Diary from a Week in Practice
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Am Fam Physician. 2000 Jul 15;62(2):353-354.
She was elated! So was WLL! The 28-year-old patient with polycystic ovarian syndrome (PCOS) had wrestled with obesity, hirsutism, mild hypertension and oligomenorrhea. She was not able to get pregnant even though her husband's semen analysis was normal. WLL suggested a trial of metformin because the medical literature (Moghetti P, et al. J Clin Endocrinol Metab 2000;85:139–46, and Sarlis NJ. J Clin Endocrinol Metab 1999;84:1510-2) suggests that the endocrinopathy in most patients with PCOS syndrome can be resolved with metformin or troglitazone therapy (see the “Diary” entry for August 1999). This is clinically important because the therapy is reported to reduce hirsutism, obesity, blood pressure, triglyceride levels and to facilitate reestablishment of the normal pituitary-ovarian cycle—often allowing resumption of normal ovulatory cycles and pregnancy. Within two months, the patient's blood pressure normalized, menses occurred and today (four months after starting the metformin) her pregnancy test was positive. Now, WLL and the patient had to decide whether to stop the metformin. Although these are considered class B drugs (insufficient human data are available but no credible animal data suggest a teratogenic risk for the fetus) and although the risk of birth defects would be small, the patient (with WLL's blessing) decided that the most prudent policy was to discontinue the use of metformin during her pregnancy.
When CAG mailed a letter to his patients notifying them of his plans to return to Tennessee, he wondered about the type of responses he would receive. He was surprised at how quickly he got his first written reply—a two-page letter that repeatedly sang his praises. CAG was embarrassed that he did not remember this patient, especially because she had written so many detailed comments. Thus, CAG's nurse was dispatched to pull the chart to obtain more information. She returned with the chart and a partially concealed smile on her face. This patient had seen most of the doctors in the practice and had only seen CAG once, about two months earlier. “Must have been quite a visit,” remarked CAG as he perused the chart. Then his eyes saw what his nurse had seen at the top of the problem list, a diagnosis of “schizophrenia with delusional tendencies.”
JTL was particularly struck today by the remorseful words of one young man who, following an excessive amount of alcohol ingestion, had engaged in sexual intercourse for the first time, despite his avowed intention to remain chaste until marriage. This compunctious 19-year-old had made the appointment with JTL to be evaluated for sexually transmitted disease. After counseling him regarding the wide spectrum of sexually transmitted diseases, JTL sensed that this young man simply needed to set things right in his own mind and heart, and to hear that his actions were forgivable. Before sending him to the laboratory for the indicated tests, JTL spent several minutes sharing words of reassurance and support with this receptive patient, and went on to praise the patient's decision to resume a chaste life until marriage. While the test results are pending, JTL believes that, simply by making this appointment, the young man had achieved the healing he was seeking.
JTL was taught in medical school that “90 percent of a patient's problems can be diagnosed simply by obtaining a thorough history.” Today, JTL was surprised by the remark made by a 38-year-old patient who, returning to him after a recent health care maintenance visit, was concerned that JTL had not obtained the “usual” screening laboratory tests (i.e., a comprehensive metabolic panel, complete blood count and lipid profile). Despite JTL's review of the many normal laboratory tests that previous physicians had obtained in this healthy patient over the years, she remained dissatisfied, commenting, “I thought 90 percent of the physical was the lab work!” Ignoring the obvious incongruity of this statement, JTL shared his concern that this patient has been “programmed” by previous physicians—and her insurance company—to expect a free battery of tests on an annual basis, even in the absence of data supporting this practice. Trying his best to explain the rationale for ordering screening laboratory tests (i.e., the patient's age, physical health, risk factors), JTL felt he was able to regain the confidence of this patient. Yet, in reflection, it would have been a lot easier simply to order the tests. JTL hopes that, in this technologic age, family physicians will still be taught that the need for diagnostic testing is dictated by the results of a thorough history and well-performed physical examination.
One of the policies of this group practice is to limit the time that physicians spend with “drug reps,” so as not to detract from time with patients. Yet, on occasion, JTL will override this policy to hear about new products and, if the truth be known, receive one of those fat pens that fit quite comfortably into his overworked left hand. Today, one such drug rep made her initial visit to our practice. It happened to be on the same day that she had listened to a talk given by WLL on a radio program devoted to family issues. The program had emphasized the unique roles of husband and wife and the many rewards that the couple will experience once the husband begins to honor and cherish his wife. Having listened to this program only days after her husband had left her (and their two children) for another woman, this drug rep expressed her desire to visit with WLL and express her thanks. As she related her story to JTL, WLL's nurse had overheard the details and conveyed them to WLL. JTL watched as WLL walked across the nurses' station and greeted the drug rep, expressing his sympathy for what she was experiencing. JTL felt honored to be associated with a physician whose actions truly fit his words, and was also thankful that his visit with this drug rep had resulted in something far more meaningful than just another fat pen.
With the announcement that CAG was leaving the practice, JTL finds himself having to respond frequently to the question posed by many of his patients, “Will you be staying or moving?” Reflecting upon the fact that five previous contributors to “Diary” had moved within the past three years, JTL could understand his patients' concerns. While there are certainly many factors that enter into the decision to leave a practice and move elsewhere, JTL knows of three predictors that physicians might consider a move: (1) this is their first stop out of residency training; (2) they have no family in the area; and (3) their children (if any) are not yet at an age where moving becomes “traumatic.” JTL, having moved four times since completion of his residency, having already lived near “family” in locations where other factors precluded his remaining there, and now having school-aged children for whom a move would be traumatic, can assure his patients that he would not likely move again. However, as with many of the patients in this practice, JTL will miss CAG's unique blend of youthful humor and deep spiritual insight.
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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