Diary from a Week in Practice



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Am Fam Physician. 2001 Nov 1;64(9):1547-1548.

Monday

It was one of those days when there was nowhere in the schedule to squeeze in one more patient. At 4 p.m., the receptionist asked whether she should have Barry come in. Knowing that Barry hated coming to the doctor, she suspected something was wrong. “What's the problem?” I asked. “He has a terrible headache,” she informed me. I suggested that he go to the ER, but the receptionist said that he'd already been there. I decided to have him come to the office. When I entered the room, he was curled in the fetal position on the exam table clutching his head in apparent misery. “Doc, I feel like someone hit me in the head with a baseball bat,” he explained. In the ER, he'd been diagnosed with a migraine headache, given an injection and discharged home with a prescription. But his headache had not eased. Although his examination was unremarkable, I had access to one important piece of information that the physician in the ER did not. Barry rarely went to the doctor. He was a silent sufferer. His mere presence in my office suggested a potentially serious problem. A CT scan of the head revealed a subarachnoid hemorrhage. Barry was transported to the hospital where a coil was successfully placed in his cerebral aneurysm. It turned out to be quite a day—and quite a headache—but also a testimony to the importance of knowing our patients.

Tuesday

Ask a silly question and you often get a silly answer! A young mother brought her two daughters to the office for treatment of upper respiratory tract infections. It was obvious that both girls, four and six years of age, weren't feeling well. They were cranky and viewed me with suspicion. In an effort to break the ice, I sat for awhile and softly spoke to them before attempting any examination. With some gentle coaxing from their mother, the girls politely answered my questions. I learned in succession what their favorite foods were, what colors they liked best, their coolest toy and the names of their pets. I saved one question for the end of the office visit. “What would you like to be when you grow up?” The six-year-old thought for a few seconds and replied, “Happy.” When it came to the four-year-old's turn, she answered without hesitation, “Five!” Sometimes when you ask a silly question you get a wise and a concrete answer.

Wednesday

Tightly grasping the sides of the examination table as if she were holding on for dear life, Dorothy looked a shade grayer than usual. It was immediately apparent that this 60-year-old woman who had smoked cigarettes for more than 40 years needed to be hospitalized. For the past three days, she explained, she'd had shaking chills, fever, a harsh cough and shortness of breath. When her purulent sputum became bloody she decided to see the doctor. Her chest X-ray confirmed what the history and physical examination already made obvious—right middle lobe pneumonia. She was too ill to treat as an outpatient. Despite her condition, Dorothy was defiant. “I can't be admitted to the hospital.” “Can't or won't?” I asked. After a brief discussion, Dorothy reluctantly shared the real reason she refused hospital admission. Two weeks earlier, one of her best friends was admitted to the hospital and died of sepsis and respiratory failure. Dorothy's confession instantly altered my perception of her. I no longer viewed her as noncompliant or self-destructive or simply stubborn. She had the honesty to admit her fear. As I was able to better understand her feelings, my respect for her grew. Together we did it Dorothy's way—outpatient treatment and, fortunately, a complete recovery.

Thursday

Over the years, I have developed a knack for moving people. This ability has nothing to do with me inspiring people. Instead, it is all about locomotion. On many occasions, I have enjoyed transporting elderly and physically challenged patients home after their office visits with me. Such a service is made possible by patience on the part of my patients. It also helps to live and work in a small town that has a population of fewer than 7,000 and only three traffic lights. Patients are always grateful, often surprised and sometimes flattered that their doctor cares enough to drive them home on those occasions when they find themselves stranded at the office without a way home. Late one afternoon, an elderly blind woman was brought to my office with a syncopal episode, profound weakness and shortness of breath. She was suffering from heart block and needed a pacemaker. She had no means of transportation to the hospital 30 minutes away where a cardiologist had agreed to insert a pacemaker. She refused to be transported by ambulance. She wanted to wait until the next day when a neighbor might be available to drive her. An hour later, I took her to the hospital courtesy of my minivan. Doctors frequently look for ways to attract patients to their offices. I, on the other hand, sometimes search for ways to take them away.

Friday

You'll never know if you don't ask. Hank is an elderly man with diabetes and severe osteoarthritis. His diabetes is well controlled with metformin. Because he lives on a fixed income with no prescription drug coverage, I recently gave him samples of rofecoxib. He could not believe how much better he felt on this new medication…at least until today. Hank's wife drove him to the office because he suddenly became weak and light-headed. Although his blood glucose level was 120 mg per dL, his BUN and creatinine were 103 mg per dL and 2.9 mg per dL, respectively. Only two months ago, his renal function was normal. In carefully reviewing his history, Hank admitted with some embarrassment that he had recently begun going to the VA hospital clinic where he receives some of his medications free of charge. He had been prescribed piroxicam for arthritis. Until now, neither I nor his VA physician had any idea that he was simultaneously taking two different nonsteroidal anti-inflammatory drugs (NSAIDs). After stopping both NSAIDs, holding the metformin and increasing his hydration, Hank's renal function gradually returned to normal. Lack of communication is a mistake that easily happens but never should.

Saturday/Sunday

House calls are still an important part of family practice in a small town where everything and everyone are only five to 10 minutes away. Ironically, the most frequent home visits are not those where the doctor travels to the patient's house but rather the other way around. Clara, a woman in her 40s, rang my doorbell on Sunday morning. She complained of a pruritic rash on her lower legs that was “driving her crazy.” She didn't think she could wait until Monday to be seen in my office but realized it was not serious enough to go to the emergency department. A visit to her doctor's home seemed to her to be a reasonable alternative. Although my wife and children were present in our living room, Clara began showing me her rash. Without any introductions, my wife quickly ushered the children into another room before Clara finished showing me her obvious case of contact dermatitis. “What are you doing for this rash?” I asked, expecting that she might have already tried over-the-counter remedies like oral diphenhydramine or cortisone cream. “Lots of scratching,” she logically responded. A prescription for hydroxyzine and a topical steroid cream ended the house call but not my children's fascination with the stranger who came to our home.

In 1995, after 12 years in solo private practice, Dr. Tony Miksanek joined the Good Samaritan Hospital in Benton, Illinois where he is the sole physician working in the hospital's rural health clinic, which also employs a full-time physician's assistant. Dr. Miksanek sees all kinds of patients, and many of them are elderly.



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