Monday, April 30, 2012

Family Medicine Activist: 31st Post in 30 Days

Wow!  The Health Activist Writers Month Challenge is over.  I 'm posting a 31st time to say thanks to WEGO Health.  The opportunity to share cyberspace with these activists is a blessing.  Thank You.  You help so many to understand so much.  Bless you.


Family Medicine Activist: Words Matter, Too

Below is a "Wordle" aggregating many words from recent posts of mine.  It looks blurry but I see the word Friends in the middle.  I like that since friends are so important to everyone.  Patients is rather large and physician is smaller, as it should be.  Pharmacy and hospital are more prominent than I would have thought would be consistent with my writings.  It's an interesting way to reflect on one's writing.  And, a great way to finish Thirty Posts in Thirty Days.

Family Medicine Activist: Doctors Need Patients

Doctors without patients are like fish without water.  We are useless without patients.  Are they useless without us?  I would generally think not.  So we are dependent on our patients.  We need you.

Sunday, April 29, 2012

Family Medicine Activist: Learning from a Dying Physician

The first patient I cared for on my first clinical rotation as a third year medical student at Ohio State was a physician.  He was dying of heart disease after several heart attacks.  Heart transplants and bypass surgery hadn't been invented yet.  He seemed to know the end was coming, but he wanted to give me some tips about being a doctor.  He told me to spend as much time as I could with my family.  "Spend time with your son" (we only had the first of three at that time).  This was powerful advice to me from a physician patient.

He let me draw blood from him and start IV's (We had no IV Team then, either).  He talked of his heart disease and clinical findings to help me with my thinking. He died on the last day of the rotation in my arms as I was holding him up to get an urgent X-Ray.  On the teaching service we didn't seem to be good at knowing when a patient was near death.  Even a physician patient.

It was literally 5 PM, the end of the last clinical day of my first rotation and no one but residents and students were around.  I felt empty as I left the hospital.  The residents and students had no process to reflect on the meaning of a patient death, not even a physician patient.

I was anxious and jittery for hours to days, I couldn't tell how long I wasn't my self.  There was no formal process to reflect on how I felt or what had happened.  The morbidity and mortality rounds to discuss this patient would be two weeks later when I was somewhere else on another clinical rotation.  Back then, this was how we learned.  Even from the death of a physician patient.

Family Medicine Activist: Tim Tebow and Primary Care Nurse Practitioners are Winners

"No one has ever played quarterback in the NFL at a high level unconventionally.  You have to stand in the pocket and throw the football at some point."...Greg Cosell of ESPN in NYT March 24, 2012 from"Passing Flaws May Negate Tebow's Physical gifts" by Mike Tanier.

"For many years, nurse practitioners have been arguing that they can do almost anything that a primary-care physician can, and that they should be allowed to practice independent of a doctor's supervision. Twenty-eight states are now considering providing that authority, and more are likely to as the primary-care shortage worsens. But it's nonsense to say that NPs are as capable as physicians or that they should be addressed as "doctor,".

NPs are good at providing routine care, especially to chronic disease patients, and we need more of them as part of care teams in medical practices. But if I have symptoms that indicate I might have a serious problem, I want to see a physician. That's not to say that a doctor might not miss my abdominal aortic aneurysm or my incipient cancer. But I'd have a better chance of being correctly diagnosed if an experienced physician responded to my symptoms." Ken Terry, blogger March 2010 CBS

So, Tim Tebow isn't a "legitimate" quarterback, but he won several exciting, close NFL games in the waning seconds, including the exciting overtime win over the Pittsburgh Steelers with the more than 80 yard touchdown pass in the 2011 NFL Playoffs.  A dejected Ben Rothlesburger, the Steelers "legitimate" quarterback and two-time Superbowl Champion, walked off the field defeated.   Nurse Practitioners aren't seen as "legitimate" team leaders in primary care, but they are winning the day in hundreds of clinics, offices and community health centers by caring for thousands of patients.  Why are Tebow and Primary Care Nurse Practitioners winning?

They are team players.  They share and they care.  They know their strengths and they know their weaknesses.  That just may have to suffice.

What do you think?

P.S., I've worked with several Family Nurse Practitioners and I believe they can step up and be the extra Primary Care workforce needed by America.  (They won't being playing quarterback in the NFL, though)

Friday, April 27, 2012

Family Medicine Activist: Know Thy "Frenemies"

Wow, we have a new hospital right next door.  How fortunate to be so close to so many caring people. Gee, we have a new pharmacy in the hospital and another "National Brand" pharmacy a few doors down.  We're blessed to have such friends.

