Wednesday, April 20, 2011

Human Centered Health Home (HCHH): Complexity to Simplicity While Working and Caring

Context is important in clinical encounters.  Each patients life is uniquely one of a kind.  The variables vary, driving clinical decision making to uniquely respond to each patient.  Flexibility in the context of the patient-physician relationship is expected of physicians by patients and should be extended by patients to physicians.  The dyad is engaged in the process I've outlined in previous writings about The Human Centered Health Home (HCHH), starting with Respect.

Each member of the dyad comes from a context of complexity, but desires simplicity in their communication and their relationship.  Each cares about themselves and the other, but has to work at task accomplishment within the context of their own lives.

The dyad itself is a complex human phenomena which seeks simplicity at its core, while "dancing" through facts and variables in a "trans-derivational state" of mutual exploration and sharing.  The entrainment of energies in the dyad offers other levels of biopsychosocial sharing beyond the words and gestures they manifest.  As mutual understanding allows the dyad to settle into a state of agreement, work flow shifts to tasks and processes that change the state of the dyad into separation mode. This leads to other agendas and/or forms, nods, transitional words and gestures and departure from the dyad back to individual patient and physician.

The humans in the dyad shift roles to patient and doctor, consumer and consumer coach, learner and teacher, learner and learner, and others during the engagement.  Both hope for a mutually beneficial outcome, but have some fear that it may not be what they expect.  Uncertainty abounds as to which exact path the biological or behavioral issues will follow.  The agreed to intervention(s) are intended to alter the course of a pathologic process to a healing process.  Contingencies may be offered/ negotiated for outcome variables that misalign the patient (and the doctor) with the desired outcome.

BUT, what happens if the physician is distracted with thoughts about the psychotic 25 year old man who was hearing voices and buying Percocets on the street again because that's the only thing that will quiet the voices?  The man was unwilling to go to a psychiatrist since they won't listen the way the family doctor will.  He only wanted some Ativans to stop the need to buy the Percocets.  But the doctor offered the ER where the patient could see the crisis intervention evaluation social worker to consider detox and psychiatric evaluation.  The patient refused and left the office saying, "I don't know what to do or where to go.  I thought you would understand.  I thought you would help me."  While thinking about how to be of better help to this man, the doctor is interrupted in the hallway by the office manager.  "You know he left without paying again.  He owes us $584 for visits over the last 18 months."

AND/OR what happens if the patient is distracted by the cell phone call from her sister saying that the ex brother in-law (sister's husband) is threatening again to seek custody of the kids because their daughter was expelled from school again?  She needs another $500 to pay initial attorney fees to prepare to block him.  The patient also remembers that she's supposed to try to get her birth control prescription filled by the family doctor today since she's about out of her last packet prescribed by the gynecologist after the baby was born a year ago.  She's not sure how to bring up that subject since her appointment was just made this morning when she woke up coughing and wheezing on the tenth day of a cold that seemed just yesterday to be finally ending.

The complexity of the other situations may prevent the dyad from connecting well enough to effectively relate to the problems at hand.  Their conflicted work flow may filter their caring.  A disjointed encounter may misalign them with their actual needs.  Can they find a connection point that affords a mutually beneficial outcome to this encounter?

I believe they can breathe and appreciate, in  the context of an ongoing relationship with a human base, the human dyad into a coherent connection that can overcome a distracted encounter with Simplicity.  They can start with the processes of the HCHH:  through respecting, protecting and connecting as humans first.  They can match their breathing, focus on their hearts and appreciate something beyond the dyad together.  They can follow this by  responding to feeling and content of each others general situations until a respectful connection to the meaning of their respective situations seems to exist. This connection may deliver enough Simplicity in the dyad, via coherence (a balance between the sympathetic and parasympathetic nervous systems, to allow the roles of patient and physician to emerge, stabilize and engage with a focus on the pressing issues of the clinical situation.  The complexity of the individuals may then be focused on those clinical issues, filtering out the life/ work context elements that are distracting.

