Am Fam Physician. 2003 Feb 15;67(4):724-726.
“Sometimes I feel more like a detective than a family physician,” JB, a third-year resident, commented to the faculty. JB was reviewing the blood glucose level of a patient who had been diagnosed with diabetes several years earlier. This 53-year-old woman checked her glucose level three or four times a day. She had excellent control until about two months ago, when the numbers suddenly jumped, often running over 200 mg per dL. The patient denied any change in diet, and she continued to walk two miles several times a week. JB was puzzled. Looking through the chart, she wondered aloud if any medicines had been changed on the last visit. At that, her patient rather sheepishly pulled out a bottle of pills that she had bought in Mexico for her arthritis. “Doctor, these pills make me feel wonderful!” she exclaimed. JB examined the box and found the medication to be a combination of a nonsteroidal anti-inflammatory drug, a muscle relaxant, and dexamethasone. No wonder her patient's glucose level was suddenly out of control! The resident spent the next few minutes discussing the side effects of corticosteroids, and she urged her patient to taper off the drug over the next several weeks.
The hospital was packed, and it seemed as if every patient had been admitted because of substance abuse. KS had seen several patients with alcoholic pancreatitis or cirrhosis with ascites. One patient with pneumonia suffered from delirium tremens; another was experiencing heroin withdrawal. A young woman in her teens was being treated for acute pelvic inflammatory disease, and one of the nurses had checked on her the night before, just in time to find her shooting heroin through the intravenous catheter that had been placed for antibiotics. “All in all, a discouraging day,” thought KS. But then she remembered the other patients she had seen. She thought about the courage and determination of the family who took their father home with hospice. Another family was thankful that their mother was being transferred out of the intensive care unit after bypass surgery. An elderly man could not say enough about the wonderful treatment his wife had received from the nursing staff during her lengthy stay. KS was impressed by the strength and dignity with which these families faced adversity. She wondered for the hundredth time why stress brings out the best in some people, but drives others to drugs and alcohol.
TJ, a first-year resident, finished writing a prescription for oseltamivir (Tamiflu). “This is the second case of influenza I've seen this week,” he commented to a fellow resident. “I sure am glad that I got the flu shot.” The other resident looked up from the chart he was reviewing and said, “I get the flu shot every year, too. But what are you going to do about the smallpox vaccine?” Overhearing their conversation, KS thought to herself that this question would affect everyone soon—the general public as well as health care workers. Having grown up in a military family, she had been vaccinated for smallpox several times. She had vague memories of her mother examining her arm to see if the immunization “took”. Certainly, there were several small scars to prove that they had. In the next year or so, these young doctors would have to decide whether or not to have themselves immunized, and then decide for their children. KS thought of her own children and realized she had the same decisions to make. She remembered conversations with several patients over the years who had been critical of the decision to stop smallpox vaccinations. They were more visionary than she had realized!
TD, a third-year medical student, learned that not all rashes respond to topical corticosteroids. He spent more than an hour in the emergency department working up a complex patient, who had presented with end-stage renal failure. The patient was homeless and a very poor historian. In fact, most of her medical history was gleaned from her empty medicine bottles. The student presented the case to DH, the third-year resident on the service. He described an unusual, purpuric, purplish-brown rash that covered her abdomen. “It looks awful, and I have no idea how to treat it,” the student explained. When DH lifted the patient's hospital gown, he was taken aback by the brilliant purple color of her skin. He noticed that it was the same purplish hue as the patient's sweater that was lying on the chair next to the bed. He scraped at the rash with the edge of his fingernail, and to the student's chagrin, the rash began to peel away. The patient explained that she had been wearing the same sweater every day for weeks and that it had been at least that long since her last bath. TD shook his head sheepishly as he left the examination room, saying, “At least I won't have to come up with a differential diagnosis for morning report!”
“Every time this patient comes in, I end up treating her entire family,” grumbled AR, a second-year resident. It had been a hectic morning. AR's clinic schedule was packed, and now he had two walk-ins. To make matters worse, he was on the surgery service and had received several calls about sick patients in the hospital. Actually, the patient he was evaluating was one of his favorites. She had long-standing diabetes, with complications including hypertension, renal insufficiency, and congestive heart failure. She was so pleased with AR's care, she had referred most of her very large family to his practice. Subsequently, every time she came in, she wanted to discuss her relatives' problems instead of her own. Today, she mentioned that her husband needed several prescription refills (luckily she brought in the bottles), and her sister needed a referral for laboratory work prior to her appointment next week (having lost the original paperwork). Her elderly mother had fallen but was not seriously hurt, and her daughter was getting a little more depressed—should she increase her medication? AR took a deep breath and directed her back to her own rather extensive problem list. “Have every one of them make an appointment to see me,” he suggested as he directed her to the receptionist.
“My patient is emphatic that she wants an abdominal computed tomographic scan to look for cancer,” TR, a second-year resident in clinic, explained to KS, who was the attending that day. A very health-conscious woman in her mid-40s, the patient had read a magazine article about a woman her age with ovarian cancer. The article concluded that routine abdominal scanning would have led to earlier diagnosis and a better prognosis. The patient felt well, and she had a negative family history of cancer. “I approach concerns like this by quoting the United States Preventive Services Task Force (USPSTF) practice recommendations,” suggested KS. Often, the physician can explain current practice guidelines, but if the patient remains unconvinced, she can be referred to the Web site. The easiest way to access this service is to perform a Google search with the initials “USPSTF”. The USPSTF presents concrete guidelines for cancer screening. In this particular case, screening for breast cancer (B recommendation) and cervical cancer (A recommendation) is indicated. Ovarian cancer screening for women at average risk receives a D recommendation, indicating that the computed tomographic scan should not be offered. Another reliable source of cancer screening information is the American Cancer Society (www.cancer.org).
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
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
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