WHAT IT’S LIKE TO BE A PHYSICIAN

20 May

WHAT IT’S LIKE TO BE A PHYSICIAN

A Day in the Life of a Physician

What do doctors do all day?

When they were small, my kids liked reading a book with this question in the title: “What do people do all day?”1 I ask now, “What do doctors do all day?” Copies of my hospital and office chart notes from 1992 provide this diary of one of my days. The hospital notes were handwritten; the office notes were dictated after each transaction, while the information was fresh in my mind. Dictating, rather than writing longhand, was a great time saver and enabled me to describe the patients’ problems, the data, and my reflec- tions in more detail.

Each note begins with the “history” of the illness, and each part of the history is titled with the name of the problem. The name focuses the note and my thinking as I integrate the data and make decisions. In this chapter, many of the notes will be followed by a brief commentary, sampling and ex- plaining the italicized medical terms and jargon, some of the shorthand of medicine. These comments also take advantage of the “teachable mo- ment,” when there is a need for explanation and an opportunity to learn. To preserve privacy, I have altered some of the details about patients and given them fictitious initials. The notes are in the order in which I dealt with them, and the reader can refer back and forth between this chapter and chapter 22, where I provide a different type of commentary, one that

examines in greater detail part of the patient’s story and additional history, the derivative issues, and the role of the doctor-patient  relationship and then addresses the question, “What did I learn?”

Read the chart notes with the recognition that no day is typical and that physicians’ practices differ according to their specialty, their specific inter- ests, and how they choose to practice. The universal quality of all practices is the diversity of patients and problems physicians see in any day.

I began my day at the hospital at 7:30 a.m., took thirty minutes for lunch at 12:30 p.m., and was home for dinner by 6 p.m. The evening’s house call took an hour.

THE HOSPITAL

Patient 1: A.B., Age 29

Abdominal pain and weight loss: Still no appetite. Tests, including proctos- copy, barium enema, endoscopy of stomach, and CT scan of abdomen, show a small ovarian mass. Thyroid tests are normal.

Seizures: now and then.

Her abdominal pain and weight loss are very likely multidetermined—related to her antiseizure medication and the psychosocial issues in her life. Prior to dis- charge, we need to settle the medication issue and arrange for adequate psychiatric follow-up.

Patient 2: C.D., Age 85

Back pain: persists.  X-ray shows osteoporosis of the lumbar spine and old com- pression fractures but no new ones. Her exam is unchanged. She rarely requires pain medication.

Commentary: Osteoporosis: Abnormally fragile bones. She… medication:

That is, she is improving.

Patient 3: E.F., Age 85

Fever and lightheadedness: She’s no longer lightheaded. Fever has disappeared. Potassium deficit: has been corrected.

Patient 4: G.H., Age 78

Fever: improving. No cough, no chills. Urinalysis is normal. Chest x-ray nor- mal.

Diabetes mellitus: Blood sugars are in the 100–200 range on a mixture of NPH

and regular insulin.

Coronary heart disease: no breathlessness, no chest pain, no significant ar- rhythmia.

Thought disorder: He is still combative, and he won’t talk to me.

Exam: Alert, does not look acutely ill. Chest: clear. Heart: regular rhythm. Etiology of the fever is still unclear, though he is improving on intravenous anti-

biotic.

Commentary: NPH and regular insulin: Two different varieties of insulin, each with a different duration of action. “100–200” ranges from normal to an elevated level of blood sugar concentration. Thought disorder: A specific broad category of mental illness. Mental illness is an important portion of what physicians see in their daily practice. Some require consultation from a psychiatrist or other mental health professional. does… ill: Despite his multitude of problems, he does not look sick, and that is important informa- tion, as any mother can tell you. I learned that this is an important observa- tion to make from one of my pediatric instructors in medical school; it will appear in many of the notes.

Patient 5: I.J., Age 68

Congestive heart failure: Overall he feels much better. Not breathless. Slept well. He has lost 10 pounds since admission, on varying doses of furosemide.

Exam: Pulse 60, irregular. Blood pressure 120/80. He weeps as he speaks of his illnesses. Neck veins flat at 30 degrees. Chest: clear. Heart: irregular rhythm, variable S-1 as before. Liver: not palpable. No presacral or pretibial edema.

