Sniffers

I was attending a “drug” dinner the other night with Teresa, my FNP, where we were surprised to find that, besides the speaker and the drug rep, we were the only ones there – not that it mattered to me. The speaker was a gastroenterologist and old friend, Kevin, and it gave me the chance to pick his brain unimpeded for three hours. The conversation went from GERD to Helicobacter pylori to irritable bowel syndrome to colonoscopies. I was going one-on-one with a real pro. The practice pearls came fast and furious.

I learned, among other things, how to load patients with proton pump inhibitors, the correct time of day to give them, what antibody is important in diagnosing H. pylori, how to test for a successful course of therapy and, in the event of a treatment failure, what to treat with the second time around, and the third. Kevin disparaged ordering upper GIs and barium enemas in favor of endoscopies and colonoscopies, but admitted that virtual colonoscopies might soon have a place in our armamentarium. He also presented some interesting cases he had missed and taught me about the clinical significance of a “succussion splash.” When it was over, I told him I was feeling somewhat inadequate.

“Don’t feel badly,” Kevin said. “You can’t know everything. I see you guys in primary care functioning on the front lines, diagnosing what you can, treating what you can and referring the rest. You sniff out the pathology. The best FPs are the ones with the best sniffers. One FP who refers to me always sends me people with disease. I don’t know how he does it.”

“Well, better a sniffer than a gatekeeper,” I thought, realizing I had a pretty good sniffer myself. Suddenly, I was feeling better than the people in those Claritin ads.

Risky business

For Father’s Day, my son gave me a gift certificate from a new computer store for some clip art on CD-ROM, which I needed for a presentation I was giving at an AAFP meeting for family practice residents and medical students. “Dad,” he said, “the guy that runs this store is a computer genius. He didn’t have the CD in stock but said it would be here next week.” With six weeks to go to my workshop, I looked forward to meeting Tyrone and getting my disk.

A week later, I was at his door, but his shop was closed, although the sign outside said these were regular business hours. Two more visits were for naught. I tried calling (no answer) but was at least able to leave a message on his answering machine – but my call wasn’t returned, despite my plea that I had an urgent need for the artwork. The next week, I found a scrawled sign posted on his door saying, “Closed on account of illness,” but the following week he was actually open and looking pretty fit. Unfortunately, he said, my clip-art disk was backordered and it would be another week. I told him I didn’t have another week and asked for a refund. “Sorry, can’t do that,” he said and showed me the fine print on the gift certificate where it stated it was not redeemable for cash but only for merchandise. Of course, his bare shelves didn’t provide any merchandise I wanted, so I was mad. “You know, Tyrone,” I began, “I’m a doctor, but if I ran my business like you run your business, I’d be out of business. You have done nothing to show me you value me as a customer. My patients are my customers, and if I wasn’t open for them and didn’t return their phone calls and didn’t try to please them, I’d be getting requests to send their medical records elsewhere. You don’t have to be a genius to be successful in business. You just have to care.”

The preceptor

Several months ago, I received an e-mail titled “Practice-management-deficient FP resident” from Sharon, a third-year resident who had attended my recent AAFP workshop. Intrigued and amused, I read on. She wrote, “As the end of my third year looms, I’m becoming increasingly interested in practice management, a topic only sparsely addressed in our residency program. … I was wondering if you would consider having a resident shadow you for a couple of weeks to learn the intricacies of managing a practice in general, and a solo practice in particular.”

How could I resist a chance to preach to the yet unconverted? Besides, it would allow me the opportunity to do a novel type of preceptorship: everything that goes into running a practice except the clinical aspects. Instead of talking about diseases and how to treat them, I would discuss scheduling, creating bills and posting payments, using aging reports to track accounts receivables, dealing with insurance companies and, in general, how to keep a practice thriving and in the black.

It would also be a way for me to give something back for all the help I received from other people along the way. Giving of our time and of ourselves to train our new initiates is one of the things that make us professionals and family medicine a great profession.