Wednesday, May 28, 2014

Family Medicine: The Myth

I've noticed after about 177,000 patient encounters many similarities and differences.  One of my main responsibilities as a Family Physician, it seems, is to make sure that each patient knows that they matter- sort of a human validation and often a role validation (father, mother, patient, guardian, etc.).
AND, that I know that I matter, too.  I value human centering as a skill/strategy of importance, as differentiated from patient centering which seems over-rated and potentially hazardous to the health of ourselves and our colleagues.
After Kurt Stange introduced us to Ken Wilber via his series in the Annals of FM, I dug into A Brief History of Everything and Integral Spirituality, finding many beneficial validations and launching points.
Extrapolating from Wilber's points about the role of religion, I can resonate to one aspect of the "priestly role" of the Family Physician as "carrying forth the myth that can't be proven" (or measured?).  People have faith that something will happen (or is happening and will continue to happen when they see or reflect upon their Family Physician and the meaning of the relationship).  What is the myth?  Well, you believe it, but maybe you don't know what it is.  It is not measurable in a coding sort of  way.

Could we have a measurable energy that when combined with our context and the patient's context, delivers wholeness? (the unmeasurable and unbillable quest of many).  I like this concept.  The human energy field of patient and physician engaged in dyadic sharing and mutual interdependence may be measurable as technology evolves (probably with a cell phone).

Their (patients) fear of short term or long term loss, or fear that we won't connect to their reality and further mis-align them with their potential for whatever, combined with our fear that their problem might exceed our skills or our coding skills or our employer's mandates for our scope of practice and time allotment may suddenly (or over time) melt into a mutually beneficial human dance of meaning, enhancing organ and system and spiritual unction for both. Can the creative tension of the dyadic dance show merit of a financial sort to someone who might pay?

I love what I get to do.  I love being a Family Physician.  I'm blessed to get a close look at the human condition in the context of meaningful relationships that enable humans to better align with their values, goals and dreams. Yes, My values, goals and dreams are included in the outcomes of doing Family Medicine.
Just a few thoughts.
More later about The Myth and The Magic.  apj

Tuesday, May 20, 2014

Review of The Direct Primary Care Ohio "Unsummit" on The Dr Synonymous Show May 20

The Dr Synonymous Show on Blog Talk Radio May 20, 2014 will review this meeting. Direct Primary Care Ohio "Unsummit" II  Tune in live Tuesday 9:30-10:30 PM ET or listen 24/7 to the recording.

The DPC "solution" moved ahead via information shared and relationships established or advanced at the Direct Primary Care Ohio "Unsummit" held in Beavercreek, Ohio on May 17.  The Center for Innovation in Family and Community Health (CIFCH) sponsored the Unsummit, with help from the Family Medicine Education Consortium, Inc. (FMEC).  Special thanks to Shayla Rammel of the FMEC staff.

"If a practice is "all in", they should remember WHY they are "all in".  Traditional overhead of 65-70 % versus DPC overhead of 30%.  Having a satisfying practice which allows adequate time to establish meaningful patient-physician relationships delivers better opportunities for mutually agreed to "quality" outcomes.  Having "quality relationships" that deliver deeper, outcome sensitive goals affords more opportunities to re-define Family Medicine as a human centered specialty.  Human centering allows alignment with patient AND physician values, goals and dreams.  Understanding of, and commitment to, the human condition allows hope for human wholeness, a commitment to an interconnected, imperfect existence of wholehearted appreciation." - A. P. Jonas, MD See more at:

The Direct Primary Care
Ohio “Unsummit” II – May 17, 2014

Morning Session
8:30 - 8:45 a.m.                   Welcome, Introductions, and Disclaimer(s)
                                                Pat Jonas, MD - President CIFCH

8:45 - 9:00 a.m.                   Direct Primary Care: Why Now, Why Here?
Larry Bauer, MSW, MEd –CEO, FMEC

9:00 – 9:15 a.m.                  Health Insurance in Ohio and Beyond   
Randy Gifford - Insurance Agent

9:15 – 9:30 a.m.                  Neighborly Family Medicine         
                                             Pat Jonas, MD - President CIFCH

9:30 – 9:45 a.m.                  Human Centering in Primary Care 
Steve Deal - Systems Engineer

9:45 – 10:00 a.m.               Academic to Private Practice Hybrid  
Phil Whitecar, MD – Independent FP, Beavercreek

10:00 – 10:25 a.m.            Town Hall: Q & A

                                                All Speakers
Nuts & Bolts Session
10:30 – 10:40 a.m.             Welcome, Introductions, and Disclaimer(s)
                                                Pat Jonas, MD - President CIFCH

10:40 – 11:00 a.m.             Vision for Family Medicine
Larry Bauer, MSW, MEd – CEO, FMEC

