So a few days ago I posted a link on Twitter about a clamp down in Nova Scotia on physicians, who will now not be able to practice exclusively in walkin clinics. I got some profanity laced comments back defending the care provided by walkin clinics. There is a terrific article on the website healthydebate.ca about walkin clinics, outlining some of the pros, some of the cons, and also discussing that there is an awful lot we don’t know about what is or isn’t happening in these clinics. So while I encourage everyone to go and read the article on the website (here is the link-http://healthydebate.ca/2012/08/topic/quality/walk-in-clinic), sometimes a story helps. So this is the story of my Dad, a diagnosis, and a walkin clinic.
Dad was single and retired.(Spoiler alert-was, so you know how this one ends) He decided to move from Toronto to St. Catherines where he could still visit a university library and not have an astronomical cost of living. Like many people who move in Ontario, he kept his family doctor, even though that doctor was now almost 2 hour drive away. Dad liked his doctor, felt he knew him well and also liked having his yearly check up in Toronto, which he would turn into an outing for the day. Dad had no major health issues which needed to be addressed on a frequent basis, was on no medications, never smoked, drank rarely, was not overweight, and was generally a pretty fit guy.
Around the end of August, 2008 Dad began feeling not so well. His apartment was easy walking distance to a large hospital in St. Catherines, but was also close to a walkin clinic, which was about the same distance in the opposite direction. After a week or so of headache, anorexia (lack of appetite) and generally feeling pretty crummy, he headed to the walkin clinic to see if someone could sort out what was wrong. There was no calling his daughter (me, a physician) for advice, no way, wouldn’t want to worry me. For my Dad to go to a doctor meant things had to be pretty bad in terms of the way he was feeling. This was a guy who rided out an episode of chest pain in favour of an outpatient visit to his GP and then a cardiologist. While that time the diagnosis turned out to be heartburn, I was furious when I found out he hadn’t headed straight to an emergency room. Anyway, this time Dad certainly wasn’t feeling up to a four hour round trip to see his regular doctor and hey, maybe it was just the flu, which he had had a bad bout of a year or two before. I don’t know how many visits to the same walkin clinic ensued, but it was quite a few. A CT head was arranged, done and reported on. The CT of his head was normal, but the headache persisted and now Dad’s pants were becoming looser, his energy levels flagging. I called my Dad just after Labour Day with my own news. I was pregnant (again) and having my own issues with severe morning sickness and a new surgical job. We compared notes on our nausea- mine lasted all day, his grew worse as the day went on. But I really didn’t like what my Dad was describing to me in terms of his symptoms and grew increasingly concerned through the course of that conversation and others that followed. I pleaded with him many times over the phone to go to an emergency room which he refused saying- “I think this guy(referring to the walkin clinic doc) is close to putting his finger on whatever is wrong with me.” The problem of course would be there were no booked visits at the walkin clinic. If Dad’s guy wasn’t there he would simply try again a few days later. Another visit to the walkin clinic led to bloodwork and an ultrasound of the kidneys being ordered (but the date he was given for the US was toward the end of October). The bloodwork came back as some degree of renal failure- but my dad either couldn’t remember the number of his creatinine to tell me, or he had never been told. Dad was what we call in medicine a terrible historian, truth be told, so it can’t have been easy to try and figure out what was going on with some pretty vague symptoms.
At this point it was close to my Dad’s birthday at the end of September and I decided to drive down from Oakville and take him out for lunch, trying to hatch a plan to move things in his workup along and see just how bad things looked. He looked awful, clothes hanging off him, even though he had been fine when I had seen him in early August.
Over lunch Dad(who usually cleaned his plate, but today just pushed food around) told me a story about the previous day that made steam come out of my ears. His bloodwork had been repeated by the walkin clinic doc earlier that week and his kidney function had worsened considerably. This explained some of his symptoms, for sure, but the cause of the kidney failure was unknown. A common cause would be an enlarged prostate at his age but the US (still many weeks away) was needed to rule that in or out as a cause of why his kidneys were packing it in at this stage.
