Practice Diary


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Fam Pract Manag. 1999 Jul-Aug;6(7):46.

Close calls

I was greeted by a call from the hospital operator when I arrived home yesterday. A patient's wife had phoned in to tell me her husband was having emergency open-heart surgery in Napa. My own heart sank.

Ron, a 57-year-old with severe diabetes and hypertension, had been my patient for six years. Recently, a Cardiolite reperfusion scan showed a small ischemic area in the septum. Ron was asymptomatic, but I prescribed some nitroglycerin for PRN use and consulted Gregg, a cardiologist.

Gregg thought it was OK to manage Ron medically but said I should offer him the option of an angiogram. Since I had told Ron to let me know if he had any chest pain, I thought it would be all right to wait until his next appointment to discuss treatment options. His appointment was scheduled for Monday; the phone call came on Saturday.

I called Ron's home and spoke with the house sitter, who said she thought he had had a heart attack. She gave me the phone number where Ron's wife, Patty, could be reached, but there was no answer; so I called the hospital and spoke with Ron's nurse. Turns out, Ron hadn't had an MI after all. He had had increasing chest pain all month, neglected to call me and was now experiencing unstable angina. He was on a nitro drip and scheduled for an angiogram and a possible stenting procedure the next day. The nurse said Ron and Patty had spoken of me and would be relieved to know I had called. That would in no way match my relief to find that Ron hadn't lost any myocardium on my account. I vowed to find more room for diligence in my otherwise crowded workday.

Drug reps

Unlike some doctors, I actually like seeing pharmaceutical reps in my office. After all, they do leave me free samples. In the old days, they were usually middle-aged men accumulating stock options and waiting to retire, but of late most of my reps look young enough to be my children. Perhaps it's just my age talking, but I'm amused when a comely 25-year-old talks to me about the side effects of using Proscar for BPH — less so when the rep shows me a profile of my prescription-writing habits and remarks, “You write a lot of Zithromax and Norvasc,” much to my incredulity.

Still, I do so appreciate the idiosyncratic rep who reorganizes my closet while waiting to spiel and the one who brought in a picture of his 800-pound award-winning pumpkin and pasted it to my door. But the rep who amuses me most is the woman who brings me Viagra and insists that I keep it apart from the other drug samples because “other reps have been known to steal it,” she says. “You know this stuff is worth $100 a pill in Mexico because it still isn't available there.”

“That so?” I ask. “Hey, Isabel. Any chance you'll be visiting your relatives any time soon?”


My accountant, Jon, has an interviewing method (called SALY, “same as last year”) that I've emulated in my practice. Every year, when we get together for taxes, he asks the same questions: Do you still have the same number of dependents, do you have any new bank accounts, what was your gross income, etc. After 15 years, going through the return has become a snap, and we usually finish in enough time to fantasize about how we might partner up and become rich.

For my patients' yearly wellness physicals, I follow the SALY method. I begin by asking about their health concerns, and then we discuss diet, exercise and life stressors; smoking, drinking and drugs; and current problems, medications and allergies. I review the patient's medical history. Then I obtain a family history, including the names, birth dates, locales and medical problems of all primary relatives. Years later, a patient is really impressed when I ask if his brother John still has that cattle ranch in Montana.

Ordinarily, I'm bored by routines, but not for the annual physical. The constancy in approach reassures me that I'm not missing anything and leaves more time for my patients and me to get to know one another — or to think up some get-rich-quick schemes.

The art of nudging

My son started college last fall, and, thinking writing might be in the genes, I had been encouraging him to try out for his college newspaper. He procrastinated for a quarter, then spent another quarter waiting for the editor to answer his e-mail request for an interview, so I finally got on his case. Tired of the badgering, he took a writing sample to the editor and was put on the music desk. His first piece, a review of a George Clinton concert, made me proud. (“A good mosh-pit is fun, but knowing you can groove to the music without fear of some big guy dancing a jig on your spine makes the evening so much more enjoyable.”) Gabe loved his newspaper apprenticeship — and its main perk: all the pizza he could eat. Sometimes a push and a shove in the right direction isn't such a bad thing for our kids, our patients, even ourselves.

Dr. Brown is a solo family physician who lives in Mendocino, Calif. These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer.


Copyright © 1999 by the American Academy of Family Physicians.
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