Monday, April 26, 2010

Technology: My New SuperPhone- Great Expectations

My new HTC Touch Pro 2 superphone should get here this week. It will do everything. I can just aim it at my patients and they will be healed. It will also impart them and me with a glowing countenance of joy and appreciation. It will quickly inform all regulatory agencies and third parties who are glomming onto everything that happens in doctors offices that all quality, safety,confidentiality (HIPPA) and homeland security issues were perfectly handled. It will produce a perfect record of the encounter using all the right codes and special modifiers, suitable for government and payor perusal.

My superphone will also print or transfer to my patient's superphone a summary of our encounter and discount coupons for use at the mall next door or on web sites for numerous vendors. Since the record of the visit will so perfectly satisfy all the agencies, the patient and I both will accrue extra hours of special event coverage on cable TV. Last but not least, it will automatically analyze their available financial resources and suck the copay and deductibles out of their assets or those of their payor into mine, leaving a happy face in its place.

What a lifestyle I'm about to develop as a result of my HTC Touch Pro2. I obviously will have to name my phone, since it's almost human. Did I mention that I'll get NFL games on it in the fall and I can catch Doctor Anonymous, my favorite BlogTalkRadio show on it every Thursday night at nine PM? My Facebook relationships and followings will now jump into my hand. My Twitterings can be almost continuous and I'll be totally available to professional groups on LinkedIn. My email and night call pages from sick folks will resonnate through beautiful and toneful reminders.

I may have to hide it in the box from time to time to get some peace, but otherwise, I'm getting pretty excited. It may take a few weeks to get it loaded and programmed before it cures my patients, but it soon will probably be a genuine board certified family physician.

More later for you technology fans.

Family Medicine: A Human Relationship Specialty Being Crushed by the Medical Industrial Complex

Family Medicine is a relationship based specialty. The generalist nature of the family physician gives us a chance to become a systems management expert. Our patient may be a generalist or a parts oriented thinker. The confluence of our knowledge, beliefs and attitudes creates a space in which two humans may help each other. We are both humans, consumers and stewards of scarce, valuable resources. Each has an individual role of patient or physician, giving unique perspectives to their individual context. Inadequate emphasis has been given to the human, consumer and steward roles. These three factors may help to protect the patient- physician dyad from the intense pressures from time and money that are used to squeeze the quality and satisfaction from the relationship and the decisions made by the dyad. The demands of the medical industrial complex (MIC) are sucking the life out of family medicine. Can the unique aspects of the patient-physician relationship,shrouded with modern sociotechnical processes, save the day for family medicine?

Family Medicine is the specialty in breadth that combines the biological and social sciences to serve individuals, families and communities. Fewer and fewer medical students are selecting family medicine as their specialty. About eight percent of American medical school graduates now choose family medicine for their specialty training.

The American people need about thirty percent of physicians to be a primary care specialist to have an adequate primary care base as the anchor for the medical care system. Primary care pediatrics only gets about 2% of the medical students and primary care internal medicine gets 2% of medical students, since the advent of the hospitalist movement. The other often stated decision factor for specialty selection by medical students is debt versus earnings. The student graduates with about $150,000 in debt. Primary care generally pays the least of all the specialties (except psychiatry, which also has a shortage). It also is known as having a high hassle factor with paper work and forms that distract from patient care.

Emergency medicine was selected by more American medical school seniors in 2010 than family medicine. The pay is higher and the hassle factor is lower in emergency medicine. The hospitalist (an internist, pediatrician or even a family physician) may work seventeen or eighteen shifts per month and receive $30,000 to $50,000 more per year to start. The people need a lot more primary care physicians, the students aren't drawn to it. That's an expensive problem. Since the people don't have enough primary care, they go to emergency rooms and see narrow specialty physicians too often, driving up the cost of health care significantly.

What will protect and expand my specialty to serve the needs of the American people? Will it be technology? Social change? Guardian Angel? More later.

Wednesday, April 21, 2010

Monday in Family Medicine

"Oh Monday morning, you gave me the warning of what was to be..." Mommas and the Poppas 1960's.