With the respect established early in the relationship, they may continue to clarify roles and goals in the next/ follow-up encounter and mutually agree on the varying process of "caring" while accomplishing the tasks of the process of care.   Respectful Humans can accomplish a lot in a relationship based clinical environment.

What do you think?

Wednesday, April 13, 2011

Family Medicine: At the Bottom of the Accountable Care Organization Funnel

Accountable Care Organization:  A Big Funnel of Health Care Phenomena into the top of which the tax payers (aka, the federal government) will drop one check as payment in full for all Medicare patients (at least 5,000) served by The Funnel. Initially, ACO's will be voluntary.  Government rules for ACO's seem to be evolving, but doctors and hospitals are preparing for them, expecting to be coerced into business and collaborative models that are unproven. Here are the rules:

Who/What is at the top of the funnel?  Who/What is at the bottom?  Is it a real/stable funnel, or something like Dorothy experienced in "The Wizard of OZ"?

I wrote this blog post in April, 2010: 

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.

April 13, 2011:  OK, so now it's later:  The ACO's are upon us.  And the medical students are alleged to graduate with closer to $175,000 of debt.  The specialty selection gods and goddesses have spoken again last month. The rosiest interpretation of the match results for Family Medicine:
AAFP Notes Match Results

So we picked up a hundred more American medical school seniors to go into Family Medicine, an increase from 7.9 % to 8.4 % or so, and we need 30 % at least.  They will serve 1700-2200 patients in each of their practices, if full time (but 15-25 % won't be full time due to family needs or administrative responsibilities which are expanding with the advent of the PCMH and ACO's). That's 2,200,000, at most, of the 50-65 million or so people without primary care who will have access (depending on the business model of the Family Physicians).  Oops, I forgot the retirements of the Baby Boomer Family Physicians which will uncover more than 2.2 million patients yearly (and they would more likely have 2500-3000 patients each in their panel).

Actually, we're still going backward, but American ingenuity might figure out how to reverse the trend.  Remember, though, to keep looking at the numbers of patients served for a reality check.  We have a diminishing capacity to deliver primary care to Americans at the present time, if you like math, in spite of the PCMH, ACO, etc.  So the emergency rooms are building more additions for the increased need.  And the cost of care is still going up.

Will The ACO Funnel be the answer for America's Primary Care Shortage? If we get hit on the head by The Funnel and "Follow the Yellow Brick Road", maybe there's Hope.

Tuesday, April 12, 2011

Family Medicine: Incidentalists for Incidentalomas

"You have an incidentaloma (an incidental finding on a medical evaluation such as a lab test or imaging study)", I tell my patient.  "I'm referring you to our Incidentalist, a new specialty started to evaluate and treat incidentalomas."

We know that CT scans of the chest will reveal pulmonary nodules on 36% of so people.  These incidental findings are currently evaluated by CT scans at regular intervals to follow the nodule.  One and one half percent of the patients will have a problem that requires further treatment.  Most would eventually be found by other evaluation strategies.  The incidentalist will save lots of money by accurately interpreting the probabilities and finding a more cost effective strategy for the patient to get reassured or evaluated.  The 27,000 yearly cancers that we apparently generate each year from the radiation used in imaging studies are a testimony to our need for a different strategy to pursue these incidental findings.  The money saved by avoiding unnecessary testing strategies will pay for the Incidentalist and their training.

There are many other incidentalomas on laboratory test results and other imaging studies and others beyond the scope of this article.  

The new specialty will fit perfectly with the Accountable Care Organization (ACO) concept.  The Patient Centered Medical Home will include the Incidentalist, along with the Family Physician, Family Nurse Practitioner, Social Worker, Holistic Practitioner and Care Coordinator.  The Incidentalist will typically wear a headset and have four monitor screens in their workspace.  They will be an information maven, celebrating the confluence of people and numbers.  Doctors and patients will love them.

