post-hospital) and I had a feeling I was going to terminate the relationship, however unwise that might seem in a province so desperately short of physicians. But my recovery can’t continue healthily if my primary care physician isn’t part of my recovery team. During our appointment, I voiced my concerns about the micropractice model as well as my disappointment in not hearing from them during the crisis. I wasn’t completely calm, but I held back my frustration and anger. There were no personal attacks or cursey words. At the point they began to read from a script and talk of “a fracturing of the patient-physician relationship”, I interrupted to confirm that I was ending our relationship and I would find another doctor and have my files transferred.

It was a very difficult conversation for me. I was trying to say the practice model failed me and Dr. Eau could offer nothing more than that this is how it is. I ended the conversation with a mixture of thanks for the help you did give and clarity that the new model was actually hurtful to my recovery. I said goodbye and ended the call. The response was swift. I was instantly locked out of the platform and I received a termination letter and a Standard of Practice document within minutes.

“Dear Colleen Macleod,
I am writing to inform you that, due to continued difficulties with our physician-patient relationship, I am giving you notice that I am discharging you from my medical practice for the following reasons:

Verbal abuse during a phone appointment on August 9, 2022

Breakdown of the physician patient relationship due to changes in clinic location/practice model that you dislike

I have attached the College of Physicians and Surgeons of Alberta’s (CPSA) standard of practice on Terminating the Physician-Patient Relationship in Office-Based Settings for your information.
. . .
As per your request and verbal indication that you wish to seek out a new family physician, and in accordance with the policies regarding verbal abuse this termination of the patient-physician relationship is effective immediately.
Kindly inform my office once you have a new family physician, and we will arrange a chart transfer.
Sincerely,”

From my former family physician

Difficulties in the relationship were never discussed prior to August 9. I think I’d remember because being without a physician is a huge trigger for me. I get very scared and worried (as I am now). My views on Dr. Eau’s two points were in disagreement with theirs. I replied to their email:

“Dr. Eau,

I’m afraid I fervently have to disagree with the way you have construed our discussion. I was not verbally abusive. Further, I terminated the relationship, not you. I would appreciate it if you would rescind the letter and replace it with something more accurate. For example, the patient expressed serious concerns about the micro-practice model and terminated the doctor-patient relationship.

Regards,
Colleen”

You can feel the anger and devastation

I don’t think I’m going forward with a complaint. I see no point. Verbal abuse will be a “they said/she said” thing. My physician was doing their best to provide care in the physician-toxic environment created by the UCP. I’m sharing this to add another voice to illustrate how damaging these cuts have been. Perhaps get people thinking about the key piece missing in this wondrous world of micropractice: healthcare workers. You need a trained healthcare professional of some type to monitor these systems and regularly check voicemails at a minimum. It would be far better to have a human answering the phone with the ability to triage the day’s patients and perhaps bump a bunion removal for a patient just discharged from hospital?

In 2015 when I had a mental health crisis, I called my previous physician’s office (hey T!) and spoke to a nurse who quickly recognized I needed to be seen immediately. We were able to manage the crisis with my physician, the nurse, some meds and a booking with AB Mental Health. If this option had been reasonably available to me this time I would not have needed to call 911.

I survived this crisis, but at what cost to the system? I don’t know those numbers but I personally have $885 in EMT and ambulance fees. I have insurance so some of this will be covered, after we pay upfront of course. My heart hurts for others like me who don’t have the personal resources and knowledge to create their own care team and case manage their own care. Or the financial resources to even be able to call 911 for assistance. It is unfair to ask this of persons with mental illness. The healthcare system can and should do better.

Let’s get back the budget money and staff up again. Let’s pay our doctors whatever is competitive to retain the top talent and recruit new physicians. Let’s have a discussion with domestic violence serving organizations about how the hospital can be a safe place for someone in a triggered trauma state. We figured things out pretty well for palliative care. Now let’s tackle trauma.

Blog writing on the deck, after the hospitalization

Deuces ✌️

4 thoughts on “The Doctor Is Never In Or, How Micropractices Fail Patients with Mental Health Challenges”

  1. First of all, proud of you for putting your experiences to paper.
    Trauma is the root of mental distress. Trauma, weither physical or mental needs to be treated with the same urgency. Both are essential to our survival.

    Liked by 1 person

    1. First of all, thank you! Hardest post to publish ever. Secondly, I could not agree more and plan to try and help change that. Finally, thanks for the comment.

      Like

  2. Good luck in your journey, thank you for sharing. As a health care professional I am embarrassed and frustrated for you. I hope you continue to share your experiences and hopefully it will become clear that patient’s needs are not being advocated for by the current system.
    Heal well my friend!

    Liked by 1 person

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