Diary from a Week in Practice
Am Fam Physician. 1998 Aug 1;58(2):379-380.
It is always odd for a physician to be on the receiving end as the patient, but SEF has discovered that this experience gives physicians a new level of authority, especially when dealing with issues of maternity care or children's care. SEF is now pregnant for the first time and has made it through her first trimester with all of its accompanying discomforts. Today, she did a maternity care examination on a 21-year-old woman who was having problems with nausea and vomiting. SEF has certainly given advice on this subject before, but adding personal experience to the advice contributed so much to the encounter. The patient felt more comfortable trying the new techniques, and the patient-physician bond was forged—perhaps more deeply—as cotravelers along this wonderful section of the road of life.
Every family physician develops areas of special interest within the context of family medicine. We have encouraged this practice not only for our own continuing satisfaction, but also for the good of our practice. We feel it allows our group to practice full-service family medicine to an ever-increasing degree. Today, JRH saw one of our staff members for bursitis in her shoulder. Glancing at the patient's hands, JRH noted how dry one hand was, compared with the other. He then examined her feet, which showed a similar picture, so a KOH prep was collected. The slide confirmed a fungal etiology, probably Trichophyton rubrum. Because we don't see this classic “two-foot, one-hand syndrome” often, JRH took advantage of the occasion to share the diagnosis with his colleagues. This experience was just another example of how we, as family physicians, wear many hats. For JRH, his dermatology hat is never far away.
A young woman presented to TBS to discuss a facial lesion that seemed to be changing. She was accompanied by her two-year-old daughter. As TBS often does, she asked the young girl why her mom had come to the doctor today. The young girl smiled and pointed to the lesion on her mom's right cheek and happily noted that her mom had a “mold” on her face.
Have you been keeping up with all of the literature questioning the use of antibiotics in otitis media? For some time, WLL has been trying to avoid using oral antibotics in previously healthy children older than three months who have symptoms of otitis media, are non-toxic and have no or low-grade fever. He applies Auralgan otic solution to the affected ear for pain relief (lasts up to 30 minutes) and at the same time gives a full dose of acetaminophen (15 mg per kg). Then, he has the parent give ibuprofen (5 mg per kg) two hours later. If needed, the parent can give the child acetaminophen (10 to 15 mg per kg per dose) alternating with ibuprofen (5 mg per kg per dose) every two hours during waking hours for one or two days. He rechecks these kids at two to three weeks. If the fever persists more than 48 to 72 hours or cannot be controlled or if the child is getting sicker, he'll consider antibiotic treatment. Surprisingly, moms seem happy to avoid the cost and exposure of antibiotics. Those of us who are older than 40 remember the days when physicians could alternate aspirin and acetaminophen (in full doses) every two hours. WLL has substituted ibuprofen (in lower doses) for aspirin in this regimen for over 10 years. There are no studies that we are aware of in the medical literature on this approach. By the way, the Auralgan/acetaminophen protocol was reviewed in the July 1997 issue of the Archives of Pediatrics and Adolescent Medicine (p. 675).
It is often surprising to see what pleases patients most about the care we provide. CAG admitted a patient with worsening respiratory distress secondary to asthma and a sinus infection that had not responded to outpatient steroids, inhalers and antibiotics. A computed tomographic scan showed complete opacification of her right sinuses and fluid in her left sinuses as well. She was placed on intravenous steroids and antibiotics, nebulizers and high-dose aqueous nasal steroids in the head-down position. Her breathing improved, and she was sent home after a couple of days. At the one-week follow-up visit, the patient could hardly contain her excitement. Thinking that she was happy to be breathing easily again, CAG asked how she was doing. “Oh, the breathing is fine, but I am thrilled because I can taste food for the first time in over a year.” Her husband confirmed that she had been raving about this all week and seemed to be eating everything in sight. CAG warned them about the potent combination of her renewed culinary sensation and increased appetite from the steroids but was pleased to see such an unexpected happy result.
Despite stories to the contrary, we are constantly amazed at what an integral position we physicians have in our communities. This point was brought home to JRH this weekend. He was watching television when the telephone rang and the caller asked for Dr. Hartman. “I read the article about you in the newspaper and I couldn't wait to talk to you!” the caller exclaimed. She mentioned that when she saw the article, she thought she would call to say hello. JRH paused and murmured something about how kind it was of her to call, wishing all the while that she would spontaneously relate the connection between them. Even when she mentioned her name, JRH couldn't place her. Soon, however, the link was revealed: both she and JRH had worked for a company building pagers in south Florida during his pre–medical school days. That was over 25 years ago. JRH was amazed that she would remember and even more amazed that she would call and share the memories of a common past. It made for a pleasant interruption of a somewhat ordinary Saturday. JRH found himself musing about how far-reaching a physician's influence is and hoping even more that he will prove worthy of the role that is his to play in the community.
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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