Sunday, March 24, 2013

Clinical Decision Making in Family Medicine: The Biopsychosocial Model

As budget crunching hits America and health care dollars become more scarce (if $2.7 Trillion is scarce) more alternatives to Family Physicians as the Primary Care workforce will be proposed.  Teamwork is assumed to be critical to expanding the frontlines of health care.  Many who aren't intimately familiar with the complex thinking involved in Family Medicine would suggest, or even legislate, replacement of Family Physicians with protocol driven physician extenders.  

I have posted extensively about the advantages of human centering in patient care.  The post below is re-introduced to again comment on the complex decision making processes commonly used in Family Medicine.  This focuses through the Human Centered Health Home (HCHH) model into the patient-physician dyad.  Although the Biopsychosocial Model involves a lot of thought and information, it is only one model that is frequently used by Family Physicians. Please refer to the HCHH posts on this site for several other models and behaviors used in clinical decision processes.

Tuesday, November 30, 2010

The Human Centered Health Home: Detecting Patient Alignment or Misalignment 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

In the Human Centered Health Home (HCHH), after the Respecting, Protecting, and Connecting processes are underway, the next process, as mentioned in the last HCHH blog post on 11/22/2010 is Detecting. I refer to it as detecting patient alignment and/or misalignment.  Many models might be applied to analyze the situation of patient and physician, including the Biopsychosocial Model (BPSM) developed by George Engel, MD, a cardiologist 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 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).

Using the model, we inquire of the patient or think about the possibility of the biosphere causing or relating to the palpitations, possibly from explosions on the surface of the Sun or the recent eclipse. Thinking of the Sun a while longer, we recall that Vitamin D3 is coming to our patient from the Sun and wonder if the decreased sunlight in the Ohio overcast fall weather could be a factor in the palpitations, recalling that a deficiency of Vitamin D3 can lead to heart attack, stroke, cancer of the breast, colon or prostate gland.  We will include a D3 level in the lab tests ordered later in the office visit.

Next in the model is consideration of the impact of the society and nation on the cardiovascular system of our patient with the heart palpitations.  The economy of the nation and the state is affecting the school system adversely, but the local society passed the school levy a few weeks ago, giving the principal breathing room in his budget for the next year.  The work culture changed as the teachers did threaten to strike and harsh words were exchanged between the principal and union leaders as the new budget was developed, including an intensely disappointing reduction in health benefits next year for all school employees, including the principal.

Worrying about the levy and loss of friendships affected the principal's sleep.  He also noted the blood pressure written down by the Medical Assistant was elevated at 144/92 and his weight was 20 pounds heavier than last year.  Even his pulse rate at 82 was higher than his resting pulse of 68 two years ago after the July 4th 5 mile run preparation got him in good shape.
The subcultures of teachers and other school workers shifted to groups of strongly supportive and strongly opposed to the changes in the school system and employee benefits.  Student subcultures reflected parental attitudes regarding the levy and the proposed changes.  The tension seemed to lead to more student unrest and angry factions with increased fighting in the bleachers at football and basketball games.  More students and their parents were meeting with the principal than ever.

The local community was mostly business as usual except there was less of it due to the economic slowdown and increasing unemployment.  The principal often ate breakfast on Saturday mornings with his family at the locally owned restaurant which was popular for their whole hog sausage gravy and homemade biscuits, served with eggs, hash-brown potatoes and coffee.  Community members were friendly with them and engaged socially without mention of budgets or politics until one week before the election.  Then he and his wife only received polite inquiries about the financial facts of the school levy.

His family was supportive of his role as principal, but the two teens were getting flack from friends at school about why their dad wanted to get rid of teachers with seniority, a powerful rumor going around the school.  They pressed him for insider details at times so they could provide secret reassurances to their friends about the security of sports and extracurricular activities.  He politely informed them of the decision processes involved in school leadership and the need for some privacy as the school board considered delicate personnel issues.

His parents (his family of origin) were retired and living about 120 miles away in a senior living community.  His father had experienced a heart attack at the age or 68 and had a stent placed in his left carotid artery last year shortly before his 78th birthday.  Mom was politically active on the town council and took medicine for high blood pressure.  They both took medicine for high cholesterol and expressed their concern that their son enjoyed eggs too much.

