Burnout: Some Patients are to Blame

I took a vacation with my family last March Break. It was fun and relaxing. I was in great spirts coming back. But I was already burnt out and angry before my Monday clinic even started.

Entitled and demanding patients kill morale.

Perhaps you’ve heard? There’s a Family Doctor shortage crisis. Over 2 million Ontarians don’t have a family doctor. And it’s only getting worse. Doctors are retiring in droves. And there aren’t enough medical students going into Family Medicine to replace them.

Family Medicine isn’t an attractive specialty these days. Those of us who are practicing burnt out years ago. There a many reasons for this. But I’ll be blunt: a major contributor is some of you patients.

You’d think that those who are fortunate enough to have family doctor would be appreciative. To be clear, most are.

But some patients are inexplicably entitled and demanding. With unrealistic expectations and zero accountability. And this minority of patients is burning out doctors and our staff.

Allow me to illustrate.

My patients don’t realize how good they’ve got it

I’m going to brag a bit here.

My patients are spoiled, relatively speaking.

Never mind just having a family doctor in this era of doctor shortages. My patients are fortunate enough to be part of one of the most outstanding clinics in the province.

My practice is exceptional. Innovative. My team and I provide superior accessibility, unmatched by anywhere else in the province. My quality of care often exceeds local and provincial metrics, despite practicing in an area with some of the lowest social determinants of health.

  • For those who need seen in person, I am generally in the office seeing patients every day of the work week, Monday to Friday.
  • I offer “Same Day / Next Day” booking. This means patients who contact me for an appointment get seen that very same day. In the rare case when my day has filled up, the patient is offered an appointment with me the very next day. (Of course, if the concern is not urgent, patients can prebook at a later date too).
  • My clinic is equipped to communicate with patients via email and secure messaging. (I’m often monitoring and addressing concerns in the evenings and on weekends).
  • My patients can submit their concerns online via my website, which offers efficiency and includes self-management education.
  • My staff and I respond to nearly all questions and requests the very same day, often instantly or with in a couple of hours. This includes prescription renewals, forms, or any general questions.
  • I leverage technology that allows for population health recalls and notices. Patients’ investigations and preventative care are automatically kept up to date.
  • Our group provides After-Hours Clinics every night of the week (Monday through Thursday) as well as Saturday mornings. Patients can walk-in for urgent concerns. No prebooking appointments required.
  • Our group of physicians covers each other with a “Doc of Day” system when one of us is away. Even if I’m away, there is a doctor assigned to cover all the questions, prescription renewals, and results that come in. Again, that very same day.

My patients don’t realize that this is not common practice.

I know many other Family Doctors and clinics across the province where patients have to wait weeks for an appointment. They wait days for a reply to a question or prescription renewal request. They wait weeks for a form to get done. And if the doctor takes a holiday, there’s no one else covering. So they they must wait an additional week for any sort of reply.

I illustrate all of this to provide the background context in which some of my patients are still not satisfied.

Within 48 hours of my return from vacation:

I returned from my vacation on a Friday, calm and well. Over the weekend, I caught up on my work.

I’m reviewing the notes and messages that transpired while I was away and come across some provoking incidents.

Patient upset by having too many options for an appointment?

A patient called in the Thursday of March Break while I was away on vacation. She had a concern about a non-urgent issue.

Keep in mind three things here:

  • The background context of superior accessibility to care that my patients have, as described above.
  • This was my first week off for vacation in several months.
  • It was Thursday, I would be back in clinic the following Monday ready to see patients again.

My staff explained to her that Dr. Stewart was currently away on vacation.

  • The staff offered her the option of our After-Hours Clinic that very same night. She declined.
  • My staff offered her the option of our upcoming Saturday morning After-Hours Clinic. She declined.
  • My staff offered her the option of booking to see me on Monday when I returned (notably, that was just 2 business days later). She declined that as well.

Instead, the patient got upset and exclaimed, “I will look for a doctor that actually sees patients!”

