Saturday, November 22, 2014

Chicken Pox, Vioxx and Goldilocks - The Song



Healthcare Healthcare Everywhere                     by Pat Jonas, MD

Chicken Pox, Vioxx and Goldilocks- Healthcare Just for you
A shot, a drug and a fairy tale, it’s just like a zoo
And if you have insurance, you won’t pay the bill
Just go into CVS, you can get your fill

CHORUS:
     Healthcare, healthcare everywhere, more than what we need
     Cat scans, ER’s, MRI’s, Chemo used like tea
     More is better, “Let’s be sure”, “You’re a friend of mine.”
     Let me see your wrist ID to bill you one more time.

Barcode reader in my hand leads to good health care
Patients lying in the bed will notice that I’m there
“Yes! A nurse someone who cares, perhaps I won’t be killed”
“OK, I can hear your cares, after you’ve been billed”

Family Doctor, what is that? Someone we don’t need.
ER, that’s the place to go when I start to bleed
Just bill my insurance, please, for more and more health care
Co-pay’s all I need to pay for everything that’s there.


I recently gave a talk titled "Chicken Pox, Vioxx and Goldilocks:  Avoiding Avoidable Care" at the Institute of Holistic Leadership Annual Symposium (see previous blog post with that title).  Included was this song which we sang together.  Just a spoof on some aspects of healthcare.  The tune is similar to the Mr. Clean song (but not quite).  Enjoy.

Friday, November 21, 2014

Family Medicine: Compassion Equals Vulnerability

"Long term relationships lead to a build-up of particular knowledge about patients, much of it at the tacit level.  Because caring for patients is about attention to detail, this knowledge of particulars is of great value when it comes to care....On the whole, our tendency to think in terms of individual patients more than abstractions is a strength...but can make it difficult for us to feel comfortable in the modern academic milieu, where diagnosis and management are more usually seen in generalizations than particulars.  The risk of living too much in a world of generalizations and abstractions is detachment from the patients experience and a lack of feeling for his suffering."
The ideal for all physicians is an integration of the two kinds of knowledge: an ability to see the universal in the particular.
     The most significant difference between family medicine and most other clinical disciplines is that it transcends the mind/body division that runs through medicine like a geological fault line". ...Ian McWhinney, A Textbook of Family Medicine

I love that last sentence more every time I read it.  But it is also sad that most of the rest of medicine employs, as Dr McWhinney notes:  "a clinical method that excludes attention to the emotions as an essential feature of diagnosis and management.  Another is the neglect in medical education of the emotional development of physicians."

Important to Family Physicians is compassion.  We care enough to hurt.  When we hurt for our patients or our relationship with them, we show our vulnerability as humans.
Compassion = Vulnerability.
When we celebrate with our patients, our enjoyment can equal our caring.
Enjoyment= Caring.

It's fun to transcend the mind/ body fault line and be a Family Physician, vulnerable and caring..

What do you think?

Wednesday, November 19, 2014

Family Medicine: Life is Not Medical, It's Human

So many initiatives make up the current healthcare transformation.  Many are fad-like IT adventures that appear exciting on the surface but detract from health care, especially as it applies to individuals.  The life of the individual is being sucked into a medical abyss by some of these initiatives such as "Meaningful Use"  which measures "measurables" and calls them "quality".  These initiatives are billed as vital and may lead to bonuses for physicians (or their employer) or labels for patients as "non-compliant".  Overall, they are leading to the Medicalization of life and a denial of the Humanity of life.

Is life just Medical?  Are we Human Beings or Medical Beings?  Is managing cholesterol the essence of Family Medicine?  Is a good Hemoglobin A1c the measure of the patient-physician relationship?  As Peggy Lee once sang, "Is that all there is?"

The Direct Primary Care DPC) movement says, "No!"  There is more.  There is the power of the patient-physician relationship to validate the humanity of both patient and physician while identifying and treating medical conditions.  There is the shared wisdom of patients and physicians that clarifies the meaning of the illness and the beauty of life.  DPC offers new freedoms and challenges to Family Physicians via more time with patients and family. The time factor allows for richer differential diagnoses and clinical decision making.  It also allows for a deeper understanding of what it means to be human.  It's not perfect and it's definitely not for everyone.
What do you think?

