Diary from a Week in Practice
Diary from a Week in Practice
Am Fam Physician. 2001 Sep 15;64(6):972-977.
In his nursing home practice, JTL has often been saddened to see so many elderly patients living out their final days in isolation from family members who, for whatever reason, choose not to visit them. On a brighter note, JTL received a note from the incredibly supportive spouse of one of his patients. She is an 80-year-old woman named Angie who has suffered numerous strokes and is now residing in a long-term care facility, with a feeding gastrosto-my tube in place and a nearly complete expressive aphasia. JTL is convinced that the only reason this woman is still with us is the loving care provided by her husband of nearly 50 years. He has been at her bedside several hours a day, seven days a week, each day of the year since she was admitted to the facility. Michael and Angie recently renewed their wedding vows, given Michael’s concern that Angie might not make it to their 50th anniversary. Michael also routinely investigates newer therapies for stroke patients and requests, most graciously, that JTL explore these options. In the brief note received from Michael today, JTL was moved to tears by the following succinct words written by this man: “Hope is what keeps me going. I agree with ‘live in hope and die in despair.’ However, I am still hopeful and I will be happy with some dialogue with my darling. My prayers keep me contented.”
In his efforts to get patients to consider quitting smoking, JTL has placed posters outlining reasons to quit in each of his examination rooms. Today, during the course of conducting a physical examination on a 54-year-old smoker, the patient, without prompting, asked JTL for assistance in quitting smoking. “That’s it, I’m quitting!” stated the patient emphatically. He then pointed to the poster behind me, which I obtained several years ago, most likely at one of the AAFP conventions. The poster graphically depicts the natural history of lung disease in smokers versus non-smokers, with a downward line clearly highlighting the more rapid progression to disability (from chronic obstructive pulmonary disease) and death in persons continuing to smoke. Perhaps most effectively, the graph highlights improved lung function and survival in persons quitting at various ages. The patient noticed that if he were to quit smoking at age 50 his longevity would be prolonged at least 10 years, barring other illnesses or injury. JTL was pleased to see the effect this poster had on the patient and hopes to see more of its kind made available to health care professionals.
These days, there are so many pressures for us to be the most efficient we can be, while at the same time being astute. Today, a 30-something young man came in after being injured in a lunch-time volleyball game at work. His foot had been stepped on by a fellow player just as he was getting ready to jump for a ball. There was immediate pain and then he had difficulty walking. On arrival at the office, the patient had a radiograph taken and JRH took a quick read of the radiograph even before he entered the room. Another quick look at the patient’s foot told JRH that it wasn’t fractured, so he said, “Here’s how we handle this one: ice pack for 20 minutes, moderate rest, a hard-soled shoe and tincture of time.” His patient retorted, “What about my toe? It looks funny.” Pausing for the first time in the encounter, JRH had to admit it did look odd. Then he proceeded to perform a digital nerve block before grasping the toe, listing to the left a bit. Applying traction to the toe, JRH felt the toe shift to the midline. The patient was right! The toe did look funny—it was subluxed! Now the patient’s toe looked normal again and he was able to walk normally. Hastily, JRH modified his directions to the patient, but made a mental note not to treat his patients so quickly (even amid mounting pressures to the contrary these days.)
JTL has previously written of his experience in listening to the “small voice” that, every so often, prompts him to take actions that he might otherwise not have taken. After finishing his fourth delivery this week, JTL was sitting at the nurses station in the labor and delivery department and thought of his remaining term pregnant patient, now at 41 weeks’ estimated gestational age. He planned to see her on Monday to discuss possible induction. Yet, the small voice prompted JTL to call the patient from the hospital on Wednesday night and request that she come in for induction on Friday morning. “Make it midnight tonight,” JTL decided. At 1 a.m., JTL received a call from the patient’s nurse informing him that the patient had experienced two deep, prolonged (five minutes) variable decelerations, with a return to a reassuring fetal heart rate pattern. JTL ordered a biophysical profile, which revealed no amniotic fluid and no fetal tone. JTL consulted an OB-GYN colleague, who, with JTL as first assist, performed a cesarean section, productive of a vigorous 10 lb 4 oz male infant who was surrounded only by scant, thick meconium. JTL and his consultant agreed that things might not have looked as good if JTL had waited until Monday to schedule induction. Yes, at times it’s quite acceptable to listen to voices that no one else can hear.
Today, a young mother of three came back to the office to complain that her six-week-old baby still looked a little yellow. Just a week ago, she had mentioned this to JRH, but because she was breast-feeding well, he simply reassured her. Today, JRH estimated the bilirubin level to be around 10, but at the mother’s suggestion, he ordered a total and direct bilirubin test. The total was 20, split almost equally between direct and indirect. JRH arranged for admission and consultation with a pediatrician. Although the differential diagnosis was lengthy, a difficult diagnosis was suspected. The next day the answer was found: biliary atresia. This young one would have to undergo abdominal surgery to construct a drainage system for the bile. Even so, a liver transplant is needed in two out of three cases. Once again, JRH found that listening to the patient was intrinsic to forming a therapeutic relationship: first JRH had to trust this young mother’s intuition and then, when the bilirubin was known, she had to trust JRH to lead her to lifesaving treatment for her child.
JTL, in writing this final diary, reflected on the many family physicians and others who have helped mold him into the doctor, indeed the person, that he has become, and, in many ways, still hopes to be. First and foremost would be his wife of 12 years, Kathleen, who graciously put her career as a maternal-child clinical nurse specialist on hold to accompany JTL while he practiced medicine in five states and Germany. She also gave birth to and nurtured four lovely daughters along the way. During his seven years as a family physician in the U.S. Army, JTL was privileged to work alongside many men and women who challenged him to grow intellectually and spiritually, including Bruce Leibert. After his military career, JTL faced seemingly insurmountable obstacles: first, dealing with small town politics as a newcomer to rural Montana; then, dealing with established staff physicians in small-town Michigan, where he was denied obstetric privileges. As he prepared for an expensive legal battle, JTL was surprised and honored to be asked to join his new friends JRH and WLL in Kissimmee, Fla. A closing thought: It has always been a privilege and an honor to be a family physician—indeed, a labor of love—and, despite ever-increasing managed care woes and privileging/“turf” battles, JTL has never doubted for a moment that he is doing what he was born to do.
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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