What a nice, heart-warming, note of events to come home to after vacation. [/sarcasm]. What more could she have expected? That I fly right back from vacation and see him that very morning?

What’s more, in the couple months leading up to this encounter, I had already indeed seen the patient in person for this same concern. We’d also coincidentally also done routine prescription renewals, and thereafter followed her blood pressure and bloodwork along for a couple of weeks.

So, I’m now irritated that she was irritated.

People upset they cannot book déjà vu appointments for the exact same advice?

One of the reasons I am able to offer my patients exceptional accessibility is because I practice very efficiently. I am pragmatic. I see people in person who truly need to be seen in person. But over half the time, patients’ concerns do not necessarily need seen in person. Many can be managed via phone call, or email, or relaying advice via staff.

Related: see this video explaining my innovative approach.

So, let’s say you have a sore shoulder. I examine you in person, confidently diagnosis you with a rotator cuff strain, and give you this advice:

If you call back in 3 weeks, demanding to book another in person visit with me for the same sore shoulder.

Before I book you, I’m going to ask, “Have you followed the advice already given, including physiotherapy?”

And if your reply is that you have NOT yet read my advice nor tried physiotherapy. Then you don’t get to take up another in person visit appointment with me! Sorry, that appointment spot needs to go to someone else who truly needs examined in person.

My advice remains the same as it was three weeks ago. Refer to above same advice …

And yet, I return after vacation to multiple messages and complaints to this sort of thing where patients are getting upset because I won’t book them in person (yet again) to give the exact same advice I’ve already given.

Patient who seemingly wanted a second opinion for the same advice?

Similar story. A person I’d seen a couple months prior. I diagnosed with tendonitis. Recommended all the standard options of rest, ice, voltaren topical gel, anti-inflammatories, gave handouts for stretches, and see a physiotherapist. Notably, this patient had coverage for physiotherapy, so I equipped him with a self-referral letter.

While I was away on vacation, he presented to one of our After-Hours Clinics and saw one of my colleagues – for the exact same issue.

Notably he hadn’t tried any of the exercises I had recommended. Nor had he tried physiotherapy.

Guess what my colleague’s advice was. The very exact same as I’d already given two months prior: see a physiotherapist!

It’s worth noting that our group of physicians has an internal agreement where we pay each other $25 each per visit for seeing each other’s patients. It keeps things fair. Point is, I now had to pay may colleague to give the exact same advice that I’d already given.

All we’re please asking for is an ounce of accountability here, people.

Back to clinic on the Monday:

So, I’m already frustrated and angry before I start my first day back in clinic. I arrive in clinic Monday morning to encounter more provocation.

A patient who wanted an MRI, then didn’t:

There are innumerable examples of this type of thing, but here is one I encounter Monday morning.

Before I left on vacation, I saw a patient for a concern. I ordered an MRI. Now, an ultrasound may have sufficed for this concern, but the patient declined an ultrasound and requested an MRI. Again, this was the week before I left on vacation.

I don’t think patients appreciate the amount of work, time, and staff resources it takes to actually order investigations. It’s a tonne of paperwork and time. Not just in our clinic, but on the hospital’s receiving end as well. Suffice to say, it’s more than you realize.

Anyway, the Monday morning I return, I receive notification from the hospital that when they contacted the patient to book the MRI, the patient declined. Not just declined a particular appointment. The patient now declined wanting the MRI at all (!?).

Again, this type of thing is far too common. Patients requesting tests and referrals, and then later declining or missing the appointment. What a waste of valuable doctor and staff time this all amounts to.

A patient who needed the exact precise appointment time he demanded:

A patient called in for an appointment. I reviewed the chart. It was a concern for which I’d already seen the patient multiple times in the last six years.

You’ll recall my exceptional accessibility options from above.

  • She was offered same day appointment with me. Declined.
  • After-Hours Clinic that night. Declined.
  • Offered could prebook into one of my own After-Hours clinics in the coming weeks. Declined.
  • Prebook with me a later date, for which there were multiple options in the coming weeks. Nope. Declined.

