Friday, September 25, 2009

Discovering primary care...

Why don't medical students want to go into primary care? Why do even primary care residents want to get out, taking routes such as fellowships, hospitalists positions, academics, even nonclinical jobs?

Perhaps it has to do with the student's experience of primary care. It is incomplete. It is a series of office visits with patients you may never see again. You get to make a diagnosis, fill out a follow-up medication and move on to the next patient, normally never seeing that patient again.

Well, I am in primary care. I think I am beginning to understand the joy of primary care.

Last week, I injected a painful hip (trochanteric bursitis), removed a small pebble from a child's nostril, aspirated a ganglion cyst, met a patient cheerful after beginning an anti-depressant, celebrated a new addition to the family of a little girl I have cared for since residency and got an 87 year old to walk again after I took fluid off his knee and injected it with steroids. Of course, the 87-year old was back the next with an even more swollen knee (he felt so good after the first fluid removal that he went home and got on his treadmill to catch up with exercise after all this time of being immobile).

They say that if you've suffered through a traumatic experience together, like fought in a war alongside someone or being involved in a life-or-death encounter, you form a special bond with that person. Well, bonds are being formed all over the place.

Last week, I was a dermatologist, a cardiologist, a nephrologist, an orthopedist, an endocrinologist and a psychiatrist, sometimes all in the same day. I love it!

Saturday, September 12, 2009

Make hay while the sun shines...

I love Peds acute care -- you never know what you're going to get (to borrow a phrase from Forest Gump).

There was an adolescent female in the room with her mother. Her ear had been feeling full and her hearing wasn't so good from that ear. With frustration, the mother and daughter mentioned that they had been seen 2-3 times now and it wasn't getting better. One diagnosis offered was swimmer's ear. The funny thing was that she had not been swimming. I asked her what she had been doing. Well, it was summer in Wisconsin and like many farm hands, she had been making hay all summer. I looked in the ear and saw something I had never seen before: it looks white and black and cottony. I got a sample and sent it to the lab, but I thought I knew what she had and gave her a prescription.

When we called her a couple of days later, she was feeling much better and almost back to normal. The lab studies confirmed the diagnosis: Aspergillus niger.

She had fungus growing in her ear. How might this have happened? During my exam, I noted that her hair was damp and there were pieces of hay stuck in. The damp, golden curls hung over the ear. I'm guessing the warm, damp weather of summer, the fungus in the hay she was making and the environment in her auditory canal probably created the "perfect storm" for the infection. Onychomycosis -- my first.

Paternalism, paternalistic and empathy

I have several young woman in my practice. Well, I'm a Med-Peds doc so I have patients of all ages in my practice.

In the interaction between an adult and a child, paternalism seems quite natural. In medical school, we were warned against paternalism: defined in medical ethics as "A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities." Appropriately warned, physicians try to walk the fine line between the patient's "beneficience" and "autonomy".

When a 20-something young lady refused the HPV vaccine, tells me that she smokes while on birth control and has had at least 4 sexual partners in the past year, and does not use condoms every time, the 'father' in me wants to break out of the white coat and speak to her as I would if she were my child. After all, I internally reflect, from the perspective of the age difference between us, I could have had a daughter as old as her.

Lest you think there's something psychosexual about this, I feel the same way when my 20-something young man with Crohn's disease and a colectomy tells me one day before he is due to go to college that he has been having some abdominal pain and fatigue. The father in me once again wants to leap across the invisible waves to his cell phone as I'm trying to leave a message to him far away to tell him that his hemoglobin is low and he needs iron supplements and to see someone locally soon.

Okay! (deep breath).

These are adults (technically, at least), with their autonomy and I must not be paternalistic... I must not be paternalistic... I must not be paternalistic... I must...

What does your doctor mean to you?

Dr. F came out of the patient's room to get me. It was a busy afternoon in the clinic and we were all in the middle of seeing our own patients. He wanted me to come and meet one of his patients.

Dr. F leaves our clinic in about a month. He is moving back to the coast to be closer to family. He has been here about 13 years. He did his residency here and is now the director of that same residency program. He is also the head of our department. As part of his last month's activities and in between trips to the coast to find a home, nail the job down and such, he is having to tell his patients that he can no longer be their doctor. He had spoken to me about this particular patient -- someone he wanted me to take over the care of after he left.

I entered the room to find a tearful, crying 50-something year old female. I asked her why she was crying and from her wheelchair she reached out to Dr. F and said, "I'm losing my best friend!"

I think both Dr. F and me fought to maintain composure in the presence of her emotional expression of what Dr. F meant to her. She held onto him for a few moments, tears flowing freely down her face.

This is what Dr. F meant to her. She told me that they shared a history together. He had told me earlier of her close encounters with death, debilitating disease and the march of chronic disease in her life through the years.

Over 13 years, relationships between doctors and their patients are forged in the therapeutic alliance for their health and wellbeing. This continuity, this partnership and ultimately, this friendship is what Dr. F and this patient have. This is primary care.

Thursday, September 03, 2009

Biting your lip...

Kind of getting into the swing of things: several days of seeing patients in my clinic, mornings of acute care in Peds, urgent care last evening. Interesting how one evolves after residency. When I see a patient, I'm sometimes torn between: did I work this up enough? Did I do too much testing? Should I have sent this one home or watched them in the hospital? Yesterday a 16 year old football player came in with a dislocated finger. I never set one of those in residency. I looked it up in a text and was all set to numb up the finger with a finger block. I got pre-reduction x-rays that confirmed the finger was dislocated. Then, I asked one of the other docs in urgent care that night -- a family physician with more years of experience if he had done one of these before. He came into the room with me and while talking to the boy yanked on his finger and set it. No pain medicine. He didn't think we should get post-xrays. I thought about the difference in comfort levels we bought had at different stages of our careers. I would have done it, but first numbed up the finger, then set it, then got post xrays, in short, spent more healthcare money and been more cautious. Some cases I think that if I was more experienced I would make the call with fewer tests. Other cases, I wonder if that is necessarily the right thing to do. Work in progress...