Sunday, May 1, 2016

Family Medicine: Working the Free Clinic with God

The vaccuum just turned off.  I turned in my prescription pad and loaded up the computers, picked up my all-purpose valise filled with confusing information about a vast array of projects.  We were finished with another night at the Free Clinic.
"Dr., there is one more patient back there.  She just got here."  I looked back the hallway, put down my case, found the prescription pad, put the stethoscope around my neck and walked down the hallway.  A door was closed and I could hear voices.  I knocked and entered to find our nurse taking the blood pressure of the patient.  (Yes, I was pressing the clock a bit since the pharmacy where patients filled our prescriptions was closing in twelve minutes).
I recorded the blood pressure as the nurse stated her findings. She was done with her part.  I read the reason for the visit and saw the list of six prescriptions requested, plus the two problems on top of the four chronic diseases.  Plus the 8 months since the last visit at which the patient agreed to get a lab test one month later.  Where had she been?  This could be challenging to beat the clock, if it was in play for the patient.
How can we help you tonight?  "I need my refills"
(OK, I sometimes get irritated when patients say that.  I practice medicine and prescribe medications if indicated.  Pharmacists give refills, I write prescriptions- a difference of some importance to me.)

"What kept you away?  We haven't seen you since last summer."
"Two jobs.  Prison. Court orders, daughter is in prison again for 30 days.  She gets violent with me, but I'm all she has.  She's only 16.  I don't know what I'm going to do."
"How do you cope?"
"I pray.  I work"
"Who loves you?"
"I guess my daughter does."
She was overwhelmed and near empty, but still human.  Someone loves her.  a someone who beats her occasionally, but a someone.
Hearing the story unfold, I listen for hope.  I ask about hope.  In her medical record she listed her religion as Christian.
I silently pray, "God we need help.  In the name of Jesus, please touch her heart with your love.  Please touch her daughter with the healing power of your love."
"And thank you, God, for bringing this woman here tonight to remind us all why we have the Free Clinic.  Please help us to show your love for her as one of your children.  Thank you for loving us as you have and leading Mary Ann Stone, RN, our "Founding Nurse Mother" (now leading from Heaven) to found this clinic."
I quickly examine her and write the prescriptions, all of which are indicated for her chronic conditions and situation.
"You're showing your daughter a Mother's Love and God's Love.  You're doing your best.  That's all you can do.  Thank you for what you're doing and what you're being.  God Bless You."

We clarified the prescriptions and her time frame for getting them filled and options for follow-up visits.
She smiled.  She left.
I cried for her. I cried with thanks that we can relay God's message to people like her and for the Hope that seemed present from the Creator of us all.  God is a great Free Clinic worker.

The names, dates, genders, exact circumstances, etc. of any references to patients are shifted to prevent identification of individuals.

Saturday, April 30, 2016

I Am a Family Physician

Yes!  I am a Family Physician!  I feel blessed to have had the opportunity for 37 years.  I'm also excited that I'm just warming up.  Practicing, practicing and practicing.  Developing discernment, insight and understanding.  The Human Condition meets Biological Variation and God steps in. Wow!  Every day these people share with me about their lives, their biology, their pathology, their variations, their values, goals and dreams.

I am a Family Physician because of the patients.  Who they are, what they do and what they have. They have trusted me with their bodies, their families and their stories.

I remember many lessons learned, unlearned and relearned, thanks to the repetition of patient care. From the first physical exam patient with migrating paresthesias at Mt. Carmel Hospital as an OSU medical student to the first inpatient at Riverside Methodist Hospital who died on the last day of the rotation when I was propping him up for a stat chest x-ray, I learned.

From the child with splinter hemorrhages on his eye exam to the one with a rare degenerative and terminal disease of the nervous system I learned at Children's Hospital of Columbus.  The openness of Marana, Arizona with the National Health Service Corps Clinic and its multi-professional health care team including a Nurse Practitioner, Pharmacist, Nurse, and Internist fresh out of residency training in Baltimore at Johns Hopkins was enlightening.  Adding the first immunizations I ever administered to children on the Pima Indian Reservation and use of the mobile health clinic used by the Marana Clinic to reach small villages expanded my perspectives about health care and medical practice and teams.

In the Department of Family and Community Medicine of Penn State University at the Milton S. Hershey Medical Center in "Chocolatetown, USA" - Hershey, PA I learned in the Family Medicine Model Unit on my own patients and in the Medical Center Hospital on patients of other physicians how to think like a Family Physician and how to act like one.  A wonderful faculty taught us about our specialty from multiple perspectives.  Tom Leaman, MD was our Department Chair who had founded the department and the Family Medicine residency training program before the specialty actually existed.  He was a great leader and role model for what we residents wished to become.

House calls, nursing home rounds, the rural clinic in Millersburg, PA and the inner city Hamilton Health Clinic in Harrisburg were other parts of the Hershey training.  I added a public health rural experience studying small town rural health centers in 3 Pennsylvania locations.  Chocolate and the Hershey Park with Hershey Chocolate World rounded out the residency experience.  Mentors like Dave Aspy, EdD somehow showed up, too.  Relationships with patients, colleagues, friends and family were at the center of the learning and growing.

Raising children of our own became an important part of my understanding Family Medicine. Rebecca and I had one son in the Army at Ft. Riley, KS, another at Ohio State and the third at the Hershey Medical Center.  I had insight about childhood growth and development, family systems, family life cycle and family structure and function from experience in my own home.  Teething, immunizations, holidays, birthdays, family vacations and grandparents were part of both the personal and professional education.  Three Mile Island was an added educational bonus since we were seven miles from the nuclear reactor that had a partial meltdown in March 1979.  Maybe God wanted us back in Ohio.