This patient needed precisely three weeks later, on the Tuesday, at 11:30 am.

Well, I’m sorry, that wasn’t an available option.

What followed was a lengthy phone call consuming my staff’s time who needed to soothe and console that patient because that precise date and time was not available as an option.

And this type of occurrence isn’t isolated to just this example. These types of complaints happen all the time. Patients rigidly requesting very specific times for appointments that aren’t available. (Can you really call it a ‘complaint’, if it’s unrealistically absurd, though?)

I’m not exactly sure what else you’re looking for here?

I saw a woman with an acute shoulder injury. The exact diagnosis was not clear, so I ordered an x-ray and ultrasound to rule out things like a fracture or a complete muscle tear.

The results came back and fortunately everything looked good except she had a partial tear in one of his rotator cuff tear muscles.

I relayed the advice to continue the standard plan of rest, ice, and advil as needed. But I also strongly recommend physiotherapy. I explained that even with partial rotator cuff tears, surgery is rarely ever suggested nor required. And things improve with physio.

Her unsatisfied response was, “Well how is physio going to repair a tear!?”

We explained that physio doesn’t directly ‘repair’ the tear. Rather, physiotherapy helps to condition the muscle and the supporting muscles while the body heals itself.

Still, given his apparent discontent, I went ahead and referred her to an Orthopedic Surgeon Specialist as well.

When the staff told her I had referred her to the specialist as well, she got further upset. She exclaimed that, “I will not have surgery! Surgery is not an option!”

Okay, I’m confused. How else can I specifically help you here? Because I’m feeling like I’ve just exhausted the spectrum of options here.

That’s my medical advice. Take it, or leave it:

I was seeing a colleague’s patient in the After-Hours Clinic. He had a concern that requires an urgent ultrasound.

It was late in the evening. He was well and stable. Naturally, he didn’t want to have to go through the busy ER and wait hours for an ultrasound.

Fortunately, our local hospital has a protocol by which patients can get an urgent ultrasound in these situations. I advised him of the plan. I will order the urgent ultrasound, and he is to go to the hospital the next morning where he can get her ultrasound.

He was hesitant and noncommittal. Lots of reasons why this was inconvenient. He had already planned things to do the next day. He didn’t like the parking at the hospital. And so forth.

To be clear, this was a medical urgency. Maybe not an emergency, but definitely merits an urgent ultrasound. I advised her of such.

The next morning, my staff called him to reiterate the plan and coordinate the urgent ultrasound. Still the same hesitations. He preferred a different time than being offered. This required my staff even more back and forth phone calls and discussions, including involving me in the messages.

I ended up having to close off the time-consuming discussions. “This is my clear medical advice. Get your ultrasound this morning as we’ve arranged. Take it, or leave it.”

Look, I appreciate our crumbling medical system is not perfect. But please. If you come to me for medical advice, please accept it or not. Let’s not waste each other’s time haggling over non-options. I promise you, I’m not withholding the ‘magic, perfect solution’, only to be offered after you re-ask ten times…

Other countless examples:

These were just some of the cases upon my immediate return from a (evidently temporarily) relaxing vacation.

Here are few others that followed in the following days.

I’m sorry I don’t make the CRA’s rules:

A woman wanted me to complete a Disability Tax Credit application.

This is a common request. Many financial and tax services will suggest patients get their doctor to complete this form for them. Unfortunately, though, many people are not actually eligible.

The Disability Tax Credit has very strict criteria. It’s not just enough to have a “disability”. One has to be severely affected as explained in their explicit criteria.

Regrettably, it was this patient did not meet the strict criteria. I had to explain this to her. I clarified, as I always do in these situations, that I would love to be able to be her advocate, but that but the government monitors physicians very strictly on these forms and continually warns they cannot be fraudulent in completing these forms. I wrote it out clearly and directed her to review the CRA’s website too.

