Diary from a Week in Practice
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Am Fam Physician. 1999 Jan 1;59(1):71-72.
Writing this entry for the 100th Diary has given WLL a chance to reflect on seven years of sharing practice experiences with the family physician community. Since writing that first Diary, WLL and JRH have seen their group grow from two physicians to seven physicians and two nurse practitioners. Physicians have come and gone. The group, like family medicine itself, will continue to evolve and grow, change and adapt. A big surprise for JRH and WLL has been the overwhelmingly positive reception of the Diary by medical students, family practice residents and family physicians “in the field.” How wonderful it is to hear from medical students who credit the Diary with helping them to choose family practice, and we have had the privilege of three of them subsequently joining our practice and writing for the Diary: Jonathan Lim, M.D., now practicing in California; J. Scott Ries, M.D., soon leaving for academia; and Chad Griffin, M.D., a member of our practice. Besides WLL, JRH, JSR and CAG, the other physicians and active diarists in our practice are Theresa Shupe, M.D., Stephanie Frisbie, M.D., and John Littell, M.D. The greatest privilege any of us has is to be called to this profession that allows us to care for the entire family as a part of the entire community—from conception through death—and in which the best compensation is the collection of warm lifelong memories and a sense of deep satisfaction.
TBS returned to the office today relieved after the delivery of a healthy 9 lb 3 oz boy. The pregnancy had proceeded quite well until three weeks before delivery when the uterine fundus measured greater than gestational dates. One week before delivery, the fundal height had increased by 4 cm in one week, and an ultrasound was obtained, showing polyhydramnios. After a quick review of the literature, noting the possible causes including macrosomia, gastrointestinal tract abnormalities and gestational diabetes, TBS met with the mom to discuss the ultrasound findings and consulted with an obstetrician to discuss a plan of care. The decision was made to induce labor at 38 weeks. (We are aware of recent literature that frowns on induction because the baby is large for gestational age or because polyhydramnios is present; however, our consultant obstetricians felt induction was nevertheless indicated.) Screening for gestational diabetes had been negative. After discussing the risks and benefits of induction versus watchful waiting with antenatal screening, the patient was admitted for cervical ripening using a 50-μg tablet of misoprostil inserted vaginally [corrected]. Within six hours the patient had progressed to 6-cm dilation. The patient progressed to full dilation and then quickly delivered the infant without difficulty. The initial examination of the infant was normal. TBS shared a prayer of thanksgiving with the parents.
Next to our office is a pond that we can see from some of the examination rooms. Being from Tennessee, CAG has been surprised by the size of some of the birds that feed at the pond. He also has enjoyed watching a 3-ft-long alligator who has taken up residence at the pond. Today, CAG was talking with the father of a five-year-old patient who was sitting on the examination table looking out the window. Suddenly, the young boy loudly exclaimed, “Daddy! Daddy! Those birds are chasing that ‘gator!” The father rolled his eyes at first but, sure enough, there was the alligator crossing our parking lot heading for the pond. Behind him, a pair of 4-ft-tall sandhill cranes were in pursuit, vigorously flapping their wings, until the alligator returned to the water. As CAG began examining the boy, they were again amused when a one-legged duck hopped past the window to a small feeding area. They agreed that the duck must have been cheering for the cranes from the sidelines.
Kissimmee, although close to Orlando with all its bright lights and attractions, is still small enough for the citizens to get excited when a new business opens up, especially when that business happens to be an ice-skating rink! Now there's something to talk about: Florida sunshine and ice-skating! As might be expected, it didn't take long for all the hoopla to generate another type of excitement. Today, JRH saw a young woman who had a linear superficial abrasion that came from using her new skates. Last week, we had a patient with a sprained ankle and, the week before, a patient with a distal fibula fracture appeared at our doors. Funny, we never thought of ourselves as being a “spin-off” industry!
Since joining this group, JTL has enjoyed using a transcriptionist for the majority of his documentation needs (a luxury he couldn't afford in solo practice). In reviewing his dictated SOAP notes, he was surprised to find that the transcriptionist at times seemingly applied her own insights to certain diagnostic entities that were new to her. One patient who presented with a multitude of concerns during an initial visit was given the diagnosis “multiple semantic complaints.” Another patient received the diagnosis “reactive air waves disease” (addiction to talk radio?). Ours is not the only transcriptionist with a latent sense of humor. One letter JTL received from a rheumatologist concerning a patient with a lengthy history of arthritic complaints noted, “Compliments have been low in the past.” That would help to explain the patient's concomitant depressive symptoms.
Sometimes, the hardest part of being a physician is letting a patient go. Since she started practice, SEF had followed an 82-year-old man with multiple medical problems. She had guided him and his wife through establishing their advance directives, and all felt comfortable with these decisions. When he presented to the emergency department with a life-threatening problem, both he and his family knew where he stood on these issues. Physician, patient and family worked together to establish a treatment plan that would comfort and honor these values and his wishes. The patient, according to his request, died with dignity and comfort. This weekend, SEF attended his funeral and was not surprised to hear a eulogy not only about the patient's long and fulfilling life but also about the man's acceptance of death. His faith was very important to his choices and desires, and not only comforted him in his time of need but also comforted his family and friends. For a physician dedicated to saving life, this can be a difficult but beautiful lesson to learn.
This is the 100th 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., John T. Littell, M.D., and Chad A. Griffin, M.D., seven family physicians in private practice in Kissimmee, Fla.
Copyright © 1999 by the American Academy of Family Physicians.
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