Diary from a Week in Practice



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Am Fam Physician. 1999 Jul 1;60(1):93-96.

Monday

CAG received an excellent suggestion from our nurse practitioner, Lori White, for giving eye drops to children and adults. The patient lies supine with the eyes closed, and another person places two drops in the medial canthus of each eye. Once the eyes are opened, the medicine bathes the eyes without much discomfort. CAG has found this technique to be helpful for parents who prefer eye drops over ointment for children and for adults who have difficulty putting drops directly in their eyes.

In a past diary (September 15, 1995), WLL shared another technique. The child lies on his or her back and keeps the eyes closed. Two ophthalmic drops are placed into the inner canthus and then, with the child's eyes remaining closed, the drops are gently rubbed to disperse the medication throughout the eye. WLL came across a study in the August 1991 issue of the British Journal of Ophthalmology (page 480), titled “Eyedrop Instillation for Reluctant Children,” which documented this technique and showed that instillation using this simple technique resulted in “66 percent of that obtained by conventional instillation.” Both methods are surely easier for parent and child.

Tuesday

Today, a 20-year-old man presented for a new-patient visit after his girlfriend suggested that he get a prescription for Viagra. JTL told the patient (who was not dealing with erectile, but rather sexual, dysfunction) that he had no medical indication for using Viagra. JTL also went on to explain that because of his own personal convictions, he does not prescribe agents such as sildenafil without proper indications. The patient, visibly disappointed, although not angry, ultimately left without a prescription. JTL reflected on how often he has, for similar reasons, found it necessary to refuse to comply with patients' requests when they conflict with his principles—and wondered whether many other family physicians find themselves doing likewise.

Wednesday

Like most of you, we take the occasion of preparticipation sports physicals or preemployment physicals to check up on our patients' immunizations. Today brought in a young woman who was applying to an emergency medical technician school. As expected, she was in the peak of health, but she needed an update on her adult diphtheria-tetanus immunization. After explaining the side effect of muscle soreness, lasting one to two days, JRH inquired which hand was dominant, so the nurse could give the shot on the opposite side. “But I'd rather have it on my right side,” the patient retorted. “You would?” replied JRH incredulously. “Sure, because when I waitress, I have to carry the trays on my left, and I'm afraid I would be just too uncomfortable when I'm trying to smile.”

Thursday

One of the more interesting phenomena in medicine is patients' use of the phrase, “Oh, by the way,” or “OBTW” for short, during office visits. Although this phrase is variously interpreted to be a nuisance, a bait-and-switch ploy or a hidden agenda, we occasionally take reassurance from the thought that it exemplifies our patients' trust in us—for both our experience and our willingness to listen. Today JRH was near the end of a visit with a middle-aged woman who had come in for evaluation of hypertension, when she mentioned in passing that her toe would sometimes get “stuck” in the flexed position and wouldn't return to neutral unless she bent over and moved it. Being accustomed to treating trigger finger first with a nonsteroidal anti-inflammatory drug and later with an injection of triamcinolone, JRH explained this course of treatment to the patient and showed her, using his own finger, how this phenomenon develops and how the treatment relieves the problem. This was JRH's first case of “trigger toe,” but one that will be remembered, thanks to the four little words: “Oh, by the way.”

Friday

A recent headline in one of the medical newspapers cited how patients enjoy physicians who spend time “chatting” with them. In fact, chatting may provide the most important information for the patient-physician relationship. Today, JTL visited with a 70-year-old German-American woman who has been known to be quite demanding with the front office staff and nurses. She refuses to wait even a few minutes for the doctor and will not sit in a closed examination room alone because she has claustrophobia. This patient generally has a list of tests that she wants performed—and she is rarely receptive to any suggestion that such tests might not be warranted. JTL has, however, found it easier to tolerate this patient's controlling behaviors after learning that, during her youth, she escaped from eastern Germany during World War II, and only a few years later had to escape from USSR-controlled Poland back to (West) Germany. At times, information such as this is helpful to office staff who otherwise may feel quite frustrated after long days of dealing with such “difficult” patients.

Saturday/Sunday

Probably the hardest part of being a physician is knowing when not to take on that role. SEF's father was recently diagnosed with prostate cancer that appeared to be contained in the prostate. His urologist had recommended a radical prostatectomy, since he was in excellent physical shape otherwise. Her father was unsure about what to do and was also uncomfortable with his urologist for various reasons. SEF encouraged him to come to Florida for a second opinion and possible surgery with a group of urologists that she recommended. He agreed and made the trip. At the consultation, the urologist outlined all of the options, including surgery, radiation implants and external radiation. SEF did not give her opinion until after her father had made his informed choice, knowing that he needed to be completely comfortable with his decision. He elected to have the surgery, and the urologist was pleased to report that all of the nodes were negative. SEF then played nurse for the two-week recovery period and sent her father back to Missouri in fairly good shape—but minus his prostate. Despite the difficulty of the situation, both enjoyed their unexpected time together.

This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Stephanie E. Frisbie, M.D., Chad A. Griffin, M.D., and John T. Littell, M.D., five family physicians in private practice in Kissimmee, Fla.



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