Diary from a Week in Practice

Am Fam Physician. 2001 Feb 1;63(3):463-464.

Monday

Many of WLL's patients have tried glucosamine and chondroitin products for osteoarthritis. Although some patients report that glucosamine (with or without chondroitin) seems to help, no patients who have tried chondroitin alone have reported success. Initially, this was a surprise to WLL. During the late 1990s, controlled clinical trials were reported on the use of chondroitin sulfate for osteoarthritis. In one study, radiographs showed what appeared to be the reformation of cartilage in the knees of patients with moderate to severe osteoarthritis who took chondroitin sulfate for more than one year. These studies consistently showed that patients taking chondroitin had reduced pain, used less pain medication and had improved mobility, compared with those who received placebo. However, many chondroitin products sold in the United States are inferior. An independent laboratory tested brands of chondroitin and combined glucosamine-chondroitin products. Among the glucosamine-chondroitin combination products, six out of 13 did not pass quality tests because of low chondroitin levels. Similarly, the two chondroitin-only products that were tested did not pass. One possible explanation—chondroitin costs about four times as much as glucosamine. The names of products that passed testing can be viewed at http://www.consumerlab.com.

Tuesday

It is not unusual in our practice to have a spouse accompany a patient into the examination room even for the most insignificant of reasons. Today, a 60-year-old retiree came to get some help with his sore ear. A quick pull on the earlobe, a push on the tragus and a look into the canal confirmed the diagnosis of external otitis. As a bonus, JRH smelled the “tutti-frutti” odor characteristic of pseudomonas infection. A prescription of ciprofloxacin otic drops was preceded by a word of sympathy about the discomfort that accompanies this infection, one that patients with diabetes should be particularly aware of. “It's his own fault!” came the voice from the other chair, “he's been putting his car keys in there all the time!” Thankful for the extra history, JRH expressed the hope that the patient's next car would be equipped with keyless entry.

Wednesday

JRH knew today was going to be a tough day. Amid all the routine appointments was the one that called for special attention: Mr. Smith's name was on the schedule! Mr. Smith was known to all the staff. It seems this lively and likable elderly man had been the cause of an accident while parking his truck at a store. He hit a young child in the process, who then had to be hospitalized. So when Mr. Smith arrived at the office, first his nurse and then JRH in succession spent the first 15 minutes just listening. As he poured out his heart, he let us hear in the process all his anxieties, worries and guilt about this mishap, the first accident he had ever had in 60 years of driving. In the end, it wasn't so much the prescription that he came in for, so much as it was for the compassion. And perhaps we did more for him by being good listeners than we ever had done before with all of his prescriptions.

Thursday

Participating in medical missions has long been a passion of ASW. Her most recent trip took her to Guatemala, where she was one of 45 volunteers. The group split into teams that traveled to different villages where they treated more than 3,500 patients in five days. Medical challenges that were new to ASW surfaced often (unusual tropical rashes, rare eye conditions, bizarre tumors) and she learned from each case. House calls taught them about public health problems such as severe overcrowding in smoky homes and the effects of poverty. These missions always give ASW renewed gratitude for her many blessings and a rekindled desire to serve those in need. A surprise during this trip was realizing how rampant depression and anxiety were in the communities she visited. Although initially she felt powerless to help with these problems during a short mission, ASW quickly realized how much her words, reassurances and prayers seemed to help others, as well as being a real blessing to her! The mission confirmed to ASW that there is nothing glamorous about poverty, that the art of medicine includes gaining skills in listening to what is not said, and that, as members of the healing arts, we are often more touched and changed by our patients than they are by us.

Friday

In dealing with beginning-of-life and end-of-life issues, family physicians may well find some days more emotionally draining than others. Today was one such day for JTL, as he reflected on three women, two newly pregnant, one dying. The first woman, after two ectopic pregnancies (with but one patent tube remaining for pregnancy) had conceived just one month ago. The second woman, after two consecutive early spontaneous abortions, met JTL when she was seeking referral to an obstetrician for care of this, her third pregnancy. Both patients were sent for obstetric ultrasounds, while JTL returned to the hospital to evaluate the third woman, a patient who had recently been diagnosed with leukemia, who was suddenly in severe respiratory distress. After a time of reflection with the patient, her husband, daughter and pastor, the decision was made to intubate the patient and place her on mechanical ventilation so as to give her and her family time to come to grips with her imminent death. Returning to the office, JTL was pleased to find copies of both obstetric ultrasounds awaiting him, each with evidence of a viable intrauterine pregnancy. Newly conceived life, imminent death—the stuff of family medicine that compels us to remain humble.

Saturday/Sunday

JTL, who enjoys caring for elderly patients for a variety of reasons, particularly likes to hear of the different ways in which his geriatric patients stay active. Recently, JTL met a new patient who surprised him with her level of energy. At 73 years of age, this woman had begun a walking program several years ago and, about one month ago, felt the desire to start jogging rather than walking. Subsequently, she has been jogging around her apartment complex and feeling younger and more energetic than ever. The patient had already had a bone densitometry, which confirmed no osteoporosis and JTL, in light of this new information, felt quite confident that this patient's bone mass as well as her other health issues could only be improved by her exuberant and enthusiastic approach to life. Today, JTL visited with this patient, who was complaining of bilateral leg pains which, on examination, were mild gastrocnemius strains caused by her running program. JTL inquired as to whether she was still running, to which she promptly replied, “Are you kidding? I figured out that running was for the dogs and young kids! I'm a walker once again!” JTL couldn't help but give this remarkable woman a pat on the back for her efforts.

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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