May 1999 Table of Contents

Practice Diary

Excerpts From a Family Physician's Journal



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Fam Pract Manag. 1999 May;6(5):48.

Endurance

The last patients of the day are sometimes the most trying. Yesterday, I had a new patient with complex medical problems that I began working up at 4 p.m. She is 45 years old and has had a four-day history of chills, low-grade fever and shortness of breath. Initially it looked like pneumonia, but I wanted a chest film to confirm the diagnosis. It was 5 p.m. before the radiologist called me back and said the X-ray showed congestive heart failure. This was not going to be a prescription for antibiotics and a two-day follow-up; this was a full-on hospital admission. It was another two hours while I consulted a cardiologist, had the patient admitted, started her treatment and ordered tests. I left the hospital exhausted.

Over the years I've learned that, at the end of a long day, it's easy to feel tired or distracted or just want to be somewhere else, but it pays to be thorough regardless of how I feel. The alternative, not spending enough time and not doing the right thing for a patient, is much more stressful in the long run.

My role model in this regard was Everett Forrester, a 78-year-old massage therapist. The first time I employed him to work on my weary bones, I was his last appointment of the day. I figured that, after the 10 or so massages he'd already done that day, he'd be spent. He wasn't. Every client, from first to last, was treated to the same service no matter how he felt. That concentration and consistency, I believe, are part of what it means to be a professional.

Malpractice

I hate getting letters from lawyers. When one arrives, I can almost hear the music from Jaws playing in the background. That happened today. Fortunately it was just a request for the records of one of my patients who had a workers' comp injury. In my career, I've been lucky. I've never been sued or even had my deposition taken, but I once received an intent to sue from an attorney who had the wrong doctor. It took me days of going through hospital records to establish I had never even seen his client (turns out it was Dr. Black, not Dr. Brown).

I take malpractice very seriously, but I also recognize that I am human and I make mistakes. If I make one that adversely affects the health of a patient, that patient is entitled to damages (just as a person would be entitled to damages if I inadvertently backed into his or her car). That's why we carry insurance. It doesn't mean we're incompetent, just responsible.

Diets

I was discussing hospital gossip with my orthopod friend Dave over breakfast when the waiter came to take our order. “I'll have the eggs Benedict,” I said, “with a side of cinnamon toast.”

Dave said, “I'll have oatmeal — plain.”

“Are you watching your diet?” I asked.

“Well, I've just begun to feel better listening to what my body tells me to eat,” he said.

“You know, Dave,” I began, “ my body tells me things, too. It tells me to eat cheeseburgers when I don't have enough cholesterol to make cell membranes and to have a donut every morning to jump start my brain, but it never tells me to eat oatmeal.”

One of our colleagues, I learned, was on the 20 g per day carbohydrate diet. She could eat a hamburger, but without the bun and ketchup, or liver and onions without the mashed potatoes. I couldn't believe what an infinitesimal amount of sugar that was — just barely enough to put a spoonful of honey into my morning tea. It seemed good advice for diabetics, but not for folks with adequate insulin response.

My approach to diet is very simplistic: If you're hyperlipidemic, eat less cholesterol and saturated fats; if you're hypertensive, eat less salt; and, assuming you're not adipose deficient, consume fewer calories. Add a liberal dose of exercise. Seems to work for my patients and me.

Electronic data

Long before the year 2000 computer bug surfaced, I was fretting about my electronic data. In fact I'm paranoid about losing it and go to incredible lengths to protect it. On a daily basis, alternating between a Monday-Wednesday-Friday tape and a Tuesday-Thursday tape, I back up my office computer files and, once a week, put that information onto another machine that I use for patient education and my wellness program. Then, on Fridays, I take the Monday-Wednesday-Friday tape home and update my home computer as well. The rest of the week, the tapes live in a small safe — guaranteed to withstand temperatures of 1,600° F. And my computer has a battery-powered backup to protect against brownouts and surges.

Why do I do all this? It's hard to feel comfortable with digital information (versus paper) because you can't physically touch it. It's kind of like doing a laparoscopic cholecystectomy: When something goes wrong, you just want to put your hands in there and fix it, but you can't. So I guess I'm stuck with an elaborate backup ritual, but at least I sleep well at night.

Dr. Brown is a family physician in solo practice. He lives in Mendocino, Calif.


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