What followed was a series of repeated angry protests and insults form this patient. That I was not a qualified doctor. That I was biased. That I was abusing my power. That I was on a power trip.

Upon receiving her email, I called the patient. I pointed out that I found his email disrespectful. I spent time re-explaining things. I understand his frustration. I wish I could help, but she clearly does not meet the CRA’s strict criteria here. I again urged her to review the CRA’s website herself. After the phone call, I again emailed her the direct link to the CRA’s website.

It didn’t end there, though.

The next day, I received another email reply from her: “… Thanks for the B.S., doctor …” and further protests that he still felt she qualified.

No amount of facts and effort were going to penetrate this patient’s fixed misunderstanding.

Patient misses appointments then get upset that we’re upset:

Missed appointments are an enormous burden on our medical system. Not just with family doctors, but with specialists and tests too.

Every time a patient misses a Family Doctor appointment, it costs the medical system $35-$65 in inefficiency. And causes further backlog.

Certainly, people miss appointments for valid, exceptional reasons. But more often, it’s completely avoidable.

Therefore, when there is no valid reason for a missed appointment, I must charge a fee to the patient (as do most doctors and specialists across the nation). It’s less about the money, and more about holding patients accountable. Those wasted appointment spots could have been used by other patients in need.

Here’s just one example to illustrate what we deal with.

A patient was scheduled for a routine visit. Had remembered to get her bloodwork done the week prior.

The day of her appointment with me, she didn’t show up. Later, my staff called her. Her reason for missing the appointment: She simply forgot.

She was charged a fee accordingly.

When she came in for her rescheduled visit (the very next day, nonetheless. Talk about convenience and accessibility), she was angry and protesting and refused to pay the fee.

No apologies for missing the appointment. No accountability. No gratitude for still seeing him the very next day. Just angry at us for charging the fee.

Entitlement much?

I’m sorry, but you need to actually have a reason to see the doctor:

A woman called in to book an appointment to see me. The staff asked for the reason.

“To go over her recent bloodwork.”

I reviewed the chart. The bloodwork in question was actually ordered by her specialist.

Furthermore, she was actively being followed by the specialist for her concerns. In fact, there was a recent consult note from the specialist just two months prior. And the plan from that last specialist note was to see her again in follow up in two months.

Accordingly, I relayed the advice that:

  • Her bloodwork was normal.
  • It was the specialist who ordered the bloodwork, so it is the specialist she should be asking anyway.
  • Per the specialist’s last note, she was due to follow-up with her any time now anyway.
  • Given all this, it seems she doesn’t actually need an in person appointment with me right now.
  • She should follow up with the specialist and then get back to me if still concerns.

I was very thorough and explicit with respect to the rationale here:

  • I sent her a link to the video I made explaining why in person visits are not always required.
  • In that email, I wrote, “Having said all this, how specifically does an IN PERSON visit with ME help you? What more are you hoping for or expecting on this matter? I ask this sincerely so I can better understand your concerns and expectations.

What followed was series of passive-aggressive, non-constructive emails and calls from this patient.

Thereafter, I personally called her to address his behaviour and to further clarify his specific concerns. She didn’t answer. I left a voicemail explaining my concern and that I’d like to connect. She never called me back. Instead, she called my reception staff and relayed even more passive-aggressive retaliations.

Here’s the kicker to all of this: turns out she already had an appointment to see the specialist that very same day!

A few bad apples ruin the bunch

These are just some examples that I was able to recently capture. I assure you, Family Doctors across the province face countless similar incidents, each and every day.

I’d like to acknowledge that the vast majority of patients are appreciative of their medical care. Many are emphatically thankful. At least 95% are at least respectful and civil.

But this vocal minority of entitled patients is killing morale. Because unfortunately, the perception of negativity always overshadows positivity.

It wears us down.

Many factors that have contributed to doctors and staff burn out.

But allow me to be blunt: part of the problem is due to patient entitlement and lack of accountability.

– by Dr. Adam Stewart

Family Physician

May 28, 2023