Tuesday, December 28, 2010

Family Medicine: Grief, Loss and Death at Christmas

"All mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated...As therefore the bell that rings to a sermon, calls not upon the preacher only, but upon the congregation to come: so this bell calls us all: but how much more me, who am brought so near the door by this sickness....No man is an island, entire of itself...any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."  ....John Donne, Meditation XVII

"Are you willing to sign the death certificate on ________?," the county coroner's representative asked me a week or two before and again a few days after Christmas, during one December.  They need to know if the patient had a medical condition that could be lethal under certain circumstances, or do they have to consider making the death a coroner's case.  I reflect in my mind on the conversation I had with the emergency physician about my patient who had a respiratory infection that suddenly overwhelmed the lungs, weakened by chronic disease, leading to respiratory failure.  Their efforts to revive my patient were unsuccessful and I felt empty, reflecting on a ten plus year relationship with a unique person and their family.  Three generations of the family are patients of mine, too.  The same is true of the person who died a few days after Christmas, both having children and grandchildren who have a relationship with me and my family medical practice.

Loss is difficult for families at any time, but often seems to hit harder at Christmas time.  I frequently see patients in December who can't wait for "the holidays" to end.  They lament the loss of their grandmother, mother, father, grandfather, child, favorite aunt, sister, brother, etc. which overwhelms their senses during the anniversary day, week or month.  The grief often is prolonged for years, generally not generating a focused attempt to integrate it into their "in fond memory" files.  It may even get the mental status of a post traumatic stress syndrome (PTSD) person with lingering emotional pain instead of positive life lessons.  I know their pain is a legitimate situation in their life.

Some of the most difficult situations with Christmas Grief come with multiple losses over the years near Christmas that get "stacked" into one grief reaction.  Individual losses may become tolerable as time passes and the patient reflects on the meaning of the deceased person's life, but stacked grief puts several grief reactions into one inseparable pile, making the grief less likely to be resolved.

In these situations of stacked grief, when the patient has enough energy to deal with grief, I ask them to list the losses and schedule times on their calendar when they will grieve each individual loss, as their brain and heart allows.  "Get the grief off your head, where it sits like an anvil, and put it into your calendar", I suggest, in an attempt to make the grief more understandable for the individual.  "Calendaring" the losses frees the patient from continuous grief, giving them freedom to live their life when not in a scheduled grief appointment with themselves.  Separating the grief reactions may allow resolution of some grief while pointing out areas where special counseling might help.

Pathologic grief often requires the help of counseling professionals (including clergy) to effect the best outcome.  Many grievers, however, put off recommended counseling for years, sometimes stating that it would dishonor the deceased if they didn't feel miserable.  The suicide of a child, spouse or parent comes to mind as the intense type of grief that requires special skills and lots of time.  Sometimes the brain just blows the facts of the loss into separate brain areas, preventing the whole story from being mentally reconstructed until there is enough life energy to handle it.  Soldiers with PTSD are a special group who provided counselors and physicians with broader insights into how the brain protected itself from intolerable mental anguish.

Physicians grieve for patients, both living and deceased, at times and places away from usual patient care.  The professional "auto-pilot" may turn on to get through a loss situation to finish "the work" before processing the grief.  We must also schedule the grief for a specific time in the calendar to avoid "Non-Grief", which could be detrimental to our patients and ourselves.  This also includes Christmas Grief of and by the physician, professionally and personally.

We all share the same humanity and seek peace in our lives.  We periodically should again reflect on the words of John Donne as a reminder:
 "No man is an island, entire of itself...any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."

Wednesday, December 22, 2010

Family Medicine: Influential with Patients, Hospitals and Employers- Let's Talk!

"You are a scarce, valuable resource," I told my colleague about 20 years ago when he felt rejected by the local hospital when bumped out of the practice he had served since proudly joining the family physician who had delivered him and cared for his family.  He was inspired by the man who had served the community so well, eventually for over fifty years, and became a family doctor, just like his role model and mentor.  Now, he saw the practice, in the neighborhood where he grew up, that he inherited at his mentor's retirement and merged into the hospital network to help with recruitment and management, redirected away from his philosophy of care toward hospital corporate values.  What happened?  Why did they close the office and order him to take the patients and practice where another recently trained family physician had been placed in practice two years ago in another retired physician's office in another neighborhood?

Hospital administrators think differently than physicians.  Family physicians may even think differently than many other physicians.  We care about our patients and their well-being.  We haven't taken the time to verify our thought processes and our differences with hospital managers and other physicians.  We need to clarify our similarities and differences now, though.  We have to find our areas of mutual interest and mutual misalignment.  We have to agree to disagree on many issues because of differing philosophies and business models.  A creative tension between family physicians and hospital leadership benefits patients and the local economy.

