Saturday, September 24, 2011

The HCHH: Humans First, Patient and Doctor Second, Humans Third

Patient and Doctor.
Patient and Doctor.
Patient and Doctor.

Imagine the Human Centered Health Home (HCHH).  Two humans engage and connect over mutual concern for each other.  Their roles shift into patient and doctor.  They collaborate to identify values, goals, dreams, strengths and problems and seek resolution or reconciliation.  After mutually agreeing on a plan  they shift roles again to a shared humanity.  This leads to human separation and departure.  Humans who share common concerns and allow each other to be free of the bonds of expectation may thrive in the HCHH.

Humans first.  Patient and doctor later.  Humans again.  Allow it.

What do you think?

Wednesday, September 21, 2011

Family Medicine: Impending Primary Care Melt-Down

I've been a Family Physician practicing since 1979 with over 150.000 patient encounters.  Patients are still fascinating and patient engagement is still satisfying every day for me and many Family Physicians. 

The business model in healthcare, however, is stifling and just wrong.  It seeks to identify "suckables" in every part of every patient to maximize the money sucked from their parts.  The more fragmentation, the better.  This now seems to be the status quo in non-primary care medical settings and is spilling into primary care settings owned by non-physicians.  Without a fundamental change in the mindset of practicing physicians, the best system we can envision will fail.  The vision just isn't yet aggressive enough to really help.

Physicians, however, are not a unified group of like-minded professionals.  In fact, it's sometimes difficult to notice whether we know what a profession is.  We are marginalized as a profession by the forces that are "sucking" the money and our own naivety.  We are also vulnerable enough to be accepting employment from entities that don't seem to have our patients best interest at heart.  The money and the patients are controlled by someone else.  There is not enough momentum in employers, the Patient Centered Medical Home (PCMH) and patients to make the changes needed for the current or the envisioned system to survive. 

I have concerns about who is going to do primary care.   Less than ten percent of senior medical students this year intend to do primary care practice.  All sorts of reports from medical schools "fib" by saying that more than 50% of their students selected primary care residencies when their alumni office knows full well what specialties and subspecialties their graduates are in.  The medical schools state that any senior student  selecting internal medicine for their residency training counts as primary care, and the government pays a bonus of Medicare dollars to the hospital that's training that resident, but both know that only 2% of them actually intend to become a primary care physician.  The primary care workforce is dying off.  Look carefully at the real numbers of practitioners.  Primary care physicians are leaving or not even starting down a much needed career path.  It's painful to see it from the inside and see the "fibs" that cover up the painful reality about front line healthcare in America.

Nurse Practitioners will play a large role in the future of primary care, but there will never be enough physicians to meet the need for primary care physicians.  Access to primary is deteriorating already.

The Dayton, Ohio market is down to two competing  private not-for profit hospital systems, both of which CLOSED the FAMILY MEDICINE residency training center at their flagship hospital in the last two years, converting most of the newly available training slots to cardiology fellowship training slots to help with their new heart hospitals.  Dayton also has a VA and Air Force Base health center.  The largest family medicine training center in Dayton closed with its entire hospital more than a decade ago.  The medical students were not knocking down the doors of the hospitals to fill the family medicine slots, since a lot fewer American graduates are choosing primary care.  The numbers are not good.

Investors have tried to make money from primary care before and failed.  I predict they'll develop another failed business model.  Profit margins are slim when dealing in an integrated way with the actual healthcare dollars of real people.  They don't actually need a lot of money sucked from their parts.

The patients and most employers don't know what is about to happen. What do you readers think?

A. Patrick Jonas, MD

Friday, September 16, 2011

Family Medicine: Learning from Popeye the Sailor

200 Cartoons it says on the cover of the DVD set.  OK, I start watching black and white Betty Boop cartoons.  Betty sings a lot.  Each episode is short and sweet, like her dog Pudgy.  Lessons are learned by watching Betty and listening for the punchline of each story.

