Monday, January 31, 2011

Personal Health: Shopping at Health Food & Book Stores

Today I went to the health food store where they had a huge sale on several brands. Fifty percent off on New Chapter products, so I thought I'd try the top of the line, pricey Prostate 5LX  offering "Total Prostate Protection".  It "promotes healthy prostate function and normal urine flow and modulates 5-lipoxygenase and promotes normal prostate cell growth in vitro."

Since my prostate gland is over 60 and I know that 70% of 75 year old men have cancer cells in their prostate gland, I want to work at being one of the 30%.  The New Chapter product (each 2 softgels) includes Saw Palmetto 320 mg, a well researched herb for prostate health, green tea 100 mg, Stinging nettle 50 mg each of 2 types, ginger 80 mg, selenium probiotic nutrients, rosemary 10 mg, organic pumpkin seed oil 96 mg.

An interesting comment on the box is, "Our premium softgel capsules are prepared without any chemical solvents and are prion free."  PRION FREE:  another first for me.  I've never seen a product that felt a need to state that it is prion free.  I don't know how one tests for the absence of prions. Many of you may know that prions are the invisible cause of bovine spongiform encephalopathy ("Mad cow disease" in cows).  Well, I'm pleased to know that my prostate won't accidentally lead me to get prion infestation.

Another New Chapter (and prion free) product I bought on sale at half off is Zyflamend to promote a healthy inflammatory response and normal cardiovascular and joint function.  Two softgels include Rosemary 150 mg, Turmeric 110 mg, Ginger 100 mg, Holy Basil, 100 mg, Green Tea 100 mg, Hu Zhang 80 mg, Chinese Goldthread 40 mg, Barberry 40 mg, Oregano 40 mg, Baikal Skullcap 20 mg.  The product is "naturally gluten free".

Zyflamend is the "#1 selling herbal in the U.S. for healthy inflammation response.  It contains hundreds of bioactive constituents from ten of the most researched botanicals that together promote a healthy inflammatory response and support multiple health benefits.  These benefits include healthy aging, joint health and heart health."

I also got a bottle of Solgar brand Niacin 250 mg, that I take nightly for cholesterol health. On the bottle is written, "cardiovascular support, promotes energy metabolism".  It's gluten, wheat, soy, yeast, sugar, sodium, preservatives, color, sweetener and dairy free.

Also on sale was SAMe 200 mg for 50% off. It's S-adenosyl-L-methionine.  I take two tablets daily  for joint function and mobility in hips, spine and knees.   It is a transmethylator, providing  methyl groups to molecules that include neurotransmitters and others that mediate cell to cell communication. It helps to form proteoglycans, which are used to renew the martrix of cartilage.  It also is known to enhance liver function.

Stevia was another sale product today at 30% off. It's a natural sweetener that I put in coffee and tea.  Five drops contains 43 mg of Stevia leaf extract, that about sweetens one cup of coffee.

I also picked up some Ezekiel 4:9 English muffins.  "Now go and get some wheat, barley, beans, lentils, millet, and spelt, and mix them together in a storage jar.  Use this food to make bread for yourself during the 390 days you will be lying on your side."... Ezekiel 4:9.  A man decided to produce this Biblical product in various breads.  I won't be on my side for 390 days of preparing it as it instructs us in the Bible.  It should be helpful for insulin resistance.

I dropped in to Barnes and Nobles to get a cup of Starbucks coffee and was suddenly seized with the need to get a few books.  These included, The Paradox of Choice by Barry Schwartz, Trigger Point Therapy for Myofascial Pain by Donna Finando and some others.

I will now be healthier, wiser and, temporarily, more awake (from the Starbuck's coffee).