Hospitals need to fill beds, CT scanners and cardiac cath labs.  Patients don't want to fill them unless there is a clear need.  If there are excessive medical resources such as CT scanners and cath labs, there will be a push to fill them by changing decision thresholds to use them.  The creative tension between family physicians and hospital leaders can serve to find a balance in use of resources.  As the family physician becomes a more scarce, valuable resource, their influence in hospitals is needed even if their presence is diminished.  We are one of the keys to decreasing re-admissions of patients.  We are key influencers of how our patients use health care resources, e.g. which hospital they relate to and where they go for physical therapy.  We are key translators of healthcare system intentions to our patients.  We are important communicators with small employers and some large employers in communities.  We are trusted.

Let's get some better communication going between family physicians, hospitals and employers.  It will better serve our patients and communities.

Monday, December 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 need it most.  ...A preoccupation with a disease instead of a person is detrimental to good medicine....Any physician who looks upon a sick patient as an exercise in diagnosis or treatment is not a complete physician....it is tempting for a physician to rely too heavily on his science."...G. Gayle Stephens, MD in The Intellectual Basis of Family Practice (1982)

Clinical knowledge and skills require continuous learning and practice by physicians, including frequent upgrades of clinical science.  Patients assume that we know a lot of science and medical facts.  Still, that leaves us incomplete as physicians.   The interface of physician and patient is a dynamic human engagement with elements beyond the two primary persons and their momentary roles that seek to effect a mutually beneficial outcome.  I have written before about clinical decision making in the family medicine office as a shared endeavor in which patient and physician explore, reach a level of understanding and act on a plan.

The patient has unique insights about their illness and life context (often including biological and medical knowledge) while the physician has unique insights about human biology, diseases, conditions, therapies and medical situations.  Education, experience and the internet seem to better prepare patients for clinical situations and environments.  Many physicians believe that it's more satisfying to care for patients who have information access and motivation.  Many others clinicians fear informed patients because they may feel threatened or have to vary their work flow to accommodate the (usual) extra information sharing.

Sometimes, the physician may hide behind their "white coat" to pressure the patient with important and/ or costly recommendations, leaving the patient little negotiating room.  Many physicians are trained to withhold information from the patients, who don't understand Bayes' Theorem or p-values in clinical studies because it would only confuse them.  They become coercive in pressuring patients to accept diagnostic testing or therapies that they don't adequately explain to patients.  They don't really inquire about patient values that would drive the decision in a direction other than the one chosen by the physician.  How could the patient understand the complexity of our clinical decision?

How can physicians better understand the complexity of the "illness" for the patient?  How can either communicate effectively with the other, and with themselves, in the work context where medicine lives and patients seek healing?  I still believe that it starts with two humans, equal in their humanity and their respective quests for meaning.  The mutual respect for each others humanity anchors the dyad at the starting line of health care quality and precludes the participants from "using" each other.

Disease oriented medical literature assumes a valueless patient initially for the purposes of learning.  Behavioral aspects of patient care are seen as less important.  So patient values aren't subjected to statistical analysis.

A model that often helps me in Family Medicine is "Get, Give, Merge and Go", developed by Carkhuff Associates in Amherst, MA and published by Human Resource Development Press, also in Amherst.  The Patient and Physician both use the same model, as indicated.  First "Get" the other person's perspective on what they think is happening (referring to other posts about the HCHH, this could include a SPIT differential diagnosis or Biopsychosocial analysis at least by the physician and possibly by both).  Then "Give" your perspective.  Next, seek to "Merge" the two perspectives, integrating aspects of both parties insights into the analysis after engaging and clarifying.  Lastly "Go" ahead with the mutually agreed to plan.

What do you do if the two parties can't seem to agree?  Dr. Carkhuff published a book in 2010 (Saving America) introducing:  "Get, Give and Grow".  Keep learning and growing until the "Merge" element might occur, leading to a mutually agreed "Go" step.  Examples of the place to use this model include patients and/or physicians with strongly held beliefs about immunizations or opiates.  These can be challenging discussions, but family physicians and their patients need to commit to "Getting and Giving".  The mutual human respect will allow the dyad to have a better chance to "Go".

Wednesday, December 15, 2010

Family Medicine: Hospital Staff Holiday Parties, Diminished Family Medicine Presence and Bananas Foster

Around Christmas time, hospital medical staffs have Holiday Gatherings to hold the quarterly medical staff meeting and celebrate with a lavish dinner, music and pleasant comaraderie.  Each physician or non-physician member of the medical staff is invited to bring a guest to share in the celebration after the meeting.  The exact format varies from medical staff to medical staff.  I belong to two hospital medical staffs in one hospital network.  I enjoy the Holiday Parties.  I'm curious about what's happening with the physicians and the system.