Gout: Erythema and pain in his hand have resolved. Pelvic tumor: no symptoms.

Commentary: Furosemide: A diuretic medicine, one that increases the uri- nary  output  of excessive body fluid. I  will, for the  most  part,  use uncapitalized names for generic drugs and capitalize brandnames. Neck . . .

30 degrees: The extent of jugular vein distension, when the patient lies with trunk elevated 30 degrees from a flat surface. Here the finding indicates im- provement in his congestive heart failure. S-1: The first of two sounds of the heartbeat. Erythema: The appearance of redness, often a sign of infec- tion or inflammation.

THE OFFICE

From the hospital, I went to my office, where my day is a mixture of transactions:

•  “Complete physicals,” a review with patients of their entire medical history, fol- lowed by a physical examination from top to toe, discussion of all the material with the patients, and planning any necessary follow-up. Each such encounter lasts from forty-five minutes to an hour.

•  Shorter visits with established patients, averaging about fifteen minutes.

•  Telephone calls interspersed between patient visits. These calls may come from patients, nurses caring for patients in the hospital or in nursing homes, and oc- casionally family members.

•  Talking things over with the staff—a receptionist, a laboratory technician,  a transcriber—and my partner, another internist.

Patient 6: K.L., Age 45

A 45-year-old woman here for annual physical. Problems are as follows:

Myxomatous mitral valve, post mitral valve replacement: on warfarin. No chest pain. No breathlessness. No awareness of irregular heartbeat. EKG today shows si- nus bradycardia, rate about 56, with frequent ventricular extrasystoles and first degree a-v block.

Thought disorder: ongoing.

Weight loss: a new problem. Weight 14 months ago was 150 and now is 138. She says she is struggling financially and often does not eat well. No special weather preference to suggest hyperthyroidism.

Medications: warfarin and some over-the-counter health-food preparations.

Review of systems is otherwise essentially negative.

Psychosocial: Though she is struggling financially, she does not consistently turn to anyone for moral support. She knows that she can rely on her niece.

(In this and the one subsequent “complete physical,” I have eliminated the de- scription of the physical exam, which is quite detailed. In the subsequent notes, the physical examination is focused on the pertinent issues, is briefer, and is in- cluded.)

Impression: Weight loss, probably due to inadequate nutrition.  Urged to eat better.

Arrhythmia, as noted above. Probably not clinically significant. With her permission, I will speak with her niece.

Return in 3 months.

Commentary: Myxomatous mitral valve: Abnormal tissue in the heart’s mi- tral valve, sometimes causing poor valve function and predisposing to con- gestive heart failure. warfarin: A drug that reduces the clotting ability of the  blood and the  risk of blood clots. EKG: Electrocardiogram. sinus bradycardia: A slow heart rate. ventricular extrasystoles: Irregular  heartbeats that may or may not cause difficulty. first-degree a-v block: Atrial-ventricu- lar block, a lengthening of the time required for contraction of the heart.

Sometimes this finding requires an alteration in therapy. hyperthyroidism: An overactive thyroid gland, one cause of weight loss. An intolerance to heat or a preference for cooler weather is a symptom that sometimes indi- cates hyperthyroidism. Review of systems: A litany of specific questions the physician asks the patient regarding symptoms related to each organ system of the body. Impression: This is the summary of my conclusions and includes statements of problems, which may be diagnoses or other kinds of problem statements such as yet-to-be-explained symptoms, findings on physical ex- amination, or abnormal laboratory tests. clinically significant: Among the important judgments a physician makes is whether or not the abnormality significantly affects the patient’s well-being or prognosis.

Patient 7: M.N., Age 50

A 50-year-old woman here for annual physical. Problems are as follows: Diabetes mellitus: no weakness, numbness, or tingling of face, arms or legs, nausea,

diarrhea, change in vision. She has periodic eye checkups by ophthalmologist and retinologist. No symptoms to suggest hypoglycemia. She is on this insulin regimen: regular insulin 12 to 18 units before breakfast, lunch, and supper, and NPH 30 units before supper. She does not regularly test her blood but chooses the amount of insulin according to how active she is going to be. She has given up sweets and finds that there are fewer swings in her blood sugar when she does test.