Thursday, January 27, 2011

January 27, 2011: 38th Anniversary: Cease Fire in Viet Nam. Thank God

 Our War
 Paris Peace Accords signed — This Day in History — 1/27/1973:

"Article I
.... The United States and all other countries respect the independence, sovereignty, unity, and territorial integrity of Viet-Nam as recognized by the 1954 Geneva Agreements on Viet-Nam . . .
Article 2
A cease fire shall be observed throughout South Viet-Nam as of 2400 hours G.M.T., on January 27, 1973. At the same hour, the United States will stop all its military activities against the territory of the Democratic Republic of Viet-Nam by ground, air and naval forces, wherever they may be based, and end the mining of the territorial waters, ports, harbors, and waterways of the Democratic Republic of Viet-Nam. The United States will remove, permanently deactivate or destroy all the mines in the territorial waters, ports, harbors, and waterways of North Viet-Nam as soon as this Agreement goes into effect. The complete cessation of hostilities mentioned in this Article shall be durable and without limit of time....
Article 4
The United States will not continue its military involvement or intervene in the internal affairs of South Viet-Nam.
Article 5
Within sixty days of the signing of this Agreement, there will be a total withdrawal from South Viet-Nam of troops, military advisers, and military personnel including technical military personnel and military personnel associated with the pacification program, armaments, munitions, and war material of the United States and those of the other foreign countries mentioned in Article 3(a). Advisers from the above-mentioned countries to all paramilitary organizations and the police force will also be withdrawn within the same period of time...."

I feel sad reading the words of the Paris Peace Accords, thinking of how many more words and photos are needed to relay the meaning of the War to people of other eras.  I think of what Viet Nam looked like, felt like, smelled like, sounded like, even tasted like.  The five senses can't even do justice to the full meaning.  My twenty West Point classmates (USMA 1968) who died there are part of the meaning to me and many others.

Gulf of Tonkin, Robert McNamara, General Westmoreland, Dean Rusk, Diem, Ky, General Maxwell Taylor, President Johnson, DaNang, Saigon, Vung Tau, Hoi An River, Monkey Mountain, Marble Mountain, Phu Bai, 45th Engineer Group of 18th Engineer Brigade, Quang Ngai, Quang Tri, Tomahawk, Sally, Rakkason, "Black Smoke",Khe Sanh, My Lai, Nha Trang, Hai Van Pass, Laos, Cambodia, Donut Dollies, Body Count, Rusty Calley, Arc Lite, Huey, Cobra, Kiowa, Chinook, Floor Show, Cold Duck, Gin and Tonic, Poker, Bridge, R & R, China Beach, Bob Hope, Ration Card, MPC, Mateus, Check Ride, Autorotation, Lam Sanh 719, Mortar Attack, Perimeter, Red Smoke, Friendly Fire, White Phosphorus, Nomex, DEROS, Peace.  The Viet Nam Veterans Memorial.

And on and on.  Peace, Peace and Peace.  Our War.  My War.

For more of the Paris Peace Accords click on the link below.

My Memorial Day Post about "The Wall" :
Grief and the Viet Nam Wall

Wednesday, January 26, 2011

The Dr Synonymous Show 1/25/2011: Culture, Right Brain Doctors, Bones, Bowels, Bible Foods and Life in Liberty

The Dr Synonymous Show January 25, 2011
Blog Talk Radio
(available 24/7 for your listening as a podcast if you click on the link above)

Introduction/ Welcome/ Disclaimer

Grant McCracken, at the intersection of anthropology and economics,  Blog Post about culture and communication between people of different backgrounds
 Musings of a Dinosaur Blog Post:  
 Requiem for a Crazy Lady

Tennyson Williams, MD  Editorial from The Ohio Family Physician Winter Edition "Health Care and Right Brain Function".  The article is on pp 20-21, 24 of the link below which is the entire magazine.
 The Ohio Family Physician Winter 2010

Jill of All Trades, MD Blog Post about Preparing for Colonoscopy

Kenny Lin, MD Common Sense Family Doctor Blog Post about the New USPSTF Osteoporosis Screening Guidelines
When Politics Trumped Science Osteoporosis Screening

Miracle Food Cures From the Bible by Reese Dubin:  Seven Herbs from the Last Supper (Number 6) "Charosets" (aka, Haroset)

Dr Synonymous Blog Post on Family Medicine Conditions

Dr Synonymous New Blog, "Set Our  Hearts at Liberty" Reflections on God, Life and People starting in his hometown of Liberty, Ohio:  
Liberty EUB Church

I'm Dr Synonymous, hoping that YOU are synonymous with your best health

Our Next Show is Tuesday February 1, 8-9 PM ET

Family Medicine: One Windmill Too Many?