This year, for the Holiday Party, the big community hospital rented the main level of a performing arts center downtown in the major city nearest the hospital.  Hundreds of physicians, spouses and significant others and hospital leadership gathered in a grand "eatathon" and brief medical staff meeting.  The chocolate fountain was a hit, but many missed the Bananas Foster that was a tradition at the smaller venue of previous holiday meetings.  The Indian food was wonderfully spicy but the music was too loud for casual conversation within about 90 feet of the entertainment (forcing some to eat more to remain sociable).

Near the salad bar, I conversed with a cardiothoracic surgeon about a shared patient who  had a difficult situation.  He was worried about her and the complex decision process that faced her.  I offered to help in the clarification session to aid in patient understanding.  I picked a seat at an empty table where a plastic surgeon joined us for conversation.  He is in private practice and proud of his certified operating room where he can do plastic surgery without a hospital.

The chief of staff announced the retirement of a general internist who had practiced in the area and admitted to the hospital for 45 1/2 years.  Wow!  How many thousands of patients must he have served.  I felt humble.  While later walking around the performing arts center to find a less noisy location to be able to hold a conversation with a friend about our family, another physician greeted me and stated that he was closing his endocrinology practice in 4 months.  He thanked me for referrals over the years.  A greeting to a medical school classmate and polite,"What are you up to these days?"  brought the response, "A lot, we just sold our practice to this hospital network, who out bid the competition."

Retirements and selling practices in bidding wars caught my attention.  There is movement in the system.  People are jockeying for position.  How do you hedge your bets?  How do you best serve your patients?

One day later, my wife and I attended the small community hospital Holiday Medical Staff Meeting.  We voted for staff leaders before the meeting.  All candidates ran unopposed and were announced as winners later during the meeting.  A brief slide show showed the progress with the new hospital next door to my office.  Enthusiasm bubbled through the room.  The food was great (pecan crusted walleye and sushi were unique items).  The dessert included the Bananas Foster and the same chocolate fountain as the previous evening.

Conversations with an urgent care medical director who trained in family medicine and another family physician who has a huge practice both centered on family medicine workforce development.  Who is going to see all these patients?  More and more are showing up at the urgent care with no family physician.  Many are from practices recently vacated by the 5 1/2 family physicians who left our county in the last 19 months.

The hospital network trains physicians, including cardiology fellows to help with the new heart hospital they just opened, but none in primary care, so they have no way to replace these physicians unless they come from elsewhere.  To make matters worse, the flagship hospital of the competing hospital system which just opened a new heart hospital tower, closed and bulldozed their family medicine training center, so they train no family physicians.  The Osteopathic hospital in town still has a small family medicine training program as does another community hospital in the northwest area of the city.  That hospital acquired a heart hospital  in 2008, so we now have three heart hospitals in case anyone didn't notice.  The biggest family medicine training hospital in the area closed over ten years ago, eliminating twelve new family physician graduates yearly.  Is this area turning into a cardiology over-served and family medicine under-served area?  Who pays attention to the primary care needs of this area?

Conversations with three independent practice physicians who are generalists resonated with some concern about their relationship with the new hospital, since other groups may show up and compete for patients.  Many are concerned about the big groups being bought by the hospitals.  "How can we compete with hospital owned groups?" they wonder.

Holiday Parties enable relationship enhancement and have information and food ups and downs, sometimes with Bananas foster (it was delicious).

Monday, December 13, 2010

Family Medicine: Fun, Facts, Reality and Challenge

Fun:  Five year old children are delightful.  Spongelike learners, they are very engaging and cooperative, except when confronted by the need for the three injections to be fully immunized before entering kindergarten.  If their parents wish, the child can get them when they're four and easier to restrain (yes, restrain, with the help of the parent holding hands or legs).  Neither four or five year old is happy for the opportunity to be immunized.  They are delightful again at the next clinical encounter, having already clarified with their parent that shots are not part of this visit.

Facts:  Flu shots were slightly more popular this year than last year, even without any pandemic concerns.  People seem relieved to know that the H1N1 protection is included.  Many get them at pharmacies when filling one of the prescriptions for a chronic disease.  It's one sign of the times that many health care prevention services will be provided away from physician offices.  Pharmacies want to become the patient's primary care provider.  I have a problem with that concept.  They also sell cigarettes a few feet from where they provide health care services.  I have a problem with the duplicity of health and sickness being sold together.

Reality:  People are getting older, along with their doctor.  More knee, back and neck pain.  I see five or six people per week with a pinched nerve in the neck or back.  One or two per month get surgery when the medicine and physical therapy don't provide relief and the subsequent MRI shows nerve root encroachment or a herniated disc. It then takes them another three to six months to fully recover. 