The Incidentalist is coming to a doctors office near you.  If they work out in primary care, hospitals will be the next site for implementing the hospital based Incidentalist.

Monday, April 11, 2011

Family Medicine: "No Brain, No Pain" or "Know Brain, Know Pain"

"Doctor, Are you saying that my pain is all in my head?", asks my patient. "No brain, no pain." is my usual response. The pain is recorded in the brain, asking for a response from the pained person. Acute pain, such as accidentally touching a hot plate or stove burner, generates a quick response leading a person to move away from the hot object. Chronic pain, on the other hand, lumbers up the spine ("Slow" C fibers) through the limbic system where all of our life files (joys, pleasures, miseries, etc) are located. It beats up the life files, unless they are protected, then moves forward in the brain pronouncing that, by the way, you have pain.

Those simple concepts have a lot to do with how we analyze and treat acute and chronic pain.  They also have a lot to do with how we explain acute and chronic pain.  Chronic pain seems to be the more challenging one for  patients, physicians and society.

Another aspect of chronic pain is that it gets "engraved" in the brain.  It may register pain even when the body isn't hurting and it takes a while to forget the pain.  "Wind up" is another unfortunate element of chronic pain in that, the longer the pain is around, the more intensely it hurts, even with the same provocation.  Hyperalgesia, painful sensitivity to less and less touch, is another unfortunate component of chronic pain.  Sounds like a bit of unfairness, right?  Right, but that's how it works.

Heredity is another interesting consideration in chronic pain.  If you "picked the wrong parents", you may be at risk for the same pain threshold they inherited or the same response to pain.  If one or both of them have a chronic pain syndrome that is treated with chronic opiate medications, and their pain  hurts worse and worse and worse, you are at risk for the same response to pain and to opiates.  More unfairness.

Since chronic pain is such a challenge, physicians are prone to avoid treating it and/or to refer patients to a "pain management" physician.  These doctors will inject your back or neck if that's where the pain is located or prescribe physical therapy and medications as indicated.  They usually are trained as anesthesiologists, but some might be physical medicine and rehabilitation experts, while a few were trained in  a primary care specialty.  'Another doctor", you moan, thinking that it's just not fair.

The best place to have your pain issues evaluated and treated is through your personal/ family physician since they know you and your family and some things about your pain threshold.  Even if one of your parts needs the pain management subspecialty care such as injections to the lumbar spine, your personal physician should be very helpful by co-ordinating your pain care as part of your overall health care.  Unfortunately, many personal physicians are becoming "opiophobic", fearful of prescribing opiates, because of a fear of peer pressure and being scammed by a drug addict or by a person who sells (diverts) the prescriptions.  They are becoming less and less likely to treat patients with chronic pain and more and more prone to refer them to pain management centers for someone else to do the treating.  That's not  fair either, right?  Right, we need to change something.

"No brain, no pain" is a helpful way to think of how we have pain and "know brain, know pain" is a very important way for physicians (and patients) to think about diagnosing and treating  the pain and its associated issues.  There is a lot to learn together to minimize suffering from chronic pain.  If we connect better with each other, patients and family physicians (or other primary care physicians) can do better at avoiding pain and/ or arranging earlier intervention before complications such as hyperalgesia,, wind up or engraved pain arise.  Let's work together and make things "fairer" for all.

Friday, April 8, 2011

A Thank You from Dr Synonymous, Celebrating One Year of Blogging

On April 9, 2010 I posted the first Dr Synonymous Blog introducing myself and the blog.  Over 100 posts later I note that it's been a great year of sharing and learning for me, using social media more and more to expand my connectedness, teaching and learning.  The Dr Synonymous "Brand" is on Blogspot and Blog Talk Radio (weekly show at 8 PM ET), promoting Family Medicine and the human quest for meaning.