Family Medicine started as a "counter culture" specialty in the late 1960's with an opportunity to facilitate a course correction for the medical profession.  Redirect medical care toward patients.  Redirect academic medical centers toward patients.  But no, we came up short.  To quote from G. Gayle Stephens, MD in his presentation "Family Medicine as Counter Culture" in 1979, "We have expended our energy on professional legitimation and enfranchisement rather than reform."

As we recently got employed by corporate interests such as hospitals and gave up hospital care of patients, we left the culture we sought to reform.  We responded to quota mandates, giving up the opportunity to effect the best outcomes for our patients in exchange for a comfortable lifestyle.  We can crank out the patients if we listen less and get efficient, to better support health system needs.  We can game the satisfaction surveys and get a high level of approval.  The more superficial we become, the more our patients feel disconnected and the more emergency room visits they experience with higher and higher expense at less and less overall quality.  Now we're aligned more with shareholder value for the system than with our patients.

We're broke financially if not comfortably established in a corporate system, sometimes groveling for dollars with procedural schemes to attempt to have a cash flow increase.  We've lost our direction and forgotten our purpose.  What happened?  How do we get realigned with the people?  Is it too late?

The Patient Centered Medical Home (PCMH) is supposed to be the model that buys our freedom and our realignment as family physicians.  In many ways, though, it looks more like the "Payment" Centered Medical Home.  It's supposed to save primary care and optimize care coordination with a team approach to primary care.  But how is the patient engaged in the new model?  Who is training patients and employers to connect to the model?  Who is  protecting the family physician from a massive work addition and burnout during and after the transformation of our practices into Medical Homes?

We attacked the windmills and had some victories, but now it looks like the last windmill defeated us.  Family Medicine and  our patients are losing fast.  I've written before that five family physicians left practice in my county in the last 19 months, leaving around 10,000 patients without a physician.  There are now two major hospital  health systems in this area and both flagship hospitals closed their family medicine training centers in the last two years and built heart hospitals that opened in 2010.  Who will protect the employers from the expense that is headed their way?  Do they even see it coming?

Who will answer?, I keep thinking as I hear the old Ed Ames song by the same title playing in my head.   There is no way this community can afford the medical care system that is being built for them.  Three heart hospitals and a diminishing primary base.  It looks like our specialty, family Medicine, has failed to lead in a way that would best serve the medical needs of the people. I am very worried.  Who will answer?

Friday, January 21, 2011

Family Medicine Diseases and Conditions: Constipation

"Sir, New Cadet Jonas has properly showered and dried, powdered and inspected his feet, brushed his teeth and has not had a bowel movement for 3 days."  This was the nightly report format for West Point New Cadets (during the first two months of Beast Barracks- boot camp before Plebe year and academics started).  One of my classmates in the next squad had 17 days without a bowel movement, which I assume was a record, but no honors were given.  Hearing of the record, other cadets found it humorous, but the constipated New Cadet may not have agreed.  Constipation causes considerable discomfort.  I believe it to be among the worst of human symptoms.

What is constipation?  Why do people get constipation?  How do they get rid of it? 

Constipation relates both to the frequency of bowel movements and difficulty with evacuation.  Less than three bowel movements in a week and or difficulty of stool passage is a reasonable definition of constipation.  The individual patient has the last call as to what constitutes constipation for them.  Often it is the difficulty in stool passage that causes the distress which makes it imperative to perform a good history and physical, including a thorough listing of all medication and nutritional supplements.  Surgical history in the abdominal, pelvic and rectal areas is important, too.

With many, especially younger people who are very active, lifestyle and cultural issues may be important.  Is the patient ingesting enough food, fiber, and fluids to support their usual bowel frequency?  Is their usual routine altered by their current situation?  In the summer with athletic activity, many become dehydrated, leading to constipation.  Certainly, the New Cadets mentioned above had a very rigorous schedule inflicted on them, in the summer with unusual meal habits and variable access to fluids.

Hemorrhoids, hypothyroidism, diabetes, hypercalcemia, parkinson's disease, recent intestinal infection, intestinal tumors, diverticulosis, rectal fissure, chronic lung disease and more may lead to constipation in family medicine settings.  There are examinations and medical tests to help with the diagnosis of these conditions.