Challenge:  Every two years, someone continues with low back pain, after having disc surgery, which remains severe.  In these patients, there is always a family history of other family members with brain problems that may include, depression, intractable pain and/or chemical dependency (alcohol or opiates).  Their brain has a dysregulated pain management system and things often hurt more than in most other people.  That's just how their brain is, they didn't make it up or intend it to be that way. 

We may have these folks on medication such as Vicodin, Percocet, Morphine, or Oxycontin plus a base of Ibuprofen, often combined with Trazadone, Neurontin and maybe Zoloft or Celexa for more brain support.  They also get ongoing physical therapy, if helpful and, if there is an injection potential, I encourage them to see a pain specialist for the injections.  I do not have the pain specialist manage the monthly medication prescriptions and ongoing evaluation and management of the patient.  They have focused training in procedures that are very focused and costly, which they do well when needed.  They don't deliver continuous comprehensive care, which is what my patients need.

We ride the waves with these people who have intractable pain with some intense misery at times, especially  when their brain seems to be "stealing" their opiates from the site of their pain.  This tells me we may need more opiates briefly and intense focus on extra therapies that may convince the brain that it doesn't need to steal the opiates.  Each patient is uniquely different, requiring a personalized treatment strategy.  Some have intense fear of the pain flare ups and we address the fear and may medicate it, if the Trazadone, Neurontin and Celexa haven't reduced it or prevented it.  Suboxone may replace the opiates later when the pain and brain aren't going the right way chemically.  Some also benefit from extra counseling support from a psychotherapist or their clergy.  Faith and religion are almost always a big factor in how our patients cope with chronic pain.  Family support is another important part of coping.
Winter Facts:  Winter weather changes  the behavior of people.  In fact, in Ohio each season has specific health risks, both positive and negative.  Vitamin D3 deficiency is rampant in winter, causing many to feel blah, down or even depressed.  Snow and ice generate more caution with travel and walking outside.  We see increased fractures of the hip and the humerus (upper arm) caused by senior citizen falls.

All these phenomena and more are components of Family Medicine, a relationship based medical specialty not limited by organ systems or pathological processes.  I still love it!

FMEC, Inc. Meeting and Hershey, PA October, 2010

Saturday, December 11, 2010

Family Medicine: I Love It

I love being a Family Physician.  My mirror agrees.  It is an amazing privilege to get to hear people's stories about their lives, families, careers, struggles, goals and dreams.  Over 150,000 patient encounters later, I'm convinced that people matter and they care for each other.  Their resilience is impressive.

Sometimes they need a little help to clarify where they're headed, especially when they're lying on the exam table moaning with pain of one sort or another.  If they can't sit up it's about 50-50 that they need a hospital and 50-50 they have a significant mental health problem.  (Just an observation over the years).  There's a high probability that they need an injectable medication if they can't sit up, maybe Toradol, Penicillin, Rocephin and /or Phenergan.

People will let the family physician know who is drinking again, if given the opportunity.  Sometimes, the offender is a person who was in my office recently singing the praises at how much money he's (almost always a he) now saving by not drinking anymore.  The truth filter comes up for the physician to try to clarify who's "truthing" the most.   Over the years, I've come to realize that the alcoholic is lying to themselves more than me.  They start to believe the lie and feel that it's true.  So when they tell it to me, they feel truthful. In the alcohol treatment health professions, they have a saying,"If their lips are moving, they're lying."

People care about each other in families.  Our practice focuses on families, so we only take families as patients, like the whole household or none of them.  Family members often come in together in twos, threes and fours.  They will share information and concerns about one another with the family doctor.  Sometimes they can't figure out what to say in front of the designated patient so they call in a message to the doctor before the visit, listing their concerns.  This happens most often with cognitive decline, alcoholism and chemical abuse in our practice.  The caller is trying to help in the best way that fits with their comfort and communication style.

People have more special requests near the end of the year.  Most are insured and may require information for the IRS to get their tax deducations.  They may need renewals of special apparatus prescriptions, such as their breathing equipment or C-PAP for sleep apnea equipment.  They want to know which insurance companies are still OK, to explore for their health insurance annual decision and why we're concerned about insurance company X as indicated by the sign in every exam room and the waiting room.  "Should we switch insurance companies now?", they ask if they are covered by that plan. It's hard to tell, I answer, but this company suddenly eliminated a dozen or so family physicians from their plan as providers in mid-plan year in another Ohio city, severing the physician-patient relationship for many senior citizens.  That concerns us a lot.

Christmas is meaningful for most of our patients, who reside in suburban cities and towns where unemployment is over 10%.  They have to watch their money closely since the next job lost might be theirs.  In spite of that, they have optimism about Christmas for themselves and their families.  Less money means less shopping and more togetherness with family and friends.  The non-Christians are comfortable with the mention about Christmas by other patients from their community.  In our local communities, the people seem to respect each others religious preferences. 

