At the Still Point of the Turning World
Residency is over, NOW what? (While I'm waiting for the answer, I'll get some spinning done....)

Tuesday, March 04, 2003


A while ago I realized the imbalance between my posts about on-call nights, which are (thankfully) infrequent events, and how I actually spend most of my time around here--namely, seeing patients in clinic, which I do three afternoons a week. So here's a quick low-down on how today's clinic went: As always, details about patient information have been changed to protect confidentiality.

The Scene: Our clinic has 15 exam rooms, a miniscule triage area, an open nurse's station, and a tiny doctor's consultation room, about the size of a small walk-in closet. On any given afternoon, there's a huge mob of patients outside in the waiting room. One by one, the medical assistants (MAs) call their names and triage them (weight, vital signs, routine urinalysis for pregnant patients, length and head circumference for babies) through an an area about the size of a small bathroom. Meanwhile, if you peek inside the consultation room, there's anywhere between three and nine providers writing notes, squeezing past each other to look up lab results on the computer, or on the phone to pharmacies or patients. Everywhere there are stacks of charts being processed from the hands of the MA to the provider to the secretary responsible for billing. The volume of chatter, in English and Spanish, is astonishing. Sometimes my ears ring after a day in clinic.

1:45pm: I arrive in clinic. In theory, my first appointment is at 1:30pm but the wisdom of experience states that there is no way a patient will have been registered, triaged and roomed in on time, so it's safe to dawdle over lunch. I'll need the energy, anyway. I review the afternoon's schedule. I'm lucky--only overbooked twice today.

1:50pm: The first patient is a 24 year old woman who recently miscarried for the second time. She tells me she had "hormones" drawn at an outside laboratory, which I guess are levels of beta-human chorionic gonadotropin, the hormone that rises during the first months of pregnancy. I don't have the results and have to make some creative phone calls to the outside lab to obtain them. The patient is worried about her future fertility and about some mild pelvic pain she's had ever since the miscarriage. She's had one successful pregnancy in the past, so I reassure her that she's likely to have another term pregnancy in the future. Her exam is normal, so I defer a pelvic ultrasound for now, and plan to see her again in one month. If the pain is not gone by then, I'll consider further evaluation. That's the beauty of family practice--the continuity. You can make decisions over time, rather than on the spot, and avoid a whole lot of invasive and worrisome studies when they're not needed.

2:05pm: A woman pregnant for the first time is here to see me. She was referred to me by one of the L&D nurses, because she wanted to see a single provider for the duration of pregnancy, and apparently I've been elected Resident Most Likely to Deliver Her Own Patients. This is the second time I've seen this patient. Her gravid abdomen has been measuring larger than expected for her gestational age--30 weeks--so she had a level 2 ultrasound by a perinatologist yesterday. The results are normal, so I explain to her that she's just got the kind of abdomen that looks bigger than it should. She tells me she's really hoping I'll deliver her baby (a girl, according to yesterday's scan), so we discuss the likelihood of that happening, and start talking about who will back me up if I'm post-call or visiting my family. I've learned to be honest with patients about who will deliver their baby, because I think it helps avoid a lot of disappointment for the patient--not to mention exhaustion for the provider--to discuss the scenarios in advance. I refill her prenatal vitamins and schedule a follow-up visit in one month.

2:30pm: Well, that little chat took a bit longer than expected. I move on to a fifty-ish woman with type 2 diabetes, which is finally in good control on a single oral agent. I'm very proud of this woman, because, despite being illiterate she somehow manages to check her blood sugars twice a day and record the values in a diabetic logbook. Her numbers are large and clumsy, but I can read them, and she never fails to write them, and that's all that matters.

Today she's here because she reported some chest pain at her last visit. The chest pain did not sound typical for angina, but I had to worry because a) she's diabetic and b) she's a woman, and for these two reasons she could have an atypical presentation of angina. At the last visit I had her scheduled for a treadmill test, but the results of this study were inconclusive because the exam had to end early because she got chest pain again. The examiner felt that the chest pain was "musculoskeletal," but I talk it over with the attending and we agree we have to pursue the cardiac evaluation. So I explain to the patient that she needs an exercise thallium test, which is more sensitive than a regular treadmill and hopefully more likely to give me a diagnosis. I schedule her to return in six weeks, at which time I should have the thallium results, and make a note to have the chart returned to me so I can ensure that the test gets done.

3:15pm: That visit took forever, because of all the explanations and consultations it required. Luckily I've got a couple of no-shows, so I'm not behind at all. We have a no-show rate of about 25% in this clinic, because many of our patients have no cars, no money for buses, and no phones in their homes to call and cancel appointments. The no-show rate is a famous source of dispute, however, because any resident will tell you that their show rate is 100% whenever they're 50% overbooked.