Friday, November 14, 2014

Direct Primary Care Informational Session Dayton, Ohio

Family Physicians, General Internists, Pediatricians and Med/Peds Primary Care Physicians and Primary Care Nurse Practitioners and Physician Assistants:

Monday November 17, 2014 at 7:30 PM in the offices of Family Health Connections, Inc at 2633 Commons Blvd Suite 120 in Beavercreek, OH:   Get the latest information about Direct Primary Care.

Sponsored by the Center for Innovation in Family and Community Health (CIFCH).

RSVP to 937-427-7540 (Medical office of Dr Jonas, President of CIFCH).

Is Direct Primary Care the business model to assure your career satisfaction in Family Medicine, Internal Medicine or Pediatrics (or Med/Peds)?

Check it out Monday November 17th.  You may be surprised to know that practicing medicine can be fun again.

Wednesday, November 12, 2014

Family Medicine: Loyalty

I noticed a loyalty rating of physicians in some hospital literature recently.  I cringed.  My patients came to mind when I read the word loyalty.  I am loyal to them.  They are loyal to me.  (OK, it isn't perfect loyalty, but often it is "Til death do us part").

I have no similar category for hospitals.  Some might say they are generic marketing units, with the "best practices" (me-too sales pitch of the week) noted in their marketing pitch in such a way that one might think they actually had an original "service line" or product idea.  I've not seen recent evidence of their inclusion of my specialty, Family Medicine, in any of their "best practices" or product lines.

When Ohio eliminated the corporate practice of medicine act, thus allowing non-physicians to employ physicians, the medical profession became mis-directed toward not being a profession any longer.  A profession is allowed to exist by the citizenry through our legislature if the profession agrees to police its own member and enforce its own ethical code.  With the shameless enabling of the bankruptcy of millions of Americans through unnecessary and over priced practices, we have bailed out as a profession.  Is our loyalty shifting to hospitals?

I am a member of the American Medical Association.  Here are the Principles of Medical Ethics from the AMA for members:

Principles of Medical Ethics

Preamble

The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

Principles of medical ethics

I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
V. A physician shall CONTINUE to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
IX. A physician shall support access to medical care for all people.
Adopted June 1957; revised June 1980; revised June 2001.

The principles of Medical Ethics simplified:  There are four basic principles of medical ethics. Each addresses a value that arises in interactions between providers and patients. The principles address the issue of fairness, honesty, and respect for fellow human beings.
  • Autonomy: People have the right to control what happens to their bodies. This principle simply means that an informed, competent adult patient can refuse or accept treatments, drugs, and surgeries according to their wishes. People have the right to control what happens to their bodies because they are free and rational. And these decisions must be respected by everyone, even if those decisions aren’t in the best interest of the patient.
  • Beneficence: All healthcare providers must strive to improve their patient’s health, to do the most good for the patient in every situation. But what is good for one patient may not be good for another, so each situation should be considered individually. And other values that might conflict with beneficence may need to be considered.
  • Nonmaleficence: “First, do no harm” is the bedrock of medical ethics. In every situation, healthcare providers should avoid causing harm to their patients. You should also be aware of the doctrine of double effect, where a treatment intended for good unintentionally causes harm. This doctrine helps you make difficult decisions about whether actions with double effects can be undertaken.
  • Justice: The fourth principle demands that you should try to be as fair as possible when offering treatments to patients and allocating scarce medical resources. You should be able to justify your actions in every situation.
            from Medical Ethics for Dummies by Runzheimer and Johnson

With increasing evidence of loyalty to hospitals instead of patients, we have to refresh our professional insights and realign with our patients.  Our approach to clinical guidelines leans away from autonomy toward "Bonus- Based Medicine".  "First do no harm" doesn't align well with all the CT Scans we're administering (80 million 3 years ago) that will contribute to 29-30 thousand cancers annually soon.  Etc., Etc.

Is there a way out of our disastrous mis-direction as a (pseudo)- profession?

I'm a bit old fashioned and my loyalty is with my patients.

What do you think?