Another aspect of family medicine in the winter is infection such as viruses, strep throat and influenza.  We see infected persons daily and notice that the meaning of their illnesses vary from person to person.  One sick person with strep throat might need to be well the next day for a college final exam, while another is pleased to get a couple days off in an isolated room from family.  It's satisfying to help people understand the meaning of their illness and to validate them as people who matter.

Each day in Family Medicine is a unique one with well and ill people wanting to optimize their health while minimizing their expenditures.  I love it!

Tuesday, December 7, 2010

Connecting as Humans First; Then as Patients and Doctors. Doc U R Fat: Insulin Resistance

The Dr Synonymous Show December 7, 2010  BlogTalkradio.com/DrSynonymous
"Connecting as Humans First; then as Patients and Doctors.  Doc U R Fat:  Insulin Resistance"

Introduction/ Disclaimer
Tribute to Pearl Harbor and WWII

Patient Blog:Since I've Been Gone by Stephanie
Medical Student Blog  http://futureoffamilymedicine.blogspot.com

New Blog from Jennifer Middleton, MD:  The Singing Pen of Dr Jen

Physician Blog Post AFP Community Journal: Kenny Lin, MD: Close-Ups Bringing Patient Perspective to AFP

Dr Synonymous Blog Posts 11/22 Human Centered Health Home (HCHH) Detecting Alignment or Misalignment & 11/30 Human Centered Health Home: Biopsychosocial Model
12/03 at drsynonymous.blogspot.com

Clinical Focus:  Insulin Resistance
Healthy for Life by Ray Strand, MD
Syndrome X by Challem, Berkson and Smith
The Glycemic-Load Diet by Rob Thompson, MD
Combat Syndrome X, Y and Z by Stephen Holt, MD
Perspectives in Nutrition by Wardlaw and Hampl

Next Show 12/14/2010

Friday, December 3, 2010

Personal Health: "We're Not Here to Hurt You" ...Dr. P., my oral surgeon

"Ouch", I thought as a sudden, intense, but familiar pain struck my tooth.  A throbbing, rhythmic classic toothache was dancing with my favorite molar, the one on the lower left (later named as #18 by my dentist) that had a fracture and a root canal in 2008.  The same favorite molar is the posterior anchor to my bridge which acts as a memorial to the adult tooth that was congenitally absent, becoming a "no-show" when the "baby tooth" graduated to a valuable spot under my childhood pillow and then to the tooth fairy, who always left some money.

A throbbing night with tooth pain, buffered by Aleve and acetaminophen, inspired me to call my dentist's office.  Laura at "Dr. Mike's" office was caring and professional in getting me an appointment 4 hours later, during which the x-ray showed a radiolucency.  Dr. M. examined the area and the x-ray before determining that I had an infection in  precarious proximity to the aforementioned molar #18.  He prescribed an antibiotic and recommended evaluation by an endodontist for potential tooth-saving surgery.

Three days and several aches later (sometimes treated with the addition of topical brandy which had a numbing effect late at night when it throbbed the most), Dr S, the endodontist whom I'd seen for a root canal 14 years ago, smiled as he greeted me enthusiastically.  He had reviewed the history taken by his dental assistant and the x-ray she took.  He proceeded to examine my mouth and the tooth with it's swollen gummy home.  "Look at that, Jennifer!" he exclaimed, wishing to show her something horrific (so thinks the patient who definitely doesn't want to impress any dental professionals with his pathology).  I started to have a grief reaction silently for my tooth.

He drew a picture to show why the tooth needed the grief reaction. Cracked Tooth Syndrome causes gum separation from the tooth allowing my saliva to percolate down where it causes infection leading to tooth extraction, which I needed soon.  He applauded the quality of the root canal performed by Dr. Mike on the tooth in 2008, reassuring me that it was wonderfully intact and not related to the infection.

As I checked out, the receptionist volunteered to call Dr. Mike's office to find out who he used for extractions (the dentists are narrowing their scope of practice just like us physicians).   I continued to thank my tooth for years of good service while driving to my office where I called Laura and asked what course of action Dr. Mike would recommend.  I heard her enthusiasm for the oral surgeon in the office next door to them.

Laura knew that since I have the bridge, Dr Mike had to "section" (cut) the bridge just before the extraction.  After calls to the favorite and next favorite oral surgeons whose schedules didn't match my need,   I called Laura back and she made a personal contact with Dr. P's office and called me back.  Can you come here at 11:45 to get the bridge sectioned and then go to Dr. P's office at 2 PM?