Posts in The Human Centered Health Home series by Dr Synonymous introduce and clarify the model of care in Family Medicine that goes beyond the Patient Centered Medical Home to the human dyad of patient and doctor.  It reaffirms the importance of human engagement in medical care while specifying steps that one may use to develop the skills that deliver the HCHH.

Some posts relate to Patriotism (Memorial Day, July 4th, Veterans Day, Anniversary of Cease Fire in Vietnam, etc.), principles learned at West Point ("Learning from the Military"- The Nine Principles of War, "Duty, Honor, Doctor"), Family Milestones, and my Family Members (Uncle Jerry, Fathers Day-My Dad, Wedding Prayer for Renee and Phil).

Several posts expound on my "Families Only" practice model that I've learned from for 30 years.  Others focus on specific aspects of health care like Hospice Nurses, Death at Christmas, House Calls, Hope, etc.  The Day in the Office series related types of patients, situations, illnesses dealt with on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday.  The comments were very interesting for these posts.

Problem Solving in Family Medicine has long been of interest to me and I wrote about this in many posts including the HCHH series.  Processes are the focus of many posts such as "Building Trust Between Patients and Doctors by Sharing Uncertainty", "Love is the Drug of Choice", "Sensitive Death Comments", "Heart, Mind and Brain".

Many posts also outline the Dr Synonymous Show with patient blog reviews listed first, followed by medical student, physician and my blog.  The interview questions were usually listed for the interview shows with thought leaders and innovators in Family Medicine.

"Family Medicine:  Learning from Marcus Welby and Dog the bounty Hunter" (here)
is the post viewed most often.  On April 7th, the site enjoyed the 10,000th visitor, a nice anniversary present.

Comments from readers on the blog site, twitter and email have been very helpful.  Thank you to all the readers and followers of Dr Synonymous.  Together we can BLOG ON!

Sunday, April 3, 2011

Personal Health: Dr S Turns 65! Medicare? Already? Me?

Today, I'm 65 years old. I note the stiff knees, excessive abdominal girth and numerous mailings from large insurance companies encouraging me to sign up for their Medicare Advantage Plan, because "the government" (which I call "the tax payers") has given us extra subsidy to offer you a better plan than Medicare.  The fitness center "Free" membership jumps out at me from one of the offers.  I note that it's from an insurance company that causes headaches for my office staff and casually dropped thirteen Cincinnati solo Family Physicians from being a "participating provider" in mid plan year using "quality criteria" that were poorly supported when one looked closely at their data base (like one of the sharper Family Physicians in Cincinnati did).  I guess the money they deny us in claims and don't spend on our patients prescription benefits goes to their marketing budget so they can juice up the mailings to naive people like me so we'll get excited about the fitness center and other perks.  I notice the first nausea of my 66th year of life is creeping in as I reflect on these circumstances.  OK, enough Medicare Advantage Plan thoughts.  Let's celebrate the birthday, Folks.

Last year I kept thinking of the Beatles song "When I'm Sixty-Four" and occasionally reflected on the lines "Will you still need me... When I'm 64?"  I love music but I don't know any songs about being 65.  OK, that's why God (or Al Gore) invented the internet- to find information.  (Actually, I think it was for the Department of Defense- to wage war better?)  I'll look up songs about being 65.  But not right now.

There probably is a Medicare Fight Song. (Forgive me Notre Dame)  Cheer, Cheer for "old" Medicare, notice the grayness all through your hair.  Take your Geritol and then, pills for your prostate and vitamins.  Try not to stumble, try not to fall, lest your hip socket gets a new ball.  Take your fish oil, B Complex, too; at 65 that's all you can do.  But not to worry, let out a shout, your teeth aren't yet the kind you take out. Now with Medicare you're limping onward to victory.--For the Medical Industrial Complex.  Sing that last phrase just like you would after Happy Birthday when you add, "And many more".

