Diary from a Week in Practice
Am Fam Physician. 2001 Jul 15;64(2):256-259.
Very early this morning, two of JTL's multiparous patients—at separate hospitals, about 10 miles apart—went into labor, and, at about 5-cm dilation, requested epidural anesthesia. Although it was 3 a.m., rather than give the order for the epidural (and remain in bed), JTL chose to visit each of his patients and then determine the most appropriate course of action. Arriving at the hospital at 3:30 a.m., JTL found his first patient with a “paperthin” cervix (dilated to 6 cm) and bulging membranes. After artificial rupture of the membranes (AROM) was performed, JTL asked all present to wait one hour before proceeding with the epidural. At the next hospital, JTL encountered an almost identical situation. After AROM was performed, JTL was paged back to the first hospital with the words, “Patient ready to deliver.” JTL arrived in time to deliver the first baby into the arms of a most gratified mother with little difficulty. Returning promptly to his second patient, JTL was able to escort another healthy baby into the world, within one hour of AROM. JTL hopes that physicians appreciate the impact they might have in reducing a patient's desire or need for epidural anesthesia, simply by being actively present during the mother's labor.
We have all struggled with patients with multiple risk factors who smoke and are not ready to quit. Luckily, we have also had enough success that we keep trying to help our patients. During her years as a physician in the military, ASW witnessed what so many studies have found—that adjunct therapies for tobacco cessation are much more successful when tied to a program stressing behavioral intervention techniques. An extensive questionnaire is filled out by each patient and reviewed during a one-on-one interview by a trained technician who then offered specific behavioral interventions for each patient. Each patient also participates in group sessions that are educational and offer a support network for them in their efforts to quit smoking. The patients are then seen by the physician who would prescribe the appropriate adjunct therapy and be available for further support. ASW hopes to see more insurance companies start covering these programs that, if they can lead patients to quit smoking, will clearly be cost-effective in the long run as well as being the right thing to do for our patients and their families.
Today, one of JTL's patients inquired, “Why didn't you visit me at the hospital?” She proceeded to describe her recent cardiac catheterization, during which she developed a life-threatening arrhythmia requiring two days of hospitalization. JTL had initially referred the patient to a new cardiologist for a screening treadmill stress test and had not heard the results of the test, which apparently were positive, leading to the cardiac catheterization. JTL was disappointed to hear the details from his patient rather than the consulting cardiologist. Later, another patient referred to the same cardiologist told JTL about her coronary artery bypass graft and pacemaker insertion. Again, this was after a routine consultation and without JTL's knowledge. JTL wondered whether this “failure to notify” the family doctor on the part of the consulting cardiologist stemmed from the practice by many family physicians to disengage from patient care once hospitalization occurs.
Consultants are genuinely surprised to find that we actually care to know how our patients are doing, not to mention managing the patient while they are hospitalized. JTL wrote to the new cardiologist, explaining his desire to be notified of the consultant's recommendations and, in particular, to be made aware of any scheduled inpatient procedures.
JRH remembers, with perhaps too much clarity, the days of treating deep venous thrombosis with intravenous heparin and chasing the elusive therapeutic window with endless partial thromboplastin times. Today, just such a patient presented with the same diagnosis, but JRH decided to treat him in a new and different way. Checking first for risk factors and contraindications, JRH selected a low-molecular-weight heparin in a dose appropriate for the patient's body size, a choice more conducive to the patient's lifestyle and his much-voiced abhorrence of hospitals. Soon he was off to the pharmacy to pick up his shots to be given twice daily, happy that he could be treated as an outpatient.
Although WLL would love to see the practice use computer technology in patient care, especially email communication with patients and pharmacies, most doctors in the group have been reluctant to move in this direction. WLL appears to be in the minority, at least when it comes to physician opinion. A recent survey showed that a majority of consumers already using the Internet would like access to their doctors online, especially for nurse consultations and laboratory test results. Surveyed doctors were skeptical that online interactions with patients could be effective without cutting into their office time with patients. About three fourths of more than 1,000 consumers questioned said they would go online to use a nurse triage service to help them manage chronic illness. More than 80 percent in the survey said that they would like to have laboratory tests results available or to receive health-related alerts reminding them of influenza shots and other issues. On the other hand, more than 80 percent said they preferred to use the telephone to schedule appointments, get prescription refills or make payments. The doctors surveyed were concerned that regular e-mail from patients would cut into the time for face-to-face patient care, feared the erosion of the traditional doctor-patient relationship and were concerned about providing further time-consuming services without reimbursement.
ASW was recently looking at the photographs she took during her last medical mission trip to Guatemala. As she sat on her bed quietly glancing at the pictures, her son joined her and started asking questions. He wanted to know why there were so many sick kids. He wanted to know what was wrong with the six-year-old girl with opaque corneas (probably from the highly prevalent infection onchocerciasis causing “river blindness”). He commented on the large eyeglasses that some of the Guatemalans were wearing, sometimes quite large for their small faces, which they were so glad to receive as donations from our medical team. He wondered why so many people had no teeth or dark teeth. ASW enjoyed sharing the pictures with her son and teaching him at an early age about sharing our resources with those in need. By the last group of pictures, however, she was having trouble holding back her tears. As she answered his innocent but poignant questions, she gave thanks for his health and that he has always had everything he needs.
Copyright © 2001 by the American Academy of Family Physicians.
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