Hypertension: No headaches or dizziness. On Vasotec, 5 mg. daily.

Asthma: rare wheezing. She takes albuterol, 2 puffs, before she runs and as needed, and Theodur, 600 mg twice a day.

Caffeine excess: drinks about two cups of coffee a day and one or two cans of caffeinated cola a day.

Possible allergy to penicillin.

Ethanol, nicotine, and drug excess: none for many years.

Rectal bleeding: none. Epigastric burning: none. Impaired hearing: unchanged.

Review of systems is otherwise essentially negative.

Psychosocial: All in all, things are going well for her. She has taken on new work responsibilities, shares her feelings with her husband. She was offered a job in another city, actually the equivalent of a promotion, but chose to remain here.

Impression: Diabetes mellitus: adequate control for her. Check Hgb A1C. Hypertension: adequately controlled.

Asthma: adequately controlled.

Plan: Continue current regimen. Call me in 4 days for test results and further discussion.

Commentary: no weakness… vision: In medical parlance, these are called “pertinent negatives,” and in this case they relate to questions the physi- cian specifically asks to determine whether the patient has any of the com- plications of diabetes. retinologist: An  ophthalmologist who has special expertise in diseases of the retina. Ethanol… years: She had a previous ac- tive addiction. Rectal… none; Epigastric… none: She had previous symp- toms that had been evaluated. The current appointment is an opportunity to review the interim progress of the symptoms. Hgb A1C: A blood test that is an index of how close to normal her blood sugar levels are and therefore one measure of adequate treatment for diabetes.

Patient 8: I.J., Age 68 (Telephone—Son)

We talked about some of the issues involved in his father’s hospitalization (con- gestive heart failure, underlying heart disease, unusual tumor) and some of the un- certainties related to the illness.

Patient 9: O.P., Age 72 (Telephone)

Goiter: Repeat TSH is low. I spoke with my colleague, Dr. S and also with Dr. M, the radiation therapist, about further evaluation and treatment.  The nodule is “cold” on the 1989 radioactive scan, but thyroid aspiration was normal. To repeat the scan now to look for any changes. Further decisions about treatment will be made after the scan.

Commentary: TSH: Thyroid-stimulating hormone, a blood test for thy- roid function and often a measure of adequacy of thyroid hormone replace- ment treatment. cold: That is, metabolically inert, not producing thyroid hormone. Cold nodules are sometimes malignant. thyroid aspiration: Ob- taining a sample of cells through a very thin needle to analyze them and look especially for signs of malignancy.

Patient 10: Q.R., Age 78 (Telephone)

Tongue biopsy was negative for malignancy, she says. Call as needed.

Patient 11: S.T., Age 46

Abnormal liver tests: Gamma GT done 3 days ago was 67. The trend is certainly not getting worse and is better than last time.

Exam: BP 130/80. Does not look ill. Chest: clear. Heart: regular rhythm. Abdo- men: soft. Liver: not palpable.

The liver test abnormality is probably of no clinical significance. No further fol- low-up seems warranted. Recheck in a year.

Wart: She has a wart on her finger for which she is using Compound W and has some dry skin on her fingers for which she may use skin moistener.

Commentary: Gamma GT: A liver test. Wart: Not all problems for which patients seek physicians’ advice are complex.

Patient 12: U.V.,  Age 58 (Telephone)

Elevated cholesterol: I spoke with her about her elevated cholesterol and will send her a diet. Recheck lipid profile in 3 months.

Nodules: She had the nodules excised and they were benign.

Commentary: Lipid profile: Test to measure blood levels of cholesterol and triglycerides (lipids). Lipids are fats.

Patient 13: W.X., Age 58 (Telephone)

We reviewed the instructions of yesterday. May stop Lactinex if stools firm up.

Commentary: We . . . yesterday: He has a complex illness. Sometimes in- structions have to be repeated or clarified.

Patient 14: Y.Z., Age 72

Polymyalgia rheumatica: Muscle and joint aching persist. He feels as bad as when he entered the hospital in December. On prednisone 8 mg a day.

