Diary from a Week in Practice



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Am Fam Physician. 2001 Aug 1;64(3):413-415.

Monday

Today, JTL received a letter from a former intern, Susan Hawn, who he remembered from his days as a member of the family practice faculty. Dr. Hawn expressed how she has enjoyed every minute of solo practice in her hometown in rural Georgia. JTL hopes that there are medical students and residents who, like Dr. Hawn, look forward to careers in rural family practice. The family doctor is expected to care for patients during their hospitalization and while they recover at the nursing home, and, if they fail to recover, to rearrange the office schedule to attend the funeral service. The family doctor is not upset, but rather appreciative, when a patient stops him or her after church, or at the grocery store, to ask what will help a newborn with colic. While practicing in Scobey, Mont., JTL recalls driving through freezing weather to be with his laboring patients to avoid unnecessary trips to the hospital; going to the home of a distraught new mother who could not get her baby to stop screaming; visiting an elderly patient with a diabetic foot infection, and driving the patient to the hospital for admission. There are so many stories, and it is a privilege to share them with others who might be writing diaries of their own one day.

Tuesday

In the July, 1990 edition of American Family Physician, Editor Jay Siwek, M.D., called for a column titled “Family Physician's Notebook.” Dr. Siwek envisioned a department that would feature stories, lessons and anecdotes from family physicians that would highlight the joys and sorrows, and the discoveries and disappointments of day-to-day family practice. He wanted “to capture the intangible heart of family practice—what it means to be someone's family physician and how that special doctor-patient relationship adds to the satisfaction of practicing medicine.” He predicted that”… how long the column will run will depend on… our readers' interest…” WLL and JRH answered the call. In that first diary entry, WLL told of “… the horrible news that one of our colleagues has discontinued the life-support system for his 17-year-old daughter, who was involved in an automobile accident two days ago. Tears, prayers and support are all we have to offer.” Recently, that same colleague attended a reception where patients, politicians and physicians gathered to tell WLL and his family goodbye. His colleagues in the practice are proud to announce WLL's appointment as Vice President of Medical Affairs at Focus on the Family in Colorado Springs, Colo. It is with our blessing that he goes to this exciting new venture. Each of us in this practice and his patients will dearly miss him.

Wednesday

As family physicians, we treat patients with medical problems that result from poor lifestyle choices such as smoking and lack of exercise; many of them come to us looking for a quick fix. ASW recently saw a woman for a health maintenance visit who had lost 10 lb in one month. During the interview, ASW discovered that the patient was receiving human chorionic gonadotropin injections three times a week as part of an intensive weight-loss program. The patient was also taking a stimulant and several herbs for weight loss. According to the patient, this intensive program allowed her to eat whatever she wanted without much exercise, and success was guaranteed if the program was followed properly. ASW was amazed that such a program had the endorsement of physicians and that this patient, whose body mass index was only 26, had no idea what she was doing to her body in order to shed a few extra pounds. Her weight-loss program did little to address her issues of self-image and poor self-esteem, and this is what ASW tried to focus on. In the end, the patient decided to stay with the program, but at least she started to give some thought to addressing the real source of her problem.

Thursday

We joke about the phrase “the practice of medicine.” We all hope that we will get better and better at this art as the years go by, but we also surmise that by the time we get it right, it will be time to retire. Today, JRH had the opportunity to reflect on that as he was called to see an obstetrics patient whom it was thought had a hand presenting at the opening of the cervix, now at 5 cm. Not having encountered this before, JRH decided to examine her himself. Before he left home, he consulted one of his favorite books, “Human Labor and Birth,” by Harry Oxorn, a British obstetrician. By the time JRH arrived at the hospital, it was clear that the hand and a good portion of the forearm were palpable. Following Dr. Oxorn's advice, JRH allowed the dilation to continue and monitored the descent, making sure that progress was not arresting. By following Dr. Oxorn's policy of “masterful inactivity,” JRH was able to safely guide the hand and arm posteriorly, and soon a beautiful 7-lb baby girl was delivered vaginally. Less than one hour earlier, a cesarean section was thought to be necessary.

Friday

One of the problems encountered by JTL and others in our practice while performing newborn nursery rounds has been the overuse of glucose screening in newborn s at low risk of hypoglycemia. For unknown reasons, the existing protocol at the hospital had called for glucose screening of all newborns using a glucometer, which led to a large number of calls from anxious nursery nurses who were concerned about low glucose readings in otherwise apparently healthy newborn infants. One of the resources JTL found useful in this discussion was “Guide-lines for Perinatal Care,” a manual developed through the cooperative efforts of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, which outlines the criteria for neonatal glucose screening (e.g., infants of mothers with diabetes, infants with intrauterine fetal growth retardation, polycythemia, or presence of clinical signs and symptoms). After reviewing these criteria, the routine screening of all infants for hypoglycemia was replaced by these criteria plus (to JTL's chagrine), all infants who are large or small for their gestational age, which includes a large number of infants with no real increased risk of hypoglycemia. JTL reminds himself that Rome was not built in a day.

Saturday/Sunday

This month was a special and sad one at Heritage Family Physicians. After 14 years, Dr. Walt Larimore (WLL) left the practice to become Vice President of Medical Affairs for the international organization Focus on the Family. His last few weeks in town were a mixture of excitement and tears, of looking back with gratitude and looking ahead with great expectation. Dr. Larimore leaves behind a legacy of professionalism and excellence that has been a gift to all around him over the years, in the state of Florida and around the country. His new position as a medical ambassador will take him around the world, where his experiences and skills as a talented, well-rounded family physician will be an enormous asset. He will continue to bring pride to those of us blessed to know him and to the specialty of family practice. God bless you and your family, Walt. We know that you will continue to do good work, no matter where you are.

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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