Diary from a Week in Practice



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Am Fam Physician. 1999 Sep 15;60(4):1127-1128.

Monday

WLL has found that he needs to ask teenagers not only if they are using standard tobacco products (smoked, dipped or chewed), but also if they are smoking anything else, since the smoke wafting through some of the teen hangouts in our small town isn't just from regular cigarettes anymore. Several of his teenage patients smoke flavored cigarettes imported from India that are called “bidis.” They are about half the size of regular cigarettes and are filled with tobacco flakes, hand-rolled in a greenish-brown leaf, tapered at both ends and tied with a colored thread. The kids say that bidis cost less than regular cigarettes and are “chic” and “popular.” Federal health officials and antismoking activists note that many youngsters do not realize that unfiltered bidis may be even more dangerous than regular cigarettes.

Tuesday

One of the most important tasks we have as family physicians is to ease worry. Today a young mother brought in her daughter for evaluation of a facial rash that had persisted. The diagnosis was pityriasis alba, so JRH explained that although little is known about this common rash, it has a promising prognosis. The mother seemed relieved but admitted that she had worried the condition might be vitiligo. JRH spent a few minutes explaining a bit about vitiligo and how it differs from pityriasis alba. The patient's mother was very relieved to hear that her daughter would not have to contend with this noticeable condition for the rest of her life, and JRH was pleased to be able to dispense a dose of the drug called “doctor.”

Wednesday

Today SEF was evaluating a 78-year-old woman in her yearly physical examination when the patient suddenly paused while relaying the story of her life. SEF patiently waited, and soon the patient said, “Excuse me. I just needed to take a Senior Moment.” SEF chuckled, thinking that this was a very cute and unique saying. Later that day, she was seeing another older woman who used the same phrase. If this expression is so common, will we soon find it in the medical dictionary?

Thursday

“Well, my research has shown that I have performed a ‘hat trick’ with my skin cancers.” The patient was apparently a hockey fan and came to visit CAG for excision of a basal cell carcinoma from her neck. Previously, CAG excised a superficial melanoma from the patient's back, and a local dermatologist used Mohs' micrographic surgery to remove a squamous cell carcinoma located just beneath her eyebrow. Realizing that she has had the “big three” of skin cancers, the patient expressed relief that the present lesion is the least serious.

Friday

At times, family physicians must turn to other specialists, not so much for their expertise, but simply to preserve the confidence of patients. Today, JTL was preparing to discharge a young girl with abdominal pain, vomiting and dehydration who had been admitted to the emergency department during the previous night. In fact, the girl likely did not require admission and had undergone a battery of tests, none of which indicated a serious pathologic condition. Since she was tolerating fluids well and was relatively comfortable, JTL initiated the paperwork for discharge, at which time the patient's mother insisted that her daughter's abdominal pain be evaluated by a “specialist.” JTL consulted a pediatric gastroenterologist on staff, whose initial response was to order a whole new battery of laboratory tests. JTL contacted the gastroenterologist and informed her that the purpose of the consultation was to reassure the patient's mother, not to prolong the child's hospital stay. Ultimately, the pediatric gastroenterologist agreed with JTL's impression, the child was discharged and the mother was content. Some battles can wait for another day.

Saturday/Sunday

SEF has decided to leave Kissimmee and return to Arkansas. Although the initial decision was heart wrenching enough, SEF was surprised to discover that saying goodbye to her patients was still more difficult. She has always thought of the physician-patient relationship as a partnership in which the patient plays an active role. For some patients, this was a difficult concept. SEF has hoped that because of their experience with her, these patients will now be able to ask questions, weigh decisions and be more assertive in demanding excellence in their medical care. She hopes that she has touched their lives as much as they have touched hers, and her former partners believe that she has more than met this goal.

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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