In the absence of a specific disease process, the initial treatment is diet change.  Increased fluids and fiber  (both soluble and insoluble) are a good start. Several fiber rich foods that may be helpful include apples, prunes, almonds, pineapple, grapes, walnuts, peppers, wheat bran, whole grains, watercress, watermelon and others.  Other nutritional supports may include Vitamin C, Magnesium, chamomile tea and dandelion roots.

Medications to treat constipation are now non-prescription, including methylcellulose (not soluble so less gas and bloating), psyllium products such as Metamucil (soluble so more gas and bloating are possible), then the powerful polyethylene glycol (Miralax) which is more costly.  Others include the time honored Milk of Magnesium or Colace.  Initially they should be taken as directed on the container, but higher doses may be suggested by your family physician if needed.

Constipation in small children requires a more delicate strategy not covered in this post.  They may also have psychological issues associated with constipation that become more challenging.  More complicated surgical conditions are not included in this post, either.  These would be diagnosed after referral by your family physician to the appropriate surgical or intestinal specialist.

I'm not sure what was done to help my classmate with the seventeen day constipation, but I know he made it through Beast Barracks to start Plebe year.

Tuesday, January 18, 2011

The Dr Synonymous Show: Patient and Doctor Blog Review, Insulin Resistance, Watercress

Dr Synonymous Show January 18, 2011 8-9 PM ET

Introduction/ Disclaimer

Patient Blog:  
Medical Student Social Media: Dr Jonathan, Senior Medical Student, Mental Health Counselor, Entertainer

Physician Blog:  Kenny Lin, MD

Dr Synonymous Blog: 

Insulin Resistance Information: Glycemic Load Diet by Rob Thompson, MD

Sarah Stein, MD leads a weekend telewebinar about health and weight:
Miracle Food Cures from the Bible:  Watercress

Next Show is January 25, 8-9 PM ET

This is Dr Synonymous-- Good Night

Monday, January 17, 2011

Family Medicine: Please Call Us "Doctor"

Doctor Jennifer Middleton (MD, MPH) writes a blog called "The Singing Pen of Dr Jen" which focuses on her career as an academic Family Physician.  Her January 13 blog post expresses her desire for the physicians she trains to refer to themselves as "Doctor" when interacting with patients.  Her blog post is here. I responded to it with the following comments.  A lot more could be said: Good topic, Doctor. In the late 70's, we also had resident physicians who didn't want to be called "Doctor". It seemed that the "denial" of doctor "status" was one way to "power down" and not be threatening or aloof from patient "status".

Sunday, January 16, 2011

Family Medicine: People Who Are Too Tough

"I felt like I might die a few times recently in the middle of the night.  I had palpitations, dizzyness and shortness of breath and almost passed out when I got up to go to the bathroom.  I almost called the emergency squad but thought that they would think I'm crazy,"  one of my patients in the office with me for their quarterly visit about their diabetes, hypertension and chronic neck pain.

I'm immediately surprised at the implication that they would rather risk death than be embarrassed, or what ever the real message is at the various levels of communication between patient, physician and the world.  I usually seek to clarify how they make their decisions late at night when their life might be on the line before I seek further information about their situation.

Many of these people are what I refer to as "Too Tough".  I hear this type of story two or three times each month.  Occasionally, one of them dies because they wanted to wait until their next office visit to clarify what was happening, or the chest pain didn't hurt like they thought a heart attack would hurt.  Most sports fans are familiar with the stories of an athlete dying of an asthma attack or renal failure during a hot summer practice.  They were very tough people and wanted to keep going instead of "looking like a wimp" or losing the respect of coaches and their teammates.

Each person has their own threshold at which they feel ill.  And another threshold at which it may cause concern.  At yet another threshold, their illness may be called ("diagnosed") a disease.  I found some clarifying comments about this in The Foundations of Primary Care by Joachim P Sturmberg, MBBS DRACOG MFamMed FRACGP PhD (Monash University, Melbourne, Australia).  In an interesting chapter titled "Disease, Illness and Health", he reviews some cultural and historical aspects of personal/patient perceptions.
Joachim continues with a discussion of illness, "Though we may construct our own illness in unique ways based on familial, ethnic and cultural beliefs, it is our experience of feeling ill that remains the driver for seeking medical- and at times lay or paramedical- care.  Patients come to see us to share the story of their illness, to make sense of (or find meaning in) it, as well as getting relief from their symptoms."  He questions whether physicians are prepared to help patients to understand their illness because of preoccupation with the process of deciding on a medical diagnosis.