Exam: BP 140/80, P 80. Does not look acutely ill. He is cushingoid. Hemoglobin: 13.6. Sedimentation rate: 43. Electrolytes: renal function tests OK. Increase prednisone to 10 mg daily. Prescription for 5-mg tabs, #60, 2 each a.m.

Call in 6 days.

Commentary: Polymyalgia rheumatica: A sometimes disabling illness char- acterized by muscle aching. cushingoid: He has the general appearance of someone who has Cushing’s disease, caused by overproduction of corti- sone, a hormone produced by the adrenal gland. One sees this appearance in a patient who has been taking prednisone, an artificial hormone similar to cortisone. Sedimentation rate: A blood test helpful in following the activ- ity of polymyalgia rheumatica. Electrolytes: Blood test determination of the concentration of sodium, potassium, bicarbonate, and chloride, often done to look for adverse effects of medication. #60: That is, 60 tablets of predni- sone 5 mg. When I write a prescription, I record the number of pills pre- scribed. That helps me to evaluate whether the patient has been using the drug as directed or too frequently or infrequently. While such information is especially useful for drugs that are tranquilizers or narcotics, the informa- tion may be helpful with all drugs.

Patient 15: A.C., age 82 (Telephone–Nurse)

Blood sugars in the 200+ range on Micronase, 2.5 mg daily. Serum electrolytes:

normal. BUN: 24 (was 17 in September). Creatinine: 1.2 (was 0.9 in September).

Take Micronase, 2.5 mg later today, then beginning tomorrow 5 mg daily. Call in 3 days with progress.

I spoke with her daughter to review her progress.

Commentary: BUN,  Creatinine: Blood tests of kidney function. was . . . September: Often the comparison between values is as important as the ab- solute number.

Patient 16: B.D., Age 62 (Telephone)

Fatigue waxes and wanes. Continue current regimen. Call in 6 days.

Two issues need to be dealt with: (1) whether he needs further evaluation of his artificial aortic heart valve, and (2) whether he needs alteration in any medications that may be causing his fatigue.

Commentary: aortic heart valve: Which may have become damaged in the years since it was inserted.

Patient 17: C.E., Age 58

Hypertension: No headaches or dizziness. Premarin dose has been cut back to .625 mg daily 3 days ago.

Exam: BP 140/80. Does not  look ill. Continue  current  regimen. Return  2 months.

Commentary: Premarin… ago: Because premarin, an artificial hormone, may cause hypertension, the physician previously advised the patient to re- duce the dose.

Patient 18: D.F., Age 88 (Telephone–Nurse)

All in all, doing well after hernia surgery. Bladder catheter has been removed, and he is voiding adequately.

Patient 19: E.G., Age 57 (Telephone)

Thyroid status: TSH 91+ 3 days ago. Increase Synthroid to 0.1 mg daily. Office in a month.

Commentary: TSH 91+: elevated, indicating need for more thyroid hor- mone.

Patient 20: F.H., Age 67 (Telephone)

He has a cough, which is evolving into symptoms of upper respiratory infection. Observe. Call if no better.

Patient 21: G.I., Age 78

Abdominal pain, colitis: She is feeling much better. She is having three bowel movements a day and she says they are more formed than before. She will shortly stop vancomycin.

Exam: BP 130/80, P 92. Does not look acutely ill. Chest: clear. Heart: regular rhythm. Abdomen: soft, nontender. Normal bowel sounds.

Continue azulfidine. She is to call in a week with progress. If no better, may con- sider specific antisalmonella treatment.

Patient 22: H.J., Age 74

Hypertension: no headaches. No dizziness. On Vasotec, 2.5 mg daily. Exam: BP 140/80. Does not look ill. Continue Vasotec, 2.5 mg daily. Abnormal prostate: He is anticipating prostate biopsy in a week and has a num-

ber of questions about the implications should malignancy be found and about the approach of his urologist. We discussed all of these issues at length.

Constipation: in the last month. Likely of no clinical consequence. He had colonoscopy 3 months ago. Prune juice seems to help.

Return 3 months.

Patient 23: I.K., Age 82 (Telephone–Nurse)

Toe ulcer: some purulent drainage. Stop the current topical application. Soak three times a day in warm water with soap. Start clindamycin, 300 mg three times a day for 10 days. Stop promptly if she has diarrhea. I will see her tomorrow.