Popeye the Sailor is next on the DVD.  I ask number one son if he would like to watch a Popeye the Sailorman cartoon with me.  He says no, Popeye is always outwitted by Bluto initially in trying to win the affections of (or to kidnap) Olive Oil until Popeye gets some spinach and knocks him out.  I wonder how he remembers the story lines of the cartoons of his early childhood.  I watch about ten more Popeye cartoons, escaping the entire world in the process.  My son was right.  They all featured the courting triangle of Popeye, Olive Oil and Bluto.  Popeye always wins once spinach arrives.

So what's your spinach when adversity strikes (and what's mine?) ? 

For my specialty of Family Medicine, Bluto is the Medical Industrial Complex, Popeye is obviously the Family Physician and Olive Oil is our patients.  What is the spinach that will help the Family Physician to save the patient from the Medical Industrial Complex, enabling us both to survive with a meaningful relationship?

Could it be a winning lottery ticket?  Direct Primary Care?  Employers of our patients?  Public Health Systems with Community Health Centers?  Hospitals (not)?  Religious institutions who develop health systems for their members (parrish nurses, etc.)? Insurance companies (not)?  Universities and other educational systems?

What spinach is going to help health care to make the right transition from the family medicine  and patient perspective?

Wednesday, September 7, 2011

Family Medicine: Why Don't FP's Talk About Their Clinical Problem Solving Prowess?

Larry Bauer, CEO of FMEC sent this email to several Family Medicine leaders and educators recently.  It's a good question.  What do you think?

Subject: Why don't FP's talk about their clinical problem solving prowess?

I have been working with Family Physicians since 1978. I have noticed two things in particular.

First they take great pride in their interest in relationship-based care. They talk about the value of continuity. They tell stories that describe how much they treasure relationships with patients. They tell these stories in their teaching. They write books about it .Its a powerful force that energizes their work and their career satisfaction.

They rarely, if ever, mention the power of their clinical problem solving abilities. Why is that? The absence of mention and the seeming lack of pride (my assumption) in this area makes me wonder if FPs really believe they are effective in the area of clinical problem solving.

From my earliest days in Family Medicine I came to believe that FPs impact as physicians was a result of their patient/relationship-centered approach that included effective communication skills, their fund of knowledge and their clinical problem solving skills. All three are essential; any two working alone, except in special circumstances, will not lead to the best results.

Family Physicians embraced the work of Barbara Starfield, MD, PhD. She told the world that FPs, in particular, and primary care, in general, had a positive effect on population health while reducing the cost of care.

When I hear FPs take pride in their relationship centered approach to care but never mention their approach to clinical problem solving, it leads me to believe they think that continuity alone produces the impact documented by Dr. Starfield.

I put this issue to a number of colleagues and I heard the following

          Because of the variety of patients and undefined illness that Family Physicians see, they become better at development of realistic differential diagnosis than any other medical specialty. Doug Smith, MD, Orono Family Medicine, Orono, Minnesota
          Another FP Shantie Harkisoon, MD director of Phelps Family Medicine Residency Program (a new program in Sleepy Hollow, NY) told me that she thinks the strength of FPs is strong skill with differential diagnosis of the patient as person while sub-specialists are generally more effective at differential diagnosis of a disease.

I have been talking to a documentary film maker who wants to tell a story about family medicine and primary care innovation and in his interviews with FPs all he finds is the value of relationship centered care. He cant understand how the care provided by FPs cost less money. When I told him that FPs are effective clinical problem solvers and their approach to decision making as a key piece of this story, he almost did not believe me. When he interviewed the FPs he was not hearing about this.

Why do I not hear more about Family Physicians clinical problem solving prowess?

What do others think?



Laurence Bauer, MSW, MEd

Chief Executive Officer
Family Medicine Education Consortium

Here's my short response.
Subject: RE: Why don't FP's talk about their clinical problem solving prowess?

Many may consider pride in one's skills to be "sinful", but our specialty, possibly because of our humility- misguided or not, is indeed "complicit" in medicalizing American life, as Allen Perkins, MD, MPH notes, and, as I believe, helping to bankrupt America by co-dependence with a mis-aligned Medical Industrial Complex. 

