Diary from a Week in Practice
Am Fam Physician. 2002 Feb 15;65(4):591-593.
AT, a third-year resident, was performing a flexible sigmoidoscopy on a 72-year-old woman. Two faculty members were closely studying the images appearing on the television monitor. “I easily passed the scope to 60 centimeters,” explained the resident. “There were no polyps or lesions, but the colon has this unusual appearance all the way up.” TA, one of the faculty members, identified the unusual pigmentation as melanosis coli, a reversible, benign condition caused by the deposition of dark pigment in the colon from long-term laxative use. After the procedure was completed, TA went to the Internet to locate some patient education information on the condition. Using a search engine, she typed in the term “melanosis coli” and was linked to a Web site (www.gastrolab.net/ku29.htm). In less than one minute, TA printed a brief description of the condition and color pictures, reviewed them for accuracy, and then gave them to the patient. After reading the description, the patient said she felt reassured, and she also vowed to do a better job of maintaining a high-fiber diet. How quickly the Internet has enhanced our capacity to educate patients!
JM, a third-year medical student, was presenting a case to MM, the faculty member in the clinic this morning. “This is a six-year-old boy who has a lump in the left groin area,” he stated. He went on to explain that the child's father had noticed the lump two days earlier while bathing his son. The student described in detail the child's unremarkable medical history, his family and social history, and his developmental milestones. Finally, MM had to ask about the lump, which she suspected was an inguinal hernia. JM rather sheepishly admitted that he could find no evidence of a hernia on physical examination. When MM and JM examined the child together, the boy blurted out, “It gets really big when I cough.” And, indeed, with a hard cough, a large inguinal hernia ballooned outward. Outside the examination room, JM described the experience to another student. “I didn't even think to ask him to cough. That six-year-old knew more about his hernia than I did,” he concluded. MM was glad to have overheard that conversation. She thought that any student willing to learn from a six-year-old patient will have a successful career in medicine.
BE hung up the telephone, turned to KS, the faculty member in the family practice clinic, and commented, “Handling the obstetrical patients in the jail is quite a challenge!” After completing her family practice residency, BE stayed for a one-year obstetric fellowship. Among her many duties is making weekly visits to the county jail where she sees about 10 pregnant women each week. She explained that she was currently treating a patient in the small jail infirmary who was about 24 weeks pregnant. The patient was receiving intravenous fluids and ampicillin/sulbactam for pyelonephritis. This is a good arrangement for patients who are mildly to moderately ill, and it often saves the expense and difficulty involved with hospitalizing these patients. “The women are always glad to see me and are so appreciative. I usually see every patient every week, and that amounts to pretty good obstetrical care,” BE said.
TA, the faculty member on the inpatient service, was making rounds with a first-year resident, RR. They were examining a 38-year-old man with a terminal brain tumor who had taken a turn for the worse several days earlier. Now he was completely unresponsive with agonal respirations. The patient would likely die within the next few hours. His family was in the room, and TA was glad to see how RR had developed a rapport with them during the week that he had been caring for this patient. RR took time to answer family members' questions and reassure them that their loved one did not seem to be suffering. As the physicians left the room, the resident turned to TA and asked, “When he dies, what should I do?” TA realized she had assumed that this first-year resident knew how to pronounce a patient “officially dead.” Later that afternoon during rounds, TA led a detailed discussion about this issue including how to talk with the family, write a death note on the chart, and fill out a death certificate. She reflected on how often she has to remind herself that the new residents have not had the experiences that are so routine to the faculty members. Residents are taught a lot about keeping people alive, but not very much about easing terminal patients through dying and death.
Yesterday, BG, a second-year resident, accidentally grazed the tip of his finger with a solid-bore needle while suturing a laceration in the emergency department. The patient, a middle-aged man who had cut his hand with a knife while cleaning fish, had no risk factors for human immunodeficiency virus (HIV). BG immediately reported the exposure to the emergency department physician and was assessed according to hospital policy. The injury—a superficial laceration from a solid-bore needle containing a small amount of blood from a low-risk source—carried a fairly low risk of exposure, but prophylaxis was initiated within two hours. BG began a basic regimen for postexposure prophylaxis of HIV consisting of zidovudine and lamivudine (MMWR 47 [RR-7]; 1–33; May 15, 1998). Today, the laboratory confirmed that the patient source was negative for HIV, and treatment was discontinued. When BG met with his faculty adviser, he described how stressful the incident had been for his wife and him.“I knew that the risk of contracting HIV was essentially zero,” he said,“but I am surprised at how upset I was until the test results came back.” He went on to say that being the patient instead of the physician gave him insight into the often unwarranted anxiety that patients feel while waiting for laboratory results. BG vowed to make more of an effort to pass on normal results in a timely manner.
RE, the director of the family practice residency program, was pondering over his trip to the quarterly State Higher Education Coordinating Meeting in Austin earlier in the week. Although the three-hour drive was tiresome, he had enjoyed meeting with directors from other programs around the state. While at the meeting, RE was asked to give a presentation titled “Words of Wisdom for the Success of a Residency Program” at the 2002 Texas Medicine Leadership Conference. After five years as director of our program, RE finds it a little ironic that he is one of the senior residency directors in the state. He considered what he might say in his presentation.
RE thought that the most rewarding aspect of the director's job is resident education. One mistake he thinks many directors make is policing the residents rather than training them to be the best family physicians possible. The days RE is scheduled to see patients in the morning and oversee residents in the clinic in the afternoon are the most pleasant ones!
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