Tuesday, November 11, 2014

How to Thank a Veteran: Do Your Duty

 How do you thank a Veteran?  We reflect on this more and more these days.  It seems that the whole nation has a sense of gratitude for our service.
One message of our service is that we had a sense of duty.  Duty- doing what we ought to do.  It's a simple concept, sometimes exacting a high price.  What ought we to do?
In military service, we may get a more direct opportunity (or many) to answer this question.
On one end of the spectrum is the cold answer:  Kill someone if necessary.  Another is to risk one's life for a comrade in arms, or a civilian, or a town. Sometimes, the choices overlap, sometimes they conflict.

I'm a Vietnam Veteran.  We had a confused mission at times.  Enable the South Vietnamese to defend themselves and become independent of North Vietnam- easy to understand.  Kill as many enemy as possible to get high body counts as a "quality" measure of warfare- harder to adjust to becoming a killer just for quality control.

Harder still if ordered to kill innocent bystanders by a confused commander, which happened at My Lai, a dark incident which cost many Vietnamese their lives and a few Army leaders their careers.  A helicopter pilot, Hugh Thompson,  saw what was happening and put himself and his helicopter between the "killers" and the "victims", risking his life to do what seemed right.  Military troops sometimes get in these situations suddenly and act quickly.  The rest is history.  Duty.

Many veterans refused to follow illegal commands in Vietnam.  Many followed the illegal orders.  Many careers ended suddenly.  The military duty seemed to conflict with the Human Duty.  What is right? Judgments over the years allow those individuals and situations to be clarified.  Some people have peace of mind because they did their Human Duty when confronted with the opportunity.  Duty calls our humanity to attention and to action.

Veterans often have stories to share of others doing their duty.  The stories don't include music in the background to make them more dramatic like many of the war movies.  .They tell of human decisions under duress.  The characters had flaws.  The situation wasn't clear, but the decision was.

You have opportunities to do your duty.  Honor a Veteran on  Veteran's Day by doing your Human Duty. Do what you ought to do.  Yes, align with your conscience.  Yes, it may mean quitting your job.  Sometimes that's the right thing to do.  If doing your job means harming people personally or financially, maybe it's time to quit.  God will know.

Thank a Veteran by Doing Your Duty!

Friday, November 7, 2014

Neighborly Family Medicine Now Open for Direct Family Medicine Patients


Neighborly Family Medicine
A. Patrick Jonas, MD
Rebecca T. Cherry, MD
@ Family Health Connections, Inc.
2633 Commons Boulevard, Suite 120
Beavercreek, Ohio 45431
937-427-7540


Direct Family Medicine is our version of Direct Primary Care (DPC), a popular business model for practice.  This is not insurance. It is medical care from Dr.'s Jonas and Cherry, both graduates of Ohio State University College of Medicine and board certified in Family Medicine.

We are Family Fanatics!  Families ONLY can sign up:
You must agree to sign up the whole family (household)
and pay the enrollment fee for the whole family at your first visit.
There are monthly fees that are due at the end of each month.  Families may disenroll with written notice after three months of membership.  If they return, another enrollment fee will be charged.
There is a visit copay which is due at each visit.   Our basic fees do not include laboratory tests which are charged at a discounted rate for most common tests.  Immunizations are separate charges.  Imaging fees are the patient's responsibility but discounted fees are available.  Money doesn't sound very warm sometimes, but Neighborly Family Medicine is warm hearted.

If you have Tricare, Medicare, ANY type of Medicaid (Caresource, Molina, Buckeye, UHC medicaid, etc.) or any other government-sponsored insurance, you are NOT eligible.

We expect that patients will find a catastrophic health insurance plan to cover their emergency, hospital, cancer and other more expensive aspects of their medical care.  Many uninsured patients won't have that luxury and we'll try to help them find affordable care as possible.  The health care system is changing rapidly and we're convinced that Direct Family Medicine is a better business model for Family Doctors.

We provide Basic Family Medical Care:
Acute Problems
Chronic Conditions and Diseases
Prevention/Physicals
Traditional After Hours On Call Physician Coverage


Costs:                       Adults     Children 2-17     Infants 0-2

Enrollment                    $80         $40                 $60
Monthly Membership   $60         $40                 $50
Copay per visit              $20         $20                 $20

If you are interested in applying, you may go to 

DABBLE with Your Holistic Health

I like to DABBLE with holistic health.  Here's a simple outline for you.

