Tuesday, July 30, 2013

Family Medicine: A Victory for Patients

I'm touched, Folks.  As a long time Family Medicine teacher/mentor, I find special meaning in messages like the email below that I received recently.  Thousands and thousands of future patients will benefit from his decision.  He's a senior medical student at Wright State.  Congratulations, Patients, you won one!

"Hi Dr. Jonas,
I just wanted to let you know I decided to go into Family Practice.  I came to the realization it is the best fit for me.  :)  If you had time, I was hoping we could meet up when it was convenient and talk about the possibility of you writing a Letter of Recommendation for me."

Sunday, July 28, 2013

Another Vietnam Personal Anniversary

43 years ago on July 27, 1970, I departed for Vietnam.  How the time flies.  I still think of  Vietnam daily.  I still wonder about undeclared war, or "non-war."  And about the somber feelings of acceptance, denial, pride, disappointment and confusion when reflecting on the meaning of the Vietnam Conflict and my service in Vietnam.  I want to remember Vietnam in a kaleidoscope of ways and avoid nailing down a false certainty about its meaning.

Denny L Johnson and 19 other West Point classmates of mine who were killed in Vietnam weigh heavy on my heart.  Forever.

Flying helicopters was very satisfying.  Movement, freedom, mission accomplishment, camaraderie are words that come to mind.  Agent Orange comes to mind occasionally these days, since I was exposed to it in numerous locations where I landed on firebases in I Corps (top 1/4th of South Vietnam).

Music comes to mind.  "Stand by Your Man" and "D I V O R C E" by Tammy Wynette were popular with the troops and officers, as was "Proud Mary" and "Bridge Over Troubled Water".  We listened briefly to AFVN when flying almost daily, but especially on Sunday flights to the outpost nearest the DMZ, where we took Red Cross Volunteers to entertain troops informally with games and conversation.

Pictured here are the two models of helicopter we flew for the 45th Engineer Group Headquarters, Hueys and Kiowas.  The other photo is me on Christmas Day 1970.

War in the distant rearview mirror of life looks sadder than in real time.  Lives lost and national interest moved on.  Was it a useful conflict?  Did it change the world?  Did it lead to lives saved later because of lessons learned?  Do I still have my camera and stereo that I got at a tremendous discount from the Pacex catalog in the "war zone"?

Just a few thoughts 43 years later.  More next year.

Thursday, July 18, 2013

Family Medicine: Recapture the Dream with Direct Primary Care

Thoughts about Direct Primary Care

As we move ahead with more Direct Primary Care practices, I hope we in Family Medicine will  remain sensitive to the small practice that is a bit "counter-culture".  Many are looking at DPC to get away from "meaningless use" of the ACA and piles of administrivia from insurance companies.  Many of these physicians are looking for help to stay independent.  Some are looking for a loose connection to an organization that helps but remains non-invasive.  Very few might be looking for an umbrella organization that exposes them to oversight and more "phony quality initiatives" that detract from patient care.  Some want pure DPC, while some want a hybrid, some want to start with one and end with the other.

When I look at the model Kurt Stange introduced at the FMEC meeting last year from Ken Wilbur's book, A Brief History of Everything, I see DPC offering a broader human focused health care than the Medical-Industrial Complex which is driving everything toward External/Measurable Numbers (the right side of the Wilbur two by two model). 

Illness has always been a deeply human endeavor (if allowed) which allows people to better understand their humanity and the human condition.  The MIC is destroying the potential for understanding while DPC offers hope, especially for Family Medicine which used to be committed deeply to caring for and protecting our patients.  Now, the Family Physician is selling out to "the beast" and "accidentally" lining up patients for overexposure to unnecessary and expensive care to get "good numbers".

DPC offers renewed hope that the internal aspects of the humanity of the individual patient can be enhanced through relationship driven dialog with their family physician in the context of health care.  Insights generated through the internal dialog leads to broader cultural inputs which expand tribal boundaries of cultures to better relate to other tribes and better understanding of our shared humanity.  Ian McWhinney clarifies the role of the Family Physician nicely in his writings about our specialty.

More later

Tuesday, July 2, 2013

Direct Family Medicine: Personalized Quality Measures

The quality of medical care or health care is an important, but confusing, concept.  What is quality?

Currently, one might say that quality in health care is a number that measures something of importance to non-patients.  Examples are the percentage of a physician's patients with diabetes who are taking a statin drug or the percentage of persons with asthma who have had an annual pulmonary function test.

 Did patients devise these quality measures?  No.

What if patients did develop "quality" measures? What do we (yes, I'm a patient,too.) believe to be important?

How about the ability to meet personal goals such as learning to play "Cripple Creek" on the banjo before the family reunion?  Or being able to lift my grandson and carry him for 50 feet without my right knee giving out by Thanksgiving?  Or  feeling free to express my opinions about finances in a church committee meeting or an organized medicine committee meeting?

How about honoring my aunts in my personal blog before Thanksgiving?  Or getting increased exercise stamina and losing 18 pounds before September 10th?  Yes, these are reasonable goals to work on with my Family Physician.  Yes, they should be entered into the medical record.  Yes, the measuring authorities should give me and my physician credit for achieving these quality goals.

Does the envisioned PCMH give credit for achievement of these personal quality goals?  Will the NCQA?  Is the AHRQ paying someone to study this approach to quality?

If my Family Physician shows me respect and protects me from unnecessary medical procedures,  should he get credit for improving quality?  I hope so.

If my Family Physician allows me to manifest human eccentricities of lifestyle, such as marching in a political protest, might he get "quality points"?  I hope so.

OK, I wonder about promoting "Wholeness".  If my physician reaffirms my worth as a human being, might he get quality credit?  I hope so.

In a Direct Family Medicine Practice (Direct Primary Care business model), a patient and physician can work together to devise quality initiatives that reaffirm, refresh and realign the humanity of both patient and physician.  Personalized quality goals are achievable.  Freedom is refreshing.

What do you think?