11:05 – 11:30 a.m.             DPC Pioneer in North Carolina (via video)   
Brian Forrest, MD – Access Healthcare; Board Chair NCAFP

11:30 a.m. – Noon              The Affordable Care Act
                                                Randy Gifford - Insurance Agent

Noon – 12:59 p.m. Lunch 

1:00 – 1:35 p.m.                  Transition to Hybrid: Challenges and Pitfalls  
Pat Jonas, MD - President CIFCH

1:35 – 2:00 p.m.                 Human Centered Design in Family Medicine
                                                Steve Deal - Systems Engineer

2:00 – 2:15 p.m.                  Break

2:15 - 2:45 p.m.                  DPC Multi-Site Tour via WWW
Pat Jonas, MD - President CIFCH

 2:45 – 3:15 p.m.                  Town Hall: Q & A
                                                All Speakers

Friday, May 9, 2014

Direct Primary Care: Transition to Hybrid- Challenges and Pitfalls IV

Balance between Traditional and DPC enroute to Hybrid may be elusive.  One strategy is to go "all in" and take no new patients other than DPC which allows focus on the marketing and office protocols for new patients.

Allowing a continuation of new patients in the Traditional track is easier for office staff.  "So and so wants her sister's family to be patients here, too.  They have insurance and don't want the DPC track.  Can we take them?  They're really nice people."

If a practice is "all in", they should remember WHY they are "all in".  Traditional overhead of 65-70 % versus DPC overhead of 30%.  Having a satisfying practice which allows adequate time to establish meaningful patient-physician relationships delivers better opportunities for mutually agreed to "quality" outcomes.  Having "quality relationships" that deliver deeper, outcome sensitive goals affords more opportunities to re-define Family Medicine as a human centered specialty.  Human centering allows alignment with patient AND physician values, goals and dreams.  Understanding of, and commitment to, the human condition allows hope for human wholeness, a commitment to an interconnected, imperfect existence of wholehearted appreciation.

Another strategy is to allow the dysfunctions to bubble up via empowered staff who undermine the Hybrid goal of practice owners.  The dysfunction of most significance may come from physicians.  Passionate people may intend well, but harm the practice financially if their passion is secret.  Meetings dripping with honesty, self revelation, passion, intensity, wisdom, humor and human vision become important.  Follow-up meetings with similar openness become important for clarification.  Physicians should understand that a gradual commitment to Hybrid may result in changing relationships, even splitting of partnerships or "split the question" types of new practice agreements or business relationships.  Remember the creative juices that must flow when physicians go through practice transformations.

Another strategy is to start a new DPC practice parallel to the Traditional one.  This allows co-existence of Traditional and DPC which may merge later into "full" Hybrid.  It also may allow a gradual splitting of a partnership via the "DPC fanatic" going "all in" on DPC new patients only while the more reluctant for DPC physician continues as Traditional only with continuing new patients in the traditional track.  The cross coverage may become challenging to afford an opportunity for the Traditional physician to be paid by the DPC fanatic for seeing their patients when DPC fanatic is not available.

The split, two practice strategy makes it easier on the DPC side to accept all patients who enroll, without consideration for dual charging of government paid patients that plagues the Hybrid practices.  In the DPC only practice, it functions like a "pure" DPC practice with no insurance relationships honored or considered. The logistics of operating parallel practices cold get complex on issues like practice identity, answering the phone, stationery, professional business cards, etc.  Competition between the two models may generate a friendly or pathologic co-existence.

Yes, it's confusing.  If it wasn't complex, it wouldn't be so much fun.  More later.

Wednesday, May 7, 2014

Direct Primary Care: Challenges and Pitfalls III

OK, We have a phone "schpiel" to present to potential new Direct Primary Care patients who call.  It takes about three weeks or five separate new patient calls for an individual staff member to get "calibrated" in our front office to the DPC patients.

Remember that we are a "niche" practice - "Families Only!"  I believe in Family Medicine!  I love it!  It works!  Families are amazing!  They know something about each other and their culture/identity.  It fits nicely into Family Medicine practice.

How does that translate into medical practice?  Perfectly.  How many people understand that?  Few.  The founders of the specialty stumbled onto "The Family" but didn't really understand the potential.  (I spoke with G. Gayle Stephens at length about this).  I digress because the "Families Only" approach has made my experience in Family Medicine so enjoyable and meaningful.  I hope that others try it and learn one of the secrets of the specialty.

Direct Family Medicine (DFM) is what I practice in a Direct Primary Care business environment.  Each new patient has to be "vetted" to clarify if we can continue, once they show up for their first.  As I mentioned before, I have a contract with government health plans such as Medicare and Medicaid that preclude me treating patients in different financial ways. No one can make a separate financial arrangement with me about those patients.  The "Pure DPC" physicians don't have to worry about this.  Many patients on these plans see DPC physicians and pay them their fees to get the personalized care and extra time.

