Everything under one roof

 I once worked rotated through a family medicine clinic that had a social worker, a psychotherapist, a clinical pharmacist, an occupational therapist, and a physiotherapist all under one roof. Because that was one of my first exposures to family medicine I took it for granted that that is what all clinics would be like, and what all patients would have access to. How naïve I was. 

Your average family physician is probably in solo clinics (just them and the admin staff), or maybe shares an office with a few other physicians. The privilege of multiple allied health professionals under one roof is a rare one, particularly here on the rock, I've noticed. I'm lucky to get a hold of someone to help with an in-clinic biopsy and suturing, let alone the family physician nurses and assistants that I once had access to as a learner. 

It is not an outrageous claim to say that patient health can only be improved by having multiple services under one roof. Think of it: you go see your family doctor, they say I think you can benefit from some counselling. Instead of waiting multiple weeks-months of waiting for counselling referrals through the local health authority or paying/being lucky enough to have insurance that covers private counselling but still needing to find a counsellor, they say go down the hall. There's a therapist who has access to my notes. 

While some may argue that patients can and should take some responsibility for their care such as finding their own physiotherapist or counsellor that suits them or booking a pharmacist consultation, isn't it just better to take that middle step out? Of course, everyone should have the option of going outside of the clinic, but I haven't heard too many people complain there are too FEW barriers in healthcare. Moreover, this kind of setup is exponentially more beneficial for the most vulnerable of our society. Do I tell a patient who can't afford the bus pass to get to clinic that they need to now go across town to the free counselling clinic with drop-in hours? What if I can tell them that there is a counsellor on-site? What about my patient who isn't suicidal enough (I've made a whole post on this but our mental health system is just sick care, it's not preventative care) to qualify for urgent services but who can really go for some qualified therapy that I don't have the time/ability to provide? Wouldn't it be nice to have that MH counsellor present? 

I was lucky enough to encounter such a multidisciplinary clinic again, although in a much different setting from the upper-middle-class-suburban/countryside-wanted-to-get-out-of-the-city area I once trained in. Downtown inner city, attached to an emergency overnight shelter and free meals. It required an amount of flexibility and "cowboy medicine" that I needed in remote rural work, too. One day a patient pulled an axe on the staff. Another day I crouched outside in the yard, acutely aware of 20 something people gathering around to listen, whilst I tried to convince a patient into a waiting ambulance. Some days I went to the kitchen begging for oil to dissolve earwax because the patient can't afford a $18 bottle of olive oil or a $50 ear syringing kit. Other days I commandeered a lounge to observe an at risk patient who refused ER transfer. I helped people get new mattresses, apply for bus passes, begged for extra patience from specialists and imaging departments when patients couldn't make it to the appointments. "I'm sorry but their social circumstances are extremely complex" x endless. What I really wanted to say was "Look b'y, their house was robbed the day before the appointment, they had bigger things to worry about." "No they can't make an x-ray across town in 20 mins because I can't give a taxi slip for this and the busses don't run that fast." 

But that's a detour for another day. The great thing about this clinic is the collaborative practice. Not only did the 3 nurses onsite act as everything from patient screener to wound care to emotional support, we had amazing social workers who doubled as counsellors. Case managers who could help get patients into a shelter or guide them through disability applications and housing and mental health top-ups and a hundred other things that I swear I've never heard of but wish I could have recommended and supplied to patients. Foot care specialists kept diabetic foot ulcers from springing up, or fungal nail growths (how is antifungal nail polish so %*^# expensive??) from exploding out of hand (or foot!). We kept running lists for when optometry clinics would pop-up. 

There were no average days at this clinic, and the only thing I could be sure of is that sooner or later I would be calling for the case managers or knocking on the door of the foot care clinic or texting the social workers. It felt very reassuring to know that I had these professionals backing me up - and I hope they also felt reassured by me being their healthcare backup! On a given morning I might start by taping closed some cuts a patient sustained during a fistfight just outside, then sit down with a case manager to discuss how a patient could qualify for more benefits. We talk about their encounters with the patient - much different from the usually more formal and directed medical appointments - compared to my clinical encounters and compare notes (literally on the EMR). They give context to the patient's life outside of medicine and I use that with their medical background to make a plea for solo housing support, for extra income benefits, for travel expense coverage. It might only be a few hours later before I call them urgently for a patient who has presented in a social crisis without stable housing or even knowing where their next meal is coming from. I swear it's almost magic how the case managers get the patient a hot meal, food to go home with, extra shoes, a shelter for the night, and a plan to get more permanent housing. All I had to offer was some medication and counselling for depression that stemmed from their situation - which they couldn't afford anyways until the case managers got them set up on the provincial medical support plan. 

I don't think there was a single day when I didn't page the social workers for one reason or another. Especially in the stresses of COVID, who didn't need counselling sessions? Time and again I called them and they called me. 

Me:

"There's a patient here who I've seen for diabetes but has some serious anxiety and isn't interested in medications, but wants to try counselling, can you see them?"

"There isn't a diagnosis yet but this patient has a lot of situational stress and wants to just talk to someone about it, are you available?"

"A patient has suicidal ideations, we need MH crisis services, please come back me up/help."

Or most commonly: "Help please!" 

SW:

"We're seeing someone for counselling who's expressing possible delusions and/or hallucinations, can you fit them in?"

"Someone who's here for social support is very depressed and interested in meds, bringing them over [to the medical clinic]". 

"Can you form/place someone under involuntary psychiatric hold for this?" 

It just always felt like a friendly environment. I could take a patient from the SWs and know that they can help me in turn. The case managers bailed me out more times than I can count for social and situational problems and I will dig through charts and write documents for them. Although I guess the more accurate thing is to say we were all helping each other and working together for the benefit of the patients, for the ultimate goal of providing them cohesive and comprehensive care. 

So why can't we have this everywhere? Why did I end up sending patients from regular family practices to this downtown institution just so they can get counselling and housing support? Why can't I go to the friendly next-door clinical pharmacist that we have in hospitals and consult them for maximizing diabetic therapies? Can I please have wound care specialists always close by so we can catch every early diabetic ulcer? Please? Please please please please please?