Monday, May 30, 2011

Memorial Day: The Vietnam Veterans Memorial Wall - Silence Beyond Words

At the Vietnam Veterans Memorial Wall, we look and listen.  The Wall and Names
We touch a name or two or more.  We touch a nameless spot to relate with the entirety of lives lost in the Vietnam Conflict.  We listen.  We think.  Our thoughts are inadequate to the meaning of these moments with this messenger.  We want to stay.  We want to leave.  We pray.  We notice the silence.

Wait a minute.  Let's look up another name in the directory, find it on The Wall, touch it and find meaning by our actions.  Take a photo of the name.  The Wall grows larger.  Look up a name on the web site at the top of this blog post.  Read the story of that person.  Look up another.  Stories hide behind each of its names.  Listen.  The silence quietly echoes the stories.

We notice the people who focus on only one name.  They touch.  They look.  They photograph.  They talk about the name.  They wonder about the others.  They feel the silence.

Some are dressed in the garb of a Vietnam Veteran.  Hats are the most common identifier of the Vietnam Veteran, often listing the years of service in-country.  They may wear a fatigue shirt with unit identifiers and rank or a T-shirt noting their service.  They are quiet.  They look at The Wall, then at the section listing the dead from the time of their service in Vietnam.  They wonder why their name didn't make it on The Wall.  The silence answers them.

Waiting in the presence of The Wall seems to slowly generate a oneness with The Wall and its meaning.  Time spent with the Wall can be overwhelming at first, as each name pulsates softly with a message.  That meaning isn't spoken in words. It even speaks through computers and social media.  It comes slowly through the silence.

The meaning of the Wall is a patient message, with a patient messenger.  It may arrive years after the only visit or immediately during the first encounter.  It arrives in our heart and grows.  A sense of wounded-ness may precede its full message.  The Wall is a patient teacher.  When the heart is ready to learn, The Wall delivers at a level consistent with the readiness of its student.  The silence delivers the meaning and may return to refresh it after predictable human lapses.

Though words seek to explain the lessons learned from the losses, especially on Memorial Day and Veterans Day, the recitals can only hope to lead the way to a more open heart that sets the stage for understanding.  Music, poetry, art and monuments may allow the hearts to open further to the message.  The Wall connects the spiritual  hearts of those engraved on its gabbro rock with those who mourn and celebrate the lives of  the deceased.  The whole-hearted communication of meaning slips through the silence that is beyond words.

Pray.  Listen.  Listen with your heart.  Be patient.

"And the Holy Spirit helps us in our distress.  For we can't even know what we should pray for, nor how we should pray.  But the Holy spirit prays for us with groanings that cannot be expressed in words.  And the Father who knows all hearts knows what the Spirit is saying, for the Spirit pleads for us believers in harmony with God's own will."   Romans 8: 26-27

Wednesday, May 18, 2011

Family Medicine: #FamMedChat "The Dreams of the Founders" Thursday, May 19 9 PM ET

The #FamMedChat this week on Twitter will focus on "The Dreams of the Founders of Family Medicine" as reflected by Larry Bauer, MSW, MEd in his guest post May 12 on The Singing Pen of Dr Jen's blog.  

Just to add a touch of the founders voice. Here is what G. Gayle Stephen, MD and Tom Leaman, MD said after reading the piece I wrote. They gave me permission to share this.
This is a perfect summary of our best motivations and intentions as they evolved following the 'Reports of 1966'. I never felt however that these dreams were fully endorsed and assimilated by our leadership which seemed more interested in professionalizing a new specialty than in genuine reform. I do not blame anybody for this because both projects were enormous. The reform ethos lasted about five years and was subverted, in part, by three economic recessions in the 1970s and another in 1982 (when unemployment rates were higher than now. I could be a bit more specific about other parts at another occasion. My point is that the dreams were bigger than our organizations were prepared to deal with. Under the circumstances, internally and externally, we did pretty well, given the politics of many physicians. We have demonstrated that we can manage a specialty and run academic departments, but can we grasp the nettle of reform again?
G. Gayle Stephen, MD author “The Intellectual Basis of Family Medicine”
I liked your document very much, but I think that it lacks emphasis on one principle that I think is absolutely basic. That is the close, almost intimate relationship that develops between the family doctor and the patient. Attorneys shudder at the mention of actually hugging a patient; psychiatrists abhor the idea of touching a patient. Many family docs, with the patient’s permission, occasionally pray with their patient. In my practice I learned, slowly, to love some of my most disgusting (physically and morally) patients.
That relationship is truly one of the greatest therapeutic agents we have - it is most in evidence when we have nothing else to offer. It is also the source of one of the greatest joys of family practice.
Thomas L. Leaman, MD founding Chair, Department of Family and Community Medicine, Pennsylvania State University School of Medicine.

