Tuesday, July 29, 2014

Reflections on Family Medicine in Dayton since 1952 from One Perspective

"Count backward by ones starting at 100," the doctor said as he put the ether bearing mask over my six year old face in preparation for my tonsillectomy and adenoidectomy at Miami Valley Hospital.  It was 1952.  I was excited because I could eat all the ice cream I desired and stay up late each night for a week, watching "I love Lucy" on our new black and white TV. I loved the hospital, the smells and the attentive people.  I thought highly of George Martin, MD, our Family Doctor, whose office in Miamisburg smelled of vitamins.

Other than an occasional "check up" for milestones like starting the first grade or going to Boy Scout camp, I only saw Dr Martin when I was infected.  he seemed to only have one response to my infections: a penicillin injection.  He would say Hmm, Hmm while looking in my ears, nose and throat and listening to my heart and lungs. then leave the room, returning several minutes later with one hand behind his back.  I knew there was a syringe in the hand that he hid.  He would announce that I needed a little shot.  I would say words to the effect that it was going to hurt.  He would say, "I bet you a nickel it doesn't hurt."  I would shake his hand and say OK.  I t would hurt which ever hip received it and he would pay the nickel when I pronounced that I won the bet.  How did he know I would gamble?  Did my mother consent to my gambling with my doctor?

Highlights for Children was my other continuing memory of my Family doctor's office.  I loved to read it and work the puzzles and find the hidden objects while waiting.  We waited a lot since Dr. Martin was extremely busy, even on Saturday mornings, when we would go to the bakery for cream horns (one of my alltime childhood favorites) after the doctor visit.  Philhower's pharmacy was another major stop in Miamisburg, not for prescriptions, since Dr. Martin dispensed the medication from his office, but for odds and ends after going through the "dime store"- Woolworth's.

Fast forward beyond 177,000 patient visits (of mine) and I still love to go to Dr.'s offices, although they don't smell like vitamins now.  And they don't give many penicillin injections, since we have a wide variety of antibiotics and we understand viral respiratory infections better.

Now, Dayton has its own medical school at Wright State University which can inspire medical students to be like Dr. Martin or his modern day equivalent.  How do they accomplish that?  They have a Department of Family Medicine.  The specialty didn't even exist until near the end of Dr. Martin's career.  Now the Department routinely gets awards for having a high number of students select Family Medicine for their specialty.  (Although there is a recent down-turn in those numbers).

True confession of author bias- I'm on the clinical faculty of The WSU BSM Department of Family Medicine and I teach students in my office every year since 1994.  That's when I arrived back home to Dayton after a decade of private practice in Granville and four years on the full time faculty of The Ohio State University College of Medicine in their Department of family Medicine.  I was hired into a WSU faculty role through the Kettering Medical Center which had worked with Dr Mark Clasen, Chair of Family Medicine for WSU, to establish Family Medicine Education at KMC in connection with the Family Medicine Residency at Good Samaritan Hospital.

Larry Ratcliff, MD was the Founding Director of Family Medicine Education for KMC in 1993 and Associate Residency Director of what would be eventually renamed, The Dayton Community Family Medicine Residency.  As former Residency Director for Family Medicine at the Grant Medical Center in Columbus, Dr Ratcliff was skilled at setting up programs, recruiting residents and teaching medical students and residents.  He succeeded at KMC via the WSU relationships with the passionate help of Lee Jean Jordan (later Heller) who was tireless in her KMC innovations and her liaison activities with the GSH residency staff.

A unique champion for Family Medicine at KMC was the Director of Medical Education, Robert Sutton, PhD who had the vision for Family Medicine that delivered the people and the budget to make it happen.  He was continuously supportive and understanding of the role of Family Medicine Education in the big picture for the KMC and the broader Dayton Community.

In 1994, Larry Bauer, MSW, MEd who had been Director of Organizational Development in the DFM at OSU and I were recruited to join Dr. Ratcliff at KMC.  Larry was also a key player in setting up the OSU Sports Medicine Fellowship which was directed by Dr. John Lombardo, also Chair of the DFM at OSU and graduate of UD and the Dayton St. Elizabeth Family Medicine Residency.  My position at OSU had been Vice Chair and Director of Clinical Services which included the direction of the OSU Model Practice (with 29 physicians, several nurses and two mental health professionals.) and oversight of the hospital services for the department.  We both had teaching (and publishing and scholarship) responsibilities with sports medicine fellows, medical students and residents in family medicine.  I also served as liaison to campus health centers at OSU, Otterbein and Denison (which I had directed for a decade) for placement of our sports medicine fellows.

Since KMC had no teaching practice for Family Medicine, I started one called The Indian Ripple Family Health Center with budget support from KMC on Indian Ripple Road in a strip mall in a failed internal medicine office site.  It was located at the confluence of four different types of populations which worked out well for practice variety and teaching students and residents.  We established the use of video technology in the IRFHC so each learner could be videotaped within their first week on site and during their last week and as needed in between.  We saw some great patients and students.  The site eventually qualified as an official/certified satellite of the GSH FM Residency.  It also scored 100% for the JCAHO site visit. We did some good stuff, folks.

Toni Clark, DO was the first physician faculty recruited to practice and teach with us at IRFHC.  Phil Whitecar later "transferred" his practice from the Fred White Center at WSU to IRFHC to join our faculty for the IRFHC, KMC and GSH team (yes, it could be confusing at times with so many masters).

Larry, Larry and I also became the management team for restructuring the Kettering Medical Center Physicians, Inc., the physician network of faculty (KMC is a major teaching center for multiple medical and surgical specialties) and purchased practices.  As the KMCPI project progressed, Dr Ratcliff became the Director of KMCPI and I became the Director of Family Medicine Education for KMC.