First patient "Diabetes and lab review"
BP 100/68, P 56. frequently lightheaded, cardiologist just added amlodipine to metoprolol and isosorbide but letter from her doesn't clarify why. Hmm. If it was me, I would stop the amlodipine. Do we wait until she sees the cardiologist, call the cardiologist (time is a big problem with dr to dr connection), ask the patient to call the nurse at cardiologist office to clarify w/ cardiologist if she can stop the amlodipine to get higher BP (generally not a cardiology concept)? Some control confusion since cardiologist seems to relate to her BP, but I'd rather manage that and the lipids myself, and I'm already managing the diabetes (patient is with my input-and she has great "numbers"). Not usually a problem, but this patient had a cardiologist in another hospital system before she became a patient of mine. I've never met her cardiologist. Etc.

2. Three call in notes from patients: "Not feeling well, would like us to order a blood test." Hmm. A diabetic who doesn't test glucose isn't feeling well, wants a blood test instead of appointment. I scribble response: What is blood glucose? schedule two visits- one for sickness at which we'll determine what blood tests are needed for the sickness and/or for the chronic disease management and prevention that we'll relate to at second visit.

Next note: "Forgot to get three meds refilled at recent visit" which was scheduled as an acute illness, but pt added desire to deal with three chronic diseases while he was here. Please write the prescriptions for him and mail to him. Hmm. Another person with diabetes and Htn, drinks six beers daily, recently decided to start checking glucose. Finally went to see oft recommended dietitian. Is his goal to avoid the cajoling and hugs from the doctor that might realign his health with his stated health goals? Don't have time to write rx now, recommend visit in one/two weeks to f/u diabetes and what wasn't covered by dietitian.

Next note: Pt with MRSA infected crush injury of a finger, "can't get car running, should pt continue antibiotic?" Hmm. Dangerous car that could lead to disastrous infection. Quickly review last visit date and recommend pt continue medication and follow up tomorrow to review and re-evaluate.

Now, I get to see the second patient (or is this my fifth patient of the day? Might I now be a bit behind schedule?)

Time for "California Dreaming"?

Monday, April 19, 2010

Clinical Decision Making: Heart, Mind and Brain

"As a man thinketh, in his heart, so is he."... The Bible

As a family physician, I see many people with a wide variety of symptoms, often undifferentiated with regard to a specific or obvious diagnosis. In these circumstances, I establish a differential diagnosis (list of possible diagnoses that might cause the main complaints) and seek to clarify, in partnership with my patient, what direction to pursue for diagnostic and/ or therapeutic strategies. If the symptoms and physical findings don't align with specific diagnoses, I further clarify with the patient what the symptoms prevent them from being, doing or having. It's also helpful to clarify the patient's misalignment with life goals and dreams as a result of the symptoms. I might ask, "When is the last time you were yourself?" As the misalignment is clarified, we review ways the patient might realign with their life direction.

Often, people are blocked from taking the ideal path to realignment with themselves by a limiting belief. "I always get bronchitis when I get an upper respiratory infection." "What's the use in following the diet and exercise plan, I know that eventually I'll have my legs cut off like my grandpa now that I have diabetes." "If I disagree with my mother about the need for her to get a home care nurse, she'll give me the 'look' and I'll freeze up again." "If I don't go to the ER when I get the chest pain, it might finally be the heart instead of the gastroesophageal reflux." "My friend took Chantix to quit smoking and got a serious depression. I don't want any part of that stuff." Many other limiting beliefs derail people's desire to be whole, challenging the family physician to be a "belief change agent".

The limiting belief is usually in the brain, so I may remind my patient that the brain is a simple filing system that can be changed by the mind which may be more creative and flexible. "You can imagineer your way to a new belief with your mind. Imagine a future in which you see, feel or hear a different reality for yourself."
"See yourself at your daughter's wedding." "Feel the sand between your toes at the beach." "Smell the breeze at the beach." "Hear the music of your church choir." "Feel the strength in your legs as you walk your dog on a spring day in your neighborhood."

Some patients can allow their heart to overcome their brain's limitations via the Quick Coherence Technique developed by Heartmath (at This entails getting a heart focus and "breathing" through the heart area and appreciating through the heart area. After establishing Coherence (geeks may wish to buy their software and ear sensor to demonstrate through analysis of heart rate variability a balance between sympathetic and parasympathetic nervous systems), the patient can inquire of their heart center as to what to do to change the limiting belief or what alternative action to pursue. This is a hard science way to clarify what may previously have been seen as a holistic or religious approach to problem solving or "integration" of mind, brain and heart.