He then refers to a paper "An introduction to medical phenomenology:  I can't hear you while I'm listening", by R Baron in Annals of Internal Medicine. 1985; 103: 606-11.  Baron questions the mind-body dualism that prevents patients and physicians from understanding themselves and others.  Phenomenology also "questions  the erroneous beliefs inherent in Cartesian dualism."   He goes on to define illness as "a loss or disturbance of the unconscious taking for granted of one's body...the disruption of embodiment."  Instead of problems exclusively with individual parts, Baron emphasizes that we have whole person problems, including the parts and the mind.

The "Too Tough", then might not be good at feeling ill.  They might not notice the disruption of their embodiment and they might continue to take their body for granted when others would feel ill and take action consistent with the risk to their wellbeing.  The "Too Tough" might have a powerful mind that seems to be fully in charge and not concerned enough about the body.  This mind-body dualism may be protective at times for individuals and profitable for the business of healthcare, but overall not beneficial to most persons, too costly for the economy and possibly dangerous for the "Too Tough". 

Thursday, January 13, 2011

Christina Taylor Green: 9/11/2001-1/08/11

Flowing tears
Empty hearts
Sadness touches all
Nine years old
Child so bold
Never to grow tall

Tucson town,
Where sadness reigns
Child of 9/11
Taken from us
All today
With a killer's gun

Congress mourns
Parents cry
Everyone says, Why?
Did our
Christina Taylor Green
Get shot and fall and die?

Tuesday, January 11, 2011

Personal Health: The Doctor is Ill

Muscle aches (myalgias), irritated throat, aches to swallow, sudden sneezing, feeling warm, thirst.  Which patient had these symptoms?  I remember one person with a common cold and another couple of patients with sore throat and cough.  What are the chances that I contracted a respiratory infection from an infected patient?

So what does a physician do for early symptoms of a cold?  Water, Naproxen Sodium, Echinacea and Vitamin C.  Rest and watch a video (The Visitor which has some nice parts about playing Djembe drums).  More water.

Headaches, neck aches.  No cough yet.  Maybe it's a quick virus that will ease up quickly.  More water.  Eyes ache and feel tired and sleepy.  One cough, one yawn.

More water.  Two more introductory coughs.  It's heading for the lungs. Bed time.  2 teaspoons of Tussin (same as Robitussin DM) and so to bed.  No thoughts, by the way, of calling a physician, needing antibiotics, or going to a health care facility. (That might be cheating, since I'm a doctor)

Awakened by phone ringing at 4:59 AM by page on cell phone to call a local Emergency Department to discuss with the emergency physician a patient I hadn't seen in ten years who had a lung infection and unusual finding on a CT scan of the chest.  Two and one half hours later another phone call from an employee calling off work for having infection worse than mine. 

I arise, feed the cat and take my vitamins, echinacea, vitamin C, vitamin D3, naproxen sodium, omega 3 fish oil and water.  No more muscle aches or sore throat.  No cough. One sneeze.  I feel fine.  Drink water, get dressed and off to work site.

I've had my annual flu shot and my diptheria, tetanus, and pertussis (whooping cough) booster.  I wash my hands about 35 times per day. I follow infection control strategies recommended by the  Henry the Hand web site.

I feel fine at work all day and the day after.  I guess my immune system warded off a viral respiratory infection.

Sunday, January 9, 2011

Family Medicine: Patient Parts and Patient Pain- Hair and Scalp

Patients tell us a lot about their parts and their pain.  We have to get the general situation and context to do our best thinking about parts and pain, then they fit better with therapeutic strategies.  We family physicians have a lot of training and experience dealing with parts and pain.  We share the patients desire to have less pain in fewer parts, or no pain in no parts.

If we start from the top, the hair roots may hurt if infected or the hair is pulled.  The scalp may hurt if traumatized or overused or overly sensitive to neck muscle spasms which can radiate pain to the scalp muscles (until it feels like your eyeballs are going to pop out).  Drug withdrawal can cause pain in the whole body, including the scalp.  The scalp may have excruciating pain such that you can't brush your hair without wincing in patients with temporal arteritis, which can lead to sudden blindness if not treated with steroids for a prolonged period of time (guaranteed to get steroid side effects like facial swelling, thinning bones, weight gain and elevated blood glucose).  Unusual viral infections may generate scalp pain also, sometimes with intense burning on only one side of the scalp similar to nerve pain in diabetic feet .

