Diary from a Week in Practice
Am Fam Physician. 2003 Aug 15;68(4):645-646.
“The medication does help, and his schoolwork has improved,” explained the first grader's mother. “But, after three or four hours it wears off, and he is even worse than before.” TA had been this child's physician since he was a newborn. The parents had been reluctant to diagnose their son with attention-deficit/hyperactivity disorder and had struggled through two difficult years of school. Finally, with TA's help, they had decided on a trial of methylphenidate (Ritalin), 5 mg, before breakfast and lunch. His parents and teacher noticed an immediate improvement in his behavior. “For the first time, we have been able to sit through an hour of church without being at our wits' end,” his mother commented. A common problem with short-acting drugs is that the child may experience a rebound effect when the medicine wears off. New, long-acting formulations allow a short burst of medication to be released immediately, followed by a slow, steady release during the day. The child does not exhibit extremes of behavior, because the blood level of methylphenidate remains relatively constant until bedtime, when levels are back to baseline. “You have made this so much easier for us,” the mother told TA as she took the new prescription. “I never would have trusted a physician who didn't know my son as well as you do.”
Sometimes, KS does her best thinking in the car. Today, the case she was considering involved a 67-year-old woman who had been diagnosed with Parkinson's disease two years earlier. A low dose of carbidopa/levodopa (Sinemet) controlled her symptoms fairly well. KS had been surprised when she first met the patient about six weeks ago, because the dosage of her medication had never been changed. What surprised her even more was the telephone call from the patient's sister, explaining how forgetful the patient had become in the past year. She also was experiencing visual hallucinations. Both women came to the next office visit, and KS performed a Mini-Mental State Examination. The patient scored 22 out of 30, confirming a mild to moderately severe dementia. KS explained to the sister that about 10 percent of patients with Parkinson's disease develop dementia. But, she continued to puzzle over the case because the patient's parkinsonian features seemed fairly mild. Stopped at a long light, it suddenly became clear that the patient suffered from Lewy body dementia. Memory loss, parkinsonian features, and hallucinations characterize this form of dementia. When she finally got through the traffic light, KS began to formulate a treatment plan.
Today, third-year resident AG saw an unusual case of dyspnea on exertion. His 64-year-old patient had multiple medical problems, including coronary artery disease and diabetes mellitus. A recent chest x-ray and routine laboratory tests were normal, and his electrocardiogram was unchanged from a year earlier. Two years ago, the patient had been diagnosed with squamous cell carcinoma of the throat, and he had undergone extensive surgery and radiation therapy. He had a tracheotomy, and he spoke well with a talking machine. AG noticed that he was holding his chin up with one hand—his talking machine with the other. On closer questioning, the man said that his neck muscles seemed to be getting weaker, and his head drooped when he walked, blocking off the tracheotomy site through which he breathed. On examination, the patient did have weakness of his neck muscles. There was no obvious mass lesion in the neck, but the patient was referred to an ear, nose, and throat specialist for an evaluation, and to physical therapy for an exercise program. AG was impressed by this patient's sense of humor despite his disability. Walking out the door, the patient turned to AG and cracked a joke: “I only ask for one thing—don't tell me when I am dead!”
“I am embarrassed to turn these chart audits in!” said second-year resident, JR. “I thought I was doing a lot better at preventive medicine.” One of the requirements for the resident on the geriatrics rotation is to review the charts of five of his or her own patients who are more than 65 years of age. The audit focuses on preventive services, including cancer screening, immunizations, and living wills. KS was not surprised at his reaction, having heard the same comment many times before. One reason physicians do not discuss prevention is a lack of time. Many patients have a lot of complicated medical problems, and it's easy to overlook simple measures such as pneumococcal vaccine. Other times, patients refuse services—such as colon cancer screening—and clinicians give up trying to convince them. One thing these simple chart audits confirm is that many times physicians think they offer more preventive services than they actually do. But KS does not mind, because making physicians aware of how they comply with medical guidelines is the whole reason behind chart review. “Don't be embarrassed about your charts,” she reassured JR. “Focus instead on improving patient care.”
A gorgeous bouquet of flowers sat on her desk when she got to work that morning. The note was simply signed, “Many thanks for all of your help!” It was such a lovely gesture from a patient that TA had seen on and off for several years. Like many patients, her insurance changed every couple of years, and the patient was obliged to see other doctors when TA was not on the current plan. The patient had come back a few weeks earlier after two years with another group. On that visit, TA ordered a routine mammogram, which revealed a suspicious area. The area was biopsied and, luckily, pathology revealed a benign fibroadenoma. The entire experience had been very stressful for this 42-year-old woman. “I am so glad I had you back as my doctor,” the patient explained when TA called her to thank her for the flowers. “I liked my other doctor, but I never got to know him as well as I know you.” Indeed, it is unfortunate when patients must change doctors every few years. They often compare one doctor with the next and may be unhappy with their care if it is not identical to that provided by the previous doctor. In this case, either doctor would have done a good job, but the ongoing relationship with TA during the years made all the difference to the patient.
“Mom, come quick! We have an emergency,” shouted three children running out the front door. KS had just driven up and was unloading groceries when she heard the commotion. Then, she saw the parents of her 12-year-old son's best friend hurrying up the sidewalk and realized that there had been some sort of minor disaster involving their son. The two boys had spent the afternoon making swords out of PVC pipe, foam padding, and masking tape. During the inevitable sword fight that followed, her son struck his friend in the lip, which became hung up on the braces on one of his lower molars. The metal wire could be seen protruding all the way through the boy's lip. KS assessed the damage and decided that the lower lip could be unhooked without much difficulty. She found a flashlight and a popsicle stick, enlisted the help of the boy's dad, and between the two of them, they wiggled the wire free. The boy's father actually performed most of the “surgery,” while KS held the light and retracted. “A good assistant is invaluable!” she said to the dad. Both boys wear braces, and now they know the value of wearing their plastic mouth protectors, which were in their bedrooms instead of in their mouths.
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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