This scenario represents how a physician may gather and analyze information about patient health and symptoms using the Biopsychosocial Model (BPSM).  We haven't gotten to the patient focused part yet, but we have some ideas about the context within which the heart palpitations occurred.  Note that the "medical" information is sparse so far, but look at the rest of the model above which will be heavily medical.  Usually, patients are driven to enter most clinical encounters at step 6, 7, or 8 , possibly avoiding the type of information we have gathered from this patient using the BPSM.

We'll start with step 6 in the next HCHH blog post, continuing to analyze the principal's palpitations.  A lot of information contributes to clinical decision making and the BPSM is one way to stimulate an expansion of the types of information gathered.  Stay tuned (and watch out for whole hog sausage gravy).

Sunday, March 17, 2013

The Human Centered Health Home: Posts to Date

The Human Centered Health Home (HCHH) is a model for use in medical practice.  
I summarize below the blog references to it in the Dr Synonymous blog posts.  
I use the model daily in my practice (Family Medicine) and hope that many others may find 
part or all of it helpful.

Oct 02, 2012
I'd like to revisit and upgrade the Human Centered Health Home model of care, developed through the Center for Innovation in Family and Community Health (CIFCH) and years of practice and collaboration with others, ...
Oct 16, 2012
The Dr Synonymous Show October 16, 2012. Dr Synonymous reviews clinical decision making in the Human Centered Health Home (HCHH) using models of thought and care that may be used in Family Medicine.
Oct 19, 2012
The last post referred to clinical decision making in the Human Centered Health Home (HCHH). After Respecting, Protecting, Connecting, Detecting, and Correcting, the dyad of patient and physician finish their engagement ...
Jun 21, 2011
During the last major process of the patient-physician engagement in the Human Centered Health Home (HCHH)- Reflecting, a primary aspect involves patient goals. The patient relates with the physician to remain in line, ...
Apr 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 ...
Jun 07, 2011
After Respecting, Protecting, Connecting, Detecting,and Correcting, the last element of the encounter between patients and physicians in the Human Centered Health Home is Reflecting. This usually occurs at the end of the ...
Nov 07, 2011
The Human Centered Health Home (HCHH) is the broad model I've been developing with colleagues in our Center for Innovation in Family and Community Health (CIFCH). Many holistic skills and the relationship driven ...
Sep 05, 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 ...

Feb 14, 2011
The uniqueness of the Human Centered Health Home (HCHH) model contributes to better sharing of uncertainty starting with its emphasis on Human Centering of the patient and physician. Their humanity and commitment to ...
Nov 22, 2010
In the Human Centered Health Home (HCHH), we've identified a process that allows for exploration and training of participants (humans acting as patient and doctor and other roles). The elements of the process are ...
Dec 20, 2010
The Human Centered Health Home: Detecting Patient Alignment or Misalignment Using "Get, Give, Merge and Go". "One of the paradoxes of our time is that the healing relationship seems most in jeopardy at a time when we ...
Oct 02, 2010
The Human Centered Health Home (HCHH) as defined by our Center for Innovation in Family and Community Health is best supported by patient-physician processes which include: respecting, protecting, connecting, ...

Nov 30, 2010
In the Human Centered Health Home (HCHH), after the Respecting, Protecting, and Connecting processes are underway, the next process, as mentioned in the last HCHH blog post on 11/22/2010 is Detecting. I refer to it as ...
Jul 28, 2010
The Human Centered Health Home: Protected and Neighborly. As a child, I always felt safe. Growing up in a neighborhood of unlocked homes where every kid could enter any house to play with other kids as allowed by the ...
Aug 24, 2010
The Human Centered Health Home: Protecting Patient and Family Doctor Like Neighbors. How do we protect each other in the patient-physician relationship? What if we try to act like neighbors act? OK, Good Neighbors, the ...

Friday, March 8, 2013

Family Medicine: Realigning with Our Heart

OK, Family Medicine Folks,

Are we out of alignment with our heart?

Are we too busy and corporate and overly focused on the latest "quality" initiative or organizational certification to feel the human needs of our patients?

Have the coders and other numerati moved us into numb numbers mode?

Are we still validating our patients humanity and honoring them for their struggles and successes or has their BMI or  HGBA1c overshadowed their worth (via the EMR)?

Are we relating through our relationship based specialty through our heart to those of our patients?

Are we loving, honoring and praising the quest of the person we see in the mirror- the quest of a Family Physician?

Rise up, Family Medicine!

Let's refresh and reclaim our heart.

What do you feel?  See?  Think? about our heart?

