Practicing in Family Medicine
I work with a solo physician in Hamilton who is a part of the Hamilton Family Health Team. The clinic works under a patient rostering model.
Why I was drawn to family medicine
I enjoy the variety of presentations that I see each and every day. There is so many diseases to know about, medications, community resources, and the referral process for specialists. It is challenging to stay up to date the guidelines that are constantly changing.
I really enjoy Orthopaedics, Geriatrics, Gynecology, and Dermatology, and working in family medicine allows daily exposure in all of those areas.
I enjoy the patient relationships and building rapport. Typically, I start out caring for a women in the family, and I end up seeing her children, then her husband (eventually, they are a little slow to go to the doctor’s office), then grandparents, and sometimes even her neighbors and friends. I work really hard to keep them as healthy as possible and prevent disease, which is what I am passionate about.
If a patient already has a chronic disease like diabetes, I provide education about their disease at every visit and schedule frequent visits to ensure the best management possible.
Deniece listening to heart sounds of one of her patients at the her family practice.
My typical day in family medicine
- 9 am to 5:00 PM (or when we are done), where I am seeing patients four days per week.
- I see 20-26 patients per day, approximately 15 minutes per patient, a little longer for physical examinations with pap smears and well baby visits.
- We try to keep at least six same day appointments available for urgent visits so we can provide better access for patients.
- Every day, I chart on patients as I see them (as much as possible), complete forms, review & interpreting diagnostic investigations (x-rays, ultrasounds, EKGs), refill medication requests, review consult notes from specialists, and call patients between seeing patients.
- Monday, Tuesday, Thursday and Friday I work in family medicine. On Wednesday, I was working in an Orthopaedic Surgery Clinic and now will being starting another teaching contract for University of Toronto.
- Currently, I do not having evening hours or weekend hours, although in the US before I came to Canada I did have one evening clinic I staffed each week. In family medicine I do not have to be on call or do hospital rounds on our patients.
Common Visits & Conditions Seen in Family medicine
Many people describe the demographic in family medicine as ‘cradle to grave’, my youngest patient is 2 days old and my oldest patient is 100. We see a wide variety from preventative health care, acute medical problems, mental health concerns, chronic diseases, endocrine disorders (diabetes, thyroid), ENT, MSK, dermatology concerns, and gynecology are very high on the list of common presentations.
Some common visits/concerns in family medicine:
- Well Baby Visits
- Anxiety and Depression (mental health)
- Paps and Annual Physical Exams
- Musculoskeletal (e.g. shoulder pain, back pain, knee pain)
- Dermatological conditions (e.g. rashes, suspicious lesions, psoriasis)
- Cough/Cold/Flu symptoms
- Prenatal Visits up to 28 weeks
- Shortness of Breath
- Hypertension management
- Sleep Problems
- Cardiac patients (CHF, Atrial Fibrillation, post MI)
- Neurologic patients (post stroke, headaches, dementia, neuropathies)
- Geriatrics / Internal Medicine (fatigue, falls, coordination of care, osteoporosis,)
This does not begin to encompass the scope of everything we see since everyday is very different. My scope of practice as a PA reflects my physicians scope of practice. Although, he does provide most of the care for the chronic pain patients working in conjunction with our pharmacist.
Checking the pupil dilation of a child’s eyes during his 4 year well child visit (Photo © Anne Dang, canadianpa.ca)
Deniece utilizing the bell of her stethoscope to ensure there are no unusual heart sounds. (Photo © Anne Dang, canadianpa.ca)
Deniece administering a childhood vaccination. (Photo © Anne Dang, canadianpa.ca)
In one visit Deniece does vaccinations, growth chart, ensuring children meet motor and cognitive milestones for their age and fields concern from parents in addition to providing education on nutrition. (Photo © Anne Dang, canadianpa.ca)
A few of the rare conditions that I have seen include
- Huntington’s Chorea
- Active Tuberculosis
- Ovarian Teratoma
- Active Syphilis
- Pituitary Tumors
- Multiple Sclerosis
- Active Hepatitis C
- Significant plagiocephaly
- Osteogenesis Imperfecta
- Gangrene of the toes
- Charcot-Marie-Tooth disease
- Addison’s Disease
- Bullous Pemphigoid
- Maggots in an infected wound
- Patient having a heart attack in the office
Deniece schedules a block of time in her day to catch up on patient charting, messages, and referrals.
