Diary from a Week in Practice



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Am Fam Physician. 2001 Jan 1;63(1):61-62.

Monday

WLL has previously commented on the evidence that pseudoephedrine (Sudafed) and phenylpropanolamine (PPA) are associated with a rare birth defect, gastroschisis. In 1992, researchers first reported a significantly elevated relative risk of gastroschisis (OR = 3.2; 95 percent CI = 1.3 to 7.7) for pseudoephedrine use in the first trimester. This was based on a case-control study in which 76 subjects with gastroschisis were compared with 2,142 control subjects with other major malformations. The researchers noted in Teratology (1992;45:361–7), however, that the results must be considered tentative. In 1996, the California Birth Defects Monitoring Program, in a case-control study of gastroschisis (110 cases, 220 age-matched control subjects), identified elevated risks for two decongestants, pseudoephedrine (OR = 2.1; 95 percent CI = 0.8 to 5.5) and phenylpropanolamine (OR = 10.0; 95 percent CI = 1.2 to 85.6). They hypothesized that the vasoactive properties of these medications had a role in the pathogenesis of abdominal wall defects (Teratology 1996;54:84–92). Based on the current data and the relatively benign nature of the condition that oral decongestants are intended to treat, WLL advises women to avoid the use of oral decongestants during the first trimester of pregnancy. This is a change in practice for him and he suspects it would be for most of our readers.

Tuesday

Recently, JTL had to defend his prescription of a sulfonylurea (specifically, glyburide) to a diabetes patient with known sulfa allergy after the pharmacist had informed the patient that the drug might cause an allergic reaction. Apart from undermining the patient's confidence in JTL's prescribing ability, JTL was concerned that the pharmacist was relying too much on the laundry list of possible interactions found on his computer printout, rather than on the voice of experience to counsel patients. In this case, JTL reassured pharmacist and patient, adding that he had never had a patient with sulfa allergy experience an adverse reaction to a sulfonylurea. Today, JTL received a call from the less-than-content patient, who had developed hives after taking two doses of the glyburide. The only solace JTL could find was in a recent Prescriber's Letter (July 2000, vol. 7, no. 7), which discussed the drugs that might cause problems in patients with sulfa allergies. As presented therein, there have been “rare reports” of cross-sensitivity with glyburide, yet no reports with glipizide. JTL, after eating yet another piece of humble pie, was pleased to see that, at least in this rare case, he would be able to select an alternative sulfonylurea that would be agreeable to physician, patient and pharmacist alike.

Wednesday

In previous Diary entries, WLL has discussed his “Philosophy of Apology”—admitting his mistakes to his patients. Now, research suggests that a physician's apology may be a powerful tool in fending off lawsuits. One study found 25 percent of such suits were initiated after a patient realized that the physician had failed to be completely honest or had prevaricated to them when a mishap occurred. More than 30 percent of patients participating in a British study said they would not have sued if they had been offered a full explanation and an apology. WLL believes that a physician who “goes silent” after a mistake risks turning the role of trusted caregiver into the role of enemy. WLL has found that after an adverse event and an apology, his patients want a full explanation of what happened. They want to know what is going to be done about it and how similar mistakes will be prevented in the future. For WLL, being able to admit and then acknowledge when bad things happen is a critical step in implementing changes to prevent recurrence. At a time when so many policy makers at all levels are seeking error-reduction tools, WLL believes that a simple apology is one of the easiest to put to use.

Thursday

Minor surgical procedures are not only enjoyable for ASW but they also provide her an excellent opportunity for getting to know her patients better. During a recent excisional biopsy of what looked like an atypical nevus, ASW had an enlightening conversation with a 16-year-old boy. Although young in years, his life experiences had landed him in jail briefly—the result of a previous drug problem. As ASW talked with him during the procedure, she was pleasantly surprised to hear a success story unfold. Through the assistance of family, friends, health care professionals and the youth group in his church, this teenager was able to rise above his drug problem and straighten himself out in the hopes of securing a brighter future. He was now actively involved in speaking engagements to other teenagers to help them get involved with positive activities and stay away from drugs and alcohol. Today, ASW called him to share the good news of the benign pathology report. She thanked him for sharing such a personal story. The patient thanked her for the telephone call, and especially for listening to his story and encouraging him. As ASW hung up the telephone, she was glad once again for choosing a profession where she can serve to assist her patients in the healing of their body, soul and spirit.

Friday

Any family physician who has had to counsel a family after a sudden infant death syndrome (SIDS) death knows the pain such an event engenders for decades. If you are like WLL, you will do anything you can to prevent a case of SIDS. That's why WLL hopped on the “Back to Sleep” advice recommended by the American Academy of Pediatrics (AAP). Now, a study has been released showing that many U.S. cases of SIDS occur in child care centers, especially home-based centers where unregulated caregivers may be unaware of physicians' advice to put infants to sleep on their backs. Researchers from the Children's National Medical Center in Washington, D.C., reported their findings in the August 1999 issue of Pediatrics. They examined 1,916 SIDS deaths reported between 1995 and 1997 and found that 12 percent occurred in home child care settings, 4 percent in a relative's home and 3 percent in commercial day care centers, and 1 percent with a babysitter or nanny. The rest occurred while the infant was under family supervision. The researchers suggest that caregivers may not be aware of the recommendation that infants be put to sleep on their backs. Family physicians need to teach parents to instruct their child care providers about sleep position—just like they would instruct the provider about what kind of formula they want given to their infant or what kind of diapers they'd want.

Saturday/Sunday

In reviewing some alumni materials from George Washington University, JTL reflected on the reasons he had chosen to enter the field of family medicine. In fact, as a fourth-year medical student, JTL had taken a “subinternship” in pediatrics, and had intended to do a medical-pediatrics residency. Yet, he had enjoyed his rotations in obstetrics-gynecology and was truly uncertain as to which direction to go. It was during a conversation with one of his deans that he discovered his vocation. “Well, you seem to be equally interested in all areas of medicine (except long surgical cases, which seemed to take a toll on JTL's back after an hour or so). Sounds like you're a family doctor in the making!” As JTL enjoys telling his patients, among specialist physicians (i.e., those who complete a residency beyond medical school), only family physicians choose to use every bit of information that they were exposed to in medical school, which explains the stacks of journals on JTL's floor and the three file cabinets full of articles.

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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