Diary from a Week in Practice
Am Fam Physician. 2000 Feb 15;61(4):1007-1008.
Today started off innocently enough when a young pregnant patient of JRH's came in to have the clips removed after the abdominal surgery she had required a week earlier. Quickly, the clips were removed; the wound was healing well. Sterile adhesive strips were applied and an ultrasound verified that the fetal heart tones were strong, so the patient was discharged home for a few days of rest. Imagine JRH's surprise when she returned in the afternoon, having dehisced her abdominal incision to a length of 10 cm. In the midst of the hustle and bustle of Monday, a passing thought was given to sending her back to the gynecologic surgeon who performed the surgery, but the patient's tears told JRH that the proper thing to do was to take care of her right now. Would this require a new incision? Surely the “golden period” had already long passed. Would the schedule allow for a full excision around the wound edges? Probably not. JRH seized on an alternative: the cyto brush. Yes, first, cleanse the wound of clots, then rough up the edges of the wound, look for the return of pinpoint bleeding, and then place several interrupted sutures to approximate the edges. Would it work? Was JRH delaying the inevitable? Would “healing by secondary intention” be the better way to go? Well, 10 days later, all of the answers came in: but the most important was the smile on the patient's face and the thank-you from her lips.
When yet another smoker presented as a new patient, JTL inquired about whether he might want to attempt to quit smoking. The patient politely declined. Falling back on recent headlines, JTL simply stated, “Well, I do appreciate the financial investment you and other smokers are willing to make toward my children's college expenses, etc.” Without batting an eyelash, the patient grinned and replied, “I've just sent off for my own seeds, so I can grow my own tobacco on my own land—without giving a dime to Uncle Sam.” I guess they call that old-fashioned American ingenuity.
Lack of patient compliance is a problem in any practice, but CAG found a useful suggestion on a recent cassette about patient compliance from the AAFP Home Study Self-Assessment program (#244, side 2 by Dr. Kevin Ferentz). When writing prescriptions, CAG now puts the reason for the medication at the end of the directions. For example, loratadine is “one daily for allergies” or atenolol is “one every morning for high blood pressure and to prevent another heart attack.” Little time is required to add this information, and patient feedback has been highly positive. In the office today, CAG found that this technique made it easier to refill a patient's medication. Instead of requesting a refill for that (name any color) pill, the patient asked for a refill on “the pill to help with blood pressure and swelling” and then confirmed that the combined triamterene-hydrochlorothiazide tablet was correct.
Because childhood asthma had prevented him from pursuing any athletic endeavors, JTL has been particularly thankful for the persistence that his college roommate, Hugh McIsaac, displayed some 20 years ago at Cornell in working with JTL on a daily basis to teach him to run. JTL's relocation to Florida from the less temperate climes of Montana and Michigan has allowed him to go for a three-mile run at least a few times a week year-round, although JTL does not not run in competitive events (unless you count the AAFP “fun run”). During his run today, he reflected on three personal rules of running that allow him to compete internally: (1) never run out further than you plan to run back; (2) never run down a hill that you're not prepared to run up, and (3) always save enough energy at the end of the run for a final sprint home. Not surprisingly, each of these basic rules can also be applied to one's life at work and at home.
As a frustrated athlete himself, JRH is particularly attuned when a patient complains that he or she cannot participate in a chosen field of endeavor. One month ago, a 60-year-old patient had a special request so that he could play golf once again. He wanted Synvisc but he had undergone a total knee replacement some years ago and was hoping for a quicker solution to his present problem. So, after checking with the patient's insurance company and finding that this was a covered service (albeit temporary), JRH began the series of three weekly injections. The patient later told JRH that the first shot was painful but, by the time he received his third shot, he could definitely tell that this “experiment” was succeeding. JRH agreed and sent him out to the links once again, hoping to hear some great stories of passion and performance in the not-too-distant future. Look out, Tiger Woods.
On most Saturday mornings, CAG cares for his seven-month-old daughter, Rachel, while his wife attends a class. Few problems arise, except that this morning CAG received a call from the labor and delivery department notifying him that one of his maternity care patients had arrived and was dilated to 8 cm. Without time to get a babysitter, CAG packed Rachel in the car and headed for the hospital. The labor nurses appeared highly amused to see him rolling in with a grinning baby in a stroller, but it was obvious to CAG that they were too busy to babysit so he headed back to the patient's room. Fortunately, his patient's sister-in-law was more than happy to play with Rachel during the birth, which went very smoothly. CAG was touched to hear his little girl's voice during the delivery, and it brought back memories of delivering her in the same hospital. CAG had always looked forward to taking his other children with him on weekend rounds, but he never expected that Rachel would get such an early start.
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.
Copyright © 2000 by the American Academy of Family Physicians.
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