I take advantage of the free time to look up labs on a patient I saw last week. She is a 38 year old woman who I've seen many times for bilateral hand pain. At first I thought it was carpal tunnel syndrom and prescribed physical therapy, wrist splints, and ibuprofen. Then she returned with more pain than numbness, and I thought her work as an in-home caregiver for a bedbound patient might have exacerbated early arthritis, so I prescribed a stronger anti-inflammatory agent and wrote a light-duty note for her job. Last week, I saw her and found that her hands were now swollen, and she was reporting bilateral knee and wrist pain as well. I started to suspect rheumatoid arthritis and ordered the first-line labs, which are back today and--are all suggestive of a rheumatological disease. I start to fill out the tons of paperwork to arrange for a rheumatology consult for this patient, and remind myself of the value of continuity of care. The diagnosis of RA is not yet fully determined for this patient, but I certainly would not have thought of it when I first saw her several months ago. Only seeing her several times and understanding the evolution of her symptoms led me to this point, which is, in fact, just the beginning of a larger work-up and many, many discussions to follow.

I look in my box and see a chart for a baby I delivered six months ago. The mother wants me to call her, so I do. The baby's been teething and has a fever, stuffy nose, and cough. The whole family has been sick and up nights trying to soothe the cranky baby, and they're starting to develop the kind of psychosis that afflicts the parents of young children in winter. I ask about the symptoms in more depth. The infant is eating well and making lots of wet diapers, and can be heard cooing in the background, so I don't think she's sick enough to come to the hospital, so I reassure the mother and tell her to give the infant Tylenol if she seems uncomfortable from the fever.

3:45pm: Okay, now people are starting to show up. The next patient is a woman in her late 30s who had a baby five months ago and is still--bless her heart--breastfeeding regularly. She's nursing her baby--a chubby boy--as I walk in. She's here because her type 2 diabetes is not yet in good control, according to the labs I had drawn last month. She had been out of her oral diabetic agent for months, and I restarted it at our last visit. Today she reports blood sugars in the 110-150 range, which, if true, I'd be happy to live with, but she hasn't brought in her diabetic logbook. I always like to see the logbook when a patient comes to clinic, because it tells me they're really trying to take care of themselves, and have developed a system for doing so. But I have to make allowances for this woman who has to take care of a busy household, including four kids and a husband who also has diabetes. Reviewing her labs, I see that her LDL cholesterol is too high as well, so now she has two risk factors for coronary artery disease. We discuss a typical day's menu, which includes large servings of refried beans with cheese, cream soups, and eggs. I advise her to estimate how much of each of these high-fat ingredients she usually uses in a week, and cut the amount in half. I never tell people to eliminate a customary food from their diet, but to cut back gradually. At our next visit, I'll talk about other healthful alternatives, but not today. You can't cram tons of information into every visit and expect people to remember everything. Besides, she needs an annual diabetic eye exam and a trip to the podiatrist to learn good diabetic foot care, so there's enough for her to digest today without having to hear about salads and whole grains.

4:10pm: As I'm sitting down to write a note, one of the secretaries brings me a fax about a patient I saw yesterday, a young man living in a board and care home. He has intermittent explosive disorder and developmental delay, and is under the care of a psychiatrist in Southern California who "sees" him via a telemedicine clinic. The patient was "seen" today and the psychiatrist reports recent escalation in the patient's aggressive behavior, so he recommends some changes to the patient's medications. I write out the prescriptions and make a note to myself to look up intermittent explosive disorder, about which I know practically nothing.

4:20pm: Next is a 17 year old girl who was seen in the ER last month for a bladder infection. She was told she had to follow-up in our clinic, and so here she is, feeling absolutely fine. Turns out her mother, who is in the room with her, is also one of my patients. Her older daughter is newly pregnant, and mom wants to know how to establish prenatal care with me. I explain the ins and outs of our scheduling system with her, interjecting this chat with a few questions about how the younger daughter, sitting before me, is doing. I don't have enough adolescent patients in my panel; most of our pediatric patients tend to be babies and toddlers. The girl has that easy, nervous laughter and "I guess so" conversational style of the late adolescent, but she seems like a straightforward kid. I pronounce her cured of the bladder infection and schedule a follow-up visit in a few months, at which time I'll have the mother wait outside while we go over some girl-talk--about boyfriends and contraception.

4:45pm: I check the schedule again. The last patient is a no-show. He's another diabetic patient who lives over an hour's drive away. He's on the county's medically indigent adult plan, so that's why he comes all that way to see me. Our clinic is the only one in the county that sees the medically indigent, so I see patients from all walks of life, from working artists in Monterey to the poorest fieldworker in Salinas. This man has no car, no job, and relies on his teenaged daughter to drive him to the clinic. I'm not surprised he didn't come in today, but I'm worried about him--his diabetes is horrendous and I really needed to talk to him about his high cholesterol. I leave notes for the staff to try to track him down--I hope he has a phone!--and reschedule him soon.

All in all, not a bad afternoon. Sometimes I see twice as many patients. Now, if only Friday afternoon could go as smoothly....