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Fam Pract Manag. 2019;26(5):33


If you suspect a patient has fractured a bone, here's a quick way to test your hypothesis using something you carry around all day.

The periosteum surrounding bones contains a lot of nerve fibers. When you break a bone, that layer gets disrupted. If you put a vibrating tuning fork on the suspected break, the patient will tell you it hurts a lot. You probably don't have easy access to a tuning fork, but you can use your mobile phone. Put your phone on vibrate, have someone call you (or call yourself on a separate line), and touch the corner of the phone to the bone in question. Patients may look at you funny. But I tell them that although I can't do a computed tomography scan in the office, I can do a phone scan.


Transitional care management (TCM) can help prevent your patients from falling through the cracks when moving between hospital- and home-based care. Despite many obstacles, two strategies have helped our practice improve the success of TCM:

1. Our hospitals and emergency departments notify us about patient visits or admissions only after discharge, which is not optimal. Our solution is to have a staff member each day review the list of admissions at all area hospitals to see if it includes any of our patients. The staff member will then proactively reach out to the discharge planner, the admitting physician, or both to plan TCM. We contact the patient before or on the day of discharge to schedule an appointment within 7 to 14 days, and a nurse calls the patient within 48 hours, both of which meet TCM coding rules.

2. We make a strong effort to personally perform preoperative clearance visits for all of our patients being admitted for procedures. During these visits, we pre-schedule a transitional care office visit a few days to a week after the patient's probable discharge date, depending on the procedure. We have found that transitional care visits within 72 hours of discharge are often optimal for complex patients. These individuals often need guidance on adjusting their medication, clarifying discharge instructions, and coordinating caregiver support.

We can reach out to the patient while still in the hospital and then call again shortly after discharge. Even if the hospital or surgeon is making follow-up calls, we find our patients highly appreciate our contact and often have important questions we can answer. We can also identify issues that need to be dealt with earlier than the patient's planned postoperative follow-up visit.


I've had a lot of success using steroid nasal sprays instead of antibiotics to treat and prevent Eustachian tube dysfunction, post-nasal drip, nasal congestion, and sinus pressure.

However, if patients say nasal spray doesn't work, I ask them to show me how they use it. Very few do it correctly. Patients often aim toward the septum, look up at the ceiling, or sniff forcefully after each spray. These mistakes greatly reduce efficacy and can cause irritation or even nose bleeds. I always show them how to do it correctly (chin down, aim straight back, sniff gently after each spray). It still may take two to five days of consistent use to alleviate their condition.


Many physicians and practice staff have trouble using electronic health record (EHR) systems. Sometimes they find the answers they need by asking others for help.

A practice in Columbia, Mo., goes the next step and schedules monthly meetings so that EHR users can get additional training and share their own problems and solutions. These hour-long “EHR Happy Hours” include at least one member of the practice's EHR training staff, have scheduled topics, and focus on high-impact, low-effort solutions (e.g., reducing documentation burden with note templates). Attendees can raise their own issues and are encouraged to share at least one thing they learn with a colleague who couldn't come to the meeting.


Practice Pearls presents readers' advice on practice operations and patient care, along with tips drawn from the literature. Submit a pearl (250 words or less) to FPM at

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