Oops, the  National Brand pharmacy is selling cigarettes and beer.  Is that good for the health of our community?  Are they friends or enemies of our community?
Oops, several of our citizens are near bankruptcy from hospital charges related to ER visits when they were involved in motor vehicle accidents and other trauma.  The ER charges were over $8,000 each and the people were uninsured.  Is the hospital a friend or are they becoming an enemy of our community?

I wonder if we should call them "Frenemies" as their mixed role and message to the community could result in wonderful happenings, addiction, cancer, death or lives saved.  Yes, the word "Frenemies" keeps us on our toes with awareness and reasonable expectation.  Know thy "Frenemies".

What "Frenemies" do you have in your life? How might one be protected from "Frenemies?"

Thursday, April 26, 2012

Family Medicine Activist: Quality and Death

Sometimes I want to disagree with the focus of the quality initiatives in health care.  The quality outcomes concept seems to imply that eternal life is possible if someone's cholesterol is below a certain number or they have a diabetic measure in a certain range.  If your blood pressure is in a certain range, you will live forever and your Family Physician should get a bonus.

Health care in Family Medicine is a relationship-based, continuous process across the life cycle of each individual and family.  It never ends, but it always ends- eventually.  A little known fact is that all of my patients eventually die.  What does that say about quality?  What does that day about prevention?  How does that affect what we do?  How does that affect the quality bonuses we might earn?

Family Medicine Activist: Life in Family Medicine

Every day someone has a delightful moment of insight.  Every day someone laughs.  Every day someone is pleased.  Every day someone is perplexed.  Every day someone is worried.  Every day someone has pain.  Every day someone gets relief.  Every day someone cries.  Every day a child laughs, cries, vomits, has diarrhea, gets injected, eats too much, eats too little, has acne, has strep throat, is hyperactive, is depressed, is cleared for sports, gets a blood test or a throat culture, hugs their mom.  Every day someone cares in Family Medicine.

Wednesday, April 25, 2012

Family Medicine Activist: Too Many ER Visits- DUH!!

The headlines of the Dayton Daily News yesterday bemoaned that there are too many ER visits- nationwide and in Ohio.  A full page story essentially said that people are baffled as to why this is occurring.  Why are there so many ER visits?  I say DUH!

There is a HUGE shortage of Family Physicians in the Dayton area, in Ohio and in America.  The biggest Family Medicine training center in Dayton, OH - St. Elizabeth Hospital- closed over ten years age along with their 12 Family Physician per year pipeline of highly skilled Family Physicians for the Dayton area and beyond.  AND both local health networks (aka, hospital chains) closed their Family Medicine training centers in their respective flagship hospital (Miami Valley Hospital and Kettering Memorial Hospital) in the last three years.  Why are there so many ER visits?  DUH!

Only 8.4% of US medical school seniors chose Family Medicine this year -an increase from previous years.  We need at least 30% of students to select Family Medicine (the only remaining primary care workforce pipeline is FM due to dramatic reductions in internal medicine and pediatric primary care careers chosen by trainees in those specialties).  Will it happen?  Is NEVER too strong of a word?  Why are there so many ER visits?  DUH!

If you don't train Family Physicians somewhere, you will increase ER visits.  Welcome to supply and demand-health care system style.  If you don't supply Family Physicians, people won't use them.  Then you get 60% more ER visits, 45% more admissions and someone is happy.  Not the government or the employer of those people needlessly going to the ER or being admitted to the hospital.  They are being bankrupted by a non-system of health care that isn't going to change without outside influence.  What is that influence?  DUH!

It's YOU!  It's ME!  It's US! DUH!

Tuesday, April 24, 2012

Family Medicine Activist: Head, Heart and Healing

When you see your Family Physician for a problem, it usually is affecting your living, learning, working or loving.  Your doctor responds to the facts of the situation with a medical analysis and recommendation.  This part of the response is from the physician's head, providing an intellectual interaction about your circumstances and your story.  This alone is the content that the business side of medicine, including the billing and paying part,  expects to happen.

The  Family Physician, however, knows that the impact on your living, learning, working or loving is equal to or more important than the clinical facts and plan.  In the context of a continuing relationship with your doctor, they relate to the context of your situation in the broader sense of the meaning of your illness.  What does it keep you away from doing, having or being?  What have you lost or do you fear the loss of as a result of this situation?  Who can you love or not love as a result of this illness?

These matters matter to you and you have a desire to get a response about them from your physician.  The information from the head of your doctor takes care of the factual items.  The heart of your physician responds to the matters of your heart for the other items.  This heart based caring may come through the five senses in many ways.  A look, a touch, or a word with a certain tone may convey an extra message from the heart.

You know you'll get a head based response from your doctor about your illness or situation.  You hope you'll also get comfort in your heart about it from your doctor.  Hearts may help with the broader sense of healing one gets through the experience of an illness more than heads.  Your Family Physician is your ally in seeking healing through your health experiences, both through the head and the heart.