Through Heart or mind or brain or a combination of two or three of them, family physicians may help patients to change limiting beliefs that impair the patient's ability to align with their ideal health strategies. Positive belief alignment may lead to better health alignment and better life alignment. Medical outcomes such as Hgb A1C, BP, Lipids, etc. may be more achievable as the patient learns to overcome limiting beliefs.

Friday, April 16, 2010

Allergy and Infection: The Yellow Victory

I practice in the Dayton, Ohio area, the fourth worst allergy city in America. I'm hoping we can move up to number one if we work on it. Maybe plant a few thousand more trees or start a ragweed farm. August 15th is "Ragweed Day", March 15th is "Tree Day" and April 1st (no fooling) is "Grass Day". From Ragweed Day til the first frost, allergy medications and tissues are popular items in all the stores. When the first frost arrives, the "sinus sufferers" facial pain stops and the asthmatics start their winter wheezing (like a tag team). I often tell patients, "Mucous is the state bird in Ohio", to apprise them of the ubiquitous nature of Ohio Mucous. Patients may have a need to dry it and block it or flow it and blow it, depending on the location and the nature of the mucous. My medical advice depends on their innate ability to store or process mucous. The normal adult head makes about two liters of mucous daily (correct- it would fill a two liter soft drink bottle).

My patients often are unlucky enough to get an upper respiratory infection in their excess allergic mucous. This adds a few hundred more mililiters of mucous to the 2 liters. Then it might feel like it's coming through their face, unless they flow it and blow it, or have huge sinuses in which to store the excess mucous. When they see the yellow mucous from the infection, many believe that they need an antibiotic to treat the infection. The associated body aches combined with the facial pain add to the pressure to get an antibiotic from their family physician. When they ask, "don't I need antibiotic since I have yellow snot" (Ohioans seem comfortable with this word)?, I tend to respond, "No, actually it's cause for celebration since you're experiencing "The Yellow Victory". That means that your body is killing the infection and you don't have leukemia. Congratulations!"

Helpful therapeutic strategies include saline nasal spray and gargle, loratadine or cetirizine for the allergies and guiafenescen to flow the mucous. To stop the mucous, pseudoephedrine is a great drier-upper of mucous.

To celebrate the yellow "victory", start with mucous and add infection. If your face doesn't start hurting, move to Dayton, Ohio. We'll celebrate the Yellow Victory with you .

Tuesday, April 13, 2010

Family Fanatic: "Families Only" Medical Practice

Over the years, I've become a family fanatic. Family Health Connections, Inc. is the Family Medicine practice that I started eleven years ago. We only take families as patients. This gives us access to the basic decision making unit in America, an age distributed practice, and a rich view of important aspects of individual and family development. We can float into issues of family function, family life-cycle, genealogy and genomics in any clinical encounter since we know about lots of relatives (as confidentiality allows) and engage in multi-generational clinical decision making.

I got the "Families Only" idea from Robert Smith, MD who was residency director in the Ohio State University Department of Family Medicine in the early 1980's, where I was a clinical preceptor. He instituted a "Families Only" practice policy in Medina, Ohio holding a family orientation meeting once monthly at which interested families could learn about the doctor and the practice without obligation. Those who wished to sign up their family members as patients were then free to do so. He had a long waiting list for the meetings and thoroughly enjoyed the richness of family contacts that his practice model afforded him. I was so excited at operationalizing his idea into my practice that I instituted it the next day in my solo practice in Newark, OH. The family learning was an eye opener. I spiced it up by attending the "Families in Health Care" meeting at Amelia Island, FL a few times to get a better handle on family aspects of family medicine.

Doing the "Families Only" (we say that a family is everyone sharing an abode, house, apartment, camper, etc.) practice from solo to group to academic group(s)and back to solo practice has been personally and professionally rewarding. After thirty years as a family fanatic, I share a few reflections:

Families will open up to their family physician, e.g. "Doctor, you need to know that my husband is drinking again." "Doctor, don't say anything to my wife, but she stopped taking her antidepressants again." "I know that my daughter is having sex and I want her on birth control. I don't want her to make the mistake that I made." "My mother was a Christian Scientist, so we never went to doctors. I'm not going to do that to my children, since we have good insurance and I want them to stay healthy." "I'm worried that my children will have the alcohol problems that my mother and her family had." "My father and brother died young of heart attacks and I know I should quit smoking." "My husband told me before he died that he wanted you to have this fishing pole. He liked how you talked to him about going fishing."

