Diary from a Week in Practice



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Am Fam Physician. 2000 Jun 1;61(11):3286-3288.

Monday

CAG was surprised by an additional use a patient found for his continuous positive airway pressure equipment. This obese man with obstructive sleep apnea had recently lost more than 80 lb and felt that he had a new lease on life now that he could sleep every night. The only problem was that his mask was aging, and he was having trouble getting an adequate seal around his nose. To compensate, he pulled the straps tighter and tighter, causing a great deal of compression against his upper philtrum. By the time he requested a prescription for a new mask from CAG, he had noticed another surprising change. A space between his two front teeth had completely disappeared, leaving no residual problems with his bite. The patient was quite proud of his orthodontic accomplishment, and CAG was happy to provide a prescription for a new mask to replace his “retainer.”

Tuesday

Although it was only Tuesday, JTL was already quite exhausted. In addition to the 30 or so patients seen in the office each day, he had assisted in the reversal of a colostomy, and made rounds in two hospitals to see his patients with such diverse diagnoses as embolic cardiovascular accident, newly diagnosed metastatic lung cancer, reactivated tuberculosis, hyponatremia and complete heart block. While many family physicians relinquish their active role in the care of hospitalized patients (not to mention maternity care), our practice has decided to forego the “hospitalist” option and be with our patients while they are hospitalized. Today, JTL noted that, despite the many subspecialists involved in the care of each of his critically ill patients, the patients and their families still relied on him as their chief source of information, guidance and support — as their health guide and advocate. As he went toward the cardiac catheter laboratory to check on one of his favorite patients, an 89-year-old man who was having a pacemaker placed, he observed the patient's wife, Bessie, seated in the waiting area next to their minister. Bessie's eyes lit up as she inquired into the condition of her husband of nearly 70 years. JTL assured her that all was well, and, though he had acted “only” as the admitting physician, he could clearly see that, in the eyes of his patients, he remained their primary doctor—their family physician—a role that he is indeed honored to serve.

Wednesday

Molluscum contagiosum is a benign viral skin disease that is seen most often in children and can be spread by autoinoculation or by direct contact. The mean duration of the lesions is about eight months if untreated, but they can last up to five years. Scarring may occur, particularly if the lesions are secondarily infected, so some physicians feel that active intervention may speed healing and limit scarring and transmission. Some parents want the lesions removed for social reasons. Although many treatments are cited in the literature, there is little compelling scientific evidence to support any one of them. WLL has tried most everything (cryosurgery with a variety of techniques, electrodessication, chemical cauterization with a variety of techniques, curettage with a fingernail or curette, and psychotherapeutic suggestion). His current favorite treatment is the “squeeze technique.” The caretaker applies a dab of Emla cream to each lesion one hour before the office visit. Then WLL physically expresses the core of the lesion with gloved fingers. A recent study compared his “expression” technique with phenol cauterization (BMJ 1999;319:1540). Overall, 76 percent of lesions completely resolved and no significant differences were observed for resolution with either technique. However, 63 percent of lesions treated by physical expression showed no scarring, compared with only 19 percent of those treated with phenol.

Thursday

A surgeon who works at one of our teaching hospitals in nearby Orlando was proudly describing an observation he had made concerning the doctors' lounge there. He claimed that he could tell who was last in the room by what was on the television. If a talk show was on, he theorized that the custodial staff had been working there. If ESPN or the cartoon channel was the station of choice, then medical students or residents had been present. He was most confident about his last observation, that the financial channel was a definite indicator of a recent visit by one of the medical staff attending physicians. Prospective studies are pending.

Friday

One of the fallacies about maternity care in family medicine is the concern that because the family physician is dependent on the arrival of someone with surgical skills before a stat cesarian section can be done, suboptimal care is being provided for the patient. CAG has never found this to be a problem. He and one of the obstetricians he uses for back-up were discussing this recently while anxiously watching his patient who had been having late decelerations. As with most of these times, the rate-limiting step was not awaiting the arrival of a surgeon. In this particular case, all were awaiting the arrival of the anesthesiologist. In the past, delays have also occurred because of equipment problems and staffing problems. This time, the nurse even commented that she was glad CAG was present because there is often an extended wait for a doctor to receive the baby (a requirement for any cesarean section per our hospital policy). CAG is thankful that he has two groups of obstetricians who always arrive in a timely fashion and are happy to provide back-up for his patients. He knows that they are thankful for the volume of work they receive from him. It is a mutually beneficial situation that leads to optimal patient care.

Saturday/Sunday

WLL has written about the experiences we have in our practice precepting medical students and family practice residents from around the country (Fam Med 1998;30:478–9). Recently, we received one of the sweetest rewards we could ever receive for this labor of love—a copy of a paper that one medical student wrote about her stay with us. She concluded her comments by writing, “I learned about medical treatments from fracture care to Duke's Magic Mouthwash. I was even introduced to a few alternative medicines. Not only did I see the provision of thorough medical care, but I also saw the long-term relationships between patient and physician built on respect and trust. The physicians addressed the needs of the total person: physical, spiritual and emotional. One patient told me of JRH, ‘You need to learn how to practice medicine like he does. Even if he only has 10 minutes to spend with me, he doesn't treat me like a 10-minute patient. I get his full attention and I know he listens to me. He is not just my doctor; he's my friend.’ I was taught as much about the art of medicine as I was about the recognition and treatment of pathology.” One of the gifts that we family physicians can give to our patients and our art is to teach the next generation of family physicians. It is one of the greatest privileges we have.

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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