The walkin clinic doctor responsibly called my dad in to review the results of his bloodwork, gave him a note and told him to go to the emergency room of the hospital I mentioned. It was a Saturday and the waiting room was empty. He handed in the note which apparently mentioned renal failure and contacting a nephrologist. Dad (who I’m not sure ever used an emergency room in his life)then sat in the waiting room for four hours, while watching people with sore toes and all kinds of minor complaints be led in to be seen by the doctor on duty. He never saw the inside of the emergency room that day, only the waiting room. Dad was told by someone that the emergency room did not arrange for patients to see nephrologists (kidney specialists) but was also not told to just go home. Four long hours later, he gave up and shuffled home, exhausted and frustrated. (Sidenote-If you were working in the emergency room of the St. Catherines General Hospital on the afternoon of Sept 27th, 2008, and had anything to do -or not to do as it turned out- with my Dad that day, your care fell well short of what I would consider the most minimum of standards. While I contacted the ombudsman of your hospital, Dad was too sick to sign papers to allow a proper investigation. And as usual he didn’t want to ruffle anyone’s feathers.)
At the end of his story I lost it, as a daughter, as a physician, and as one angry hormonal pregnant lady. Anybody who got within shouting distance of me got a rant about what had happened (sorry work colleagues). It was Sunday and after a lot of convincing, my dad agreed to let me arrange to have his kidney US urgently done at Oakville Hospital. He drove up for the test 2 days later on a Tuesday. He had had symptoms for over 6 weeks at this point, and had lost almost 20 lbs. I got a call from the radiologist reading the ultrasound -Dad’s kidneys didn’t look blocked, but did appear abnormal, but more concerningly, they had noticed fluid in his chest cavity and had picked up a large mass in his chest. A urgent CT was arranged, along with admission to hospital for dialysis. An over two month admission to hospital followed, with a thoracotomy (big surgery) to diagnose a particularly agresssive type of lymphoma(a blood cancer) which was neuroblastic (yes I had to google it) and normally diagnosed in much younger people. The lymphoma had invaded both kidneys, putting him into renal(kidney) failure and filling his lung cavities up with fluid. Dialysis continued, although the chemotherapy he received did mean his kidneys recovered dramatically. He would be one of the few people who will ever come off hemodialysis without the aid of a transplant. He was able to be discharged home in early December, although he would never be really well again.
My dad died of the lymphoma less than 6 months later, at the age of 70 on Star Wars Day- May 4th, 2009. It was 7 days after my daughter, his third grandchild, was born.
So this raises questions for me about what would have happened? Make no mistake, I don’t really believe the outcome would have been any different for him in the end, but the early journey should not have been that rocky and difficult for everyone involved. Not everyone has a relative who is a physician or healthcare provider ready to step in and navigate the healthcare system when it’s not working properly.
And make no mistake, what happened in my opinion was a SYSTEM problem, not a problem with individuals. The walkin clinic doc was doing the best he could under the circumstances of not really knowing Dad and having very few resources. And for sure the vast majority of people going to walkin clinics do not have extremely rare forms of lymphoma waiting to be diagnosed. BUT….what would have happened if my dad had chosen or been able to find a regular family doc close to him? What if he had driven back to see his regular family doctor, who maybe would have realized more quickly a visit from my dad meant something serious was going on? Would Dad have been treated differently in the emergency room if he hadn’t had a note from the walkin clinic? Or if he had gone to the emergency room first and not the walkin? Did the walkin clinic doc ever learn what had happened to Dad and what the diagnosis ended up being? How many variations of this story are there? Of course there will be no answers to these questions but the debate about the utility of walkin clinics in the care of patients needs to be had. It would be nice to think that had I not chosen to move back to Ontario 6 months before Dad got sick that the healthcare system he paid into as a taxpayer would have been able to sort his problem out without me having to get involved.
We are looking at badly needed reforms to primary care in Ontario, and all aspects of walkin clinics need to be part of that discussion, the good, the bad, and the ugly.