I had my schedule in my hand and already knew how we could shift patients to the nurse practitioner's schedule that was light today.  "Yes", I said to Laura, and proceeded to see patients until 11:30.  Then off to Dr. Mike's for sectioning the bridge.  "It's Laura's birthday," the office staff at Dr. Mike's happily noted.

Dr P was in his office in the city 23 miles east (not the one next door to Dr. Mike), so GPS for guidance and Wendy's drive through for the 99 cent chili plus a 30 minute nap in my car got me into Dr. P's office at 2 PM.  Dianne efficiently got me to fill in the forms and sign three pages about information transfer and payment, etc.and immediately a dental assistant called me back and into room 4 where I gave a brief history and listened to Christmas music on the overhead speaker.

Dr. P. entered, engaged me about the history and said, "Let's get that numb for the extraction."  He injected me with 3 or 4 chunks of lidocaine and left for several minutes.  I enjoyed "O Holy Night" and a couple other songs while he was gone.

On re-entry, he applied a device to the tooth and leaned.  He heard a moan and noted that my body wasn't touching the dental chair and stated, "We're not here to hurt you.  Let's inject that some more and wait a few minutes."  I appreciated the heck out of that approach.  Many physicians I've seen over the years tend to ignore patient "discomfort", but Dr. P. was not out to hurt people.  God bless you, Dr. P.

Ten minutes later, after Dental Assistant Sidney reaffirmed that I understood the post op instructions about wound care, he was back.  As he securely grabbed the tooth and started to rock back and forth to loosen it, I noticed that "Rockin' Around the Christmas Tree" was playing and I didn't re-experience the pain of the previous attempt.  I got a prescription for Vicoden, an envelope full of gauze squares to press into the hole until the bleeding stopped.  I paid my half of the fee and left.

Then to Wendy's drive through for a small frosty per Sidney's instructions and back to the office to see one patient who refused to see our nurse practitioner.  I mumbled through the gauze as I took the history and examined the patient who didn't share my confidence in our nurse practitioner.  I was still numbed by the extra lidocaine and didn't take the Vicoden until safely back home in my recliner.

Lessons learned or reaffirmed:
If you need to see three dentists in one day, you're going to get some pain and probably lose a tooth.
The primary dentist and his staff know the system and the players, they know how to get things done.
Receptionists make things happen, especially on their birthday.
Family Nurse Practitioners are flexible, valuable members of the health care team.
Teamwork and relationships are really important aspects of health care.
Get an oral surgeon who believes, as Dr P, "We're not here to hurt you." (And thank/honor them)
Don't forget to ask the dentist for your extracted tooth so you can put it under your pillow.
(If I could put it under my pillow, I'd give all money /coupons left by the tooth fairy to Laura, Dr. Mike's receptionist for good work on her birthday.)

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, November 28, 2010

Triple Thanksgiving Poem 2010

Triple Thanksgiving Poem 2010

Thanks, Thanks and Thanks
Family, Family and Family
Nostalgia, Nostalgia and Nostalgia
Turkey, Turkey and Turkey
Food, Food and Food
Football, Football, and Football
Photos, Photos and Photos
Internet Shopping, Internet Shopping and Internet Shopping
More Food, More Food and More food
Christmas Music, Christmas Music and Christmas Music
Exercycle, Exercycle and Exercycle
More Family, More Family and More Family
More Thanks, More Thanks and More Thanks
Amen, Amen and Amen

Monday, November 22, 2010

The Human Centered Health Home (HCHH): Detecting Alignment or Misalignment

“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 Family Medicine

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 Respecting, Connecting, Protecting, Detecting, Correcting and Reflecting.  Other blog posts have introduced and explored the first three.  We’ll focus on Detecting in this post.

What are we detecting and how do we do it? It starts with the patient's chief complaint (CC) or current illness. We’re looking for alignment or misalignment with the patient’s self-defined life goals including physical, intellectual, emotional and spiritual aspects, as needed.  Context is important, too, to “understand the person who is ill”, including the patients living, learning and working worlds.  The past medical, family, and social history of the patient forms part of the context considered in the clinical encounter.  Information about chronic diseases, past hospitalizations, allergies to medications or environmental sensitivities, current medications and nutraceutical use, immunizations and transfusions are located in the medical record by the end of the first or second visit with a physician.  

As we understand what the patient isn’t able to be, do or have as a result of their current illness, we clarify how that deficiency defines their goal. The deficiency also helps both patient and physician to define the meaning of the illness.  We may even engage the patient after exploring their situation with a goal statement that starts with their deficiency and their feeling about it, if necessary.  “You’re feeling ________ because you cannot _________, and you would like to be able to___________.  The goal statement helps the patient move toward resolution, as possible, after engaging the physician with their context and value beliefs.

