Now On Duty for the Vacationing MD: Not!

If your doctor takes a late winter getaway, you had better not get sick. All too often, doctors go away without providing a replacement. An editorial just published in the Canadian Medical Association Journal says your health may be the price of your doctor's time off.  
As an ER physician, I see that all the time.

Every shift I work in the ER, I see patients who come not because they have an emergency but because their doctor is away for anything from a few days to a few months. Sometimes, the patient has a real emergency because their doctor has been away for a month and the patient's health has deteriorated in the interim.  The story that drives me crazy is the patient who comes to the ER because they need a renewal of their prescriptions - especially narcotics. That puts me in the bind of renewing the script so I can move quickly to the next patient or saying no and being perceived as bad actor.

The CMAJ editorial says patients whose doctors are on vacation or extended leave tend to let medical problems slide - hoping they don't get worse before their doctor gets back.  As a result, patients tend to get sicker as problems go untreated.  If the patient seeks medical attention, they doctor they see doesn't know them and doesn't have access to the patient records locked up in the regular doctor's office.  Whoever cares for the patient in the absence of the doctor probably ends up repeating tests that the regular doctor ordered.  That wastes money and time.  Sometimes, the doctor's vacation means that a patient is waiting for the results of a mammogram or a breast biopsy, causing needless anxiety.

As the editorial in CMAJ says, leaving a medical practice unattended is not acceptable. A policy document by the Canadian Medical Association says doctors (should?) "optimize their availability so that patients can be seen and their needs addressed in a timely fashion."  As well, doctors must "ensure that patients have access to after hours and emergency care when they are not personally available." To me, not designating a replacement in their absence seems a clear violation of that.  And, as the editorial states, from a legal standpoint, since being personally available to patients is key to the doctor's role, providing coverage is a requirement. 

In general, provincial colleges say it's not acceptable for the doctor's answering service to tell patients to go to the ER when the doctor is not available.  Still, that sort of thing happens all the time.  I think it's tantamount to abandoning the patient, but I don't see the colleges going after doctors who do that. 

If you think about it, it would be quite easy for the colleges to use robocalling to find out which doctors leave a message telling patients to go to the ER.  But I'd be very surprised if the colleges were that proactive. Chances are, the only way the college would investigate a doctor leaving patients without a replacement is if the patient complains.  In that case, the college has an obligation to investigate. That said, I doubt patients who have difficulty finding a doctor would have the nerve to beef.  And if they did complain, I think they'd have to be injured seriously for the college to go after the doctor

So what are the solutions? If we had a portable electronic health record, then the substitute doctor (or an ER physician like me) would have access to your medical history and it would be easier to care for you in a pinch.  Some believe a provincial call centre could direct you to the right place for care when your doctor isn't around.  In my opinion, a call centre would not work because it would err on the side of caution and direct a disproportionate percentage of callers to substitute physicians at great cost and at the risk of generating needless anxiety.  

The bottom line is that a physician needs to take responsibility for the patient. Doctors have every right to take some time off.  If they don't, then they won't be any good to their patients.  The best solution is for doctors to work in a group practice in which a colleague is always available to step up in his or her absence.  The editorial cites a survey that says that for the eighteen percent of GPs and thirty percent of specialists who work alone, that's going to be a big challenge.

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