Diary from a Week in Practice
Am Fam Physician. 2001 Mar 15;63(6):1081-1083.
At times, family physicians are called on to counsel patients in areas that might seem to be off limits at first glance. Today, JTL visited with an elderly man who has been married for more than 50 years and who, in the past, has received sildenafil to improve his sexual relations with his wife. JTL, aware that the patient's wife (also his patient) was suffering from rather severe osteoarthritis and was a candidate for hip replacement, asked how the patient's wife had responded to his use of sildenafil. The patient became rather somber and offered that, in fact, his wife was not tolerating sexual advances at all well. JTL shared with him his recent experience of an elderly woman who lamented that her husband of many years, while using sildenafil, had come to view her solely as a sex object. JTL then suggested that his patient explore other means of expressing his love for his wife, particularly given her limited ability to perform physical acts of lovemaking. The patient shared with JTL that he appreciated this opportunity to reflect on his own use of sildenafil and assured JTL that he would visit with his wife about this issue.
What is in a name? We don't know for sure, but we always ask for the baby's name, either during the labor process or soon after birth. We admit that sometimes the names are hard to pronounce these days, much less spell. Nevertheless, the effort to ask sometimes pays off with great rewards. Today, JRH received the answer to this question first by hearing the name and then by hearing its significance. “We named our son after my husband's father and his uncle. Now, after many years, they are talking to one another again!” “What good news,” JRH exclaimed, “and what good things will come to this family through the birth of this son of yours!” Today the joy of this delivery was multiplied and all because of the power of a name.
JTL, who spent several summers during his college years working with children and adults with cerebral palsy and muscular dystrophy, has always enjoyed working with patients who have neuromuscular disorders. Today, JTL met one such patient, a 50-year-old woman who had been diagnosed with amyotrophic lateral sclerosis just one year ago, after more than two years of seeing multiple physicians and hearing multiple diagnoses. During his interview with this remarkable woman, JTL could not help but notice her joyful, enthusiastic outlook on her life, her work and her family, despite her disease. JTL queried, “what keeps you going given all your hardships?” The patient told JTL, “I say to myself, ‘Lord, help me walk without falling and help me drive without wrecking!’ ” JTL assured her that, should he have the opportunity to be her physician when, and if, she becomes unable to drive or walk, he would be honored to visit her in her home. Yes, truly honored.
This morning, ASW met a 65-year-old woman who had been taking benzodiazepines for three years to “treat” insomnia. In the classic “by the way” style at the end of a long appointment, the patient asked ASW to refill her medication. After some discussion, ASW convinced the patient that an underlying problem was likely causing the insomnia that now had her dependent on a sleeping agent. With some reluctance, the patient shared a bit more about her personal life and seemed shocked, in the end, to agree with ASW's diagnosis of an anxiety disorder with depressed features. ASW has found the selective serotonin reuptake inhibitors to be extremely helpful in getting these patients adequately treated and off their chronic benzodiazepines, and almost invariably she has found that the patients eventually thank her for taking the time to search for the real problem. It is especially helpful when the consulting psychologist reinforces to the patient the benefits of psychotherapy and tapering off chronic anxiolytics when safer, nonaddictive and effective medications can be used to treat the anxiety.
Endometrial biopsies are performed in our office for the work-up of dysfunctional or abnormal uterine bleeding. Although WLL has his patients take a nonsteroidal anti-inflammatory drug (such as ibuprofen) before the procedure, some women still have much discomfort. A recent study (Obstet Gynecol 2000;95:345–7) studied the effectiveness of intra-uterine lidocaine for reducing pain during endometrial biopsy in 41 subjects. Pain scores were significantly reduced in patients receiving lidocaine, and the pathology results showed that infusion did not interfere with the ability to interpret specimen history. With the next endometrial biopsy, WLL tried 5 mL of 2 percent lidocaine (without epinephrine) slowly instilled into the endometrial cavity via a plastic venous catheter (with the obturator removed). With his first three cases, WLL and his patients were delighted—however, the angiocatheter could be flimsy. So, WLL changed his approach to use a small blunt needle attached to a syringe and fitted into the end of a Pipelle catheter. He removes the piston of the Pipelle, attaches the blunt needle into the distal end and then advances the proximal end of the Pipelle through the os. After attaching the syringe filled with lidocaine to the Pipelle, he slowly instills the anesthetic. The study did not address risks of the procedure; however, the authors noted that infusion of lidocaine lengthens the procedure time.
One of ASW's favorite things about medical missions is the opportunity to participate with a team of physicians and other health care professionals. During one of her recent mission trips to Guatemala, ASW treated the usual tropical diseases and malnutrition-induced maladies. She also had the privilege to hear and attend to some of the team members' medical problems. From angina to spider bites to giving advice on treating bipolar disorder, she felt honored to have the nurses, doctors and other volunteers trust her with their concerns. She was particularly touched by one of the doctors whom she had just met. He shared with her his struggles with a chronic illness and anxiety, and after many conversations over the course of a week, she really felt as though their interaction was going to make a difference in his life. It helped her too, because this type of sharing among colleagues helps reinforce her belief in the need to balance our careers and our personal lives. ASW enjoys the privilege of helping and empowering other health care professionals so that they can better care for their patients and families.
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.
Copyright © 2001 by the American Academy of Family Physicians.
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