“You’re feeling worried about your inability to grip the handle of the cooking utensils, threatening loss of your job as a cook and you’d like to get rid of the weakness in your grip before Tuesday when you have to go back to work in Shorty’s Bar and Grill.” That sort of statement personalizes the deficit and the goal and gives insight into possible meaning of the illness or injury.  It also pre-identifies the outcome goal and let's us know when we've succeeded. 

“You’re pleased that your grip is weak, preventing your use of a spatula until next week so you can get home for the holiday weekend and get engaged to your girlfriend.”  Different contexts and goals arise uniquely for each unique individual.  Note that the patient may have goals other than what the clinician may suspect, i.e. not wanting to work or not wanting to play in the big game, etc.

As a result of the above exploration, the physician (and the patient, but maybe with different perspectives) develops a differential diagnosis, listing mentally or in print the potential diagnoses that relate to the chief complaint of the patient.  I tend to us a pneumonic SPIT standing for Serious, Probable, Interesting, Treatable, reminding me of four major categories of possible diagnoses. 

What is serious that could be causing the weakened grip strength of the patient mentioned above? Stroke, Herniated intervertebral disc in the cervical spine, malignancy of the spinal cord may be considered among hundreds of other possibilities.  What is probable, meaning common in my practice for persons with the same symptoms in the age group of the patient. Overuse syndrome, carpal tunnel syndrome are two possibilities.  What is interesting, meaning what is the patients theory as to cause of the chief complaint.  I ask the patient and assembled relatives, if indicated, "What do you think is happening to cause this?"  Their theory is the most important one we're pondering.  If they are right, it's wonderful, indicating good self knowledge and insight.  They might say carpal tunnel syndrome or what they don't want to have, "I'm worried that it might be multiple sclerosis like my mother had." Lastly, treatable implies something we can treat and resolve or control, correlating with our mutual experience.  This might again drive us to think of overuse syndrome or carpal tunnel syndrome (mild, early).

Other models of diagnostic thinking used by family physicians include the biopsychosocial model, the principles of family medicine and the natural history of disease.  All of the interactions, both subjective and objective are recorded in a SOAP note (Subjective, Objective, Assessment and Plan) in the medical record, helping to better focus the patients and physicians as to the deficiency and the goal desired by treating it, if indicated.  We'll expound in other blog posts about these.

Sunday, November 21, 2010

Personal Health: Mirror to Me: "You Are Fat, Olive Juice"

My mirror told me recently that “you are fat”.  A medical mirror would have said,  "you have Insulin Resistance" (Healthy for Life by Ray Strand, MD is my favorite book about this condition, I’ll blog more medically later).  It would never say, "You're Obese", because that isn't medically billable.  It noted the size and contour of my body and compared that to 15 years ago when it first looked at me.  In those days when I looked into the mirror and said, “I love you”, it seemed to say it back to me at the same time.  Now it says, “Olive juice” which looks like, “I love you”, but isn’t.
Losing the love of my mirror, all because of the insulin resistance.  (AKA, “You’re Fat”).  (In case you started to think of Roberta Flack singing “Killing Me Softly with His Song”, I started singing that in my mind as I felt the rhythm of the words “losing the love of my mirror”.)  So what am I doing to get my mirror back? 
My Morning Health Ritual:  Feed cat in kitchen.  Read book while pedaling exercycle for ten minutes (it’s best to start with 5 minutes daily until addicted to exercising, then increase slowly since you’ll do it for the rest of your life.  I disagree with those who would have people start with 30 minutes of anything, including walking briskly, free weights, bicycling, etc.  That tends to get people hurting enough one way or another that they give it up very soon. Folks, get addicted to exercising, then play with slow increases, staying short of injury and pain.). 
The arthritis in my knees causes me to alter the amount of weight bearing exercise I will do.  At a certain body weight, the pain in my right medial meniscus (cartilage) whispers truths similar to my mirror.  Naproxen Sodium 220mg twice daily (with one 81 mg coated aspirin daily) in addition to the fish oil and flax seed plus glucosamine 750mg twice daily helps with inflammation and pain at present, but adds a bit of kidney damage risk (the naproxen) over time.  I’m over my weight limit for the knee and that means I can’t pick up the grandchildren without wincing.  More motivation.  (It’s OK, Natalie and Andrew, Grandpa is unloading some excess body to be able to carry you around your new house at Christmas.)

One “exercycle focused” book I recently finished on the exercycle is Broken by Lisa Jones, a book about the author’s “Journey Toward Redemption on the Wind River Indian Reservation” and featuring Stanford Addison, a Northern Arapaho native American horse trainer with quadriplegia who had unique spiritual and healing insights.  I often pick parts of the Bible for my exercycle reading, speaking of spiritual and healing insights- it’s the best information for me, because it’s always helpful and interesting and I want to read more.  The reading material may be key to some people getting the exercise.

