Monday, February 28, 2011

Family Medicine: Hippocrates, Hope and Heart

The Hippocratic Oath
(Original Version)
"I SWEAR by Apollo the physician, AEsculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgement, I will keep this Oath and this stipulation.
TO RECHON him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look up his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according the law of medicine, but to none others. ...."

 The Hippocratic Oath
(Modern Version)
"I SWEAR in the presence of the Almighty and before my family, my teachers and my peers that according to my ability and judgment I will keep this Oath and Stipulation.

TO RECKON all who have taught me this art equally dear to me as my parents and in the same spirit and dedication to impart a knowledge of the art of medicine to others. I will continue with diligence to keep abreast of advances in medicine. I will treat without exception all who seek my ministrations, so long as the treatment of others is not compromised thereby, and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient....."

The second paragraph of the oath I took as a graduating medical student in 1976 (the modern version of The Hippocratic Oath) includes a teaching mandate for physicians to teach others.  This may include learners of many levels, including medical students.  Teaching (and learning from) medical students has always been rewarding for me.  They know a lot and they are a member of my "guild".  Patients almost always enjoy their youth, energy, knowledge and promise for the future of medicine.  They also feel a sense of pride, as I do,  in helping the student to become a physician.  

Young, smart enthusiastic learners, like all humans, are flawed.  One of the outstanding flaws of almost all medical students is their desire to reassure patients, even if they don't know enough to be able to reassure them.  I have taught medical students since 1977, often using audio and video technology to assist.  Early in the experience almost all medical students falsely reassure a patient or two. "You will be better after the surgery (or chemotherapy)".  "Don't worry about the side effects, you probably won't get any."  "I think this infection won't bother your diabetes."  "You're going to be OK." Etc.

Why are they so compelled to make comments to ill people with disease processes they may not understand? (Some of the students had just completed their first year of med school).  I don't know.  I do tend to tell the students that, if they need to reassure patients, reassure them that the student will review the situation with Dr. S. and we'll be in soon to further examine and clarify the patients situation.

My current best theory about the intense need of the student to reassure is that it fulfills their dream of helping people, at least by giving them hope.  The dream might be so intense that they forgot the part about knowing more medicine before they prematurely reassure.  The students are living part of what I call the "paradox of the medical healer".  Their heart is so committed to be a helper that it's blind to the brain, which is inadequately prepared to be a helper.  The other end of the paradox is that a trained physician may have so much medical brain that the helper in their heart is overwhelmed into silence.

Teaching medical students is one of the ways to balance the "paradox of the medical healer".  Being around the passion in the healing hearts of the students may warm the hearts of their mentors, teachers and patients with hope.  The other part of the paradox is that many patients feel the caring heart of the student and sometimes appreciate the hope it generates more than the medical brain of their personal physician, which they know is going to follow the student part of the ambulatory clinical encounter.

How might the dyad of student-teacher balance out their respective shortcomings?  Somewhere between Malcolm Gladwell (and between Blink and Outliers) and Donald Berwick, MD's speech to Yale U graduating medical students on June 11, 2010 is the potential to imagine the development of physicians from the neophyte who puts on the white coat at The White Coat Ceremony to the master,coat-less, busy family physician.  The white coat is a symbol of separation- from patient to doctor, from all heart to mostly brain, from free spirit to burdened potential healer, from broke-ness to huge debt and potential brokenness, unless heart and brain get to balance, from helpee to helper.  (A full discussion of the white coat is beyond the scope of this post.)

So how can physicians learn about heart from students and students learn about brain from their mentors and teachers, while learning together how to balance the two?
One aspect comes from the Berwick speech:
“…But, now I will tell you a secret – a mystery. Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity – of the dignity in each and every soul. When you take off that white coat in the sacred presence of those for whom you will care – in the sacred presence of people just like you – when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear and fragmentation, an “aching” world, as your Chaplain put it this morning, that has never needed healing more.”

