Diary from a Week in Practice



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Am Fam Physician. 2000 Oct 15;62(8):1807-1812.

Monday

Today, JTL had the pleasure of presenting various aspects of the life of a family physician to his daughter's first grade class. JTL enjoyed the opportunity to share with these youngsters some of the “toys” of his trade; specifically, his black bag from medical school days which, at times, still has some use, particularly in making house calls to homebound elderly patients. He also brought with him a Doppler ultrasound used to assess fetal cardiac activity. Using the ultrasound, he was able to allow the children to listen to the heartbeat of one of their classmates. Thinking it would be good to elicit some audience participation, JTL asked the students if any of them aspired to become a physician. About a half dozen students raised their hands. JTL asked them why they thought they wanted to be a physician. Immediately each child thrust his or her hand into the air and, one by one, echoed the same sentiment. Clearly, the overwhelming reason to become a physician was the desire “to help people who are hurt or sick.” Reflecting for a moment on the many demands of modern “managed” health care (e.g., will the patient's insurance cover this procedure or medication?), JTL found it refreshing to be reminded by these youngsters why he became a physician in the first place.

Tuesday

JTL has been following the debate on the practice of “co-sleeping” between children and parents. As he counseled one young mother today regarding strategies for helping her toddler fall asleep in his own bed, JTL reflected on some of the lessons he learned only by becoming a parent. For years, JTL discouraged co-sleeping, but he has now come full circle to empathize with parents who believe strongly in allowing infants and children, at the very least, to fall asleep while rocking in a chair or lying down with one or both parents. In addition to the usual bedtime rituals such as nighttime prayers, JTL's wife frequently allows one or more children to fall asleep in their own bed while she lies at their side. This has led to fewer bedtime struggles and night waking. The practice of co-sleeping is supported by a recent study (Arch Pediatr Adolesc Med 1999;153:339–46) that compared sleep practices in Japan with those in the United States, and notes that more Japanese than U.S. children “coslept” with their parents. The study demonstrated a significant difference between these two cultures with regard to bedtime struggles, night waking and stressful sleep problems (favoring the practice of co-sleeping). From now on, JTL will share with his patients his own personal experience and the results of this study as he makes an effort to assist parents anxious to solve their child's sleep problems.

Wednesday

As data accumulate on natural medicines, we learn more about their benefits and risks. Recently, WLL had a patient whose INR increased from its usual 2.3 to 9.2. The patient had been taking garlic tablets (Allium sativum). WLL searched the Natural Medicines database and found that warfarin and garlic potentiate each other. He had the patient stop taking the garlic and the INR dropped back to baseline one week later. Now, he has more warnings for his patients taking herbal or alternative remedies in combination with warfarin. One review (Am J Health Syst Pharm 2000;57:1221–30) reveals that common herbal remedies such as garlic, ginkgo (Ginkgo biloba), red clover (Trifolium pratense), ginger (Zingiber officinale) and willow bark (Salix alba or Salix nigra) have antiplatelet properties and may increase the risk of bleeding. Other remedies, including vitamin E, devil's claw (Harpagophytum procumbens) and dong quai (Angelica sinensis) may enhance warfarin's effects. Green tea (Camelia sinensis), coenzyme Q10 and ginseng (Panax quinquefolis [American ginseng] and Panax ginseng [Asian ginseng] but not Eleutherococcus senticosus [Siberian ginseng, a totally separate genus]) have properties that make them likely to decrease the effects of warfarin. The report highlights 38 herbal treatments that have the potential to interact with warfarin.

Thursday

Heritage Family Physicians is honored to introduce ASW. She has been reading “Diary” since her first year of residency. She relates that she was always impressed by the variety of patient scenarios and enjoyed the humor, clinical pearls, its alternative medicine twist and the spiritual dimension that was often a common denominator among the stories. For years, she followed the practice from a distance, knowing the physicians only by their abbreviations, some of their accomplishments and the pieces of their hearts shared in the column. She later learned that JRH was honored as family physician of the year in Florida and featured in the American Academy of Family Physicans' book on the history of family physicians. After serving three years in the Air Force, ASW began to look for practice opportunities. In a surprising turn of events, the name of this group kept coming up during her job search from unrelated sources. She decided to pursue joining the practice after attending a conference by WLL that taught physicians how to combine their spiritual faith and their practice. ASW is grateful for the opportunity to work with such respected colleagues and excited to share some of her own stories as she continues to develop her skills in practicing the art of family medicine.

Friday

In our office, as in most physician offices, patients at times wait in the examination room to see their doctor. JTL and the others in our practice have tried to improve the atmosphere in the examination rooms. Appropriate magazines, including spiritual readings, are appreciated by most patients. JTL recently decided to display a picture of the military base at which he was last stationed, a gift he had received from one of his patients. The photo has prompted favorable comments from many patients who, themselves or their spouse, have served in the armed forces. Photographs of JTL's children, and the endless supply of their most original artwork, allow patients to understand that Dr. Littell has a full life outside the office. A wall hanging with “930 reasons to be happy” seems to be a big hit. “Gee, doc, I only got to number 215!” is nice to hear from a patient, particularly when you're running behind schedule. Today, after an extended “lunch hour” caring for several hospital patients, JTL returned almost one hour late to start his afternoon appointments. Entering the examination room, JTL was most apologetic about being so tardy. “I'm glad I had a chance to wait, doc. This is the first time I've been able to relax all day!” was the reply. Now wasn't that a bit of music to JTL's ears.

Saturday/Sunday

Every year, our community has a livestock fair, which JRH has found himself enjoying. Many patients he delivered and cared for in childhood are now involved in 4-H and are proud to display their work and their talent for all fair-goers to see. This year, JRH decided to go to the steer auction at the urging of several of his young patients. Not only did he get a VIP tour behind the scenes to view the grooming of these animals and admire the work involved, but he also experienced the pride these youngsters feel as people view and bid on their steers. For many of these kids, the money they collect goes partly to pay for their costs in raising these animals and partly into a savings account for college. The upshot of all this: JRH bought a 1,122 lb steer. He and his office staff were treated to some of the best beef they had ever tasted!

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


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