Families understand medical heritage, when asked, "What concerns do you have about your family medical history?", all adults who responded to our practice survey had concerns. They were concerned that they might develop Alzheimer's Disease if it affected a parent or grandparent. They were concerned that their children would develop alcoholism or drug dependency if that was in the "family tree". They had few concerns about heart attacks but many about stroke risks if family members had experienced a stroke. If family members had experienced amputation from diabetic complications, they were interested in diabetic prevention or testing.

Families have heart for each other, positive and negative. Mothers and grandmothers of newborns have a special feeling in their heart for the baby and each other. People near the end of life generate focus in their family. Family relationships are enhanced and family values reviewed with family stories before and after the death of a senior family member. Dying persons may delay death until family members arrive for a "farewell". Miserable family members with chronic pain syndromes seem to "suck" energy out of family members. Zero to 12 year olds seem to be able to recharge the energy batteries of grandparents and great- great grandparents. The extra energy, possibly generated by genuine caring and love, helps to decrease pain and fatigue for the ageing person.

The family physician also is heartened by the love and caring shown by family members for each other. I found myself honoring families for their strengths, especially if they had forgotten or needed a reminder. Senior citizens near the end of life sometimes aren't aware of tasks to accomplish in that phase of their life. The family life-cycle developmental tasks literature can be quite helpful to provide the family doctor with broader insights about a family member in the last stage of the life-cycle. I sometimes inquire as to whether the end-of-life senior has made sure that all the photos of previous generations are labeled.

Religious beliefs about the end of life and the afterlife vary widely and families are comfortable sharing these beliefs with the family physician (if the family physician is comfortable). I remember one family member feeling devastated because her sibling was cremated, violating the survivor's expectation for the afterlife of the deceased. Another family fractionated when one member took a photo of the deceased in the open casket at the viewing. Seniors are usually comfortable discussing end of life issues, while there is often a caretaker (also a patient in my practice) who seems to want desperately for mom, grandpa or grandma to live forever. Each family seems to be uniquely one of a kind with beginning of life and end of life beliefs and traditions. I was blessed to learn from and about a vast array of beliefs and traditions.
I'll always be a family fanatic. A lot more about families later.

Saturday, April 10, 2010

House Calls: Paid in Full Plus Tips

I just made a house call which was, as usual, very satisfying. I can't mention more since I'm being followed on Twitter by HIPPA, as of 4/06/2010. (Should I be flattered?). Old house calls come to mind that won't create problems with my HIPPA friends, so I'll flash back a bit for you.

My first holiday weekend on call in a small Ohio town over thirty years ago included my first house call. Someone exacerbated a herniated disc, was bedfast and called for relief. I accommodated with an examination, a differential diagnosis, a diagnosis and an injection of Demerol (meperidine) and a prescription, a treatment plan and a time for follow up visit in the office. He paid me with a check (He asked about the charges and was provided with the fee amount of $75, including injection, which he gladly paid from his sick bed). He then asked his wife to provide me with some of his homegrown fresh tomatoes, which she selected from a freshly picked array on the kitchen table. I gathered up my black bag and my tomatoes which added a nice touch to their gratitude. The intense pain was relieved, as was the patient (of my partner). I felt good about being able to help someone in pain, which I perceived to be part of my calling to family medicine.
Later I discovered that the man in pain was a millionaire which added to my sense of how human we all are. Human to human we're all human. First house call, first tomatoes, first millionaire. Paid in Full. The tomatoes were great.

On a cold early winter nite, a patient with pre-terminal congestive heart failure called with SOB and edema. I examined her, clarified the situation (dying at home, pre-home hospice, not interested in hospitalization), injected furosemide and chatted about her church and family. She showed me the photos on the walls and told a few stories about her deceased husband. She was teaching me about meaning at the end of life. She then sought to pay for my services and wrote a check for the home visit (100% of the Medicare allowed charge- that's how long ago this was) and then surprised my by insisting on giving me another check for me personally, as a sort of Tip. I quickly rejected on the grounds that Medicare didn't allow physicians to take more than the approved medical fee. She became visibly short of breath as I became firm in my "no tips for me" posture. I stopped my protesting and she stopped her further CHF exacerbation, breathing more comfortably. I accepted the $10 tip (but with federal paranoia about Medicare, I endorsed it over to her church the next day and washed my hands of potential banishment by Medicare or prison- maybe that's why HIPPA is following me- they found out about the Tip).
First teaching by a home-bound dying patient, first Tip. Paid in Full.

