Diary from a Week in Practice
Am Fam Physician. 2002 Jul 1;66(1):73-42.
Errol, an elderly man of above-average intelligence, was in my office today for follow-up of his chronic obstructive pulmonary disease. Three months ago I had prescribed for him a combination metered-dose inhaler of ipratropium bromide and albuterol sulfate (Combivent). He had been reluctant to start any medication for his breathing problem, so I was curious as to how much better he might be. “How is that inhaler working for you?” I asked. “Like a charm,” Errol replied. “A couple of squirts in my nose four times a day, and I’m breathing like a kid again. You’re a genius, Doc.” Surely I misunderstood him. “In your nose?” I asked. He nodded and pantomimed with his hands how he sprayed the medication into his nostrils. I’m not sure who was more embarrassed—the patient, who for three months had been inserting the medication canister into the wrong body orifice, or his physician, who assumed the man understood the proper technique and therefore failed to demonstrate it. Now that I have carefully reviewed the use of the inhaler with Errol, I suspect his breathing really will be much better when he returns.
Apparently, patients aren’t the only ones with great expectations. I met with a young couple today to initiate a work-up for infertility. Both the husband and his wife had normal findings on physical examination. The woman was already keeping a basal body temperature chart to determine her ovulatory cycle. I recommended that the man undergo a semen analysis. I gave him some instructions and handed him a sterile specimen container that happened to be in the examination room cabinet. He squinted at the 4-oz plastic container and then rolled his eyes back. “Do I have to completely fill this up?” he asked with an incredulous look on his face. Immediately realizing the impossible task the size of the container had conjured up, I quickly replied, “Oh no. Only a small sample is necessary.” The obvious sense of relief on the man’s face was soon replaced by loud and sustained laughter—first his, then mine, and finally his wife’s. Doctors frequently send unintended signals to their patients. We should probably not expect more from them than we would from ourselves.
I admitted an elderly woman to the hospital after she came to my office describing a five-day history of nausea, lower abdominal cramping, and constipation. Although Zelma had been a patient of mine for a number of years, I hardly ever saw her in my office. As I dictated her admission history and physical examination, I recalled that she had not used the word “pain” when describing her symptoms. In fact, throughout all the years I had known her, I did not ever remember her using the word “pain” or “hurt.” Perhaps her high tolerance for pain, or denial of it, had something to do with her delay in seeking medical assistance this time. A computed tomographic scan of Zelma’s abdomen and pelvis demonstrated a large amount of free intraperitoneal air. She underwent emergency surgery where extensive diverticular disease with a ruptured colonic diverticulum was found, along with intramural and pericolonic abscess. A long segment of sigmoid colon was resected, and a temporary colostomy was performed. Zelma had a lengthy hospital stay, but she never complained. I cannot imagine how she must have suffered those few days before entering the hospital. Some people are just born tough. Yet, there are times when those same individuals are too tough for their own good.
We all have “borderline” patients in our practices. No, I’m not talking about those with borderline personality disorder. I am referring to patients with mildly abnormal laboratory findings. For example, Norma is a 77-year-old woman whose blood values have been a bit off-target for the past few years. She tends to worry about everything. In addition to essential hypertension, osteoarthritis, and hypothyroidism, she also has mild anemia, slightly decreased renal function, and mild hyperlipidemia. In an effort to make these latter diagnoses more palatable to Norma and spare her unnecessary anxiety, I had gotten into the habit of referring to these out-of-normal-range laboratory results as “borderline.” As we reviewed her most recent blood tests today, Norma posed an interesting question. “I already have borderline hyperlipidemia, borderline renal function, and borderline anemia. What happens to me if everything becomes borderline? Or do I want to know?” All I could think to say was “I guess you’ll just end up over the border!”“Or maybe out of order,” she added with a laugh. We made stale puns like this back and forth until neither of us had much more to say. I patted her arm and reminded her that she was really doing quite well. Numbers can be misleading. Norma is more than the sum of her laboratory results. In fact, by my calculations, she is well above average.
I had just begun my examination of Dennis, a clever middle-aged man who was a new patient in my practice. I had already inspected his eyes, ears, and nose. Next up was the oral cavity. “Would you open your mouth and say ‘Aah?’” I asked him as I readied the tongue depressor in one hand and steadied my penlight with the other. “Don’t worry, Doc,” he answered. “You won’t find any cavities.” He opened his mouth and unleashed a thundering “Aah.” Sure enough, there wasn’t a cavity in sight. Neither, however, were there any teeth. He was completely edentulous. Sadly, too many folks in our area lose all their teeth long before the age of retirement.
Generally speaking, people living in rural areas experience a more rapid rate of tooth loss than residents of more populated communities. One dentist in our region has a long waiting list of patients who want to see him for the sole purpose of having their teeth extracted. While physicians everywhere try to give their patients reasons to smile, doctors and dentists in rural areas struggle just to preserve a smile’s most important pieces.
At some point in time, just about every patient I see leaves the office with a virtually identical prescription. In fact, it is as close to a perfect prescription as is possible. The prescription is inexpensive with a low incidence of side effects, can be filled practically anywhere, and has an excellent rate of compliance. Yet, you won’t find it stocked in pharmacies or listed in the Physicians’ Desk Reference. It is walking. Perhaps the simplest of all exercises, walking prolongs life and delays disease. Safe for almost all ages, walking programs can be recommended in a wide range of “doses.” I encourage most patients to begin walking for a period of 20 to 30 minutes, three times a week, and then gradually advance their frequency, duration, and pace. The ultimate goal for most people is to exercise 30 minutes every day.
One 40-year-old man took my advice to heart and found such satisfaction in exercise that he switched from walking to jogging and eventually to running. Last year, he successfully completed his first marathon. Now that’s what I call refilling a prescription!
In order to preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario.
Copyright © 2002 by the American Academy of Family Physicians.
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