Diary from a Week in Practice
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Am Fam Physician. 2001 Jul 1;64(1):70-73.
Today, JTL evaluated a 15-monthold toddler who, when JTL first met him at 13 months of age, weighed only 13 lb and was far below the third percentile for weight at that age. In contrast, his two-year-old brother was above the 50th percentile for age in all growth categories. Watching this child's single mother trying to control her two-year-old in the examination room led JTL to consider the possibility of psychosocial deprivation as a cause for this child's poor weight gain. The mother simply did not have the time or energy to feed him as much as he needed. JTL was able to demonstrate this by placing the child, with his mother at his side, in the hospital for five days. With the help of a dietitian, the child's intake gradually increased to meet his energy needs. Following his discharge, JTL implored the mother to refrain from working and keep the child with her rather than at day care. This resulted in a modest improvement in the child's weight and development.
When she joined this practice, one of ASW's first patients was a nine-year-old girl with midabdominal pain. Starting in the umbilical region as a fairly mild discomfort, the pain traveled south and to the right within about 24 hours, settling in the right lower quadrant. With the onset of a low-grade fever and a minimally elevated white blood cell count on day 2 of this presentation, ASW suspected early appendicitis and ordered appropriate testing. The fairly comfortable-looking, though thin, patient walked from the office to the radiology department to the operating room. Her parents, initially frustrated by the need for blood work and radiographic studies, were relieved and thankful for the prompt surgical intervention and treatment. ASW remains grateful for the gift of clinical judgment that urges us to take that extra diagnostic step instead of standing still.
In performing circumcisions on newborn male infants, JTL has never given consideration to the age of the infant at the time of the procedure. While discussing the topic of ritual circumcision with one of his orthodox Jewish patients, JTL asked why the circumcision was not performed until the infant was eight days of age. (The infant is presented at the temple and receives his given name at the same time as circumcision.) “Why, you should know that, Doc…the baby bleeds less at that age.” JTL thanked the patient for refreshing his memory, then returned to his neonatology text, where he discovered that about 5 percent of newborns are significantly deficient in vitamin K, causing a prolonged prothrombin time and increasing the likelihood of bleeding problems. This potential deficiency, which is addressed primarily by the routine administration of vitamin K shortly after birth, is generally eliminated by about eight days of age. Further reading revealed that the content of vitamin K in cow-milk-based formula is fourfold higher than that in human milk. While the Plastibell circumcisions that JTL performs rarely have the bleeding complications one might find with other techniques, he was pleased to discover at least one medical argument for scheduling this procedure after one week of age, rather than in the first few days of life.
Yesterday, JRH met with a young 38-year-old mother of three to discuss why the lump in her neck had not gone away. If anything, it had grown a bit despite the cephalexin that was prescribed two weeks earlier. Being frank and honest, JRH allowed that it could represent cancer. But as soon as those words were spoken, he knew that the biopsy would need to be done immediately. Today, JRH performed a supraclavicular lymph node biopsy. The patient was grateful the biopsy had been performed so quickly, but now her worry took on a different face. It was true that she had not slept much the night before, so as JRH prescribed propoxyphene hydrochloride for pain, he made a request that the pathology slip be marked “rush.” How will she cope as her life is rearranged by the biopsy report, JRH wondered. When JRH received the feared confirmation of Hodgkin's disease—nodular sclerosing type, he knew it would be a major blow to the patient. JRH prepared to help her deal with the illness and guide her in making some important decisions.
Several years ago, JTL recognized that, while many of his patients chose not to use artificial methods of birth control for a variety of valid reasons, he had not received any training in the modern methods of natural family planning. He was still relying on outdated information on the rhythm method or periodic abstinence. Eventually, JTL and his wife, Kathleen, became instructors in the ovulation method of natural family planning, which was developed more than 30 years ago by the Australian physicians, Drs. John and Lynn Billings. When taught and used correctly, this method has an effectiveness rate approaching 100 percent (Lancet 1972;2: 813–6). As a service to his patients, JTL and Kathleen offer classes on natural family planning twice a month. Recently, two Islamic sisters, JTL's patients, expressed an interest in learning about natural family planning because artificial methods of birth control are not permitted by their religion. They were unable to attend the class, so JTL offered to teach in their home. At their home, JTL deferred the teaching to his wife, allowing the sisters to avoid wearing the cover garments required in the presence of men. This experience reminded JTL of one of basic beliefs expressed by the Drs. Billings—that women teaching women about the natural signs of fertility is the most effective means of promulgating the message of natural family planning.
ASW has enjoyed working in a practice with an uplifting office environment; she enjoys the soothing paint colors chosen for the halls and examination rooms and the paintings on the walls. Over the years, ASW has learned to appreciate how our surroundings affect the way we feel. Several months ago, she decided to take down her medical diplomas and awards, replacing them with photographs of her son, inspirational sayings such as the wellknown Serenity Prayer and notes she had received from grateful patients through the years. Not only does she enjoy walking into her office more, but she also noticed that her patients would now ask questions about who she is rather than what she does. The previously common statement, “Oh, so you went to Penn State,” was replaced by “How old is your son?” or “Isn't that a great prayer to read throughout the day?” Meaningful conversations followed and stronger bridges were built as they discussed issues of the heart rather than her past accomplishments. She recalls a mother who, after commenting on ASW's picture of her son, reflected on how she had not spoken to her daughter in more than two years. ASW stopped writing on her prescription pad and looked up as the tearful mother shared her pain and sadness over a broken relationship. As she walked out, the patient said, “I probably never would have mentioned this had it not been for that picture of your son. Perhaps I should call my daughter. Thanks.”
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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