Then there's the shingles, herpes zoster, a delayed effect of childhood chicken pox that hides in the spinal cord until the most in-opportune time when it burns like fire for 7-12 days before breaking out in a rash.  Not just any rash, but one that is on only one side of the body (scalp in this case) in a narrow band, aligning with a dermatome (area served by one nerve) in blisters with a red base.  Every grandma and great-grandma in America can tell when a rash is the chicken pox (trunk first then it goes elsewhere) so most can carry over that wisdom to recognize the shingles rash.

Bad news on the shingles is that the pain may persist, after the rash is gone, intermittently forever.  This is called post herpetic neuralgia (PHN) happening about 6% of the time if you read the studies conservatively and possibly 30% if you own shares in a company that manufactures the "shingles" shot, which is available for people 60 and over for $250 (not covered by medical insurance).  The shot is only effective 14% of the time for 80 year olds, so the $250 may not be such a good investment for many.  It also may cause you to break out with the shingles.  In families that all get the shingles and the PHN, they are anxious to get the shot.

Also in shingles of the scalp it may move down across an eye onto the face, threatening vision loss and requiring evaluation by an ophthalmologist.  Bummer of a pain.

I've also seen scalp pain from staphyloccal infection of the hairline (sometimes methicillin resistent staph aureus: the famous MRSA) sometimes resulting from a haircut.  Burns of the scalp from accidents in hair salons also hurt and can make your hair fall out.

Unusual scalp pain might be caused by insect infestation, stings, bites or burrowing under the skin.   

Wow, we haven't got to the sinuses and face yet and I'm low on blog space.  I'll split parts and pain up and dole it out in bits over the next year or two.  Pain is a big deal in family medicine practice.  And it hurts.  And we care.

Friday, January 7, 2011

Family Medicine: Another Thursday in the Office

Four messages from or about patients on my "hot pile" greet me right away.
1.  Someone over 80 died in a hospice situation in a nursing home where she was placed after terminal metastatic cancer piled on to her deteriorating general health.  I reflected on she and her husband, also terminal from various chronic problems plus acute events. We've dealt with rheumatoid arthritis, hypothyroidism, stroke, cancer, depression, hypertension, foot problems, back pain, skin cancer, hospitalizations, arrhythmia, alcohol, nicotine, dog's death, housing changes, discussions of heritage, dying, family issues and aging.  A long, rich and meaningful relationship.  Amen.

2.  Fat chart with note on front saying the mobility device (e.g., scooter or powered chair) sales company wants the form changed that we submitted after our nurse practitioner spent 45 minutes with patient carefully answering each question on the multi-page questionnaire.  Looks dishonest to me.  My comment: "No, we won't change the answers on the form, even if it means that the patient doesn't get the chair."  I've seen this before, where a vendor says that the form has to be filled out a certain way, even though it's lying, or the payor won't approve payment for the product.  That's not how professionals function.  Lying isn't our strength.

3.  The"back pain is unbearable" in a patient, "someone has to do something.  It's worse than ever."  She doesn't want to come in because she was just here.  I look at the note and remember that the recent visit wasn't about the back.  It was hypertension and urinary problems.  I ask the MA to get the medical record for this patient.  Sure enough, the reason for the appointment, the chart note and prescriptions written had nothing to do with the back.  These type patient comments are confusing and troubling.  We're not connecting somehow with this patient.  I feel disappointed that we're not on the same page.  And the time/money isn't available to facilitate my direct calling of patients instead of seeing those who make appointments.  And a back in severe pain needs a history and physical exam if a physician is expected to relate to its owner as a physician.  It's the minimal expectation of our profession, inside and outside of it, we see, listen, think, touch, speak and act.  Less is less quality and maybe not real medical practice.  I write a note at the bottom of the patient call note. Call pt. "I'd have to see her to help with the severe back pain, we didn't relate about it at the recent visit."

