Diary from a Week in Practice
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Am Fam Physician. 1998 Feb 1;57(3):454-455.
Not one of us has been in practice for more than a week before we've heard the words, “Oh, by the way . . .” One of the benefits of family practice, however, is the fact that we also, as physicians, get the opportunity to turn the tables sometimes and utter, “Oh, by the way . . .” Today was such a day. One of JRH's patients was in the office for the treatment of a cold. After discussing treatment, JRH could not contain his curiosity any longer. “What's the cast for?” he inquired. “Got in a car wreck last week,” the patient replied. “What happened?” JRH asked. “I broke this bone right here” (motioning to the 5th metacarpal). Because JRH had been taught that this type of fracture was a boxer's fracture until proven otherwise, he plied his patient for more details. It seems that when this man's car hit an oncoming car, the air bag deployed and immediately blasted his hands off the steering wheel. The left hand was blown into the metal of the driver's side door, fracturing the bone in the process. JRH expressed his amazement, but then was even further amazed to see the abrasions on his forearms that were caused by the rapid inflation of the air bag. And, just like his patients, JRH was not sorry that he had paused to say “Oh, by the way . . .”
Today, a 56-year-old man presented for follow-up of his new-onset diabetes mellitus. At his complete physical one month earlier, he told SEF, “Doc, I just don't feel good.” He was unable to delineate this more, but SEF thought she found the problem when she checked his screening laboratory report. His fasting glucose was 240 mg per dL. After four weeks of following a new diet and exercise program, and of taking Glucophage, he returned saying, “Doc, I feel so much better now. Thanks!” Now his fasting glucose was 140 mg per dL, and his weight was down 2 lb. In the age of more and more regulation on physicians' orders for laboratory work, how do we handle situations in which the diagnosis becomes clear only after the test results are known?
In the “old days,” before becoming the parent of twin daughters, TBS often found some parents' explanations of their child's injury unbelievable and actually was somewhat judgmental, thinking to herself that they obviously had not been watching their child carefully. Now, with two small toddlers, TBS realizes that it is just not humanly possible to watch a child every second, and even if you do, they somehow find something to get into, no matter how “childproof” your home is. For example, this morning, before leaving for work, TBS was with the two girls in their room. While changing Sarah's diaper, she heard a “crunch” sound from behind. She turned, and Amber was sitting quietly on the floor chewing on something. Putting half-clothed Sarah down, TBS looked into Amber's mouth to find that she had bitten into a mini-light bulb from the Christmas tree which had been taken down some time ago. Luckily, the fragments of plastic were removed without difficulty, and no injuries occurred. TBS has decided that some days Medicine is easier than Motherhood.
WLL loves searching out medical tips and information on the Internet, but he has learned to accept any information with a “grain of salt” until he can independently verify it with additional sources. The Web sites can be incorrect and/or incomplete. His concern was recently quantified by an article published in the June 28, 1997, issue of BMJ (p. 1875). In this study, the authors compared published guidelines for the treatment of children with fever with the advice given at 41 different Web sites providing medical advice. Only four of the sites mentioned the published guidelines. Only one half of the sites mentioned sponging and, of these, only six mentioned giving an antipyretic first. Several sites advised the potentially dangerous use of cold water or alcohol sponging for fever. Only three fourths of the sites mentioned acetaminophen and, of these, only one fourth mentioned instructions for administering acetaminophen.
All of us have favorite patients who grace us with their presence when they come to our offices for care. Today brought one such patient to JRH for management of her severe anemia. While they were discussing the next steps in her therapy, she couldn't help but exclaim how happy she was with her new intraocular lenses. JRH thought she was justified in her enthusiasm, since the operation had been held up for such a long time (until her hematocrit level could increase to about 30 percent). This waiting surely made the experience of re-experiencing the brilliant color and the majestic hues of the world all the more thrilling. JRH allowed her this moment of exuberance, and then she digressed a bit, saying, “Dr. John, before my IOL, I thought you were old, but now I see how young you are!” With remarks like this, is there any wonder why she is one of JRH's favorite patients?
It was with a heavy heart that JRL decided to move back to California after his father was recently diagnosed with cancer. JRL's father, who is a vascular surgeon, had been examining a patient's lymph nodes and coincidentally felt his own cervical lymph nodes and found a lump. Findings on subsequent palpation and needle biopsy proved inconclusive, and open biopsy ruled out Hodgkin's lymphoma. It turned out to be a very rare origin spindle cell sarcoma. According to the results of an Internet search, only 18 of these cases are known in the world. JRL's heart was drawn back to California. He recognizes that, greater than any particular location of practice, family is a big factor in the practice of family medicine.
This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Theresa B. Shupe, M.D., and Stephanie E. Frisbie, M.D., four family physicians in private practice in Kissimmee, Fla.
Copyright © 1998 by the American Academy of Family Physicians.
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