Monday, December 13, 2010

Family Medicine: Fun, Facts, Reality and Challenge

Fun:  Five year old children are delightful.  Spongelike learners, they are very engaging and cooperative, except when confronted by the need for the three injections to be fully immunized before entering kindergarten.  If their parents wish, the child can get them when they're four and easier to restrain (yes, restrain, with the help of the parent holding hands or legs).  Neither four or five year old is happy for the opportunity to be immunized.  They are delightful again at the next clinical encounter, having already clarified with their parent that shots are not part of this visit.

Facts:  Flu shots were slightly more popular this year than last year, even without any pandemic concerns.  People seem relieved to know that the H1N1 protection is included.  Many get them at pharmacies when filling one of the prescriptions for a chronic disease.  It's one sign of the times that many health care prevention services will be provided away from physician offices.  Pharmacies want to become the patient's primary care provider.  I have a problem with that concept.  They also sell cigarettes a few feet from where they provide health care services.  I have a problem with the duplicity of health and sickness being sold together.

Reality:  People are getting older, along with their doctor.  More knee, back and neck pain.  I see five or six people per week with a pinched nerve in the neck or back.  One or two per month get surgery when the medicine and physical therapy don't provide relief and the subsequent MRI shows nerve root encroachment or a herniated disc. It then takes them another three to six months to fully recover. 

Challenge:  Every two years, someone continues with low back pain, after having disc surgery, which remains severe.  In these patients, there is always a family history of other family members with brain problems that may include, depression, intractable pain and/or chemical dependency (alcohol or opiates).  Their brain has a dysregulated pain management system and things often hurt more than in most other people.  That's just how their brain is, they didn't make it up or intend it to be that way. 

We may have these folks on medication such as Vicodin, Percocet, Morphine, or Oxycontin plus a base of Ibuprofen, often combined with Trazadone, Neurontin and maybe Zoloft or Celexa for more brain support.  They also get ongoing physical therapy, if helpful and, if there is an injection potential, I encourage them to see a pain specialist for the injections.  I do not have the pain specialist manage the monthly medication prescriptions and ongoing evaluation and management of the patient.  They have focused training in procedures that are very focused and costly, which they do well when needed.  They don't deliver continuous comprehensive care, which is what my patients need.

We ride the waves with these people who have intractable pain with some intense misery at times, especially  when their brain seems to be "stealing" their opiates from the site of their pain.  This tells me we may need more opiates briefly and intense focus on extra therapies that may convince the brain that it doesn't need to steal the opiates.  Each patient is uniquely different, requiring a personalized treatment strategy.  Some have intense fear of the pain flare ups and we address the fear and may medicate it, if the Trazadone, Neurontin and Celexa haven't reduced it or prevented it.  Suboxone may replace the opiates later when the pain and brain aren't going the right way chemically.  Some also benefit from extra counseling support from a psychotherapist or their clergy.  Faith and religion are almost always a big factor in how our patients cope with chronic pain.  Family support is another important part of coping.
Winter Facts:  Winter weather changes  the behavior of people.  In fact, in Ohio each season has specific health risks, both positive and negative.  Vitamin D3 deficiency is rampant in winter, causing many to feel blah, down or even depressed.  Snow and ice generate more caution with travel and walking outside.  We see increased fractures of the hip and the humerus (upper arm) caused by senior citizen falls.

All these phenomena and more are components of Family Medicine, a relationship based medical specialty not limited by organ systems or pathological processes.  I still love it!


  1. You make family medicine sound fun and worthwhile. I'll bet your patients love you.

  2. You are definitely right on target with how different people perceive pain.

    Another good point I have heard is that there is a misconception by many people who have never lived through pain that life is supposed to be "pain-free" and any twinge, sprain, spasm, or hint of arthritis means something is wrong and should be fixed to a consistent 0/10, not baseline, but constantly pain-free. Everybody has a little bit of pain every now and then.

  3. Thanks for the feedback. WS, it's always had some fun associated with it (family medicine) as well as emotional intensity.

    mds31, thanks for your input. Treating pain is one of the baseline skills needed by family physicians. Patients expect it, we have to deliver. It can be a challenge.