Diary from a Week in Practice

Am Fam Physician. 2000 Sep 15;62(6):1305-1306.

Monday

Many family physicians pay lip-service to a pillar of our specialty: continuity of care. But, in truth, much of what we do is episodic in nature. Today, an elderly man presented with a bleeding varicose vein. While JRH has seen this occur in advanced cases, he suspected the original diagnosis was in error. Reviewing the chart, JRH recalled that he had indeed attributed this man's leg pain to varicosities on a visit two to three months earlier. Today, clearly, this was not the case. The right calf showed a reddened irritated area that drained serosanguinous fluid. At that point, JRH recalled that this patient and his wife had survived a tornado two years ago. He lost quite a bit of blood at that time from multiple glass missiles launched by the fierce winds. Some wounds were deeper than others, but he truly had too many to count. This wound begged to be counted, however. So JRH set up the minor surgery room to remove the sliver of glass that had been embedded in the patient's leg for two years. Having removed it successfully, JRH pondered the benefits of continuity of care. To an acute-care doctor, this may have been nothing more than another leg ulcer in an older man. To JRH, it was the continuing story of a courageous man who had suffered injury during a natural disaster.

Tuesday

JTL had the opportunity to see firsthand how a potentially disastrous patient encounter can have a positive outcome. In visiting with one of his menopausal patients for a complete physical today, he was reminded that, during their last visit, JTL had been rather rushed and had been unable to address the list of complaints the patient had. Recognizing that he was indeed rushed at that time, JTL had dictated a brief letter to this patient apologizing for his rushed behavior and expressing his desire to continue to serve as her family physician. Today, this patient remarked how appreciative she was of this letter. She had shared the letter with many of her co-workers who were amazed that a doctor would not only apologize but also take the time to write the letter. In an era of managed care, in which it often becomes necessary to see as many as 30 patients a day, it might serve physicians well to know that there are ways such as letter writing to enhance patient-physician relationships which might otherwise be jeopardized by the “tyranny of time.”

Wednesday

“Doc,” exclaimed one of WLL's patients, “Have you ever heard of boomeritis?” WLL had no clue. On reading the paper later that day, WLL saw an article reporting: “Boomeritis is a term coined by the American Academy of Orthopaedic Surgeons (AAOS) that refers to the growing number of sports injuries among baby boomers.” Boomeritis is so rampant, says the AAOS, that the organization has trademarked the term and developed a Web site (http://www.boomeritis.org) geared to help those who suffer from it. According to a U.S. Consumer Product Safety Commission report released in 1999, the sheer number of baby boomers has led to a record number of hospital emergency department visits for “weekend warrior” sports overuse injuries. In 1998, more than 1 million sports injuries sustained by people born between 1946 and 1964 were treated in emergency departments, a 33 percent increase from seven years earlier. And, according to the AAOS, that's probably just the tip of the iceberg because most sports injuries don't require a visit to the emergency department. By drawing attention to injuries among baby boomers, the AAOS isn't trying to dissuade people from exercising. The group advises boomers to stay active because being sedentary is a greater health risk than injury from exercise. The AAOS also hopes to encourage family doctors to get patients exercising more often and safely.

Thursday

A 31-year-old, healthy looking social worker, accompanied by her husband, presented as a new patient. She related to JTL her tale of symptoms—abdominal pain, pelvic pain and now, chest pain—which have led to a bevy of diagnoses and nine operations. Most recently, this woman had been experiencing intermittent dyspnea and chest discomfort, with her most recent physician having ruled out significant cardiac pathology. JTL asked whether she or her husband had ever entertained a stress-related component to her symptoms. Almost simultaneously, husband and wife nodded in agreement. Further questioning revealed that the patient had been molested as a child, yet had received very little counseling to deal with the scars resulting from such trauma. JTL had little difficulty convincing the patient to try a low dosage (10 mg daily) of sertraline (Paxil). He also explained panic disorder to her, which quite accurately described nearly every symptom this woman had been experiencing for several years. In addition to medical treatment, JTL has recommended that patients suffering from panic disorder seek support groups in the community, where others suffering from this condition share stories and exchange suggestions for achieving a balance between the sympathetic (“fight or flight”) and parasympathetic (“relaxation response”) components of the nervous system.

Friday

A friend of WLL's, a pediatric orthopedic surgeon, who has kept his type 2 diabetes mellitus (formerly known as non–insulin-dependent diabetes mellitus) well-controlled with metformin (Glucophage), diet and exercise recently reported to WLL that he had been able to stop taking metformin by taking American ginseng (Panax quinquefolium L.). Canadian researchers (Arch Intern Med 2000;160:1009–13) reported that ginseng, one of the most widely used herbs, is hypothesized to play a role in carbohydrate metabolism and diabetes. The study showed that ginseng had glucose-lowering effects, especially when given 40 minutes before meals. These results suggest to WLL that allopathic and osteopathic physicians have much to learn about natural medicines.

Saturday/Sunday

In these days of managed care, it has become more and more important to choose capital expenditures wisely. Several years ago, we bought a used treadmill, but after checking reimbursements versus equipment costs and physician time, it soon became apparent it was a loss leader. Now, we are considering an ultrasound machine for the office. This equipment has become even more attractive because of the keen interest of a new associate, whose training in NaPro Technology (discussed in a February 15, 1999 “Diary”) allows him to investigate and help many cases of ovulatory dysfunction. Imagine our surprise today when, on viewing a 16-week pregnancy, it was discovered, purely by accident, that a subchorionic bleed had occurred. Finding this at an early stage in the pregnancy, JRH was able to counsel his patient and hopefully intervene in time to save the pregnancy. When dollars are short and reimbursements even slimmer, discoveries like these have the power to tilt the arguments in favor of adding ultrasound to the range of services we offer.

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


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