We have a one page summary of Direct Family Medicine that we review with each patient- twice if possible because they are too busy with forms, etc. to grasp the details on the phone and at the initial visit.  Relationship-based, Continuous, Comprehensive care of the individual patient and their family who resides  in their home is the base/ anchor for my practice.  We offer care for prevention as well as acute illness/ injury, as well as chronic disease.  Physicals are part of the prevention strategy.  We use the MilCom patient history forms to organize the initial information about each patient, providing discussion starter information and a place to scribble notes.  (EMR aspects of this later).

After the initial visit, persons with multiple problems or chronic diseases are usually scheduled for one or more follow-up visits to "peel the onion" of chronic disease and hear their story.  The time available in DFM is generally more than in traditional practice.  They also are more likely to align with the prevention and health strategies than the traditional practice patient.  In the traditional part of my practice, it's more difficult to have people come in three weeks in a row to get through their whole story and sort out the diseases and medications and their impact on individual and family life, goals and dreams.  This is not a superficial undertaking.  Burrowing with someone into their living room their life and their DNA to clarify and develop differential diagnoses using the biopsychosocial model helps me to form the patient physician relationship and develop direction and mutually agreed to outcome goals.

If it was easy, it wouldn't be so much fun.

More later.

Tuesday, May 6, 2014

Direct Primary Care: Not for Everyone

If you are FED UP, CONFUSED or CURIOUS with the health care dilemma, Direct Primary Care (DPC) may be for you.  Pay for your Family Physician yourself.  And, generally, save money.  If you're not FED UP, CONFUSED or CURIOUS Direct Primary Care is probably not for you.  It's not for everyone.  Don't worry, either, only two practices in the Dayton area offer DPC, so you may not be able to try it.

In DPC, patients generally pay an enrollment fee, and a membership fee monthly (In Ohio, this has to be at the end of the month).  Other fees may arise for labs or imaging services and more complex procedures like office surgeries.  Each practice seems to vary from its neighbor somewhat.  It's up to them to provide the patient with a list of services provided.

Direct Primary Care IS NOT INSURANCE!  It is health care.  And it's not for everyone.

Saturday, May 3, 2014

Direct Primary Care "Unsummit" II May 17 in Dayton

We're pleased to be offering the second in a series of Direct Primary Care "Unsummits" in Dayton, OH May 17th.  Many Family Physicians, other primary care physicians, nurse practitioners, physician assistants, medical practices and non-primary care physicians are interested in exploring the shift to a direct pay business model.  Many patients, employers, community leaders, politicians, health care leaders and others want to hear more about direct pay strategies for health care, especially primary care.

The Center for Innovation in Family and Community Health is delighted to organize and sponsor the Unsummit.  We appreciate the  support of the FMEC in this effort.

A unique feature of the Unsummit is a 90 minute breakfast session for persons in the groups mentioned above to get introduced to Direct Primary Care.  New practices are popping up every day using the DPC business model which usually involves an enrollment fee and a monthly fee (at the end of the month in OH) and may include fees per visit.  Individual practices vary on whether they have a per visit fee and extra fees for labs, imaging services (e.g., x-rays, etc.), or office surgeries.  Other descriptions are available at The Direct Primary Care Coalition and The American Academy of Family Physicians (AAFP).

Another unique feature is an insurance agent, Randy Gifford, who will update us on health insurance, including the availability of catastrophic coverage in Ohio which would complement DPC nicely.  Steve Deal,  a systems engineer with a special interest in the socio-technical interfaces in health care, will speak to the factors in health care that may dehumanize both patients and physicians.  He also notes how DPC helps to maintain the humanity of both.

Larry Bauer, MSW, MEd a thought leader in Family Medicine Education who is CEO of the Family Medicine Education Consortium will provide insights about the DPC movement nationally, while Gabe Fine, MBA CEO of Health Access Rhode Island will speak via video or social media about how DPC is a "solution" in health care.

Pat Jonas, MD, ABFM will present about his transition to a hybrid (DPC practice plus traditional insured patients) from a "traditional" (but "families only") family practice model.  Phil Whitecar, MD, ABFM will review his transition from an academic practice to hybrid DPC practice.  Both physicians include medical student teaching in their practices.  Dr Jonas also teaches Family Nurse Practitioner students in his office.

Brian Forrest, MD, ABFM, one of the national leaders in the DPC movement from his DPC practice in Apex, NC, will present via video or social media about how DPC works for him and those he trains across several states and specialties.