In 1995, we had opened the  IRFHC site that would later expand and house our official satellite training site for the Dayton Community Family Medicine Residency.  In 1996, at the request of the Kettering College of Medical Arts, I became Professor and Chair of the Physician Assistant Department and Director of the PA Program.  This enabled integration of some of the clinical training of medical students from both Loma Linda, WSU and the PA students of KCMA on site at IRFHC.  Scott Massey, Associate Director of the PA Program joined the faculty at IRFHC and WSU DFM faculty were contracted to teach PA students at KCMA.  (OK, it may get confusing, but I'm a proponent of team training and teaching).  We taught Pastoral Care residents at IRFHC, also. I was on the advisory committee for their training.   They were great at helping patients with advanced directives and stress and prayer needs.

Further team teaching happened through the Multiprofessional Course of WSU taught through Wright State and including Medicine, Nursing, Dental Hygiene (from Sinclair), PA's (from KCMA), Social Work, Psychology (and one more that I'm forgetting, but I taught in the course for several years along with faculty from the other six schools, including my good friend and colleague, Kate Cauley, PhD, Director of The Center for Healthy Communities.  It was extremely rewarding).

As the Satellite at Indian Ripple was integrated more fully into the DCFMR, merging of tasks and courses and personality alignments (or misalignment) lead to Larry Bauer and I splitting away from Family Medicine Education and IRFHC to start The Center for Innovation in Family and Community Health which remained a part of Family Medicine Education at KMC.  The CIFCH was to produce academic products and services, which we did by developing electives for residents in Behavioral Health (that psychiatry residents could also take), Family Medicine (another one that psychiatry residents could also take), and Practice Management. After one year, Dr Sutton had left to take a position in Michigan and KMC restructured their financial reporting and software, resulting in budget confusion through the whole KMC system.  Dr. Phil Whitecar became the next Director of Family Medicine Education and Medical Director of the IRFHC.

Our CIFCH was not funded for 1999, in spite of making a profit for the KMC. Larry Bauer's position was not funded and I resigned my faculty position, seeing it was my time to leave.  I started another private practice in Beavercreek, taking the CIFCH with me.  I noticed recently that I have a bottle of vitamins that smell like Dr. Martin's office.  I've not yet taken up gambling with my younger patients about th epain in injections.  Maybe that's next.

Throughout the KMC adventure, our people remained active in the Department of Family Medicine.

KMC eventually closed the IRFHC and stopped training Family Physicians.                                                                                                                                                                                          

That's a piece of my perspective.

A. Patrick Jonas, MD




Thursday, July 24, 2014

Human Centering: Enhancing Success in Health Care Situations

Presentation at The Institute of Holistic Leadership  with Pat Jonas, MD  August, 2014

Introductions: Megatrends, Avoiding "Non-Compliance"

Centering: Patient, Payment, Physician, Hypnotherapist, Health System, Public Health, Human

Human Centering:            What it is

                                             What it Does

                                             Why it’s important
Where and/ or when human centering may be beneficial?
How to do it:  Notice how you use your five senses.  Which one leads?
               Become Wholehearted by balancing the autonomic nervous system (“The Mommy Heart”)
P O L A R to another person in dialog  whole (sort of) wholehearted
Notice:   Assumptions, Context of them and you, Process of them and you
Human Centered Health Home (HCHH) Process for dyad
               Respect
               Protect
               Connect
               Detect
               Correct
               Reflect
Holistic Strategies for Human Centering
               Mind-Body Therapies
               Nutriceuticals
               Body Work
               Energy Work (Overtones – one of the secrets)
How to use Human Centering
               In Health Care Engagement as patient/client or practitioner (working and caring)

               In HC System as visitor- e.g., in a hospital (working and caring)

               With a friend who has health problem

Human Centered Health Care (HC)2
               Model
               Context of dyad

               Process of R P C D C R

Heart to Heart Rapport
               Trance A to Trance B
               Rapport: Human to Human, Heart to Heart
               Dialog: Wilber’s Four Quadrants from A Brief History of Everything by Ken Wilber
               Human Connection: P O L A R to Explore, Understand and Act   P I E S x L L W
The Art of Health Care by Bill Anthony, The Art of Helping by Robert Carkhuff
The Structure of Magic Volumes I and II by Richard Bandler and John Grinder
Consulting with NLP by Lewis Walker
Hands of Light by Barbara Brennan, Wheels of Light by Rosalyn Bruyere
HeartMath.com for Quick Coherence Technique

WWW.DrSynonymous.Blogspot.com numerous blog posts: HCHH and process of care in Family Medicine

Tuesday, July 22, 2014

Non-Compliance Soon to be Top Diagnosis

Within three years, the top diagnosis in EMR's will be non-compliance with medical therapy or dietary therapy or exercise recommendation, etc.  (My opinion)  Patients and physicians are now trapped by the Electronic Medical Record.  The plan of care must include the recommended therapies for the diagnosis or the physician loses bonus potential.  There must be proof that the medicine was prescribed and the pharmacy dispensed it or the physician and/or the pharmacy may lose quality points or bonus dollars.  Just watch.

Information Technology tightens the system and decreases choice.  We used to be forgiving about patients that would sometimes decide not to fill prescriptions or sometimes decide not to take the medicine when they did fill the prescription.  Often, their judgement may have been better than ours as we came to realize.  Over time, we got to understand each others perspectives as our patient-physician relationship developed. Physician and patient learned how to honor each other's judgement.  The quality of the relationship depended on it.  IT initiatives now risk the patient-physician relationship, a central aspect in the quality of health care. The patient has to align with the "Patient Centered" decision of the EMR protocol that aligns with "quality".

Unless they want the diagnosis soon to be number one: Non-Compliance.

What's "Patient Centered" about that?

What do you think?