Diary from a Week in Practice
Am Fam Physician. 2004 Jun 15;69(12):2814-2817.
Waiting for patients to come out of the operating room can be stressful for family physicians. KS had seen her 80-year-old patient in the holding room just minutes before he was wheeled into the operating room. He had been diagnosed with colon cancer on routine colonoscopy just two weeks earlier. “I’ve never had a stomachache in my life,” was his only comment when she had discussed the pathology report with him and his wife. Actually, he rarely was ill and was lucky enough never to have spent the night in the hospital. He had experienced a transient ischemic attack several months earlier, but he had fully recuperated. He enjoyed a full, active life. Aside from his age and well-controlled hypertension, he was at low surgical risk and was expected to do well. Still, KS was happy to see him later that afternoon sitting up in a chair, awake and alert. The procedure had gone smoothly, and on the initial report, the tumor was well localized. “My stomach finally hurts,” he complained, then added, “but I am glad this is over.” KS was glad, too. “Why did I worry so much?” she asked herself as she headed home. The answer was that as much as she enjoyed being his doctor, she also liked him quite a bit as a person.
KS’s nurse paged her during nursing home rounds one afternoon to report, “One of your patients was bitten by a wild raccoon last week, and he wants to know what to do.” The wound had healed completely, but the patient had read something about rabies and became concerned. KS had a vague notion that raccoons carry rabies, and that he needed some combination of rabies shots and rabies immune globulin—the sooner the better. She finished with a patient at the nursing home and went directly to the office to do an Internet search. The Centers for Disease Control and Prevention Web site (http://www.cdc.gov) quickly told her everything she needed to know. All wild raccoon bites are considered high risk for rabies transmission. The patient needed to have one dose of rabies immune globulin and a series of five rabies immunizations. KS called the Texas Department of Health (TDH) and was immediately connected to a knowledgeable woman who recommended that the patient go directly to the TDH to pick up the medications. He should then take them to the clinic to be administered that afternoon. After making a few more telephone calls and faxing the prescriptions to the TDH, KS was ready to go back to the nursing home. All in a day’s work!
“Of course, I will continue to be his doctor if you take him home from the nursing home,” reassured KS. “I just would like you to think it over a little longer.” One of life’s most difficult decisions is how and where to care for frail family members who need 24-hour-a-day care. This couple had been married for more than 50 years. The wife was in perfect health, but at age 82, she was overwhelmed by caring for her husband who had Alzheimer’s dementia. They had managed until one month ago, when he fell and broke his hip. After surgery, he was transferred to the skilled nursing unit at a long-term care center. It was not surprising that the patient became somewhat more confused. He repeatedly called out for his wife, and worried about going home. He was unable to walk. Now confined to bed or a wheel chair, he was completely dependent on staff for all activities of daily living. Despite all of this, he was settling in fairly well—he enjoyed his daily meals and sitting outside in the garden of the nursing home. It seemed to KS that it was his wife who found the arrangement most difficult. As KS talked to her, it became clear that she was lonely and was having trouble adjusting to living alone. “It is not easy for you,” KS said, “but no matter what you decide, I will help you as best I can.”
“I worry when patients gain weight, and I worry when they lose it,” KS said to her nurse. Through strict calorie counting and a rigid exercise routine, her patient had managed to lose 82 lb since her last visit one year earlier. She looked wonderful, and felt even better. Her blood pressure was normal, and her blood glucose levels had dropped 14 points. Still, KS felt the compulsion to do a quick review of symptoms to make sure some dreaded occult illness was not responsible for the makeover. Her patient had started laughing and reassured her that the weight loss was the result of hard work and determination. “I still have to lose 32 lb to reach my goal,” she added, “and by the time you see me again, I will be there.” KS and her staff congratulated her for a job well done. By changing her lifestyle, this woman had added more years to her life than any medical treatment imaginable.
“You cannot get addicted to this medication,” KS explained. “And as a matter of fact, if you don’t take the pill every day it won’t work for you.” She had diagnosed this 32-year-old patient with generalized anxiety disorder (GAD) and was trying to persuade her to begin a selective serotonin reuptake inhibitor. Like many anxious patients, the young woman was concerned about the side effects, and even more concerned about the addiction potential. KS patiently reviewed the side effects for the third time, and reassured the young woman that the medication was generally well tolerated and effective. She discussed alternative treatment, including counseling, which the patient would not even consider. “I just think I should be able to deal with these problems on my own,” she repeated. At her last visit, KS had explained that GAD was caused by an imbalance of neurotransmitters in the brain, and that she probably was born with a tendency to develop this disorder. As she repeated this, her patient nodded and admitted that her mother and sister had many of the same symptoms. Like many patients with GAD, she added the thought of taking daily medication to her already lengthy list of worries. “At least try it,” KS encouraged her patient, “and if it doesn’t work for you, stop it and let me know.”
Today, KS waited more than an hour for a scheduled appointment. The receptionist apologized several times, and she had ample time to read the signs in the waiting room reminding clients that delays often are unavoidable. Those same signs hung on the walls of her own family practice center waiting room, so KS did, in fact, understand. As the minutes stretched on, however, it was only natural to feel a little annoyed and impatient. Patients often complain about the long wait in their doctor’s office. Most people realize that there is no perfect appointment system. She spent some of the waiting time thinking about how to make her practice run more efficiently. One way would be to cut down on the dozens of telephone calls the office staff manages every day. After playing “telephone tag,” busy patients often suggest that they correspond via e-mail. KS has been hesitant to add yet another form of communication to her already busy workload. Furthermore, there were concerns about confidentiality and privacy communicating with patients “online.” She had spoken with doctors who were implementing the “e-mail office visit.” In her own practice, many patients simply did not have one half-day every three months to spend in the doctor’s office. E-mail seems like an ideal way to communicate with patients who have chronic problems such as diabetes and hypertension. Another step closer to the “virtual visit.”
Copyright © 2004 by the American Academy of Family Physicians.
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