Today, a 41-year-old woman presented to SEF for her first maternity care examination at eight weeks of gestation. This would not have been an unusual occurrence except for the fact that the patient had undergone the exact same examination about eight months ago. She had been SEF's patient since SEF started her practice two years ago. Throughout their interactions, they had become friends. Eight months ago, when the patient discovered that she was pregnant just a month before she was supposed to be married again, she came to SEF for her maternity care. Two weeks later, she started bleeding and had an incomplete miscarriage. SEF performed the dilatation and curettage and helped her through the emotional maze of dealing with the loss. SEF and her family even went to her wedding a few weeks later. Today, both patient and physician were excited about her pregnancy, although both were a bit apprehensive. This tension between joy and sadness is one that every young physician must learn to handle, first personally and then as a guide for others who must travel this road.
The older he gets, the more WLL learns to listen to his wife and to his patients. The patient today, a 35-year-old mother of three, absolutely refused to discontinue her nightly mesalamine enemas. She was also receiving oral azathioprine and sulfasalazine tablets after being tapered off of oral prednisone in the management of a severe flare of pancolonic ulcerative colitis. “Walt,” she gently reminded WLL, “every time you take me off the enemas, my ulcerative colitis flares. I don't want to stop, no matter what the FDA or AMA or AHA or anyone else says!” Well, a study from Italy published in the American Journal of Gastroenterology (1997;92:1143-7) has revealed what the patient, but not her doctor, knew all along—“ . . . in this randomized, controlled trial of either daily oral 5-ASA plus twice-weekly 5-ASA enemas, or oral 5-ASA and placebo enemas, endoscopically proven relapses were significantly less common with combination therapy than with oral therapy alone (39 percent versus 69 percent).” Wise is the family physician who can develop listening skills.
Things happen in threes! That's the adage that we all acknowledged from our earliest days (or nights) in the emergency department or on the labor and delivery floor or with late-night admissions to the intensive care unit. Today's variations saw three patients with low back pain grace JRH's doorstep: all of the patients were men who were in a lot of pain, and all of the injuries were overuse related. However, each patient was different, and it was the third one who was the charm. His pain was on lying down. It did not radiate. His pain was duplicated and exacerbated when his right leg was placed in a figure-4 position. JRH knew from seeing this type of pain frequently in his pregnant patients that it might respond positively to sacroiliac joint manipulation. And so it did. Quicker than a wink, this 278-lb man was off the examination table and was walking normally again. He was pleased. JRH was also pleased, and found himself thinking, “I wouldn't mind having three more like that!” But, alas, his quota of threes had been used up for the day.
TBS finds that during health maintenance examinations, many women confess to her that they have trouble remembering to do a routine breast self-examinations—particularly after menopause, which may be the most important time. TBS has devised a system of encouraging her patients to choose the date of the month that corresponds with the date of their birthday (e.g., if the patient's birthday is on the 13th of the month, then the 13th of each month will be her day to do her breast self-examination). This appears to be helpful and patients seem to be pleased with such a simple reminder. More importantly, on subsequent visits they report that this system has helped them remember to do their examination.
In this mobile society, it is hard to establish the ideal of long-term continuity of care for which we strive and which our patients desire. Today, a young mother proved how ingenious many of our patients are when she brought in a home videotape of her three-year-old daughter that showed the spasms she had been having, and JRH and the mom were able to discuss the past medical history and the interval events and previous medical reports, and finally come to a definitive conclusion about a sound course of therapy. Up to this point, the essential information had always remained elusive, since the physical examination was always normal. It wasn't until the videotape was aired that both JRH and the concerned mother could see and explain the short but characteristic spasms that are diagnostic of epilepsy. These pictures were definitely worth a thousand words and helped build a bridge for continuity of care.
Our lives are shaped by a series of decisions we make in physical, intellectual and spiritual areas of our lives. This weekend, JSR was reflecting on the influences that led to his decision to specialize in family medicine. He recalled two especially significant influences. First was the mentoring of Dr. Richard Kiovsky, a family physician on the faculty at Indiana University School of Medicine. Through their friendship, JSR saw clearly a role model of excellence in the field of family medicine. The other major influence was a regularly featured column in American Family Physician. This column reflects on the real-life experiences of a group of family physicians . . . both their triumphs and their trials. JSR was halfway through medical school when the column debuted, and he hasn't missed reading a column yet. Isn't it interesting that the group of physicians who author the “Diary from a Week in Practice” is the same group with which JSR now works?