Family Medicine, the journal of the Society of Teachers of Family Medicine, recently featured the writings and career of G. Gayle Stephens, MD, one of the founders, in an article by John Geyman, MD (another founder) titled, "G. Gayle Stephens Festschrift".     G. Gayle Stephens Festschrift

John Frey, MD from the Department of Family Medicine at the University of Wisconsin wrote a letter to the editor of Family Medicine in May congratulating the journal for the Geymen article about Dr. Stephens.  In the letter he expressed a concern "about the discipline and our adherence to the values about which both Geyman and Stephens write.  Unfortunately, Stephens' comments about the moral nature of general practice and family medicine in its historical affiliation with traditions such as utopianism, community service, and a special emphasis on the poor is belied by the conduct of those of us still caring for patients."  He notes that AAFP reports in 2008 indicated that 27% of family physicians were not accepting new Medicare patients and 45%  were not accepting new Medicaid patients.

Dr. Frey asks if we as a discipline affirm Dr Stephens' assertion about the care of the public.  "I would suggest not.  We have a long way to go in holding ourselves true to what Gayle Stephens and John Geyman helped create this discipline to do or our country"    

We will invite comments from persons who participate on #FamMedChat about these items and how they relate to where Family Medicine was intended to be, where we are and where we are going via their response to stimulus questions from the moderator (@apjonas) for this chat.  Everyone on Twitter with an opinion is welcome to voice it (in 140 characters or less).  We should have fun with this discussion as we quest for the type of health care that everyone needs and the access dreamed of by the founders of Family Medicine.

Sunday, May 15, 2011

Family Medicine: A Salute to Unit Secretaries in Hospitals- You Rock!

Since  a brand new hospital, the Indu and Raj Soin Medical Center, is being built next door to my Family Medicine office in Beavercreek, OH, I have to strongly consider admitting patients again.  We gave up admitting about 18 months ago when we had a paucity of admissions to our primary hospital.  We noted the 30 minutes to travel to the hospital and the large amount of time required to admit and care for each patient (about 1:30 if we had one patient in the hosp, which seems to be what is happening now- but admitted to our hospitalist friends).  The hospital rounds were done before or after office hours, so they extended the day a lot, while not yielding a financial benefit for the added physician time and energy expended.

So, to warm up to the possibility of admitting again, I'm starting to admit a person or two to the "Sister of Soin", Greene Memorial Hospital (GMH) in Xenia, OH.  In doing so, I'm reminded of the numbers and types of persons needed to run a hospital as soon as I enter the Emergency Department of GMH.  They are energized and focused on their multiple tasks, and I'm also reminded about how well these persons function as a caring community.  Chaos hits from time to time and they bubble up for the intense responses needed.  It's much more meaningful to me than the big ED's featured on various TV programs.

On the patient care floor of GMH, nurses and aids are engaging each other via the tasks at hand, which they masterfully and continuously reframe to patient focus.  The size of their caring hearts resonnates toward patients and patients and patients.  They have their clinical issues, but they never stop caring.  New forms jump up from the patient chart with regularity, challenging the caring hearts to get distracted with mechanistic mandates from the healthcare gods and goddesses who initiate "quality" initiatives with regularity so outsiders can have "quality" ratings available when they have a dysfunctional part to shop around for repair.  I admire the nurses for still caring.  They appear to me to be the glue that enables the hospitals to survive.

The unsung warriors in hospitals who work at the leverage point for all issues about patients in hospitals is the ultimate performer of tasks per unit of time- The UNIT SECRETARY.  These folks have always amazed me with their speed and smoothness.  They watch the heart monitors (24 or so in the unit where I'm writing this), answer the phones from outside, (patient families, doctors, etc.), answer the switchboard inquiries of patients and their roommates about every sort of patient issue (including excrement of scheduled or unscheduled types), etc.

They also know the human aspects of the staff and patient lives around them.  They know how and when to provide a caring comment to a stressed nurse, med student or physician.  They may help the staff to get lunch from a local carryout or enable everyone to know about who had a new baby or a dying parent.  I've marveled over the finesse, sensitivity, boldness and humanity of these folks for over thirty years (plus medical school where they could save the fanny of floundering med students).  Likewise in residency, they knew the 5 WH (who, what, why, when and where) of everything needed in their bustling community at the interface of the entire world and all its people with their unit, its patients and its staff.  They are doing what looks to me like the hardest job in healthcare hospitaldom.  Their actions save lives, minds and careers every day.

A few of the best I've ever seen are at Greene Memorial Hospital.  OK, I've forgotten some wonderful ones at Kettering Medical Center in Kettering, OH, The Ohio State University Hospital, Licking Memorial Hospital in Newark, OH and the MS Hershey Med Center of Penn State University in Hershey, PA.  Thanks to the Unit Secretaries:  You make it happen!


