Diary from a Week in Practice
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Am Fam Physician. 2000 Oct 1;62(7):1549-1552.
JTL had an interesting experience while on rounds visiting his hospitalized patients this morning. As he reviewed charts at the nursing station, he had the opportunity to interact with other health care professionals making rounds, specifically, the registered nurse making rounds for the pulmonary group, the registered nurse on rounds for the cardiology group, the physician-assistant making rounds for the hematology-oncology group and the hospitalist who cares for many of the patients admitted by other practices. JTL reflected for a moment on the many consequences of becoming less involved with his patients who require hospitalization for chronic or acute medical needs. Despite the extra time and lower compensation associated with the care of hospitalized patients, our practice members derive much satisfaction from being with our patients at times in their lives when they are most ill, not to mention confused, vulnerable and helpless. Would the hospitalist or other health care professionals be able to fill the same role, in the same way, as the family physician in providing “continuity caring” for patients who otherwise find themselves in strange, stressful surroundings? We don't believe so and hope we can continue to provide this service we and our patients seem to need and appreciate.
One of the joys of being in private practice for more than just a few years is the opportunity to discover some of the nuances of common problems. Today, a young pregnant woman came in complaining of tingling in her middle fingers, especially at night. A quick examination using Tinel's sign over the carpal tunnel confirmed the diagnosis of pregnancy-related carpal tunnel syndrome. However, her complaints were mild compared with many of these cases we have seen. So, instead of discussing night splints or injection of the carpal tunnel with triamcinolone, JRH chose to teach her a method of stretching he learned from his colleagues in orthopedic medicine. The examiner's thumbs are placed on either side of the bony eminences of the tunnel (the scaphoid on one side and the pisiform and hamate on the other.) Next, an outward stretch is performed. The theory is that this form of stretching compresses any edema out of the perineuronal tissues and reduces compression on the median nerve (for more information on another proven set of exercises for carpal tunnel syndrome, see the July 1997 “Diary” entry). Beginning this procedure early enough in the course of carpal tunnel syndrome should yield a good result and avoid unnecessary encumbrances on a pregnant woman.
One of the problems that JTL has faced with increasing frequency in performing health maintenance examinations is adolescent obesity. Today, JTL had the opportunity to visit with two 12-year-old patients whose body mass index was more than 35. JTL has noticed several common factors in obese youngsters: (1) failing to eat breakfast; (2) failing to engage in adequate exercise; (3) watching too much television; and (4) not having a scale in the home. By addressing these issues, JTL has anecdotally been able to see immediate benefits in many of his young obese patients. Specifically, JTL encourages all school-aged children to eat a healthy breakfast, preferably a high-fiber cereal with skim milk, and avoid fast food or the equivalent while at school. JTL also recommends extra physical fitness such as an additional physical education class for his school-aged patients. Reducing television watching and increasing outside activities with friends or family seem to help and JTL's patients are not as resistant as he would have predicted. Finally, he implores the patients' parents to buy a scale so that they, along with their child, can see the progress they are making in dealing with the problem of obesity. To enforce these strategies, we encourage parents to not allow television sets in the bedroom and to limit the number of hours that the television is on.
WLL has become more aggressive in treating dyslipidemia. Statins, fibrates and sustained-release niacin have become mainstays in his clinical toolbox. Until recently, it was a coin toss deciding to use one over the other. Now, the use of statins may have an added benefit. Previous research showed that statins increase osteoblast activity and enhance bone volume. Now, researchers studying the association between statin use and hip fracture rates (JAMA 2000;283: 3211–6) have found that statin use was associated with a 71 percent reduction in risk, even after controlling for various clinical and demographic factors. In a second study, researchers examined whether the use of statins only, fibrates only or other lipid-lowering agents affected the risk of bone fractures (JAMA 2000;283: 3205–10). After adjusting for body mass index, smoking status, number of physician visits and concurrent use of steroids or estrogens, these authors also found that statins significantly reduced the rate of bone fractures (OR 0.55 [0.44–0.69]). Fibrates or other lipid-lowering drugs had no influence on fracture risk. The authors of both studies assert that their results do not mean that physicians should begin treating osteoporosis with statins—yet. Nevertheless, WLL is finding this information useful when considering a lipid-lowering medication in patients with osteopenia or osteoporosis risk or disease.
Recently, the wife of an elderly man with early Alzheimer's disease asked WLL about starting her husband on a trial of huperzine A. The patient had no changes on neuropsychiatric tests after trials of donepezil (Aricept), tacrine hydrochloride (Cognex) or even Ginkgo biloba. Huperzine is being touted to improve memory and to treat Alzheimer's disease. WLL has found that there may be some validity to the claims. According to the Prescriber's Letter (April 2000), huperzine A is extracted from H. serrata and has been shown in animal studies to be a potent, reversible acetyl-cholinesterase inhibitor that crosses the blood-brain barrier, similar to donepezil and tacrine. Theoretically, use of these prescription drugs with huperzine A could have additive effects or side effects (these medications should be avoided by persons with asthma, chronic obstructive pulmonary disease, cardiovascular disease or seizures). After searching Facts and Comparison's Review of Natural Products and Natural Medicines Comprehensive Database, WLL told her that he could not recommend huperzine A until clinical data in humans was available about its safety and effectiveness. But, he sensed that she was going to try it anyway. As she left, WLL said, “If you give it a try, let me know how it goes. Okay?” She smiled and said, “Okay.” She turned to leave, then looked back and said, “Thanks.”
Recently, JRH and his daughter Heidi traveled to Honduras for two weeks as part of a medical mission. Having traveled abroad before on this type of trip, JRH had a pretty good idea of what to expect. Still, this trip presented a unique opportunity: the chance to learn prolotherapy, the procedure by which solutions (such as dextrose) are injected at the junction between bone and ligament or bone and tendon. While he returned experienced and confident after performing 50 to 75 cases, what he received in Honduras was much more than that: (1) the occasion to experience a different culture; (2) the opportunity to help people with chronic pain free of charge; (3) the time of confer and converse with colleagues in a relaxed setting; (4) the time to reflect on the meaning of medicine and its application to our culture; (5) the opportunity to practice medicine without HMOs, PPOs, IPAs, etc.; (6) the chance to bring home some really fresh pineapples; and (7) the chance to spend a wealth of quality time with his daughter. The first six were valuable. The last was priceless.
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.
Copyright © 2000 by the American Academy of Family Physicians.
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