The (experienced-"Outlier") teaching Family Physician is someone who can help with overcoming the potential for the "paradox of the medical healer".  The experienced, teaching Family Physician knows how to role model for the student by taking off the white coat and leaving it off.  Their humanity is easily shared with the patients humanity.  Even while empathizing with the patients plight, they are helping the patient and the system of care to get better connected.  They are relating the natural history of the disease process to the patients life and family processes while reflecting on the patients illness and suffering.  They know that the patient has an illness that may or may not include a "medical" disease process.  Their human to human connection skills already span the gap between big heart and big brain medical learners.  Teaching medical students is one way to hold onto the "heart" part of health care while sharing the much needed clinical brain that the students desire.

As discussed in The Foundations of Primary Care (by Joachim P Sturmberg, MBBS DRACOG MFamMed FRACGP PhD Radcliffe Publishing 2007), illness is "a loss or disturbance of the unconscious taking for granted of one's body...defined by the disruption of embodiment, rather than necessarily a structural change.  ....illness is intimately related to the patients personality and his life experience and understanding the doctor's role as helping patients to come to terms with, i.e., to find personal meaning in, their illness has a profound impact on the way we organize and deliver health care.  Illness is a whole person problem, not a problem of one part."  This perspective is at the heart of the patient-physician relationship in family medicine.  We're already there, and the students can keep us there.

The intensity of this era unfortunately is driving the family physician from practice and the medical students from selecting it as their specialty.  Both the "hearts" and the "brains" are being crushed by the cash registers of the Medical Industrial Complex.  The "paradox of the medical healer" faces a difficult challenge as we head toward the PCMH and the ACO.  Let's make sure the students go with us.  They can reassure us that everything will be OK.

Wednesday, February 23, 2011

Dr Synonymous Show 2/22/2011: Patient and Doctor Blog and Tweet Review

Dr Synonymous Show on BlogTalk Radio                Listen to this show on   BTR: Dr Synonymous 
     Introduction/ Disclaimer

I:  Patient Blogs:

     Seaspray: Its a Wonderful Life

Grief Songs:   Music From a Grieving Heart: Self Help Expressions

II:  Tweets Retweeted by @apjonas (dr synonymous):

Sara Stein MD
by apjonas
Now's your chance to submit your idea to impact childhood via Slate - actually some good ideas!! What's...
June Soyka Cook
by apjonas
Grief Songs: Music for a Grieving Heart. Great list of songs.. -
Dan Munro
by apjonas
30% of docs don't use Anti-virus s/w and 34% don't use a firewall. We need to all practice safe IT ;-)
Susan D'Elia
by apjonas
Shouldn't all this communication between providers and patients be via an online portal and automatically archived as part of an EHR?
Stephen Meyers, MD
by apjonas
T3: One issue, e-mail, like EHR, tends to bring more work (that was previously delegated) upon the provider.
Liza Bernstein
by apjonas
@ re: institutional soc med are mostly just ads. Our dr says this or that./Yes IMO, those who do it r not getting thepoint
P. F. Anderson
by apjonas
SocMed particularly good for health literacy outreach
April Foreman
by apjonas
t2 If both pts. and hc agencies have common goal of good health, then soc med is another way to make that happen. Everyone wins.
III:  Physician Blogs:   

The Singing Pen of Dr Jen: The High Stakes of those Conversations About Flu Shots

IV:  Family-Oriented Primary Care by McDaniel, Campbell and Seaburn:  Working with Couples

V:  Next Week, March 1st:  Blog and Tweet Review

VI:  March 8 Show:  Founders Interview with Tennyson Williams, MD Founding Chair of The Ohio State University College of Medicine and Public Health

VII:  This is Dr Synonymous:  Good Night

Saturday, February 19, 2011

Family Medicine: A Flu-less, Star-less week in Little Boxes

I'm thinking this will be the start of the flu week, reinforced by the blog post of Dr Fatty Finds Fitness in Texas who said they're full of flu patients this week.  So two or three folks today were close to flu but not miserable enough.  The flu is associated with lots of pain and lots of mucous (which I refer to as "the state bird of Ohio").  One common finding in my  flu patients over the years:  They are so miserable with pain and mucous that they often say, "for a while I felt like I might die, and it would be OK."  THAT is THE FLU.  No, the flu warriors haven't arrived yet.

The strep mongers showed up, though.  Group A, Beta hemolytic Streptococcal pharyngitis is ruining many President's Day Weekends for the local school kids.  Parents seem to be slightly more likely to choose the Penicillin injection for their child this year than most.  In the "Families Only Practice" model that I adhere to, if we get half of the family with strep throat, we offer treatment to  everyone in the family with an appropriate antibiotic (because an old study showed that 75% of family members will get strep pharyngitis once two people have it).

