White Coat, Black Art

Q&A: Two family doctors on why they needed to cut back

Some family doctors are struggling with huge patient loads, paperwork and the pandemic and have opted to cut back or cut out of medicine altogether.

Physicians say they’re drowning in paperwork, working long hours and missing family time

Dr. Rashmi Bhalla (left) and Dr. Marc Cotran (right) say that as family doctors, they struggled with long hours, unpaid administrative work, and rising patient numbers. (Submitted by Dr. Rashmi Bhalla and Dr. Marc Cotran)

In April, at the age of 45, Dr. Marc Cotran handed in his medical licence and left his family medicine practice in Montreal. 

The patient workload and 16-hour days were too much. 

In London, Ont., Dr. Rashmi Bhalla is still practising as a family doctor. But to have a day off, she's paying for a nurse practitioner out of pocket. 

Across the country, many family doctors are raising the alarm over a health-care system that they say leaves them overworked, underpaid, and burnt out. 

White Coat, Black Art host Dr. Brian Goldman spoke with Cotran and Bhalla about why they chose to cut back and why patients need to know about their workload. Here is part of their conversation. 

The following transcript has been edited for clarity and length.

Q. Marc, can you say more about what it was that made you say 'I cannot do this anymore'?

A. So many problems … The sheer volume of patients. As the number of registrations go up, I felt my stress level increase exponentially.

My ability to provide the kind of care that I learned to give in medical school and in residency, I was just not able to give that level of care to so many patients and yet, still felt the pressure to take on more. And that's for political reasons and other.

The joy of waking up in the morning and going to work just came less and less. The hardest part of my day became just getting that first leg out of bed … knowing that I had this list of patients, list of problems, list of challenges in the system that I was up against. 

And it just, for me, became too much.

Q. At the worst of times, how many hours a day were you working in your practice, Marc? 

A. Sometimes 16 to 18. Not daily, but the next day after a 16 to 18-hour day, my brain doesn't function.

When I was sitting at my desk, it was just a constant barrage of work. There's no breaks … I wouldn't drink in the morning so that I wouldn't have to get up until 6 p.m. and go to the bathroom for the first time.

That's obviously not healthy and there are other ways to build a practice and manage a practice. 

But once it got to that point, it was just a matter of 'how do I get out of this?'

Q. Rashmi, what has your experience been like? 

A. I have a practice of 1,500 patients right now. 

I start my day formally in the office around 9 a.m., but I would say that it really can start as early as 7 a.m. where you start to look at your lab work and that's just all the time. 

The patient volume has gone up in the last few years. I, too, feel obligated to take on more patients.

And then with the new Physician Services Agreement, there are aspirational quotas to require family physicians in that practice model to maybe see around … something like 88 patients a week right now, which may not sound like a lot, but when your patients are complex and each person requires a half an hour appointment because of the complexity of their situation, trying to meet that quota can become quite challenging. 

Q. We've talked about the administrative work, the hours that you've been putting in. What impact has that had on your personal life, Marc? 

A. Definitely had a large impact. 

The way I would think about that is the constant knowledge that there are hundreds of bits of unfinished business that I never felt I could catch up on. It was very, very rare that I would say, 'OK, I'm up to date.'

Dr. Marc Cotran sits with his daughter, Kassaundra. While he has just left his family medicine practice, she is a medical resident. (Submitted by Marc Cotran)

Carrying that around 24/7 had an impact on the way I acted in personal relationships, with my partner, with my children.

Added to that, when I had my home clinic in addition to the Montreal clinic, I would come home from the Montreal clinic, have supper, and then come downstairs and see a few patients at night. 

That meant that I wasn't able to properly spend time with my kids after supper, put them to bed, and really wind down before laying my head on the pillow. 

In the summertime, hearing my kids playing in the pool while I was downstairs, seeing patients or a barbecue happening and I just couldn't be there. 

It's a choice. I could have organised myself differently, but that just built the tension for me to a point where it was untenable. 

Q. Rashmi, was it the same for you? 

A. For me, a little different. At the end of April 2020, my father passed away. He had metastatic prostate cancer. It was unexpected when it happened. 

The result of that is my mom, I'm constantly having to worry about her and care for her now because she's alone and she's 81 years old. That is one extra thing in my day that I'm constantly having to be aware of and worry about.

And when the pandemic started, there was online school. 

You would work your full day and then as a parent, I would come home and start a whole other day all over again … and then still finish the things from my workday in medicine.

Probably like Marc, I was [working until] 11 p.m. or midnight, still trying to sign off on lab work and get through some administrative stuff. I found that very, very challenging. 

Dr. Rashmi Bhalla (left) with her husband and two children. (Submitted by Rashmi Bhalla)

Q. Rashmi, why do you want the public to know what you're going through?

A: I think that the public maybe take it for granted the work that we do.

I don't think that the public really realizes that we are working in a system that is broken, that we're literally duct-taping together, and physicians are trying to make that system work.

And that's why I think it's important for people to hear our stories as physicians, because we, too, are human beings. 

And that sense of despair or feeling overwhelmed or whatever it is that a lot of people feel, we feel it, too. 

Q. Marc, why do you want the public to know what you've been going through? 

A. As family doctors, we're also patients… I think if we really get the public behind us to understand the challenges that we have, I think we can all work together to make a better health-care system. 

I would have loved to wake up in the morning and be excited to go to work and have all of the tools and resources at my disposal to give excellent care, because I think that's what patients deserve.

Edited and produced by Sarah Krymalowski and Stephanie Dubois