We have moved beyond McWhinney,  who wrote and spoke of the clinical methods and skills of Family Physicians, but forgot to integrate his message in many of our teachings. We now understand in a different way that "all our patients will die". That fact dampens clinical pride a bit and enhances our relational connections with patients for the long haul. 
Intense celebration of diagnostic wizardry and "high fives" for clinical acumen give way to quests for better understanding of the human condition. Patients teach us that allowing them to be human and protecting them from medical misadventures is part of our job. Another part is validating their humanity and their sufferings. The heartfelt quietness of the slow dance with the human condition is instructive.  Family Physicians Dance well, but we may dance slow.  
We love the dance. BUT, it doesn't do much for the quarterly return on the investment of Wall Street or help the budget of the local hospital that may own our practice and expect us to feed it. Many questions face Family Medicine.


Comments are invited.  What do you think?

Monday, September 5, 2011

Human Centered Health Home: Further Detecting Using the Biopsychosocial Model

“The central tasks of a physician’s life are understanding illness and understanding people.  Because one cannot fully understand an illness without also understanding the person who is ill, these two tasks are indivisible.”…McWhinney in A Textbook of Family Medicine

Let's continue using the Biopsychosocial Model to analyze the patient mentioned in the previous HCHH post about the BPSM  Using the BPSM for Detecting.  Many other models might also be applied to analyze the situation of patient and physician, but we're focusing on the Biopsychosocial Model (BPSM) developed by George Engel, MD, who was a psychiatrist at the University of Rochester.

Please remember that the use of models may distort, delete and generalize information that is analyzed using the model.  The model is not the reality, but attempts to represent reality.

The biopsychosocial model is a linear heirarchy used to review an individual situation of a patient and even  a physician. From the biosphere to the subatomic level, what are the implications for the individual patient?

Biopsychosocial Model from George Engel
1. Biosphere                                 8.  Organs/ Organ System
2. Society/ Nation                      9.  Tissues
3. Culture/ Subculture               10. Cells
4. Community                             11. Organelles
5. Family                                       12. Molecules
6. Patient                                      13. Atoms
7. Nervous System                     14. Subatomic

Let's look again at a 45 year old married, male high school principal who lives with his wife of 18 years and two teenage children (girl 15 and boy 13) in their home on the edge of the 5,000 person town in which is located the school that employs both of the adults.  He is seeing his family physician, with whom he has a long standing personal friendship and professional relationship, for palpitations (notable sense that the heart is beating- not supposed to be notable).

We have analyzed many aspects of the situation using steps 1-5.  Now, we consider step 6: the patient himself.  In a typical office visit, I would usually use a human centered process and the biopsychosocial model to further detect patient alignment or misalignment with their best health.  Although the model is linear, the order of perusal depends on the situation defined by the particular visit, so I may start with step 4 or 5- community (since that's where the shared activities with my patient are and if that's where friends are considered as one uses the model) or family (if we have people whose friends are closer than family).

The personal relationship with the patient may be reaffirmed first as we seek a mutually beneficial outcome to this encounter that is health affirming/enhancing and relationship affirming/enhancing.  As a physician, I know that his health is more important than our friendship in the short run and the long run where our ethical sensitivity has to stay ever-vigilant, even with a friend, for situations that get near the boundary of ethically sensitive professional behavior.

We may talk about a shared activity that relates to a shared value.  It is best to use a positive situation, maybe the success of passing the school levy (but that might cause him to suddenly reflect on the negative aspects of the levy campaign and related stresses) or a more neutral comment such as how good the pep band sounded at the basketball game last Friday night, preparatory to getting the best information from him about his palpitations and the associated symptoms and contextual circumstances, noted in the 11/30/2010 post about the biopsychosocial model.  I know that I will bring up the stress associated with the school levy campaign, if he doesn't, because I'll get to assess how he's responding to a significant strain and stressor, which may be a factor in his palpitations.

He, my friend and patient, may inquire about me and my family or activities due to our friendship.  I know I have to be genuine in my responses and self disclosing and fully human (Can I turn off the physician and the clock, risking whatever that entails while I am his friend, allowing him to befriend me in the middle of physicianly activities and schedules?  To be the best Family Physician I can be, my human self has to be allowed to stay in the room, the friendship has to be in the room, the physician and physicianship has to be in the room.  The patient, also as human and friend is in the room.  Is it too crowded for all this?  It is an important dance.  That, friends, is at the heart of Family Medicine.  I love it.)

