Diary from a Week in Practice
Am Fam Physician. 2001 Sep 1;64(5):765-766.
While the secondary prevention of osteoporosis through the use of bone density screening is increasingly popular, JTL still most enjoys counseling his adolescent and pre-adolescent female patients and their parents about strategies for enhancing bone mass and minimizing risk of osteoporosis. Avoiding tobacco use and achieving an adequate intake of calcium and vitamin D are the obvious suggestions. Less well known may be the adverse effects of long-acting progestins (i.e., Depo-Provera) on bone density, because of the association with reduced levels of estradiol. One more common offender may be the consumption of carbonated beverages, which have been found to be associated with an increase in the bone fracture rate of school-aged girls (Wyshak G, Frisch RE. J Adolesc Health 1994;15:210–5, and Wyshak G. Arch Pediatr Adolesc Med 2000;154:610–3). JTL sent copies of these studies to the superintendent of schools, after reading in the local newspaper that the school district is negotiating a contract for soda machines with the two leading manufacturers of soft drinks. JTL recommended that more nutritionally sound beverages, such as milk, might be offered to school-aged children.
As JTL has learned over the years, quite often the best medicine is not what we learned in medical school or residency. One example is the issue of allergic rhinitis. During his residency and faculty years, JTL's standard approach to patients presenting with seasonal allergic rhinitis was the prescription of antihistamines and nasal corticosteroids. When he arrived in Montana in 1995, JTL found that, at the beginning of the wheat harvest, farmers suffering from allergies would come into the office requesting their allergy shot. Knowing that the typical series of allergy shots (i.e., desensitization therapy) lasted one or two years, JTL was perplexed until he reviewed the medical records from the previous physician and realized that this allergy shot was a cortisone injection. A 40-mg dose of triamcinolone or a 125-mg methylprednisolone injection would be sufficient to get the farmer through the harvest free of symptoms. While clearly the family physician must exercise prudence in this practice, JTL has been thankful to have yet one more weapon against allergic disorders in his armamentarium.
JTL has followed the recent developments regarding possible associations between inflammation, infection and heart disease. He has noted that several of his patients also seem to be aware of these developments and, at times, request such tests as cardiac C-reactive protein and homocysteine levels to help predict their risk of heart disease. In his interaction with one such patient, JTL pointed out to the patient that, apart from these new tests, he already had an increased risk of heart disease based on his history of tobacco use, documented hyperlipidemia with an unfavorable total cholesterol:high-density lipoprotein ratio and a family history of heart disease. JTL told the patient that it would be more prudent to address his known established risk factors and make necessary changes in his lifestyle rather than obtain new tests that incur greater expense. The patient seemed appreciative of JTL's efforts to assist him with quitting smoking, and the practical advice for modifying his diet and adopting a regular exercise program.
JTL has noted the soothing effect that his new choice of office music has had on many of his patients. The decision to switch from a contemporary “soft rock” station to a format of “easy-listening golden oldies” has seemed to improve the atmosphere in the examination room and also while patients are holding on the telephone. Today brought a new twist. An elderly minister in the Dutch Reformed Church came to see JTL for a medication check. JTL, noticing that Bing Crosby and Louis Armstrong were singing in the background, could not help but point out the song to this patient, assuming he would associate it with a memory or two. Instead, the patient retorted, “What kind of music do you play here anyway? Do you realize that I had to listen to “The Lady Is a Tramp” while I was on hold this morning? Do you know what a tramp is?” JTL realized that this was not a good time to get into a discussion about Bing Crosby or Louis Armstrong, and finished up the encounter with the realization that, indeed, one cannot please all of the people all of the time.
Not unlike many physicians, JTL and others in the office have worked diligently to minimize the frequency of interruptions that occur during patient examinations. Typically, the nurse will knock on the examination room door only when another physician is on the line requesting to speak with us. During the past few months, JTL has noted a disturbing trend. Today, while in the midst of a patient interview, JTL was notified that a physician had called to speak with him. As JTL discovered, the physician was working for a pharmaceutical company as part of a medical information exchange for the purpose of discussing new medications with practicing physicians. JTL was most displeased by this marketing strategy, given the already overwhelming number of interruptions that occur during the usual office day. To help solve this problem, JTL has requested that he be interrupted only when the calling physician wishes to discuss a particular patient.
As in many practices, our new patients fill out a form providing details about their medical history. The last question on our new-patient questionnaire asks patients to write down their philosophy of life. ASW has learned that the answer to that question often gives insight into her patient's problems, and it can provide a tool in helping them get healthier. She recently saw a woman who stated that her philosophy of life was “work, work, work.” After meeting her and briefly talking about her hyperventilation-type symptoms, ASW discovered that the patient was unhappy in her marriage, estranged from her two children and working two jobs. She could not remember the last time she'd had a vacation and had forgotten what her hobbies used to be. She couldn't understand why she felt so unfulfilled when she was so successful in the business world. Indeed, this patient's life was all work, with little time to renew the spirit, mind or body, or for building and nurturing relationships. ASW feels that, as physicians, we too are at risk for such imbalance and must strive to take care of ourselves, our families and each other, so that we can better help our patients. The reality of our life need not become our philosophy, as in the case of this patient.
This is one in a series by John R. Hartman, M.D., Amaryllis Sanchez Wohlever, M.D., and John T. Littell, M.D., three family physicians in private practice in Kissimmee, Fla.
Copyright © 2001 by the American Academy of Family Physicians.
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