Diary from a Week in Practice



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Am Fam Physician. 2002 Apr 15;65(8):1555-1559.

Monday

Patients are often concerned about the side effects of medications. But sometimes physicians can take advantage of anticipated side effects and actually use them to treat patients. AT, a second-year resident, learned about this strategy in the family practice clinic. She had been treating a 45-year-old man for depression. He had initially responded to a selective serotonin reuptake inhibitor but, because of gastrointestinal side effects, had been switched to bupropion (Wellbutrin) four weeks earlier. Today, the patient was pleased to report that not only was his depression better, but he had also quit smoking! Having seen an advertisement in a magazine about the drug Zyban, the patient realized that it was also bupropion, which he had been prescribed for depression. “After I looked it up on the Internet (www.zyban.com),” he explained, “I realized that I already had less of an urge to smoke. So, I set a quit date and stopped smoking 17 days ago!” AT was a little embarrassed that she had not thought to mention the dual use of bupropion when she initially prescribed it, but one of the most enjoyable facets of family practice is how we learn to fine-tune our practices every day.

Tuesday

“Computers have really improved patient satisfaction,” commented GL, a first-year resident on the inpatient service. He had just finished examining a 45-year-old man who had been hit by a car while riding his bicycle the day before. The man had fractured several ribs and, more seriously, sustained a large liver hematoma measuring 10 cm by 12 cm. Because of the considerable risk that the hematoma might rupture, the patient was restricted to complete bed rest for five days. GL was pleasantly surprised to see the patient, who was a professor at a local college, sitting up and typing furiously on a laptop computer. The computer was connected to the Internet through the telephone line, and the professor was busy answering e-mails from his students. “I've explained to my students that I'm in the hospital,” he said, “and taking medication for pain. Being able to keep up with my classes really keeps my mind off the misery.” GL wondered if, in addition to telephones and televisions, hospital rooms might soon be routinely equipped with computer terminals for patients to use.

Wednesday

BE's spirits fell as she read the ultrasound report describing a 16-week fetus with anencephaly. BE thought about her 19-year-old patient who she had been following since the beginning of the pregnancy. When laboratory results revealed elevated alpha-fetoprotein levels, BE had counseled the young woman that there may be a problem with the baby. Nevertheless, her patient had been excited to schedule the ultrasound, anxious to find out if her first child was a girl or a boy.

BE thought about her day so far. As a fellow in obstetrics, she had worked in the high-risk obstetrics clinic this morning where several of her patients' pregnancies were complicated by diabetes, hypertension, and other medical problems. Several of the women had severe substance abuse problems, including cocaine and alcohol. But what all of her patients had in common with this young woman was that they hoped and planned for a healthy baby. BE thought it did not seem fair that someone so thrilled to be pregnant would have such a terrible complication. As she reached for the telephone to ask the young woman and her husband to come in to discuss the ultrasound results, she thought that because her relationship with this patient was strong, she would be able to support her through the difficult ordeal.

Thursday

“I feel like I'm really getting to know these patients,” commented AL, as he made nursing home rounds with the attending physician. They both smiled then shook their heads at an elderly man in a wheelchair who was repeatedly asking for a quarter. AL certainly knew Harriet, an 84-year-old woman with dementia who introduced herself to him five or six times in half an hour. There was Hortencia who followed the pair of physicians from room to room, smiling, nodding, and mumbling incomprehensibly. Mr. Green wheeled his chair around the ward saying, “Do you know where I am? I don't know where I am…” And finally, there was “The Whistler,” an elderly man whose piercing whistle could mimic any bird in the sky! AL remembered his first day of rounds at the nursing home when, like many family practice residents, he had very little enthusiasm for being there. But today, in his third week of the geriatric rotation, he was actually beginning to enjoy it. He was surprised to discover that most of his patients were happy and, considering all their chronic illnesses, still enjoying life.

Friday

Walking three children to school in the morning can be educational for a family practice physician—it is a great way to learn about the neighbors' medical problems. KS woke up to her own second grader complaining of a stomachache. Her symptoms miraculously resolved once she remembered that she had soccer practice that afternoon. Just after stepping out the front door, KS examined the wrist of a 10-year-old boy who had sustained a sprain while playing basketball. At the street corner, she diagnosed a subconjunctival hemorrhage and reassured the mother that it would resolve on its own. Another mother was recuperating from sinusitis and wanted to know if she was taking the appropriate antibiotic. At school, a teacher asked if there was any new treatment for her husband's recurring fever blisters. And finally, she examined the scraped knee of a fourth grader who had slipped in the hallway. As she drove to the office, KS thought that she had a very satisfactory day already—and it was all accomplished before 8 a.m.

Saturday/Sunday

“¿Hay alguien que puede ayudar en este parto del nino?” (“Can anybody help deliver a baby?”), sounded an urgent voice in the midst of a busy clinic. Once a month, DE travels to Nuevo Progreso, a small town just across the border in Mexico. In a small, church-run clinic, he and five other volunteer physicians see about 200 patients in two days. Because there is no hospital in the town, most of the women in this very poor community deliver their babies at home. VW, a resident who accompanied the group, volunteered to attend the delivery. She grabbed some supplies and headed out to the pregnant woman's home. In the living room of the tiny house, she delivered a healthy baby boy, cut the cord, wrapped him up, and handed him to his mother. As she later described this wonderful experience to DE, she ruefully admitted that, although she had delivered more than 50 babies, she had never had to clean up afterward. “I turned to the nurse…. and there was no one there!” she declared. VW thought about how different the medical care in this community (just one mile over the border) is from that in the United States.

Kathy Soch, M.D., is a clinical instructor with the Corpus Christi Family Residency Program, affiliated with the University of Texas Health Science Center in San Antonio. This community-based program, which employs nine full-time faculty and 36 residents, primarily serves low-income, uninsured patients.

Address correspondence to Kathy Soch, M.D., 2606 Hospital Blvd., Corpus Christi, TX 78405. Reprints are not available from the author. In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.


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