Saturday, May 14, 2011

Family Medicine: Fibromyalgia Flashback , Let's Upgrade for National Fibromyalgia Awareness Day

A patient on my first month of in-patient general medicine in medical school at The Ohio State University had a lot of pain.  Back, neck, arms but somehow mysterious to the attending physician and threatening to the resident and intern.  They treated her with Demerol injections and physical therapy, but sought mostly to get her out of the hospital with her challenging pain.  Fibrositis was the diagnosis, but it didn't satisfy the physicians.  They also didn't know what to do for her further management, since Demerol injections weren't exactly suitable for self administration.  I read about Fibrositis in Degowin and Degowin, the physical diagnosis book that still is my favorite, but the mystery persisted.

I don't remember patients with Fibrositis in residency training in Hershey, PA, but a couple people early in my practice in Granville, OH had something similar with soft tissue pain in the back.  After six or seven years in practice, someone came into my practice with the diagnosis of fibromyalgia.  Her neck, upper back and low back hurt frequently.  She also had fatigue and painful, cystic breasts.  She took Darvocet chronically for the back pain and ate a low caffeine diet and B vitamins for the breast pain.  She developed more and more pain and fatigue, then seemed to disappear for about two years.  At that time, she came to the office for an acute respiratory infection.  I was surprised at how cheerful she was.  I asked how she got to be so cheerful.

"Divorce, I got divorced."  Wow, I thought and asked what led to the divorce.  "He was controlling and abusive.  He said if I ever divorced him, he would kill me.  I finally realized that I was already miserable, maybe even worse than dead, so I divorced him.  I feel great.  I feel alive again."  "So, where is your ex-husband now?"  I asked.  "He moved back near his family about 150 miles away," she replied.

I was impressed that getting freedom could alleviate so many symptoms.  I wondered about the workings of Fibromyalgia.  How can such misery take a vacation?

I read more about soft tissue inflammation over the years and was fortunate enough to co-teach a course in chronic pain to Wright State University Medical Students for six years, over-lapping with six years of teaching a train the trainer workshop to family medicine faculty in the NE states through the Northeast Regional Meeting of the Family Medicine Education Consortium.  We even published a Pain Management monograph through the Society of Teachers of Family Medicine a couple years ago.  I was pleased to be the lead author on the Complementary and Alternative Medicine section while collaborating in other sections.

There is no pain management teaching without teaching about Fibromyalgia.  It has many symptoms and many faces and many seasons.  It seems to happen in those (mostly women) with a genetic predisposition for it who take a huge hit from illness plus life that gets stuck somehow and beats the daylights out of their body and their spirit.  It sometimes goes away after a couple years.  Treatment is multifaceted.  Touch and love are important therapies, while energy therapy seems to be temporarily helpful at regular intervals.  Gabapentin often is a helpful medication.  We don't know yet how best to prevent it.  It still holds mystery, challenge and frustration for both patient and doctor.  It forces the relationship based nature of Family Medicine to rise to therapeutic levels.  It sometimes can't be described.  It is often misunderstood and still doubted by many physicians.  But it is very real and it isn't going away.

I salute the efforts of so many patients with Fibromyalgia to have a life and to be understood.  Today is National Fibromyalgia Day.

Check out these sites for more insights about this disabling disease:

National Fibromyalgia Awareness Day

Fibromyalgia by Meredith Gould

Saturday, May 7, 2011

Family Medicine: Looking for Partners at the Starting Line

Patients hold the key to a meaningful course correction for health care reform.  Employers are the next group who can influence and/ or generate a course correction for health care.  Family Physicians are probably next. What can we do?  When?  How?  With whom?

Next step:  Go viral on the internet to "bypass the sludge" and rapidly get to the starting line for changing the world of medicine.  Who will be there with us?  Who are our partners and friends?  Who are the enemies?  Where is the money?  How can patients unite to influence the money in health care?  How long will it take?

Will the Government allow and support the will of the people for health care?  Will Wall Street take the money, control the Government and run?

Right now, it's feeling like we are "powerless" over the course of change of health care.  Are we Adult Children of Health Care?  Twelve Step Program, anyone?

Friday, May 6, 2011

Personal Health: Techie in NC Loves YouTube Sesame Street Song

To intensify my ponderings about techie questions of "what hath the web wrought?", I visited my North Carolina (where the sun seems to always shine) son, daughter-in law and (the real reason for the trip), two grandchildren.  My fifteen month old grandson was anxious to tap on my cell phone when I took it out to get a photo of the lad (off the growth chart for height, 75th for wt- would be the envy of Lake Wobegon).  My son noted his son’s wishes and put his iPad on the table in front of the youngster who immediately tapped to get his favorite app, proceeding to the YouTube Sesame Street song section to play’s song, “What I Am”.  When the song ended, he pushed a few times on the screen and played it again, making hand gestures along with the singer at key moments during the video. This is a great example of the web based society, I thought, the desired information is produced by a creator and put on the world wide web, not on a vinyl record (78, 45 or 33 1/3 RPM), eight track tape, cassette tape, CD, or mp3, etc.  What will happen next?  Check out my grandson's favorite song:   "What I Am"