Notice that the parents or patients are choosing which therapy they wish after I apprise them of the risks/benefits of the various treatments.  Since they are conscious adults, I believe they can make their own choices after we clarify their assessment (diagnosis) and therapeutic options.  The medical literature implies that physicians treat patients exactly as the literature says, like dictators, and holds physicians responsible for patients always following clinical guidelines.  Patients are worthy of more personal consideration than that.  The insurance companies also act as if patients should have no choices but should be forced to follow clinical guidelines (that may not apply to to them).

We get bonuses from many of the managed care plans if the patients follow the medical literature guidelines (for eye exams, prescribing generic medications, liberal use of statins, mammograms, colon cancer screening, etc.).  The patients aren't usually aware that we make more money if they agree to follow the guidelines.  I disagree with anything that removes the patient's freedom to decide.  They make decisions after we give our perspective and recommendations (there are writings about how we physicians should be more forceful with our recommendations).  With infections that have risks of spread to others, I strongly recommend appropriate infection control strategies such as staying home, staying away from others, covering coughs, washing hands, etc.  If they are impaired from their usual decision making abilities, I help more in the decision process.  Obviously, if patients are suicidal or homicidal or endangering children, we have ethical obligations to act against their wishes, but that is pretty rare.

I believe that patients can define their own quality goals with input from their personal physician.  This leaves me out of Anthem "quality" bonuses for last year (although I always write for generic medications except Plavix, Januvia and a couple others that don't have generics) and their data said I only did it 79% of the time which surprised me.  I also just lost two "stars" on my United Health Care web site where they changed their criteria for quality and cost effective physicians.  I felt like both companies pushed us to diminish the importance of patient uniqueness and choice.  So I'm feeling a bit boxed in by artificial quality guidelines.  Now I'm also a starless physician and somewhat proud of it and somewhat annoyed by it.  Patients are too interesting to get jammed into little boxes (ala, the old Pete Seeger song,  Little Boxes).  I guess we're in the Little Boxes together for a while longer, then the PCMH and ACO's will offer bigger boxes.  Onward.  Where are you, Flu?


Monday, February 14, 2011

The Human Centered Health Home: Building Trust by Sharing Patient and Physician Uncertainty

"Years ago, I thought that everything doctors said was totally true.  The treatment for an illness was one hundred percent effective, I would always respond by being cured.  I'll never forget the time my family doctor sat me down to clarify what my oncologist meant by five year survival percentages.  Then I was afraid for a while.....  In a few months, though, I realized how much more trust I had in my family physician than previously.  I realized that he wasn't going to withhold the truth from me when I needed it."  

Many patients have expressed thoughts like these about trust and uncertainty to physicians over the years.  This era with more complexity and uncertainty may require patients and doctors both to upgrade their sharing and trusting skills.  As the complexity in the modern health care world increases, patients and physicians both deserve the opportunity to make their best decisions, individually and together.  Trusting each other enough to share uncertainty may enhance the quality and results of their complex decisions.

How do we know when patient and doctor are relating well enough to be safe and effective with their decisions?  How might each relate their certainty and uncertainty about information that should be and is shared?  How and when do they acknowledge and/ or clarify understandings and misunderstandings?  How might each one know when to withhold disruptive information (usually for later sharing) due to the  temporary or permanent vulnerability/suffering of the other person (which usually would abate, allowing the sharing of the withheld information)?
The uniqueness of the Human Centered Health Home (HCHH) model contributes to better sharing of uncertainty starting with its emphasis on Human Centering of the patient and physician.  Their humanity and commitment to humanity starts the relationship before the roles of patient and physician emerge.  This is followed with the six step process of the HCHH including Respecting, Protecting, Connecting, Detecting, Correcting and Reflecting by patient, physician and the dyad of patient and physician.
Some specific aspects of the six steps that allow sharing of certainty/uncertainty and (therefore) trust building are:                                                                                                         
                Respecting:  Patient and Physician respect themselves and each other enough to allow the “truth” to be shared, including uncertainty about important (if not all) aspects of the diagnostic, therapeutic and administrative processes.  The timing of the sharing may vary depending on the communication style of the patient- physician dyad and comfort levels of each during the engagement.  Each learns to respect the roles that they may manifest during the engagement and across the relationship's lifespan.  (Including roles as human, patient, physician, consumer, consumer coach, steward, teacher, learner, friend, neighbor, leader, follower, household member, head of household, etc)
                Protecting:  Both protect the time allotted for this engagement and the time allotted for scheduled engagements before and after this one, including those of other patients, family and friends.  Both members of the dyad and office staff are protected from unreasonable aspects of health care process and the Medical Industrial Complex (MIC).  Both protect each other from unreasonable expectations and their respective family of origin pathologies.  Both protect each other by timely sharing and withholding of information as they realize when and how the other and the dyad is most vulnerable and most powerful. 