Many house calls and years later, I agreed to care for a home delivery newborn. The family called me one hour after delivery to see their 9lb 4oz son. I was greeted at the door by a smiling new (second time) father and taken into the family room where a smiling mother was breast feeding a one hour old infant. The older brother was eating a bowl of ice cream on the floor and two neighbors knocked and entered with supper and cake. They chatted with the resilient looking new (second time) mother while the smiling and nursing continued. No nurses. No needles. No circumcision.
I examined the baby, shared my perspective with the parents, chatted with the older boy and partook of a piece of cake when it was offered. What a natural process. They taught me another perspective on childbirth. They bubbled with wholeness and love and shared it with me. First home birth house call, first family expansion natural on site education, first house call cake. Paid in Full.

I also examined an elderly patient with an arrhythmia and CHF flare up while the Fourth of July Parade went by her front door. Heart sounds hard to hear through the bands, but we figured it out. Many house calls were to people with terminal cancer, initially without the benefit of home hospice. Initial home visits also were before emergency squads were commonly available. Families, neighbors and friends provided a lot of the care to these folks. The doctor was always prepared with one or two injectable medications. Incision and drainage of abscesses was another challenge on home visits, but doable and necessary at times. Overall, I still learn something new at each home visit, especially about life in America and life in families. People know a lot and share a lot with their family physician.
Many are surprised when I initiate a home visit. A friend and patient called one night with severe low back pain. I asked if he had any coffee in the house. He asked with confusion, "Am I supposed to put coffee on my back?" I said, "No, put on the coffee, I'm coming over to treat you." He was pleasantly surprised and I was Paid in Full.

The kindness of the individuals and families I've seen on house calls has been impressive. The learning has been touching and meaningful for me personally and professionally. I consider myself Paid in Full.

Friday, April 9, 2010

Fossil at the Starting Line

I'm Dr Synonymous, a family physician thirty years into my medical career feeling like I just hit the starting line. Wow! It reminds me of running the Marine Corps Marathon in 1980 with my friend Larry Bauer (and 10,000 others). It was about two minutes twenty seconds into the race before we got to the starting line.
With the medical career, at eleven years of practice I started to hear the music and enjoy the patterns of health, illness and disease. At twenty years, I hit a snag but found holistic practices that freed me to better allow patients to tell their story and to become themselves. At thirty years sometimes I am the music or find myself dancing with the patient's story to find a way to validate their humanity and to help them to know that they matter. That's one of my main jobs: letting people know that they matter. The medical stuff often isn't the real agenda: the human quest is.

I've started four practices from scratch and directed three others along the way. I've been in small town (3,100 people) and urban (Columbus, OH) and suburban practices and directed two campus health centers part time. I went full time academic at Ohio State for four years in the '90's to help restructure the Dept of Family Medicine. I've admitted my own patients to the hospital for thirty years. Still do house calls and newborn circumcisions and manage my own patients in home hospice mode at the end of life. I might be a fossil and definitely have gray hair. I am still having fun as a suburban, independent family physician.

Financial hurdles have arisen now as payors pay less and less for more and more services. Patients pretty much expect to pay little (about what they paid in 1984 at present) and the government is dangling a 21.2% Medicare/ Tricare pay reduction in front of doctors repeatedly. We're all broke at one level or another.
Patients and their stories are generally quite interesting. They are getting better at using the internet to prepare for their visit to my office or to avoid needing a physician's help. I congratulate them for using available resources and often list a useful web site for them to review (hot item now is "the didgeridoo and snoring" via google). After 148,000+ patient encounters, I'm learning some things and seem to have some understandings about people that are useful to others and me.
Just a brief intro about the blogger who is initiating the blogging career at the starting line for my holistic medical career. More later as we become synonymous with who we are. Greetings from the starting line.
Dr Synonymous