Diary from a Week in Practice
Am Fam Physician. 1998 Mar 1;57(5):987-991.
At the beginning of one's career as a family physician, it seems that all of the consultations are one-sided; that is, all of the consults go out and none come in. However, as time passes and our colleagues begin to know us, a shift toward a balance between in and out is evident. How this happens is immaterial—it's just nice to be respected for what we do. Today, JRH was asked to do a liver biopsy on one of his patients. The request for consultation came from her rheumatologist, who practiced a couple hours' drive away. Previously, JRH had used a 16-gauge Jamshedi needle that comes with the standard tray in our hospital. Today, however, no tray could be found. Since considerable effort had been expended transferring her from warfarin to heparin and then stopping the heparin at midnight, JRH felt compelled to proceed. Choosing a 20-guage spinal needle, a thinner, but adequate core of tissue was obtained and sent off to the hospital laboratory. Afterward, JRH reflected on how true it is that “Necessity is the mother of invention!” JRH was grateful to be able to help both the patient and the rheumatologist.
A recently retired 65-year-old woman returned to TBS for follow-up of her type 2 (non–insulin-dependent) diabetes, which was controlled with oral hypoglycemic medication. She had been traveling across the country and reported having trouble with hypoglycemic episodes because of irregular meals. She found it inconvenient to have orange juice available at all times in the car. However, she had found a solution. She showed TBS a jelly bean about 3 inches long and 1 inch wide that she had bought in a candy store in Gatlinburg, Tenn. She eats one of these when her symptoms start, and it works great for her. TBS was a little hesitant to agree with this solution, but when the woman stated she had bought 10 lbs of these to take on her future trips, TBS knew she would have trouble convincing the patient not to use them.
Recently, JSR learned the validity of a well-known medical axiom. A five-year-old boy presented with his grandmother. She said he had been persistently clearing his throat for the past two days. “This is how all of my children were when they had strep throat,” the grandmother replied when JSR appeared puzzled at her request for a strep screen. The test was obtained and, as an explanation of viral illnesses was being given, the nurse interrupted with news of a positive strep test. The child was treated, but JSR was still not convinced he hadn't happened on a strep carrier or a false-positive screening test in a patient with another explanation for his symptoms. However, a follow-up phone call a few days later confirmed that the child's persistent throat clearing had stopped. Another example of what has been often said, “Always listen to the (grand)mother!” Or, as WLL says, “The two most important words for a physician to learn are, ‘Yes Ma'am.’ ”
SEF has been told that part of the art of being a physician is to appear wise even when unexpected things happen. She experienced just such a case today. A 42-year-old man presented with an infected sebaceous cyst. SEF was going to try incision and drainage of the lesion, but during the course of the procedure, she decided to completely excise the cyst. While 1 percent xylocaine for local anesthesia was being injected, the pressure of the xylocaine pushed out the contents of the cyst and its lining with quite a bit of force and in one neat package. The art of appearing to be wise came into play while trying to explain that this is a new technique for evacuation of a cyst.
Several months ago, JRH performed an office circumcision on a six-week-old infant, using just a papoose board, a penile block and 16-gauge closure with 5.0 chromic suture after removal of the foreskin with a 1.6 mm Gomco. All went well, and all parties were relieved and pleased. Emboldened by this success, JRH performed an out-patient circumcision last month on a three-year-old, using the same technique. Once again, all went well, but this procedure required a bit more lidocaine for the penile block than the earlier procedure. Today, the three-year-old returned for his last postoperative check-up. All of the stitches but two had dissolved, and the postoperative swelling of the penile shaft was gone. Later, as JRH mused over how well things had gone, he thought about two aspects: first, young children tolerate this procedure much better than adults do, and, second, it might be time to revise the maxim that any circumcision performed on a child over three months of age needs to be done under general anesthesia and by a urologist.
As a family physician ages, it is said, so does the family physician's practice age. For family physicians who deliver babies or who provide antenatal care, and who tend to have more complete families and more children in their practice, the aging practice allows the aging physician to see and follow growing families. One young high school girl came to WLL nearly 15 years ago. She was rebellious and angry at life. Eventually, the experiences of becoming a single mom, surviving bump after bump in life and then returning to school to get her education and returning to her church to regain her spirtuality provided her with both a meaningful vocation and faith. She married a wonderful man and had three more children. Recently, she sent a thank you note to WLL and JRH for their support and care of her family. The encourging words were written on the back of a picture of her family. This picture has now been carefully placed with others. WLL calls it his “portfolio.” Her note was as profound as it was heartening. No paycheck, no salary, no employee benefit can begin to provide so much wealth or satisfaction as the family doctor/family relationship.
Copyright © 1998 by the American Academy of Family Physicians.
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