Thursday, July 29, 2010

Thursday in Family Medicine: Odds and Ends

Several messages to read/answer on walking in door.  Hospice nurse calls, we discuss patient and clarify next nurse visit.  I ask MA to call Mrs. X to get afternoon appointment for sick husband who called at 7:15 AM through our pager system.  I notice family nurse practitioner is only working half day (AM).  Greet her with comment about what she's up to this PM (teaching).  Thank her for willingness to cover next Sat AM.

One of AM patients:  Thyroid follow up, weight gain, medication side effects- palpitations, oral ulcers, medication off the market- now back on and maybe worth retrying.  Hormone therapy from other doctor -several questions.  Snoring conversation- it's worse.  Multiple allergies.  Bone health. Back pain.  Non-coverage of massage by insurance.  This was scheduled as 15 minute visit (took 40 minutes).  Note to self to continue quest for optimal scheduling wisdom.

Examine patient, driven by aspects of the probabilities of various diagnoses considered during the history, narrowed into a short differential diagnosis that varies as we clarify higher or lower risks with clinical information gathered by listening, questioning and examining.  This is the essence of physicianship in the clinical domain- thinking clinically in the context of the patient-physician relationship.

Knowing the population that we serve, we know the type and prevalence of illnesses/ diseases that are possible.  This varies by age, gender, season, occupation, heritage, exposure, etc.  Each area examined further clarifies and leads to changing or validating the differential diagnosis.  The uniqueness of the current patient keeps filtering all the clinical thoughts and findings of the physician.  A lot of information is flying through the conscious and unconscious mind. The context for their life keeps coming into play as a critical filter for every bit of information.  Gradually, we family physicians know our patients lives first and diseases second.  Life is powerful. And limited.

Note to self:  these people (aka, my patients) are fascinating as we (our team and I) get to know them over time.  The relationship is the driver for the engagement and it becomes more and more powerful. This is still fun after 152,000 patient encounters.  Thanks for the opportunity folks.  More later...


  1. Relationship centered medicine - makes it all worthwhile - doesn't it?

  2. Indeed it does make it worthwhile, Dr. Heaton. We're blessed to be in a relationship centered medical specialty.

    By the way, readers, Dr Heaton is past president of the Society of Teachers of Family Medicine.

  3. As someone who's been the beneficiary of an appointment that took more than double the time allotted on the schedule, I know how much it can mean to have a doctor stop and really listen to how all the symptoms interrelate - how much it means that the doctor cares enough to make sure the diagnosis is right and the treatment is effective. Thank you!