Dream   Allow  Become  Become again  Listen  Enjoy



Dream like Goldilocks (that's a good start)

Allow like a great teacher allows their students to succeed/ fail/ learn

Become yourself with honored parts (if awakened by bears, run like Goldilocks)

Become your next (near) whole self again

Enjoy it like the (near) whole you, as your parts allow


As you imagine wholeness and fulfillment in your future, supported by personalized healthcare that aligns with your values, goals and dreams, how content might you feel as you visualize or sense your future self?

What is your dream?
If you wish to have success (as you define it), it may be more readily achieved by:
     Defining your Dream
     Having a Burning Desire to achieve it
     Believing you will reach it

Allow an honest assessment of yourself at regular intervals
     Physically
     Intellectually
     Emotionally
     Spiritually

     In your Living, Learning and Working Contexts (If you like grids, make a 4 x 3 grid giving 12 boxes to reflect on).
     Does your honest assessment yield strengths and needs conducive to actions that better align you with your values, goals and dreams?


Tuesday, November 4, 2014

Vioxx and Trust

Vioxx was a great medication for thousands of people with osteoarthritis.  It was great for pain relief.  Many persons, though got serious side effects.  Heart attacks and strokes.  Here's some of the initial background information:
In VIGOR, a study in 8076 patients (mean age 58; VIOXX (rofecoxib) n=4047,NAPROXEN n=4029) with a median duration of exposure of 9 months, the risk of developing a serious cardiovascular thrombotic event was significantly higher in patients treated with VIOXX (rofecoxib) 50 mg once daily (n=45) as compared to patients treated with NAPROXEN 500 mg twice daily (n=19). In VIGOR, mortality due to cardiovascular thrombotic events (7 vs 6, VIOXX (rofecoxib) vs NAPROXEN, respectively) was similar between the treatment groups. (See CLINICAL STUDIESSpecial StudiesVIGOROther Safety Findings: Cardiovascular Safety.) In a placebo-controlled database derived from 2 studies with a total of 2142 elderly patients (mean age 75; VIOXX (rofecoxib) n=1067, placebo n=1075) with a median duration of exposure of approximately 14 months, the number of patients with serious cardiovascular thrombotic events was 21 vs 35 for patients treated with VIOXX (rofecoxib) 25 mg once daily versus placebo, respectively. In these same 2 placebo-controlled studies, mortality due to cardiovascular thrombotic events was 8 vs 3 for VIOXX (rofecoxib) versus placebo, respectively. The significance of the cardiovascular findings from these 3 studies (VIGOR and 2 placebo-controlled studies) is unknown. Prospective studies specifically designed to compare the incidence of serious CV events in patients taking VIOXX (rofecoxib) versus NSAID comparators or placebo have not been performed.

How did we miss the intensity of the medication's effects beyond the 45 of 4047 patients mentioned above?  45 of 4047 is bad enough, but it was even worse.

We physicians are gullible.  Fifty percent of major medical advances are disproven within five years. We refer to post marketing reports to understand the effects of medications on a broader population than those initially studied.

We lost some patient trust with Vioxx and similar drugs.  How do we get it back?

Monday, November 3, 2014

Chicken Pox

In "the old days", parents expected their children to catch chicken pox.  Everyone got it.  It was not considered to be a big deal.  Starting with red spots, then blisters on the trunk, it could evolve into hundreds of blisters all over the body.  It itched.  It sometimes scarred.  It took several days for the rash to get crusts and be declared, five or six days later, non-contagious (suitable for return to school, church, scout meetings, etc.).  If there were several children in a family, they could get chicken pox sequentially and result in prolonged absence from work by the care-taking parent(s).  Schools might experience a prolonged period of absenteeism as the infection went through the grades.  

The Center for Disease Control has a web page for the public about chicken pox (varicella virus) here and the chicken pox vaccination here.  A more detailed report for health care professionals is here, starting with this paragraph:  "Varicella (chickenpox) is a febrile rash illness resulting from primary infection with the varicella-zoster VIRUS (VZV). Humans are the only source of infection for this virus. Varicella is highly infectious, with secondary infection occurring in 61%-100% of susceptible household contacts.[1-5] Transmission occurs from person to person by direct contact with persons with either varicella or herpes zoster (shingles) lesions or by airborne spread from respiratory secretions or lesions of persons with chickenpox. The incubation period for varicella is 10-21 days, most commonly 14-16 days. Varicella is characterized by a pruritic, maculopapular vesicular rash that evolves into noninfectious dried crusts over a 5- to 6-day period."

