Friday, September 24, 2010

Another Friday in Family Medicine

Start with senior citizens. A delightful couple with multiple degenerative processes. Issues with their adult children: emotional, financial and life-cycle issues. Issues with medications, price, side effects, prescription needs. "The doughnut hole" for prescription coverage. He shows concern for her and vice versa. Separate styles and separate perspectives on health and health care, all three of us. Seeking common ground as we listen to each other.

An engineer with hypothyroidism and neck pain (from yard work) who has an impressive new superphone.  A twelve year-old girl with mother, child has constipation and school stress due to child's perfectionistic tendencies. Well baby check up on three year old girl who is very engaging and even says Ah when she sticks her tongue out for throat exam (3 year olds almost never can do that).  I congratulate her on the "Ah" skill.

Mother and daughter with stress and depressed mood. Medicine or no medicine to add to the ongoing counseling. Depends on many variables. Eating change, addition of Omega 3 fish oil, Multivitamin, B complex 50 and vitamin D3, and sleep discussion after info gathering about the mood. Complex situations, simple recommendations. Then follow up visit in 2-3 weeks, depending.

Lunch: 2 tablespoons crunchy peanut butter, large glass water, one can chicken noodle soup (microwave).  Review letters from other physicians, lab results and imaging studies of patients while eating. Check Facebook, email and Twitter while eating.  Another huge glass of water then XS Energy Drink.  Off to see afternoon patients.

Hospital follow-up patient:  Review hospital generated list of going home meds with patient.  Three of them used brand name that patient didn't know, since patient takes generic meds.  This is how people get readmitted to hospital.  Drs in hospital write for same drug with different name, patient gets confused, may or may not take the medicine as expected.  Has the generic at home and the new prescription from the hospitalist.  If patient frail elderly, may take the new drug and the old generic that is same, resulting in double dose of med.  Patient gets ill, may go back to ER if really bad or see family doctor for illness (dizzy, SOB, nausea, abdominal pain, etc.) a few days before scheduled hospital follow-up visit with same family doc.  Acute visit gets slotted for less time and patient gets less thorough evaluation by family doctor, etc.  Cascade of dilemmas may happen when we change drug names on patients.

Sometimes, frail elderly transferred from hospital to rehab center before going home, getting a new set of generic drugs than the list given at hospital discharge. Then new list given from extended care facility where rehab occurred, listing the facility "favorites" that replaced the list from the hospital.  Patient's adult child/ caretaker fills new rx from new list and that leads to duplication of many pre-hospital meds unless the people involved are really attentive.  With EMR, some of this may be caught earlier and corrected, but with 12-13 drugs plus vitamins and supplements, it's a challenge to keep the meds straight.  This is another important example of how family physicians save lives, re-admissions and money for patients and tax payors.

Walk in patient:  family stress, uncontrolled diabetes and  upper back strain from over use caused by angry response to grandson's lying and chemical dependency.  Patient coped with the stress by vigorous yard work leading to the overuse syndrome, and enough pain that we can work with her to get a different stress reduction strategy.  Adjust Lantus insulin dose to get the diabetes better controlled.  Recommend name of counsellor in response to patient realization that professional mental health support will benefit her.

Get agreement on follow up interval for upper back and diabetes, schedule fasting blood tests, write one prescription for short term  $4 NSAID and list steps for self care upper back.  Fill out encounter form with billing info and dates for labs and follow-up visit. Touch her shoulder with response to her feelings ("You're relieved that you've decided to move ahead with a new coping strategy") and encouragement that "You can do this.  You're tough." 

Only eight more people to see this afternoon...Onward.


  1. :) You sound like you enjoy seeing patients and helping them feel better. Patients can tell when the doctor really cares.

  2. I love your blog, Doc. Keep up the houghtful articles!


  3. Interesting snippet of a day. Dealing with the patient needs for medication as well as treatment clarification and summary gets easier when we can control the variables which hospitalists and limited specialists offer. Need for interface of EHR/information/details between sites is important. Avoiding unnecessary duplication of lab work is also important.

  4. WarmSocks, Wesley and Ross, Thanks for the feedback. WS: the richness of family medicine feeds the relationship between patient and physician, it gets better and better as we grow together. Good point on the EHR and controllable and uncontrollable variables, Ross.