                Connecting:  The dyad works to connect as humans first, considering and clarifying each persons context. (see posts- 11/22/10, 11/30/10, 12/03/10)  Then they may choose to connect via other roles such as patient and physician, once their shared humanity strengthens their trust and helps to protect them.  They use  three or more of the five senses to connect as they allow trust to develop.

                Detecting:  While detecting patient alignment with goals and dreams, the physician may do likewise to enhance their wholeness and ability to respond effectively to the patient's situation.  Therein they will detect and share the certainty and uncertainty of each person’s insights about current and ongoing problems and situations as they relate to the current and future engagements of the dyad.  They share in detecting supporting information that may clarify a better understanding of probabilities that impact their individual and shared decisions.

                Correcting:  While developing a shared plan for addressing the realignment of patient situation with patient goals and dreams, both will seek to further clarify levels of certainty and uncertainty using available resources.  They will each give their perspective on the important probabilities that impact the current decisions facing the dyad and seek to correct misunderstandings about the probabilities under consideration.  After sharing their perspectives they will merge their understandings as possible and go ahead with the plan for correction.

                Reflecting:  They will reflect on the dyadic interaction and share their perspectives on the trust levels of the dyad.  They will each allow and accept that the interaction and the decision process happened.  Both will reflect on levels of certainty and uncertainty involved in the agreed to decisions and identify if any need exists for later clarification.  Both will reflect on their sense of trust in each other and their process of communication.   They may elect to forgive themselves, the other or the dyad as indicated as they seek to nurture the relationship via the HCHH process.

Saturday, February 5, 2011

Family Medicine: Winter Weather Leads to Full and Fun Fridays

Suddenly, on Monday, most of the patients for the next day call and reschedule their appointments.  "Dr., your schedule is full now and these two want in today.  They said the snow and ice tomorrow is predicted to close everything, so they don't want an appointment then.  Mrs. Smith says the baby has diarrhea and is passing some blood.  Mr. Jones is really anxious since he still has left shoulder pain in spite of the physical therapy."

This type of conversation causes a re-evaluation of the patient schedule for the next few days and some quick decisions about patient care. 

After three frozen days, it's Friday and the world is unfreezing.  Most have their electricity back on, or they stayed in a motel or with relatives.  Ohio has looked like a scene from Dr. Zhivago with the cold, all-white outdoors look for over two months.  The ice storm this week knocked out the power supply for over 90,000 people in the Dayton, Ohio area.

Who comes to the doctor in this type winter situation?  People with deteriorating chronic problems who were getting acutely ill for seven to ten days.  Children with fevers.  People just discharged from the hospital with a list of new medications and an incredible story of hospital personnel who withheld some of their chronic opiate medication.    Parents who finally caught the kids' infection after kids and spouse recovered.  Someone who slipped on the steps at the high school three days ago, now getting more pain and shortness of breath.  Check for fracture, bruised kidney, stunned lung, etc.  Kill pain, support breathing, decide on how pain fits with job situation, negotiate ideal strategy for next few days with patient.  He gets the main vote.  I advise him about the medical stuff and the drugs.
Then come the poor, unemployed people who used the fireplace for heat and exacerbated their emphysema.  Their cigarettes comforted them in the cold, dark night while adding to their breathing problem and sputum production.  The boy with intense cough until he vomits has no insurance.  "Just send us the bill.  We're applying for medicaid for the boy, but we knew we had to bring him in after four days of fever and his loss of appetite."  I congratulate the parent on his good judgment about his son.