So, what's your approach to chicken pox?  The initial vaccine is recommended for one year olds with a booster later per the CDC schedule.  A lot of people just want their child to get the chicken pox "naturally", which is hard to do when the majority get the vaccine, so they wait for them to get exposed.  If they don't get the chicken pox, they may decide to go ahead with the immunization, or they may decide to download a form from the Ohio Department of Health to submit to the school nurse opting out of the vaccination.  Ohio is one of thirteen states that lets parents opt out of any or all immunizations.


The decisions about chicken pox are simple and complex.  We study a lot about infectious diseases, the immune system, immunizations and human behavior to help people with decisions about vaccine preventable diseases. Chicken pox is a good example.


What do you think?





Saturday, November 1, 2014

Patient Enrollment in Direct Family Medicine aka, Direct Primary Care- Family Medicine Style

When figuring our charges for Direct Family Medicine (using the Direct Primary Care business model), we consider the context in which we relate to our patients.  Family Medicine is a relationship based specialty defined by the American Academy of Family Physicians (AAFP) as :  "Family medicine is the medical specialty which provides CONTINUING, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity." (1984) (2010 COD)

The specialty has been cut apart by the current nit picking approach to physician reimbursement that distracts both patient and physician.  The relative value units used to determine billing codes is a key element of the distraction.  The DPC business model, generally anchored by a monthly payment after an enrollment fee, frees patient and physician from many distractions related to the RVU's and the Electronic Medical Record. The focus of clinical encounters is dependent on the relationship of patient and physician instead of physician and reimbursement rules, EMR and employer.  The patient doesn't have to be concerned about their insurance company preventing them from acting on the plan agreed to with the physician.

OK, you may be sensing less clutter in the office visit.  In fact, the office visit doesn't have to be the center of the activity.  Without the focus on  RVU's and traditional coding and billing, the office may be omitted from being the venue where we solve many problems.  Many follow-up visits may be accomplished online, or on the phone or via home visits.  With fewer patients, more time and less office "lock", more home visits may fit in.

The enrollment fee allows the physician to have some front money to prepare for patients and to offset the Ohio end of the month mandate for the monthly membership charge.  They cannot prepay or we would be seen as an insurance company and arrested for not following the Ohio rules.  Each state has the potential for making similar unusual rules that may stifle this business model.

What if patients enroll and never pay the monthly fee at the end of the month?  Or only pay for one month and never show up again or pay again?  We require a three month initial enrollment to get the relationship established and to guard against doctor shoppers or people who may not appreciate the value of Family Medicine and the patient- physician relationship.  If the patient drops out after the initial enrollment, we figure that they gave it a good try and it just didn't work out.  If they re- enroll, they are charged the enrollment fee again and signed up for a minimum of three months.  They are allowed to drop out and re-enroll twice unless there are unusual circumstances (such as, they moved and came back).

Another twist for our practice, Neighborly Family Medicine, is that we take "Families Only" as patients. That means the whole household has to enroll as patients or we con't take any or them (I've done this for 34 years- it works well).  It also means they'll be paying enrollment fees for multiple persons.

To make this process smoother, we have a member management platform company that allows online enrollment for Neighborly Family Medicine.  Patients can read about Direct Family Medicine and our philosophy of care and various practice policies on the site at www.Hint.com and apply with their information and credit card number.  Yes they apply and we review their information to clarify that they actually qualify for our Direct Family Medicine path.  It detracts slightly from the beauty of this process when we have to review their information before accepting them.

We're a hybrid practice with about 2500 "traditional" patients from all sorts of insurances and government plans that preclude us offering this path to them so we have our original Family Health Connections, Inc. practice that houses them (but with the same tax ID number as Neighborly Family Medicine).  Insurance rules and contracts combined with our current confusion about Direct Primary Care type payment strategies make it challenging to do something that enhances healthcare and the patient- physician relationship.

So, there you have a bit of information about one DPC hybrid practice: Family Health Connections, Inc. and Neighborly Family Medicine and our enrollment process.

What do you think?