Diary from a Week in Practice



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Am Fam Physician. 1999 Jan 15;59(2):309-311.

Monday

TBS struggles daily with the demands of being a mother of three-year-old twins and the responsibility of caring for patients. Today, TBS brought her girls along to the hospital for what was anticipated to be a brief check on two patients who had been admitted earlier in the day. On arrival, TBS was surprised to find that both patients had received less than adequate care; in fact, one of the patient's orders had not been found since she was brought up from the admitting area five hours earlier. Furthermore, the chart was not prepared and the IV and laboratory work had not been started. TBS paged the nursing supervisor for assistance with the care of her patients and help in locating the orders. The twins had been sitting quietly in their chairs behind the nursing station while TBS took care of her problems. All of a sudden, the fire alarm went off. TBS spun around to see one sheepish looking twin. Her daughter had become curious and had pulled the white handle of the red box directly behind her. Needless to say, TBS got a great deal of attention from that point on as the CEO of the hospital, the nursing supervisor, the head of security and the fire department all arrived on the floor posthaste. As TBS was leaving, she smiled to herself, thinking that if her patients had received the care that they needed, her 10-minute trip would not have turned into a 45-minute trip, and the alarm would probably never have been pulled.

Tuesday

CAG enjoys it when his pregnant moms bring their other children to routine prenatal visits. He finds that their perspective on things can be quite amusing. One four-year-old named Cody enjoyed sitting on the edge of the examination table and helping CAG auscultate his mom's abdomen with the fetal Doppler stethoscope to listen for the fetal heart tones. After a visit during the Christmas holidays, Cody excitedly proclaimed that God had answered his prayers for a little brother. When CAG asked him to explain why he was so confident, Cody pointed out that the baby's heart sounded like a drum, so “he must be a boy because the song only talks about the little drummer boy!”

Wednesday

JRH is fond of telling his patients, “Florida is famous for its allergies.” Often he is greeted with a sniffle in response. Occasionally, the trouble manifests as a cough or a wheeze. In either case, the patient is often frustrated and weary, wishing for some quick relief. JRH and his partners have started recommending what they hope will be the answer to some of these complaints, even if it's not a quick one. Today, JRH explained to a new patient that he should use the nasal steroid spray according to a “new” protocol. Explaining Moffat's position (head down) that was described in a letter published in the October 1, 1997, issue of American Family Physician, JRH emphasized the importance of getting the medication into the sinuses. As a reward for following these instructions faithfully, JRH promised relief and control of this pesky problem. Nodding, the patient showed understanding of this special technique. Both the patient and the doctor end today by voicing hope that Florida will soon be famous for its remedies, not its ailments.

Thursday

For family physicians, providing care for the whole family can certainly have an advantage during the diagnosis of some problem cases. SEF saw a 46-year-old woman today for her annual physical examination and asked the patient if she had any particular concerns that she would like addressed during the appointment. The patient had a list of problems including palpitations, shortness of breath, headaches, insomnia and abdominal pain. A list such as this might easily require a long and extensive work-up, but SEF knew that the patient's teenage daughter was receiving chemotherapy for cancer. The patient's symptoms seemed to coincide with each round of chemotherapy that her daughter endured. Her routine laboratory results and physical examination were normal, but results of anxiety and depression tests showed her to be anxious as well as depressed. The patient admitted that this was more than likely the cause of her problems and was very agreeable to entering into counseling to help her deal with her stress as well as her daughter's illness. Both physician and patient felt comfortable with this decision in addition to close follow-up to ensure that the physical complaints resolved as the psychologic stresses improved.

Friday

WLL saw his first patient with a positive “18-wheeler” sign. A letter in the February 11, 1998, issue of JAMA (p. 434) discussed a finding that patients with fibromyalgia (as opposed to patients with other rheumatologic disorders), in response to the question, “How do you feel when you wake up in the morning?” would respond with an answer like, “I feel like I was hit by a Mack truck.” The report states that “some [patients who used the ‘18-wheeler’ sign] did not specify the truck manufacturer, and others substituted bus or train.” The investigators subjected this question to over 350 patients in their clinic over a 14-month period. Forty-two percent of the fibromyalgia patients (30 of 93 patients) had the 18-wheeler sign, while none of the other patients used this statement. They did not test any patients with chronic fatigue syndrome, cancer or thyroid disease. They found the sign to be a “specific, although not very sensitive, historical marker for the clinical entity fibromyalgia.” WLL has several patients with fibromyalgia and was anxious to try the new test. After entering the patient's room and chatting for a moment, WLL said, “Tell me how you feel when you wake up in the mornings?” “Walt,” the patient sighed, “I feel like I've been hit by a truck.” WLL shared his newly found knowledge with the patient. They finished the visit and when WLL said goodbye, the patient turned and replied, “That's a big 10-4, good buddy!”

Saturday/Sunday

Hanging in WLL's office is one of his favorite quotes. He often shares this information with his patients who are planning to get married. Nearly all of his patients not only appreciate the advice but also comment that it helps them reset some of their expectations going into the marriage. As WLL and his wife (his best friend of 42 years) enjoy their 25th wedding anniversary, they are able to remind each other of the truth of this wisdom expounded by J. Allan Petersen, “Most people get married believing a myth—that marriage is a beautiful box full of all the things they have longed for: companionship, sexual fulfillment, intimacy, friendship. The truth is that marriage, at the start, is an empty box. You must put something in before you can take anything out. There is no love in marriage; love is in people and people put it into a marriage. There is no romance in marriage—people have to infuse it into their marriages. A couple must learn this art and form the habit of giving, loving, serving, praising—keeping the box full. If you take more than you put in, the box will be empty.”

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., 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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