Saturday, October 28, 2017

Medical Stewardship for Family Medicine

What health care model might get us beyond "Statin Sluts", Incidentalists, Inflictionists, or Bonus-Based Physicians - all of which I've written about in previous Dr. Synonymous blog posts?

I believe we're poised for an era of Medical Stewardship, appropriate use of scarce, valuable medical resources.

Medical Stewardship.
More later.

Friday, July 28, 2017

July 27, 2017 My 47th Anniversary: Leaving for Vietnam

I often reflect on my Vietnam Service.  Every July 27th I remember the day I left Dayton, Ohio for Travis AFB in California.  We flew out of Travis to Alaska to Japan to Vietnam.  I came back in late July 1971.
I frequently reflect on the 20 members of my West Point Class of 1968 who died in Vietnam as a result of injuries incurred during their service.  We now have others who are dying of cancer from toxic exposures to Agent Orange, etc. while serving in Vietnam.
War changes people on a continuing basis over a lifetime.

I flew helicopters for the 45th Engineer Group in I Corps, from the DMZ to south of Quang Ngai.
travel vietnam Quang Ngai.  I loved flying OH58A and UH 1 helicopters.

I pray for those who served and were affected by the Vietnam War (actually a "Conflict").

I'm still learning about the meaning of the Vietnam service daily.

Three Dr. Synonymous blogs each year focus on Vietnam.  Here are the last three anniversary blog posts:  departure-for-vietnam-46-years-ago.   vietnam-departure-45-years-ago       another-vietnam-personal-anniversary

Monday, May 1, 2017

Hypermobile Spectrum Disorders in Family Medicine: New Hope for Patients & Doctors

"How does it hurt that bad?" " What is the pathophysiology?" " What is my differential diagnosis?"
These are questions that occur to a family physician when evaluating a patient with problems that include excruciating pain.  With a big push to prescribe fewer to no opiates for pain, physicians are shying away from patients who hurt.  We seem to be developing an aversion to pain and suffering, a surprising paradox for a profession that was invented to prevent and/or treat pain and suffering.

The updated categorization of connective tissue disorders by our genetic friends offers hope (and confusion) to those who want to better diagnose and treat disorders that include a pain component. International Classification of EDS and HSD

The Ehlers Danlos Society does an excellent job of staying on top of and communicating about Ehlers Danlos Syndrome (EDS).  They have quickly updated to inform their members and interested others about the new definitions and diagnostic criteria for EDS and Hypermobile Spectrum Disorders (HSD).  What is HSD?

How might we assess joints for hyermobility? Assessing Joint Hypermobility

What does this mean to patients and family physicians?

More later in this series about EDS and HSD

Thursday, April 27, 2017

Ehlers Danlos Syndrome in Family Medicine: Painful Surprise

Ehlers Danlos Syndrome:  Rare? Not so Rare? Not even Rare?  Pain, Pain and Pain.  It drips with clues to the possible presence of a connective tissue disorder.  When I was in medical school, the more likely term was collagen vascular disease.  Marfan's Syndrome became the poster child for this group of diseases/conditions.  Now it should be Ehlers Danlos Syndrome (EDS).

Coming in at 1 in 100 persons (per Dr. Nielson- EDS wizard at the University of Cincinnati, with whom I strongly agree), it races by hemochromatosis and others as a disease to know to provide care for patients in Family Medicine.  Every Family Physician has several patients with this diagnosis that hasn't been made.

The categorization of EDS types was reorganized in March of 2017 for better understanding.  The term Hypermobility Spectrum Disorders is added to better understand EDS and that which is beyond EDS.  It will take a while for physicians to get acquainted with the clarification.  Most family physicians are not aware of the prevalence of EDS in their daily practices, especially patients with pain syndromes.

What is Ehlers Danlos Syndrome?

From the EDS Society:  "Ehlers-Danlos syndromes are a group of connective tissue disorders that can be inherited and are varied both in how affect the body and in their genetic causes. They are generally characterized by joint hypermobility (joints that stretch further than normal), skin hyperextensibility (skin that can be stretched further than normal), and tissue fragility. (For information about the hypermobility spectrum disorders, please visit “About HSD”.)
The Ehlers-Danlos syndromes (EDS) are currently classified in a system of thirteen subtypes. Each EDS subtype has a set of clinical criteria that help guide diagnosis; a patient’s physical signs and symptoms will be matched up to the major and minor criteria to identify the subtype that is the most complete fit. There is substantial symptom overlap between the EDS subtypes and the other connective tissue disorders including hypermobility spectrum disorders, as well as a lot of variability, so a definitive diagnosis for all the EDS subtypes—except for hypermobile EDS (hEDS)—also calls for confirmation by testing to identify the responsible variant for the gene affected in each subtype."

Per Genetics Home Reference Definition

What are the types of Ehlers Danlos Syndrome?

Chart of Types of EDS with detailed definitions.

Wednesday, March 8, 2017

"Thank You" Used to Mean Quality

This is a response I wrote to a Blogger Friend who was lamenting about her mother being ignored out of getting a referral which she needed in a part of the healthcare system out west.
When I read your Mom’s story, I know it’s totally true. And sad. I mourn for my profession which sold out to Wall Street, dressed as harmless hospital administrators and pharmaceutical representatives and faceless insurance companies with phony quality initiatives and empty terms that somehow appealed to good boy and girl scouts like physicians. 
Now, we have “Value” based care and drop down bonus-based EHR’s that prevent us from seeing the patient, who doesn’t get a drop down bonus of their own. The mutant brain of the physician, who amassed impressive SAT and/or ACT scores is dulled by the mechanistic drivel of the pile of prescription rejections at the start of every year and the ensuing Prior Authorization forms to get the patient out of tier 4 and back to tier 2 on their pharmaceutical co-pay. There’s little room in the physician’s brain for the challenge and fun of developing a complex differential diagnosis that get’s your mother aligned with the best opportunity for achieving her remaining dreams. They used to have fun and get great satisfaction our of the patient’s “Thank You, Doctor.” That was the bonus. That assured the quality. That relationship kept the thieves away. I mourn for my profession and the patients it has abandoned.
The NP’s and PA’s are used in places to keep physicians practicing at the “Top of their license”, meaning they don’t get to enjoy and deliver relationship-based care. The PA’s and NP’s have their own limitations in education and sometimes of licensure, depending on state laws, some of which you already mentioned.
(p.s., I don’t use an EHR, but own two. I have fun every day. Patients say “Thank You, Doctor.” I get to discuss personal (even complex nutrigenomic) strategies daily with patients, if indicated, with time to listen to their story- the most important part of the visit- and their values, goals and dreams. I am a fossil. Endangered fossil. I expect to drop all relationships with insurance companies at the end of this year to expand my Direct Family Medicine practice which enables patients to tell their story, unencumbered with the next massive wave of phony quality initiatives which will result in a 6 to 9% penalty ($) for Medicare patients and already is 12% with one commercial carrier.)
Oops, this is long enough to be a blog post- so I’ll post it on my blog, too.
Peace to you and yours.