- Patient history, assessment, diagnoses and treatment
- Physical Exams and Paps
- Preventative health (smoking cessation, cancer screening, immunizations, weight management)
- Review Labs and Investigations
- Review consults
- Facilitate referrals
- Phone patients and counsel on results
- Filling out insurance and work forms
- Coordinating Care (specialists, CCAC, long term care facilities,)
- Liasing with other health care providers to coordinate care, in our office dietitians, a pharmacist, mental health counselors
- Assessment and Treatment Plan:
- Prescribing medications and medication renewals
- Physiotherapy, massage, orthotics, chiropody, OT, compression stockings, and other nonoperative modalities
- Referral to specialist/surgeon
In one visit, Deniece address patient concerns, does a lot patient education about COPD, demonstrates use of inhalers, manages blood pressure, and addresses concerns about diabetes. She also does medication reconciliation. (Photo © Anne Dang, canadianpa.ca)
How patients schedule appointments with the PA
When it comes to whether a patient sees the PA or the physician, it really is up to scheduling and patient preference. I tend to work earlier in the day, so if they want an early appointment the patient will schedule with me. The patients can also request a provider, so many times they request to see me. The other factor is that we try to keep them with the same provider if they have already had an initial visit for the same complaint to help with the follow up and coordination of the plan.
Since I provide care for any gynecologic cases and well babies visits those will be booked exclusively with me. For more complex patients I may see them for a couple of visits, then I will schedule their new visit with the physician. I offer same day or next available day, however majority are booked in advanced.
Deniece does about 40 women’s physical and PAPs each month and compliance with cancer screening tests (e.g. pap smears and FOBTs) has gone up! (Photo © Anne Dang, canadianpa.ca)
What should patients expect when they see a PA?
When I enter the patient room I always introduce myself as a Physician Assistant. Sometimes they ask questions about what types of things I can help them with. I let them know the type of patients I see, the fact that we can write prescriptions through delegation from the physician, which is usually is one of their biggest question.
If there is something above my scope of practice, I am able to discuss the case with my physician and we can work together to create a plan for the patient. I function relatively autonomously within established medical directives. Each day, see my own list of patients.
At our practice, the patient can pick, whether based on availability or preference, on whether they’d like to see the MD or the PA. However, not all practices function in the same way when it comes to booking patients with the MD or PA.
Deniece measuring the head circumference against protests (Photo © Anne Dang, canadianpa.ca)
An unhappy patient who was woken up from a nap for my exam. The lungs are working well! (Photo © Anne Dang, canadianpa.ca)
Deniece checking the red reflex in a 15 month old child. (Photo © Anne Dang, canadianpa.ca)
Deniece completing a return to work form for a patient following an injury (Photo © Anne Dang, canadianpa.ca)
My work as a PA in the United States
For my first job in California as a PA, I saw between 20-70 patients per day working in a low-income hispanic speaking clinic. I worked alone in the clinic 4 days a week and with the supervising physician once a week. There were many visits each day for sexual health counselling and screening, birth control, well baby visits, preventative health (pap smears), diabetes management and high blood pressure. I was relatively autonomous starting as a PA, with the physician available by phone. I was in charge of the staff at the clinic.
The second job in California was at a family practice with multiple offices. In our group there were 12 physicians and 9 PAs, and 1 Nurse Practitioner. At my practice location, there were 2 physicians and 3 PAs. I saw between 25-35 patients per day.This clinic was a wonderful place to work where they allowed all the clinicians (MD, PA and NP) to vote on the decisions that impacted the clinicians.
When I first came to Canada, I started at the McMaster StoneChurch Family Health Team. The clinic and physicians were not familiar with PAs. I was happy to introduce them to the role of a physician assistant and explained to staff and the patients what my role in the clinic was. This was a dramatic change from my previous practice where the clinic understood how to use PAs to their fullest potential by having PAs practice at the top of their scope. Orientation at the Canadian FHT involved shadowing, discussing tracking patients, informal discussion with EMR (we used Oscar). I enjoyed having a slower transition into the practice since this was my first job with an actual orientation. I worked part time at this practice while teaching as Assistant Professor at the McMaster PA Program.
After working there for 3 months, they realized what an asset it would be to have a PA full time. I sat on the committee to interview and help the physicians hire a full time physician assistant for our team.
Here Deniece sees a patient for a follow up visit after a trauma crush injury to the finger (Photo © Anne Dang, canadianpa.ca).