I did wake up a bit early today.  It's my birthday.  But I don't expect any presents, just people.  We're going to church with Mom in Liberty, where I grew up (see blog, "Set Our Hearts at Liberty" for my reflections on growing up in Liberty)  I was her twentieth birthday present, one day later.  So whatever age I become, she's always got me by 20 years.  That's how I remember how old she may be.  So this is a special birthday for her and we all celebrate by worshipping together.  My brother will be there with his family and I with mine (except for those in NC and Phil who is making rounds at OSU-will probably catch up at his Grandma's home after church).

I have been blessed for these 65 years.  I am thankful.  Peace to all.

Saturday, April 2, 2011

Family Medicine: Honoring the Family In Family Medicine and 30th Anniversary

I just read a summary of the Family in Family Medicine Conference by Michael Crouch, MD,  MSPH, from Texas that bubbled my heart a bit with nostalgia.  It is where my dream about families was focused and reaffirmed.  The Amelia Island, FL venue didn't hurt either.  This is the 30th year anniversary of the original conference started by Roy Gerard, MD and Don Cassata in 1981.

The Conference faded the last few years and STFM (the Society of Teachers of Family Medicine) responded to the poor attendance with cancellation of the series.  Other groups are working to carry on the concepts about family and behavioral science in a unified way that will generate supportive attendance with the task of naming a merged group of STFM as one of the first challenges.

I wrote previously of Robert Smith, MD teaching me about how to run a "Families Only" family practice (here).  I did what he said and reaped the rewards of rich relationships and clinical insights that otherwise would just be a dream.  The family has always been alive and well as the basic unit of decision making in America.  I love learning from and about families every day in my practice and daily life.  I presented about my "Families Only" practice at the FIFM meeting one year.  Another presentation was with Larry Bauer, MSW, MEd about Five Levels of Family in the family practice office visit.  We presented in San Diego at a later FIFM Conference about Genomics in Family Medicine.

I'll never forget how Joan Patterson, PhD mesmerized me with her Family Evaluation tools for every type of situation.  She gave a couple presentations at one of the first FIFM Conferences I attended and I still have her book of scales to measure family strength, weakness, adolescent situations, etc in each stage of the life cycle.  I was amazed at all the ways to look at the family and apply the learning to family practice (later renamed Family Medicine).

The Family Life Cycle is one meaningful concept that helps me to better evaluate developmental issues in family life.  Each stage of the life cycle has developmental tasks that should be accomplished in that stage, otherwise the family may stagnate and stay stuck.  Family APGAR is a useful element in the STFM medical history form (that all new adult patients fill out) enabling the family physician to get a glimpse of the patient's family support.  Models of family structure and function are useful in evaluating relationships in the family that could smolder into significant family dysfunction.  I learned about the application of these concepts at Amelia Island at the FIFM Conference and I loved it.

In more recent years at the conference, no longer at Amelia Island, I was surprised to learn from some of the marital and family therapists that men are very dependent on their wife, if they are married, but the wives are not nearly as dependent.  Translation:  men will quickly seek out the next woman after their current wife divorces them but women don't need to quickly find a new male mate because they have friends who support the woman and help her process her feelings.

I remember a wonderful session at FIFM during which Steve Allen, Jr., MD taught us to juggle, and there were a couple or more of the usual STFM dances and social gigs.  We sang one year in Karyoke fashion.  Caryl Heaton, DO, later to become a president of STFM, was a natural party organizer and song leader and a Family Fanatic.  Deborah Taylor, PhD was passionate about teaching the family and behavioral issues in Family Medicine to residents and faculty.

The Amelia Island weather was usually supportive except the last time I went there it was raining and cold.  Still that was a great meeting at which we learned of the "Team Approach to Cost Effective Health Care" via family medicine and professional networks doing family focused home visits on heavy utilizers of medical services.

Thank you to the founders and supporters of the FIFM Conference series and good luck to those reframing and upgrading the family and behavioral training for future Family Fanatics!  You never outgrow your need to Know Family!