Diary from a Week in Practice
Am Fam Physician. 2000 Jun 15;61(12):3594-3597.
A nurse practitioner in our group had been taught to obtain Papanicolaou (Pap) smears in all women older than 18 years, regardless of their level of sexual activity. Because our practice has many women who choose to remain chaste until marriage, JTL felt that this issue needed to be addressed to avoid unnecessary trauma to women who are not at risk of contracting genital human papillomavirus (HPV) and are consequently not at risk of cervical dysplasia. JTL brought up this issue at today's monthly clinical meeting. After reviewing the known association between genital HPV infection and cervical cancer, as well as guidelines such as those established by the U.S. Preventive Services Task Force, the group agreed that there is no indication for obtaining a Pap smear in virginal women, given that cervical cancer is almost exclusively a sexually transmitted disease. Hopefully, this brief discussion will also support our education of those patients who, before the “age of HPV,” were taught to obtain annual Pap smears regardless of the risk of sexually transmitted disease.
When one of his spunky elderly patients, Alma, was recently hospitalized in the intensive care unit for unstable angina, JTL had once again attempted to broach the topic of “do not resuscitate,” or DNR, status with her and her family, again to no avail. Any mention of the possibility of death to this already anxious 89-year-old was simply intolerable and provoked even more alarming complaints of chest pain. No, Alma has her own unique way of dealing with the finality of death, i.e., “when in doubt, get the heck out.” One morning, Alma told her nurse that she no longer wanted to be hooked up to the monitors, and was informed that she could not make that decision. “Oh, yes I can!” responded Alma, who proceeded to take off her monitor leads, one by one. The patient ultimately was discharged to her home that same day, and her family shared this story with JTL, who realized that, at times, there is simply no point trying to convince elderly patients that they need a DNR status. Patients like Alma will die when they are good and ready, and quite likely not a moment sooner. And that is truly an admirable trait.
Certain diagnoses, over the course of a lifetime practice, are continually intriguing. For JRH, one of these is temporomandibular joint (TMJ) syndrome. Occasionally, JRH has had success with the use of amitriptyline for TMJ syndrome, especially if he suspects nocturnal bruxism. Today was the third day in a row that JRH saw this particular patient for jaw pain. On the first visit, this normally cheerful woman of 43 years came into the office complaining of severe jaw pain all the way from the right side to the left. It had started after a trip to the dentist for a cleaning and examination. “How bad is the pain on a scale of zero to 10?” JRH inquired. In dead earnest she replied, “15!” So JRH proceeded to give her intravenous dexamethasone and sent her home on oral ketorolac tromethamine. On day 2, the pain had diminished to 6 on a scale of 10 and was unilateral. Next, JRH tried an injection into the joint on the painful side with a mixture of a steroid and lidocaine. This gave her immediate and complete relief. The third day she returned and was very happy to report her pain level at 0.5 on a scale of 10. When discussing this sequence of events with a colleague, JRH was encouraged to consider another option next time: osteopathic manipulation therapy.
Another of the roles of the family physician is to be able to use lessons learned from one patient encounter to benefit future encounters. In caring for two of his young female patients with hyperhidrosis, JTL had hoped to be able to one day offer a remedy other than “Dry-Sol.” Today, he met with one of his teenage patients who had long been afflicted with this condition. It was so bad that she had to have a towel handy at all times, simply for the purpose of wiping the perspiration from her palms. Today, on shaking her hand, JTL immediately noted the dry palms and her smile from ear to ear. She had had a procedure known as endoscopic transthoracic sympathectomy (ETS), also known as thorascopic sympathetic trunkotomy. JTL looks forward to learning more about this procedure and sharing the information with his two other patients with hyperhidrosis. At the end of the office visit, he again enjoyed a warm, dry handshake with a most delighted patient.
As often as we can, we like to offer our patients more than one way to get from point A to point B in their journey of achieving or maintaining optimal health. This not only challenges us to think in new directions but also allows our patients to become collaborators in their health care. Today, a young woman came in for an endometrial biopsy, having already chosen to forego a dilatation and curettage. Another choice offered her was whether to have JRH use a tenaculum. She chose to have the biopsy taken without the tenaculum, noting that this part hurt worse than the biopsy when it had been performed in the past. Unfortunately, JRH could not get the curette into the cervical canal (even when “stiffening it up” by dipping it in ice-cold sterile saline). After being told by his nurse that we had no endocervical probes with which to gently dilate the stenotic cervical os, JRH explained to the patient that he would have to use the tenaculum, but told the patient that he could numb the cervix using a topical anesthetic spray. JRH used the tenaculum without patient discomfort and obtained the needed tissue. However, afterward, he thought of another way: perhaps by using a circumcision probe, the endocervical canal could have been induced to open and allow passage of the curette. Alas, another option for another day!
“Which plan should I choose, Doc?” is a question JTL seems to be hearing more often these days. Because one of the leading health care plans has recently announced that it will no longer cover anything other than generic prescription drugs, JTL has been asked to rewrite dozens of prescriptions, completely changing patients' medication profiles, so as to save these patients some money. This weekend, after yet another patient requested his assistance, JTL simply stated that he could no longer change his approach to medicine to meet the unique demands of each patient's insurance plan. Visiting with WLL, JTL expressed his frustration over these increasingly frequent scenarios. JTL was appreciative of WLL's advice, paraphrased as follows: “I consider my most important role to be that of the patient's physician, and therefore I provide them with what I believe to be the best medical therapy. It's up to the patient to select the insurance plan that allows me to be their physician and allows them to follow my plan of therapy.” So the next time a patient asks JTL, “Which plan do I choose, Doc?” his response will be, “Choose the plan that allows me to be your doc!”
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