Didgeridoo Hullabaloo Session Three at the BellHOP Cafe

Join us at 8:15 AM (yes, AM) on Saturday March 9th, 2013 for the third session of the Didgeridoo Hullabaloo at the BellHOP Cafe in Bellbrook, OH.

Bring your own didge or use one of our extras (2 or 3) to make beautiful sounds (OK, some of them sound like a dying cow) and tone your throat into ex-snorer territory.

Immediately after our droning, at 9 AM, Dr Synonymous will broadcast Whole-Hearted Health on the BlogTalk Radio Show of the same name (Dr Synonymous).  The broadcast remains as a podcast on BTR and ITunes for later listening.

Join us for fun and great coffee/breakfast at the BellHOP!

Session Outline:

Didgeridoo Hullabaloo Session Three at the BellHOP Café March 9, 2013
Introductions Dr Synonymous (Pat), Group Members, Guests
Sweet Spot
The drone “raspberry”, “raspberry with smile”, spitting seed
Dah Dah Dah
Tah Tah Tah
Duh Dah Duh Dah Duh
30 second  drone?
Circular Breathing cup of water & straw
One minute performance:  Group  Drone- A-E-I-O-U- Ah as adjusted by the group spark
Rhythm practice solo and w/ partner
Online options

Monday, March 4, 2013

Whole-Hearted Health with the Dr Synonymous Show at the BellHOP Cafe

Saturday March 9th, Dr Synonymous will broadcast at 9 AM from the BellHOP Cafe in Bellbrook, Ohio again. 

The Dr Synonymous Show on Blog Talk Radio

The subject is Whole-Hearted Health.

The presentation will engage a live audience about medical, natural and supernatural strategies for healthy hearts.

Holistic Strategies for Healthy Hearts to be discussed or mentioned include:

Medical Practices and entire Systems of Practice (TCM, Ayurveda, etc.)

Natural Products

Mind and Body Practices

Manipulative and Body Based Practices

Energy Practices

I hope you'll tune in or come to the BellHOP for great coffee and breakfasts and enhanced insights about Whole Hearted Health.

Session Outline:

Whole Hearted Health at the BellHOP Cafe
A Patrick Jonas, MD, aka Dr Synonymous
We’ve already heard of the 5-5-5 healthy behaviors
Another way to think of health practices is through the NIH five categories of complementary and alternative practices:
1.      Complete Systems of Health Care
2.      Neutriceuticals/ Natural Products
3.      Mind-Body Practices
4.      Manipulative and Body Based Practices
5.      Energy Practices
We’ll focus on Heart Health in a holistic way, adding comments about our medical approaches, too.
OK, what Complete Systems of Care are you familiar with, beyond Western Medicine?
How about Neutriceuticals/Natural Products that promote healthy hearts?
What about Mind-Body Practices that are heart healthy?
And what are some Manipulative/ Body Based Practices that help the heart?
And how about Energy Therapies that are measurable or un-measurable and heart healthy?
Let me say a bit about how I think about whole hearted health using the NIH model, interspercing comments about our traditional therapies.

ROPES model for each.
Closing comments.

Drafts of Posts to Finish Someday

Bloggers like me start a lot of posts.  I have 32 drafts started.  Many will never be finished.  You may wish to write about the same topics and do better than I would.  Titles include:

Family Medicine:  Codons or Holons?

                            Differential Diagnosis

                            Snow Angels and Didgeridoos

                            Uncertainty Rules

                            Drug Samples

                            If It was Easy, It Wouldn't be Fun

                            Fear and Tension


                            Phenomena and Proclivities

                            Abandon Ship?

                            I Almost Died, and You Weren't Available, Doctor

                            I Want My Life Back

                             Partnering with Patients

                             Blue Collar Doctors

Have fun with these in the blogosphere as you wish.  (And send me a copy).


Sunday, March 3, 2013

Family Medicine: We are Blessed

Stories, Stories, Stories.  People, People, People.  Families, Families, Families.

We get them all in Family Medicine.  And health and disease. We are blessed.

We are also thankful--  thankful for the opportunity to  witness and participate with our patients in decisions that enhance their human experience.  And our human experience, too.

We're in this together.  We care about each other.

Thanks to all our patients who share their stories.  Thanks to our teachers who enabled us to learn the medical and behavioral science.

Thanks to our mirrors that show us who we are through our own eyes.

Thanks to God for joy, beauty and the mystery of life.