Monday, May 17, 2010

Friday Morning in Family Medicine

The office staff members are laughing, with the youngest standing in the center with hair down and others interacting about her appearance. "Are we converting into a salon?," I ask. I look at the patient schedule, noting the first two have chronic pain, one with a congenital musculoskeletal condition, another with remote history of occupational disaster and ensuing pains and dysfunctions. 3 slots open in AM for acutely ill people followed by a luncheon for staff and physicians from a local hospice.

A glance at my work area, where action items can be piled for same day perusal, yields notice of a thick chart: "he had fasting labs drawn, what tests should we order?"(I wonder why the mystery on the tests. Looking into his medical record, I note one no-show for this "diabetic in denial" since his last visit five months ago. He was having fatigue and concentration problems, noted by his wife, due to financial struggles from the untimely purchase of a new house before selling his first house. He opted not to take the antidepressant I offered to prescribe and had no time for counseling.  Now he is catching up to his health with the blood test, hoping to have a great HgbA1c to avoid a discussion about the financial stress and his depressed mood.) 

I next see a note from a mother of two teens asking if their sports physical can be used to approve and sign their summer work physical forms. Yes, with the usual form and doctor has to review the physical and peruse the risks noted in his medical record fee. We're no longer able to work for free, so we have charges for our services.

The first patient is here for medication and right arm pain according to the note written by my medical assistant.  His vital signs are normal except for heart rate of 105.  I knock, enter the room and shake his hand, make eye contact and ask, "how's it going?"  "OK, how have you been, Doc?  How is your leg?"  He remembered my infection (celllulitis) and expressed his wishes for me to heal completely.  Then he spoke of his sadness that someone had beaten his son, who went to the ER for evaluation, stitches and x-rays.  His son's girlfriend had a miscarriage after the beating.  He was saddened by the loss of his first grandchild, but he expressed concern that the baby might have been too much  for two seventeen year-olds to care for.

We did the medical part of the encounter with examination, clarifying questions and prescriptions.    His heart rate was down to 88 as he reflected on the coffee and cigarettes he had just before coming to the office. Then he showed me the words to a song he had written to honor his lost grandchild.  He plays the guitar, smokes and talks like Johnny Cash (bless his soul).  The words and the heartfelt compassion he had for the parents and their deceased child touched me.  "I'll see you next month, where are you riding your Harley this month?" I asked.  "I'm riding around Kentucky with a buddy.  That'll help me to forget what's happened."

The next patient room houses a couple including one of the "pain" patients and his lifemate (who was terminated from the practice years ago for misuse of benzodiazepines twice). "What are your plans for the summer? How is your walking and stretching going this spring? What are you doing for Memorial Day weekend?", are questions I asked during the visit. In his responses to my questions, I hear many aspects of his functional status and pain medication use.  "How is your back doing?  How does your hip feel?" are the type of open ended questions that I start with to clarify aspects of his pain and management.  Further questions yield specifics about the pain and the treatment.  A knock on the door interrupts my prescription writing after my examination of  ENT, Neck, Heart, Lungs Back, Hips, Strength, Nervous System, General Demeanor and Gait (he added that he was sneezing and coughing a lot since the grass and cottonwood trees had partnered to assault his mucous membranes, so I added those elements of history and physical to evaluate the respiratory symptoms).

"The hospice nurse is on the phone,"  she notes.  I excuse myself and the couple grants me permission with polite comments.  I only have one patient in home hospice at present, so I prepare to interact with the hospice nurse about the patient I'm thinking of.  I have a standing order for the hospice nurses to call me whenever they are in my patient's home, so we're talking one to five times weekly.  We have about six minutes of discourse, during which I listen to her nursing perspective and share my medical perspective with her.  We agree on next steps in testing, treating and reporting, including aspects of weekend communication between her cross-covering nurse and my cross-covering doctor.  I congratulate her on doing a wonderful job.

I knock on the door of the room before re-entering (this shows respect and prevents embarrassment for the couple in rare situations) and enter.  "It must be Friday, I'm sorry for the interruption, but I always speak with hospice nurses when they call."  They acknowledge that it's probably a good idea and refocus on my comments.  I congratulate the patient on his priority of stretching and walking, recognizing how difficult it is to balance the pain versus the health and fitness.  Too much fitness work may result in too much pain and dysfunction, leading to confusion about optimal therapy.  We discuss their grandchild and how "love is the drug of choice" in families.  Five prescriptions are written as fast as I can, checking those for controlled substances twice to see that the extra information is included.  "I'll see you in a month, have a good holiday with your grandchild."

I read the note and vital signs before knocking and entering the next room.


  1. You just captured the typical day in the life of a primary care doc on a good day, Dr. S! Lots to take in, our job sure is not easy. Great post.

  2. the other element to this involves the administrivia required to get paid a meager fee. I am mindful of Barron's recent article in NEJM.


  3. The patients mentioned are an amalgam of various experiences over thirty years in practice. Ages, genders, era's have been changed to filter the individual out of the blog. If there are facts that are in the public record, I may use them (e.g., cause of death from death certificate, news item, obituary, etc.)

    Dr Synonymous