The physician role is then expanded as I transition into seeking clarification of his chief complaint- palpitations- through discourse and response to his comments and clarifying/ probing questions as needed.  As the visit evolves, I may reflect on MY OWN BPSM if my lead senses (visual, auditory and kinesthetic) seem to be inadequately connecting to the patient's life/BPSM.

The physician part of us is continually developing the differential diagnosis using a wide array of mental, mathematical and visual models as we flesh out the patient's story.  We should also continuously seek to clarify the meaning of the situation for the patient.  Getting the patient's perspective about perceived losses/gains resulting from the symptoms/situation is an important element in developing a goal for the patient. What is it they can't do, or fear the loss of,  as a result of the chief complaint?  What would they like to be able to do and when?  I've written about this process in the series on the Human Centered Health Home over the course of a year.  The differential diagnosis is a key piece in a physician's clinical thinking skills.  It cannot, however, be separate from the patient's life, goals and dreams in Family Medicine.

Using the Biopsychosocial Model to detect patient alignment or misalignment with their values, goals and dreams is part of the dance in Family Medicine.  We dance well but we may dance slow.  The natural history of many conditions and diseases, especially chronic diseases, is nicely aligned with the relationship-based nature of Family Medicine and our clinical problem solving and management skills.  No matter where the patient may weaken in their BPSM or need a congratulatory pat on the back or hug for an existing or regained strength, we are there if needed.  The BPSM helps us to remain aware of the strengths and needs of our patients.

As the Family Physician continues to relate to his patient's BPSM they will next relate to his nervous system, (step 7 in the model above) a great integrator, informer and deceiver.  Stay tuned, it will get even more complex as we move down the BPSM.

Friday, September 2, 2011

Family Medicine: Serving Patients with Declining Health and Supporting Their Families

Note on front of patient chart I read just before knocking to enter the exam room:  "Please read before seeing my father, John Smith, and don't say anything to him about the note.  He is falling again and forgets to eat sometimes.  He is more depressed and frustrated more often.  He would be very upset if he knew I wrote this."  Sally Smith (daughter)

How do family members deal with an aging loved one who is losing more and more memory?

It looks very difficult, up to and including the moment when driving privileges are removed and frustration, guilt and anger intensify.  Then the decision about home safety, nutrition and hygiene followed by assisted living and/or an extended care facility and/or hospice.  It looks like a downhill course toward the patient's ultimate demise.  How do families know what to do?

Family Physicians often become facilitators for families, while evaluating the patient for their ability to perform their Activities of Daily Living (ADL's) and their Instrumental Activities of Daily Living (IADL's). 

From "Activities of Daily Living: What are ADLs and IADLs" by Gilbert Guide on
Activities of Daily Living:  Hygiene (bathing, grooming, shaving and oral care), Continence (urine and/or stool), Dressing, Eating ( feeding oneself), Toileting (using a restroom), Transferring (e.g., going from a seated to standing position and getting in and out of bed).

"In an assisted living facility, the amount of help one needs with ADLs determines the resident's needed level of care. Typically, the cost of care for each individual is based on the level of care he or she requires.

IADLs are more nuanced and complex social activities than ADLs. IADLs can include, but are not limited to:
  • Finding and utilizing resources (looking up phone numbers, using a telephone, making and keeping doctors appointments)
  • Driving or arranging travel (either by public transportation,... or private car)
  • Preparing meals (opening containers, using kitchen equipment)
  • Shopping (getting to stores and purchasing necessities like food or clothing)
  • Doing housework (doing laundry, cleaning up spills and maintaining a clean living space)
  • Managing medication (taking prescribed dosages at correct times and keeping track of medications)
  • Managing finances (basic budgeting, paying bills and writing checks)"
As the Family Physician hears of or sees limitations developing in the ADL's and IADL's of the patient, they can advise the patient and family about some of the options and resources available as the body is less supportive of the patient's life needs.  One of our responsibilities is to support people and families through difficult times, especially when health is declining.