The on site faculty will present the 90 minute breakfast session.  All faculty will be involved in the 6 hour Nuts and Bolts session for Family Physicians, General Internists, General Pediatricians, IM/Peds Physicians, Primary Care Nurse Practitioners and Physician Assistants, Medical Office Managers and Primary Care Office Staff.

We should learn a lot, but still have many questions about this evolving and exciting movement.
Here's the formal link with registration information for atttendees, vendors and sponsors, with an alternative for more sensitive computers.     DPC Ohio Unsummit II     Short Form Unsummit Poster/Registration

Friday in Family Medicine: The Spring Brings Smiles and Mucous

Return to full work, it says in the chart.  A form.  I write too slowly- patient brought up two more problems while I copied the codes written on the last form.  A drum beat tells me I'm behind.  Literally, we use a Remo Buffalo drum for the staff to let the Dr know that too much time has elapsed with a patient.  I own the place, so I can take the drum under advisement instead of racing from the room.

Smiling patient with lots of problems- has none today, except the one they made the appointment for- a rarity these days.  "I read the book you recommended (Wheat Belly) and I don't have migraine any more.  I am wheat free.  My pain is a lot better, too"  I see the smile again.  The relief.  On Friday. Nice.

No pain in the next room, either.  Patient who always has fatigue, aches, painful urination.  "I don't know if I need to be here.  I don't hurt any more."  "Why not?" I ask.  "Could it be the vitamins?  I've only been taking them for six weeks. I sleep well now."  (Methyl B12 and L Methyl Folate).

Next- a physical to satisfy an entity.  Entity and patient satisfied.

LDL 51.  Too low for me.  You are at higher risk for violent events with the super low cholesterol.  Consider dropping the statin to 25% of current dose, from 40 to 10 mg.  With known coronary disease- we have one in 64 chance of preventing a non-fatal heart attack with the statin.  "It may not be in my best interest to take the medicine."  "You get to decide"   "Well, the cardiologist talks about it every time I see him, and I say I'm worried about the side effects."  "Good news and bad news is that you get to decide"  "What else would you like to know to make your decision?"  "I want to start by taking the lower dose and retesting."  OK.

"I've been coughing since I got back from Paris.  It's worse outside."  "Are you allergic to Ohio?  We're in one of the top ten worst allergy cities here in the Dayton area..  Mucous is the state bird in Ohio, we have so much."

On to the next patient(s)

"When's the baby due?"
"How's your mother doing?"
"What are you doing with all that money now that you've quit smoking?"
"Welcome to spring"
"Did you get the new dog yet?"
"You look miserable"
"You have your spring hair-do"
"When is your daughter's graduation"
"When is your prom?"
"Congratulations, your blood pressure looks like it's back in Ohio.  How did you do that?"
"I think they're all cured, all the rooms are empty."

Spring is here.

Thursday, May 1, 2014

Direct Primary Care: Challenges and Pitfalls II

OK, so everyone in our office had to shift attitudes to embrace Direct Primary Care while still appreciating "Traditional" Care.  We had meetings.  We fretted as our attitudes smoldered.  We had six or seven ways to answer the phones with a DPC schpiel if a potential new patient called.  Traditional new patient wannabees were surprised that we weren't taking any patients with insurance.  Potential DPC folks were also confused.  Many people stretched the truth (lied) to try to get into our practice as a patient.  Several became patients, but hadn't agreed in their heart that they would bring the whole family- our niche for 33 years of Family Medicine practice.

The Christian couple from the coffee house showed up and understood the model of care.  It was fun to see them (I gave a couple mini lectures about DPC at the coffee house and they told many people coming in for coffee or food about DPC and our practice).  They understood how the lab charges worked for outside labs.  They brought some comfort to the process.

The phones:  "Yes, we're currently taking new families into our Direct Family Medicine (DFM) Track. It's for people without primary care insurance who want a different approach to health care, more personalized care and/or a physician who will listen to them."
"If one of those people is you then our practice might be a good fit.  It's definitely not for everyone, though.  AND, It's definitely NOT INSURANCE"

The attitudes- We went "all in".  All new continuity patients had to sign into our Direct Family Medicine Track.  (We have committed to our insured patients to accept everyone in their household.  Some of them sort of "trickled" in as insured new patients even after we started the DFM Track.)

Our style is to "ooze" into new things, so we're continuing to ooze into DFM.  We're changing slowly and ducking frequently.  With intense staff and patient loyalty, we're continuing to love our traditional patients while hugging our way into DFM.

Each Direct Primary Care practice is different.  That's part of the fun as each tries to be sensitive to the needs of a specific community.  One size does not fit all.  One "Pure DPC" Family Practice in Ohio started and closed about two years ago because the financial need versus cash available resulted in financial problems.  It ain't easy, Folks, but is sure is fun.

More later.