What do you think?

Monday, April 23, 2012

Family Medicine Activist: Library Expansion for Activism

I love to read.  I love books.  Yes, real ones I can prop up on my exercycle while I pedal in the morning, others I can mark up and underline and dog-ear and read in bed.  Activism needs to be informed, so I read on the internet a lot, too.  I Tweet, Blog, Post, Comment, Broadcast, Network, Curate on line.  Books, though are heavenly and reusable.

I was in Columbus, OH for an OAFP cluster weekend (of meetings) Saturday and, to punctuate the trip, I went to two of my favorite bookstores: The Village Bookshop in Linworth (now West Worthington, OH) and Half Price Books on West Lane Avenue just west of the OSU campus.  I had a great time in each store, first in Linworth, then on W. Lane.  The results for my activist library:

Carlisle vs. Army   Jim Thorpe, Dwight Eisenhower, Pop Warner (and the forgotten story of football's greatest battle) by Lars Anderson.  To inspire his players at The Carlisle Indian School to try to defeat a much bigger Cadet team at West Point in November 1912, Pop Warner asked them to remember "it was their fathers and grandfathers who killed your fathers and grandfathers ....and destroyed your way of life.  Remember Wounded Knee.  Remember all of this on every play.  Let's go!"

Officers and Gentlemen Historic West Point in Photographs by Jeffrey Simpson

Sacred Ties   From West Point Brothers to Battlefield Rivals:  A True Story of the Civil War by Tom Carhart.  The Civil War through the eyes of six West Point Graduates including George Armstrong Custer and Henry Algernon du Pont.  The author was two years ahead of me (class of 1968) at West Point in the class of 1966 which lost many of its members in Vietnam.

Healing From the War Trauma and Transformation after Vietnam by Arthur Egendorf, Psychologist.
(OK, folks, you guessed it, I'm a Vietnam Veteran, too.  Activists can learn from war-and peace.)

Original Sinners A New Interpretation of Genesis by John R. Coats

Saving and Secular Faith An Invitation to Systematic Theology by B. A. Gerrish

Evangelism and Missions  Strategies for Outreach in the 21st Century by Ron Blue

The Anatomy of Grace by Peter W. Marty

The Maker's Diet by Jordan S. Rubin

1776 by David McCullough The intensely human story of those who marched with George Washington in the year of the Decalration

Human Biological Variation  by Mielke, Konigsberg and Relethford

Sinus Survival  The Holistic Medical Treatment for Allergies, Colds, and Sinusitus  by Robert S. Ivkor, DO

Musculoskeletal Medicine Joseph Bernstein, MD, MS, Editor

Essential Reiki Teaching Manual, A Companion Guide for Reiki Healers by Diane Stein

I encourage my fellow activists, as well as non-activists to read daily in your field and read often in others.  As a generalist, I find that lots of information relates to what I do and what I have to know or be familiar with.  I love to learn.  The quest is endless.  Quest On!

Sunday, April 22, 2012

Family Medicine Activist: More Patient Radiation Safety

Just in case you didn't read the article (Cancer Risks from Diagnostic Imaging Procedures) in my last post about Radiation Safety, here's a table from it noting how much radiation in "chest X-Ray equivalents" you might be exposed to with the imaging studies listed below:

Table 4. Typical Effective Doses From Some Medical Imaging Examinations
  • mSv indicates millisieverts; AP, anteroposterior; PA, posteroanterior; CT, computed tomography.
  • a
    Number in the third column indicates the equivalent number of chest x-rays for that procedure.
  • b
    Effective dose was calculated using the mean glandular dose found in the Mammography Quality Standards Act (MQSA) inspection in 2006 in the United States.54
  • c
    Average effective dose, health care level I countries, United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) report 2000.13
  • d
    Effective dose was calculated using entrance surface dose, nationwide survey (2001-2006, United Kingdom), and effective dose conversion factor.5253
  • e
    Average effective doses for axial and helical scans from a nationwide survey between 2000 and 2001 in the United States.55

    We see many people who get the abdomen/pelvis CT for lower abdomenal pain.  People who get kidney stones seem to get a CT of the abdomen each time they go to an ER.  People with head or neck pain seem to get the "trauma series" if they go to an ER after a motor vehicle accident.  That includes CT of the brain, CT of the neck and CT of the low back.  I say WOW.  What do you think?
 Skull AP or PA0.0151
 Chest PA0.0131
 L-spine AP0.4430
 Abdomen AP0.4635
 Pelvis AP0.4835
Mammography (4 views)b
Dental radiographyc
Diagnostic fluoroscopy procedures
 Barium swallowd170
 Barium enemad5350
 Angiography: cardiacc7500