Commentary: purulent: Infected. diarrhea: In this situation, an adverse ef- fect of the medication, sometimes a sign of a potentially serious complica- tion of the use of clindamycin.

Patient 24: J.L., Age 61

Headaches and hypertension: They persist. In addition, he has nausea from time to time. All of these symptoms are long-standing. On his own, he continues to take an over-the-counter preparation.

Exam: BP 120/80, P 60. Does not look acutely ill. Some limitation of rotation of neck to the left. Tenderness at level of C 4-5, left paravertebral area.

Continue atenolol 25 mg daily.

He wonders about referral to “neuropathologist” because of what he feels are

“spasms of the blood vessels.”

Head and neck ache may be due to cervical osteoarthritis. Get cervical spine x-rays. Add diazepam 2 mg #60, 1 four times a day. Return 2 weeks.

He has concerns about his wife, who has an ongoing sensation of “noise in her ears.” He asks for her referral to the Mayo Clinic, and I suggest that she first return to her local ear specialist.

Commentary: level of C4-5: The back of the neck at the level of the fourth and fifth cervical vertebrae.

Patient 25: K.M., Age 67

Hypertension: no headaches or dizziness. Feels better on Vasotec than on Calan

SR and is not “tired.”

Exam: BP 160/70 sitting, 160/80 standing. P 80.

Increase Vasotec to 10 mg each a.m. Return in a month.

Diabetes: Blood sugar now is 257 at 2:50 p.m. Urged to lose weight.

Patient 26: L.N., Age 72 (Telephone)

Constipation: We discussed her bowel problem. Milk of magnesia taken 4 days a week seems to help. On the fifth day, she has some diarrhea. Change to milk of magnesia, 15-30 cc at bedtime as needed.

Some dizziness. Change diazepam to 2 mg four times a day, only as needed, in- stead of regularly four times a day.

Commentary: Constipation: Though often a trivial and passing symptom, constipation may be painful and disabling and needs to be addressed care- fully. Sometimes constipation may be a symptom of a serious illness or an adverse side effect of medication.

Patient 27: M.O., Age 49

Edema, left leg: persists and is somewhat more prominent now, with some dis- comfort. He continues on anticoagulation.

Exam: BP 130/80, P 80. Does not look acutely ill. Gait is normal. Left leg: 2+

edema.

He has swelling that extends up into his thigh. No appreciable pelvic pain, but lymphatic obstruction needs to be considered.

Continue current regimen. Return 2 weeks.

Commentary: Edema: Abnormal accumulation of fluid, often graded qual- itatively from 0 to 4+.

END OF THE DAY

At the end of the office day, I return to the hospital to see one of my pa- tients for a second time. Then I go home to my family.

Patient 28: N.P., Age 40

In the evening, I receive a telephone  call from the husband of a patient, a

40-year-old woman. He tells me, “She’s talking and she’s not making any sense.” On the way to their home, I begin thinking about what might be wrong with her. (See Case 2 in chapter 10 for a discussion of this patient.)

I have presented twenty-eight  separate transactions,  a complex day filled with a variety of problems and decisions. A student or a patient could legitimately ask: “How do physicians manage such a day? How can we do it efficiently, make best use of the time, and give it some order? How do we gather and handle all the information and keep it all straight? How do we define the issues? When do we call a consultant? How do we choose the consultant? What do we do when we have no idea what is wrong with the patient? How do we avoid mistakes? How do we handle mistakes when we make them?

“Is the information we have important or trivial? When problem A oc- curs following problem B, did A cause B? Do all the present problems define the context of a new problem, or should we look elsewhere, beyond the confines of the identified problems?

“How can we let the patient know that we are aware of all the informa- tion, that the patient is the only person on our mind at the time? How can we make it easy for the patient to tell the story?

“How can we do all of this in a way that is satisfying not only for the pa- tient, but also for us, the physicians? How do doctors integrate their per- sonal and professional lives?”

The next chapters address these questions regarding what it is like to be a physician—and other questions too. Which considerations are universal to all patients? Which are unique to the individual patient? And where do we start?

We start with the history.

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