Diary from a Week in Practice



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Am Fam Physician. 2000 Jul 1;62(1):88-91.

Monday

[corrected] While the physicians in our group love to be involved in our patients' maternity care and thrive on the unique advantage that we have as family physicians in taking care of the whole family during pregnancy, occasionally we are asked to see pregnant women who have chosen to have their maternity care elsewhere. Today, a woman in her 14th week of pregnancy came in complaining of ear pain. She was having trouble hearing and unblocking her ears. It had begun early in her first trimester when she experienced so much nausea and vomiting. After examining her, JRH surmised that actually her diagnosis was eustachian tube dysfunction caused or aggravated by her “morning sickness.” So JRH talked about the options available for nausea control in pregnancy, reassuring her that this problem would likely be over soon. He then directed her to use saline nose drops, which are slightly hypertonic, to “bathe” her eustachian tube orifices via a nasal route. Even as he did this, JRH remembered to “B-A-T-H-E” the patient: taking the few moments she needed for him to explore the Background, finding out how it was Affecting her, exploring what was Troubling her the most, asking her how she could Handle the problem and then Empathizing with her about just how difficult this vomiting was to cause even her eustachian tubes to be bothered.

Tuesday

WLL is finding that more and more of his patients who are diagnosed with cancer want to surf the Web for information. WLL supports this activity as long as the patient understands that there is some bad information on the Internet. WLL steers his patients toward several reliable sites. The American Cancer Society (http://cancer.org) is extraordinary. Patient information is comprehensive and well organized. The American Association for Cancer Research site (http://www.aacr.org) demonstrates Web technology at its best. You or your patients can use this site to listen to speakers at a variety of medical conferences. The National Cancer Institute (http://cancer.gov) has the Cancer Information Service (CIS), a nationwide network that provides accurate, timely information on cancer to patients and their families. The CIS can also provide information about particular types of cancer and cancer screening, as well as information on local resources and the availability of clinical trials. The National Cancer Institute treatment database, called the Physician Data Query offers state-of-the-art treatment and clinical trial information. At SciCentral (http://www.scicentral.com/index.html), patients can order personalized e-mail that will allow them to obtain the latest information on cancer treatment, care and research. Family physicians need to direct their patients toward reliable Internet resources.

Wednesday

Sometimes patients who have been coming to us for a long time feel so comfortable with us that they mention complaints that they really don't expect us to fix and that don't bother them that much. Today, a woman of 45 presented with a chief complaint of an upper respiratory infection but happened to mention that her left scapula was bothering her. JRH then mentioned that nuisance pains sometimes serve as a reminder for us to do things we really ought to be doing anyway. “For instance,” he said, “suppose that pain was referred pain from the breast, wouldn't that remind you to examine your breasts? By the way, have you done your breast self-exam recently?” “Gosh, no, not for awhile,” she said. And, then taking that moment to ascertain that she did in fact have a first-degree relative with breast cancer, JRH issued a pointed but gentle reminder about this important aspect of health maintenance. She agreed, and in addition to scheduling a health maintenance office visit with JRH, she scheduled her mammogram for the following week.

Thursday

In caring for hospitalized patients requiring consultation by subspecialists, JTL has learned that the role of the family physician is, at times, to serve as arbitrator between various consultants with conflicting opinions. Today, JTL found the need to intervene between two consultants providing their opinions on the management of a 51-year-old man who had suffered an embolic cerebrovascular accident, related to the presence of a left ventricular mural thrombus in the likely setting of postviral cardiomyopathy. While the cardiologist had ordered heparin to reduce the likelihood of further thromboembolic events, the neurologist had, during the night, ordered to discontinue heparin, because of concerns about hemorrhagic changes seen on the brain computed tomographic scan at the sight of the infarct. JTL, recognizing the medical and legal consequences of these decisions, spent significant time reviewing the literature on this topic, contacted each of the consultants and came up with a consensus for patient care that would be medically, morally and legally acceptable to all parties involved.

Friday

WLL's 74-year-old patient had refused for years to stop smoking or to even consider trying to stop. That is, until he became computer active. The patient has a normal blood pressure, a low-density lipoprotein level of 115 and high-density lipoprotein level of 55. He has an ideal body weight (body mass index of 24), walks two to three miles daily, has an evening glass of wine with dinner, eats almost no saturated fat in a diet rich with ocean fish, fruits and vegetables. He takes a multivitamin with trace elements and majors on the antioxidants—such as vitamins C and E. He's even begun adding soy protein to his diet. No way WLL could convince this fellow that his smoking was a significant risk factor for him. That is until WLL gave this computer-active senior a program that calculates the patient's 10-year absolute risk of developing heart disease. An advantage of this program is its ability to quantify the impact that behavior changes, such as smoking cessation, are likely to have on a person. The patient took the program home and was in today for an office visit to discuss nicotine-replacement therapy and a counseling approach to smoking cessation. Why? The program told him that if he stopped smoking now, his risk of developing symptomatic heart disease in the next 10 years would drop from 26 to 16 percent.

Saturday/Sunday

The call of family and home is a strong one, and CAG has decided to heed that call and return to Tennessee to be closer to his family. He will be joining two family physicians in a small town, and he looks forward to continuing to practice the full scope of family medicine including maternity care. The decision was not made lightly, as CAG has been exceedingly thankful for the opportunity to work with such extraordinary family physicians and build relationships with a marvelous group of patients. CAG has also appreciated the opportunity to be involved in “Diary from a Week in Practice,” and he has found the “forced introspection” that came from the month-to-month writing of these diary entries a fruitful and fulfilling endeavor. He plans to continue to take time out once in a while to ruminate on the good gifts that God provides through the day-to-day practice of family medicine. So, it's back to Rocky Top for CAG and his family, and a return to some very excited grandparents.

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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