4.  A subspecialist discerned that the weird pain in one of our patients was a rare side effect of one of his diabetic medications.  Patient would like to stop that medication and get a replacement.  I know offending drug is a $4 drug and replacement is about $130, tier 3 on most prescriptions benefit programs.  It may even be disapproved by his plan until he uses one or two other drugs.  OK, I write a note to stop the first drug and call in the new one #30, one daily with one refill.  And to schedule a follow-up visit with lab test in four weeks regarding the pain, chronic disease and the new drug for the chronic disease.  Also, I ask the MA to call patient and let him know the new drug is costly, just as a heads up.

5. I look at my schedule for the day again, noting that two acute illness slots are still available at the end of the day.  While looking, one of the MA's informs me of a cancellation at 2 PM by someone recently found to have another physician, also prescribing anxiety and pain medication.  An MA from that office called to let us know about the duplication, which is an illegal act by the patient.  I already called the patient personally to inform him of this situation.  He knew he was about to be caught.  I just don't know if he's addicted and abusing the drugs, or selling drugs.  Anyway, it's a felony in Ohio to lie to a physician to procure controlled substances.  If the patient comes in and I find that he's lying to me to procure these medications, I call the county Sheriff and a deputy shows up with a simple form the next day.  The patient is arrested one or two days later.  I feel professionally obligated to report the violation instead of ignoring it.  The patient may need an addiction program and get their life back.  Or, they may get jail time and save lives by terminating their sales of controlled substances.  We'll see, unless the patient never comes in.

6.  Now it's time to see my first patient of the day.  A typical day in family medicine.

PS. The patients here are assemblages of multiple persons over the years and not just one specific person.

Tuesday, January 4, 2011

Family Medicine: Hospice Nurses Lead with Love

Over the 31 years in family medicine, I've had many patients reach the end of their life, one way or another.  Those with a terminal diagnosis were often fortunate enough to get enrolled in a hospice program and meet some special nurses.  Some of them are like angels who connect with the patient and allow nature to take its course with minimal distraction.  They may befriend patients in a unique professional way.  They may give back rubs or scalp massages.  They may be the honest mirror that the patient needs to relate to their own struggles with the end of life.  They may be the prayer connection to allow the patient to refresh their spiritual self. 

The hospice team includes a chaplain, social worker and nurses.  They care deeply about people at the end of life and develop special insights about their circumstances and their family members.  They have to relate to family physicians and other primary care practitioners who are involved in a more distant sense with their dying patients.  I'm a bit more involved than most, I'm told, since I want to be the attending physician for my patients who are "referred" to hospice.  I've made house calls on most of my hospice patients. Hospice has pre-printed orders to facilitate understanding by all involved about medications and specific orders for medical issues at the end of life.

Caring for the patients at the end of life has always been meaningful to me since I care for most family members of my patients.  I've had a "Families Only" new patient policy for 30 years so generations of people relate to my practice.  Giving their care over to another physician at the end of life would be a violation of my commitment to our patient-physician relationship.  If I've treated their life and their hearts, lungs, brains and pains over the years, the dying process shouldn't and doesn't separate us.  The individual and family life cycles make more sense in the context of family care in family medicine.

For family physicians, the contact with hospice nurses is critical, but sometimes challenging since we usually don't get to meet each other face to face.  We have to talk on the phone a few times to get to know each other before anything medically intense happens.  We need to hear their philosophy of care and share ours.  We need to share our perspective on what's medical and what's nursing and what's both.  We need to know how we perceive this terminal patient and their family and their situation.  Context matters.  I see death as a natural process that may have some medical components and the care of the dying as having many nursing and even more family components.  How do we best relate our beliefs to each other?  How do we allow dying and death to be as natural as possible?  How do we allow the family to follow their own beliefs and processes with the dying?

Not with "efficiency".  Not with overly rigid protocols.  Dying isn't smooth and predictable. At the end of life,  "Love" is the treatment of choice and generally the hospice nurse is the leader with the most love.  Hospice Nurses:  Thank you for all you do.

What's next (should be already widely used)?  Now we need the web cams and two way real time and asynchronous communication to the patient's home/bedside.  We need to use social media and whatever it takes to get our best connections between hospice nurses and family physicians.  The audio-visual contact will tighten the relationships in the primary care end of life team and allow more connection between patients, families, hospice nurses and family physicians.  Sometimes even angels need technology to get the most heavenly results.