Diary from a Week in Practice
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Am Fam Physician. 1998 Feb 15;57(4):663-664.
We are doing more and more procedures in our office that once were done exclusively in the emergency department, hospital or outpatient surgery center. Today, JRH saw a longtime patient of his who had suddenly experienced shortness of breath two months after coronary artery bypass surgery. After a differential diagnosis that included congestive heart failure, angina, asthma and hypersensitivity pneumonitis was considered, a chest x-ray revealed the problem (which could have been deduced by more careful physical examination including percussion, pectoriloquy and assiduous auscultation): left-sided pleural effusion. The effusion was so extensive that it was easy to select an entry point for thoracentesis on the left posterior axillary line just above the ninth rib. Soon JRH was able to remove about 3,000 mL of serosanguineous fluid, which was sent for analysis. Although cancer was a fear of both the patient and the physician, they were hopeful that the cause would be benign. JRH was pleased to find out that the patient's anxiety level was diminished to a great degree when he learned that the thoracentesis could be done in our office. Here, he was familiar with the staff and the office environment, in addition to his own physician. We think this makes more sense. (Maybe some day Medicare will, too.)
One of the joys of group medicine is that we constantly learn from each other. You may recall the Diary entry in the August 1997 issue of AFP, in which WLL discussed the use of decongestant nasal spray for the treatment of postcoital headaches. JSR first heard of the decongestant nasal spray trick by reading this column. Anyway, today JSR saw in follow-up a patient in his mid-40s who three weeks earlier had presented with classic symptoms of recurrent postcoital headaches. After a discussion of treatment options, he chose to try using the nasal spray before having sexual intercourse. Now, on his follow-up visit, he was all smiles with our new-found “cure.” “I have had this problem for years, and this is the first treatment that helped,” he stated.
TBS has always worked with patients and staff to clarify medical terminology and help patients to understand anatomy, at least in basic terms. This morning as she headed for the next examination room, her nurse jokingly told TBS that she had not made a mistake but had written down the chief complaint exactly as the patient had given it to her. TBS realized that she had her work cut out for her when she read the chief complaint of the elderly gentleman in the examining room: “Pain in his left tentacle!”
Today, a 40-year-old female patient presented to SEF with worsening bilateral hip pain. She had previously been diagnosed with osteoarthritis and had not had much relief with any medical treatment. SEF decided to try a steroid injection to see if this would help. With JRH's supervision, SEF injected 1 mL of triamcinolone, 4 mL of xylocaine and 5 mL of bupivacaine into each hip joint using a lateral approach. The patient seemed to tolerate these procedures very well, but when SEF reentered the room to discuss follow-up, the patient was crying. Thinking that the injections were quite painful, SEF tried to comfort her, stating that she could try other options. The patient said, “No, Doc, you don't understand. I'm crying because this is the first time in several years that I haven't had constant pain!” SEF did remind her that in five or six hours, when the bupivacaine wore off, she may not be quite as happy, but the steroid should give relief in a few days. The patient walked down the hall for the first time without limping, tissue in hand and smiling.
We enjoy the opportunity to share problem solving with our patients. On this day, JRH saw a young girl with pharyngitis whose mother was at her wits' end because her little girl was unable or unwilling to take any fluids by mouth. Her antibiotics could be given by intramuscular injection, but when it came to prescribing something for her intractable cough, clearly an impasse had arrived. When JRH asked if there was anything that she would take, the mom said that the daughter would suck on a popsicle. Mom went further to say that she had even made Pedialyte popsicles, and these go down fine. “Dr. John, do you think I could then mix the codeine-fortified cough syrup into my popsicles? Do you think that might work?” asked the mom. “I don't see why not. Why don't you give it a try?” was JRH's reply. It is this sort of mutual problem solving that we have come to enjoy, and clearly our patients enjoy it, too.
When JRH and WLL started out in practice, they shared a vision of practicing together for life—sort of a professional marriage. How times have changed! It seems to be increasingly uncommon for physicians to stay in one practice for their careers. When TBS joined the practice and subsequently, during her pregnancy, developed complications requiring bed rest, we had two female family physicians step in to help. Neither was able to stay. Then followed RWP, who after a season with us felt called to another practice environment. We thought that when JRL and SEF joined the practice we would be working with them for life. However, JRL's family situation was such that he had to return to California. Each of these physicians has shared part of their soul and spirit with us. Now, WLL, JRH, TBS and SEF welcome two recent family practice residency graduates to our practice. JSR (J. Scott Ries) is a graduate of the Indiana University School of Medicine. CAG (Chad A. Griffin) graduated from the University of Tennessee, Memphis, College of Medicine. We are delighted to be associated with these young family physicians and their families. Their recounting of their learning experiences in the “real world” will remind experienced family physicians of those first baby steps we each must take in our practice lives.
This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Theresa B. Shupe, M.D., Stephanie E. Frisbie, M.D., J. Scott Ries, M.D., and Chad A. Griffin, M.D., six family physicians in private practice in Kissimmee, Fla.
Copyright © 1998 by the American Academy of Family Physicians.
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