Diary from a Week in Practice



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Am Fam Physician. 1999 Dec 1;60(9):2534-2538.

Monday

CAG recently learned another helpful trick from our nurse practitioner, Lori White. A one-week-old infant presented with head lice acquired from his sisters, who had just started school. To avoid any medications that might be toxic, Lori suggested applying petroleum jelly to the infant's scalp for eight hours and then washing it out. This is a more modern application of the age-old mayonnaise or margarine “pomade.” Medications for the sisters and control of environmental factors were also recommended. The next week, the mother and infant came in for a well-child visit. The mother was thrilled to have a lice-free family, and she raved about the brilliance of our office in helping rid her home of these vermin. CAG was happy that something so simple could be such a stress reliever and was thankful to be working with such an innovative nurse practitioner.

Tuesday

Readers are likely to be familiar with the entity “psychogenic polydipsia” as one of the many possible causes of hyponatremia. One of JTL's patients, who has frequently been hospitalized with bouts of near-syncope in association with hyponatremia and “dehydration,” was recently hospitalized at a nearby teaching hospital for two months in an attempt to unravel the mystery of her multiple attacks. Finally, after being closely monitored in a room where she was unable to get fluids, her laboratory test results normalized and symptoms abated—until she got back home. The presence of a central line for venous access allowed the patient to self-administer large volumes of normal saline, creating “psychogenic intravenous syndrome of inappropriate diuretic hormone”—the first such case of which JTL has heard. The next step is to get the central line out, which will take much effort in this patient who likely has Munchausen's syndrome.

Wednesday

Every once in a while we are faced with a request that stumps us. Today that happened to JRH, and right from the start he knew that the answer was not going to be found in the books. While JRH was reviewing the birth plan, a young first-time mother asked if he could do a “daddy stitch.”“A what?” JRH exclaimed. “A daddy stitch.” JRH paused for a minute, thought for awhile and then uttered a very pensive “Hmmm,” which was a little longer than usual so as to give the appearance of careful consideration of this request. In fact, it was the first time JRH had ever heard of this. Finally the light came on: this must be an “extra” stitch taken while sewing up the episiotomy to “tighten” the introitus. After ascertaining that he and the patient were indeed on the same page, JRH went on to explain the remarkable recuperative powers of the human body and suggested that Kegel exercises would probably be of much greater benefit.

Thursday

Surveys show that many family physicians are unsure about matching specific antidepressant medications with individual patients and may be undertreating their patients with depression (Worrall G, et al. Effectiveness of an educational strategy to improve family physicians' detection and management of depression. CMAJ 1999;161[1]:37–40). Recently, WLL found a wonderfully helpful algorithm that increases the chance that he will match the right treatment with the right patient (Katon W, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1996;53:924–32). The Texas Medication Algorithm Project (TMAP), a Web site started in 1996, was designed to develop, implement and evaluate a set of medication algorithms for the management of psychiatric disorders in adults to allow physicians to improve the quality and cost-effectiveness of care. TMAP is a collection of evidence- and consensus-based medication treatment algorithms designed to be easy enough to permit implementation by clinicians. WLL has found the guidelines to be very informative and useful, as they recommend not only specific treatment strategies but also discuss methods to use these medications. Better yet, it also allows patients with Internet accessibility to be active partners in the care regimen. The address of this Web site is http://www.mhmr.state.tx.us/meds/tmap.htm.

Friday

Over the past few years, family physicians in training have been warned about the effects that managed care will have on their practice. This was reinforced recently for CAG while caring for a man in his 40s with multiple large, superficial lipomas, many of which the patient wished to have removed. CAG started by removing two of the smaller but more prominent lesions on the patient's forearms. The lipomas were easily removed, and the patient was pleased with the result and wished to have some of the other tumors removed. While these future procedures were being scheduled, it was brought to CAG's attention that the patient's health maintenance organization expected all of these procedures to be included under the patient's capitated monthly fee, with no additional payment for these surgeries. They would, however, pay fee-for-service (without deducting money from the office's capitated fee) for a dermatologist or a general surgeon under the patient's plan to perform the same procedure. The decision for this busy family physician was obvious—send the patient to the subspecialist and free up the patient care slots in the office for other patients. The warnings had become a disappointing reality.

Saturday/Sunday

JTL frequently encounters patients of great faith, yet even faith has its challenges. Today, JTL visited again with a young woman with apparent metastatic cervical cancer. She had earlier refused referral to a gynecologic oncologist, citing her faith that she would be cured. Ultimately, she sent letters to JTL professing not only her faith in God but also her faith in JTL as her advocate and physician. Ultimately, JTL was able to convince her to visit the oncologist for at least one visit to review her options. Today, JTL received another letter from this patient, who had such a terrible experience with the oncologist that she has decided to forgo conventional medical therapies. JTL is finding it most difficult to reconcile the power of this patient's (and his) faith in God's ability to heal and his objective opinion that this patient's condition warrants some help from the traditional oncologic armamentariums.

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


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