Someone is in the next exam room who lost nine pounds in January by reading and acting on Healthy for Life by Ray D. Strand, MD (I recommended it) to reverse their insulin resistance.  See my post about, and listen to,  The Dr. Synonymous Show (BlogTalk Radio) on December 7, 2010 for four reference books and a discussion about Insulin Resistance  (Here).  I cheer for them and schedule a follow up lab test and office visit in two months.  The follow up visit in Family Medicine is one of the most important ways to get issues wrapped up.

People often have more confidence in lab tests than their own mirror for feedback about health.  While both can be important, seeing how the patient looks and affirming their success clinically can help with restoration of their confidence in their health.  The lab results can be icing on the cake of success, but the patient is the central player. 

A Rapid Strep test in the East Room, a nebulizer treatment with albuterol in the West Room, a Toradol injection in the Blue Room, four brief call-in notes about four patient situations requiring physician action and we're turning the corner toward the end of Friday sigh.  Re-examine the two people who had the albuterol therapy for wheezing to make a treatment decision for home, check the rapid strep result and recommend treatment for a child with fever, cough and sore throat.  Write fast, engage with eye contact, ask if there are any other questions of patient.  Hand them the chart (or parent or caretaker depending on situation) to take to check out counter, "to the people having more fun than they can stand".

Last room, last chart.  Read chart in hall (Chief complaint, vital signs, last visit note, patient written sign in sheet with reason for visit in their handwriting- note difference (s) between that initial patient note and the medical assistant note once patient is in room and responds to question about purpose for the visit).  Deep breath, focus, develop plan for initiating this encounter, knock and enter, make eye contact, greet with name and handshake (unless cough is part of chief complaint in which case I usually don't shake hands since most patients still cough on their hands.  I have to think of public health, contagious diseases and my own potential to spread infection or catch it).  Respect, Protect, Connect, Detect, Correct, Reflect.  Use the whole process every patient, every day to the extent possible.  It's more fun and satisfying that way.

Note time, reflect on entire office, who is the "late person", who needs a physician OK before they can leave.  Look through remaining pile of lab results, imaging studies and patient notes from calls quickly before releasing last MA.  Cringe at the number of tasks per unit of time that I need to deliver before I can feel comfortable leaving.  Place the piles on a work table in front of a large window.  Get twelve ounce glass of water, walk through front office, gather any remaining reports.  Translate illegible writing for staff to finalize codes for diagnoses.  Listen to issues of people or programs from people at the front, especially if there are left over intense feelings about interaction with patients or physicians.

About 18 patient issues are represented in the end of the day pile today.  Eighteen different patients with various documents to review, comments to write, forms to sign, people to contact by MA, front office person or me.  Abnormal thyroid test result -patient has work up scheduled; the Monday baby with blood and diarrhea actually didn't have blood on further clarification, but culture of diaper rash verified it was the infection I theorized and treated that came from a session in the children's hospital.  Pleased that I selected the best antibiotic now verified by the culture report.  Refill two meds for disabled senior citizen.  Put six patient call backs on Saturday MA's work pile for morning disposition, when we'll both be here.  Etc.,etc, etc.

Look at laptop for Facebook, Twitter, Blog, and email. Thirty minutes later, pack it up and leave.  Reflect on how lucky I am to be a Family Physician.

Tuesday, February 1, 2011

The Medical Profession and "Physicianship"

After the events of September 11, 2001, the leaders at the United States Military Academy (USMA) at West Point studied and revised the training and currriculum for the Corps of Cadets.  Increased emphasis was placed on "officership", which expanded the concept of being an Army officer.  It is time for the medical profession to do a similar upgrade of professional development.

In discussing professional development of physicians, the term "physicianship" could be used to refer to the needed upgrade of the profession which faces considerable challenge in the current and coming eras. Physicianship means more than being a doctor and practicing medicine.  In this post I offer for discussion a short list of some roles and attributes that I believe are important for physicianship.  What do you think?

Physicianship is striving to be and becoming:

     A professional who is competent and technically proficient

     A member and citizen of  a respected profession

     A leader of character who inspires, motivates and communicates
     A servant of patients and society

     A warrior for humanity, safety and teamwork