We moved back and enjoyed Granville, Ohio for 15 years before coming to Bellbrook for 21 more years of practice. Many ups and far fewer downs added to my Family Medicine skills and attitudes and insight.  Missing a brain tumor in a child was a significant developmental scar.  Many subsequent patients of mine have benefited because of what I learned painfully through that failure.  We care and we hurt and we learn.  That's part of being a Family Physician.

A woman stepped into an elevator in Licking Memorial Hospital in Newark, where I admitted my patients, and looked at me, the only person in the elevator.  I recognized her as a patient from several years before and remembered her story.  "I bet you don't remember me."  Before I answered, she continued, "You saved my life.  My husband almost killed me and you helped me to understand what was going to happen next.  I left him because of your help."  "Thank you," I said.

I've grown in my appreciation of the Creator and the creation, including people.  I speak of God with patients in the course of our conversations daily.  One of my main responsibilities is to make sure that people know that they matter.  Like they say in My church, they are "children of God".

Patient encounters in one setting or another number about 190,000 for me.  They are still teaching me and inspiring me to learn more.

Somewhere along the way, I became a Family Physician.

Stories from the journey are sprinkled in my more than 500 blog posts as Dr. Synonymous and more than 200 Dr. Synonymous Blog Talk Radio Shows.  Hits on this Blog will number 150,000 in the next few days.  I'm thankful for the opportunity to share some insights about Family Medicine and the human condition and God.

Thanks to the patients I've been blessed with since 1973 when I started at OSU, I am a Family Physician.

More later.

"Medical" Marijuana May Disrupt Medicare and Medicaid

The Ohio legislature, like 23 legislatures before them, intend to pass a "Medical" Marijuana law soon.  There is nothing "Medical" about marijuana, by the way, as I already blogged two weeks ago.

What happens when thousands of primary care office appointments are taken up by patients wanting approval for their "Medical" marijuana?

Disaster!  Primary care physicians are pretty much operating with full schedules.  There is no room for thousands of marijuana seekers.  Assuming that those visits won't be covered by "medical" insurance, and since they involve a controlled substance, they are longer visits.  They will be billed at a separate charge, paid at the time of the visit (how desperate might someone be to get their marijuana?).  The OARRS report must be consulted, etc.

A cash business line for these special patients will generate lots more revenue than Medicare and Medicaid, without the hassles and onerous "quality" initiatives and penalties.  Thousands of Medicare and Medicaid patients will be suddenly without a physician or without the ability to get timely appointments.  More physicians will see the "Medical" marijuana law as an opportunity to dump Medicare/Medicaid and help our marijuana friends for more financial stability.

Hassle Free Marijuana patients may start to look more appealling than Hasselful government funded patients.

What do you think?

Wednesday, April 20, 2016

Guidelines are Not Policies but Should Get Consideration

I confess that I am annoyed when someone writes or says that medical guidelines must be followed.  I disagree.  Guidelines are reminders of what one should consider.  Biological variation is so vast that each unique human warrants individual consideration.  I like guidelines as reminders of what could or should be considered in clinical situations.  I've never thought them to be policies or mandates.

An over reliance on guidelines as mandates could be disastrous for many patients.  One size does not fit all.

What are your thoughts about guidelines?  What are your experiences?

Saturday, April 16, 2016

Nurse Practitioner Marijuana

I believe that the words "Medical" and "Marijuana" are mutually exclusive.  A plant such as cannabis may not be prescribed in plant form by physicians.  We physicians can prescribe four cannabinoids ("Any of a group of closely related compounds that include cannabinol and the active constituents of cannabis") as legal, FDA approved pharmaceuticals.  They are not plants of 160 or more chemicals, as is the cannabis plant.  The contents of a puff of marijuana smoke are not exactly known, since there are so many chemicals in dosages that are not known.  That's beyond anything we are licensed or trained to prescribe.

Our profession is defined and limited.  We are being used by parties interested in legalizing smokable marijuana to ignore our profession and become shills for misguided legislators.  There are thousands of medications that I may prescribe as a physician.  There are hundreds of recommendations about vitamins, supplements and foods that I may make professionally if I make the patient aware of the potential limitations of the specific product.  None of these are whole plants.  Many are derived from plants and made into tablets, capsules, IV solutions, etc.

The Ohio legislature is intending to propose "Medical Marijuana" soon.   Ohio Marijuana proposals 
I am against so-called "Medical Marijuana", for which there is no Medical definition.  What if the legislators step in a different direction and call it "Nurse Practitioner Marijuana"?  They have sought independent licensure in Ohio, free of physician encumbrance.  Would the legislature pass a Nurse Practice Marijuana bill as part of a deal to grant them their request?

Would the newly independent nurse practitioners welcome the Nurse Practice Marijuana and dive into setting up the practice network that enables Ohioans with appropriate problems, as defined by legislators, to be treated by their independent nurse practitioner?

In New York there are complaints (Compassionate Marijuana Use Law in NY ) that they haven't registered the needed 30,000 patients that would enable financial success of the vendors.  How many physicians are they expecting to leave primary care practices to prescribe the plants (aka, marijuana)?  We have a huge shortage of primary care physicians in America.  Why ask them to make it worse by spending practice time dealing marijuana prescriptions?

Save the primary care physicians!  Legislate the Nurse Practitioners to be independent marijuana prescribers. Physicians will still prescribe legal cannabinoids and retain the professional identity and some of the integrity of the profession.

OK, I don't really want the nurse practitioners to be used by legislators in this way.  The professions may want to stand together on this issue, although I predict they will both sell out.

What do you think?