Then I prepare two packets of instant oatmeal mixed with about 1/3 cup Bob’s Red Mill Organic Whole Grain High Fiber Hot Cereal with Flaxseed, (10 grams of fiber and 1000mg omega-3’s)  www.bobsredmill.com and ¼ cup frozen berries, cook in microwave for 1:45 minutes.  While that’s cooking, I drink 12-18 ounces of water and take vitamins, minerals and supplements (see my blog of October 5th and/or listen to October 5th Dr Synonymous Show on Blogtalkradio.com/dr synonymous for a couple vitamin comments, or www.lef.org for massive amounts of vitamin/nutraceutical information).

Next, I enjoy a lemony tasting  one and one-half tablespoons of Carlson Fish Oil www.carlsonlabs.com (a very high dose that I got in the habit of taking when I bought a bottle of orange flavored fish oil that didn’t block out a fishy taste- I’m sort of cheap, so wouldn’t just throw away the product but decided to get rid of it fast and healthy.)  Read The Omega 3 Connection by  Andrew Stoll,MD (a psychiatrist) if you want to know some brain health and body health benefits of Omega 3’s and Barry Sears book, The Omega Rx  Zone: The Miracle of the New High-Dose Fish Oil for more Omega 3 information and tips.)

“Carlson Fish Oil, Omega-3’s DHA & EPA, Great Lemon Taste!  Purity and Potency Guaranteed.  Dietary Supplement.  Vitamin A & D Free.  Each teaspoonful (5 ml) contains 1600 mg Omega-3 Fatty Acids, including EPA (Eicosapentaenoic Acid)  800mg, DHA (Docosahexaenoic Acid) 500 mg and Other Omega-3 Fatty Acids 300 mg.  Contaminant free, tested by FDA-registered lab to be fresh, fully potent and free of detectable levels of mercury, cadmium, lead, PCB’s and 28 other contaminants.  Manufactured and bottled in Norway for J.R. Carlson Laboratories, Inc. Arlington Hts, Illinois .”

I then feed the birds at two feeders that are suspended from a swing frame on our deck with sunflower seeds.  About ten varieties of birds show up from time to time to partake of the sunflower seeds, including finches, cardinals, blue jays, titmouse, woodpeckers and others.  Hummingbirds hover at their feeder that my wife cares for in summer to late September, but that’s not part of my ritual.

After showering, dressing and teeth/hair care, etc. I gather up wallet, keys, cell phone, lap-top in carry all, go into the garage where I feed Buckeye and Shadow, our outdoor dog and cat and load my “stuff” into my 2005 Chrysler mini-van.  I go back inside, hug and kiss my wife (unlike the mirror, she’s not saying “olive juice” yet), get a 12 ounce glass of water to go and an XS Electric Lemon Blast Energy Drink (OK, some may frown on this, but it’s not the alcoholic one and it’s zero sugar and 2 carbs, with 4900% RDA of B12, 300% B6, 100% B3 & B5 and 83 mg caffeine mostly from green tea, sweetened with sucralose, including an “adaptogenic blend” of various ginsengs, Schisandra- I love the sound of that word, uplifting and magical-Astragalus and Reishi).

Last, but not least,  I put on my yellow- tinted sunglasses (my mother got these on sale-as seen on TV-  for my brother and I - they make everything that has color look brighter, which I love- Thanks, Mom) and drive 12 miles cross country and through the suburbs to my medical office.  OK mirror, I’ve started the road to recovery.  A long, long road, way beyond "olive juice".  More later.

Thanks for inspiration from the gifted family doctor writing, Dr Fatty Finds Fitness

Saturday, November 20, 2010

Family Medicine: Could Curious George Be a Family Doctor?

"If you don't have a label,  you don't exist" .. undiagnosed patient with chronic condition.
Persons with some conditions that don't  get a medical diagnosis can feel lost in the Medical Industrial Complex grinder, so they try to avoid it and often enter through the "wrong door".  Starting with their chiropractor, massage therapist or neighbor who is an EMT, they get referred or go from doctor to doctor until they finally might get a pamphlet for a pain management center from someone in the third ED they enter in a two month struggle with "spells", "seizures" or muscle spasms.

After four months of back injections at the pain center, they come in for a post air travel ear pain and we may get to hear the story of their misery adventure.  The eustachian tube dysfunction causing the ear pain after air travel is a chip shot for the family doctor who gets curious when the patient says, "while I'm here, can I get a refill on my Vicoden?"

The time allocated for their acute illness is 15 minutes, not including time with check in, MA for vital signs and clarifying their chief complaint, but including time with physician and prescriptions, forms, referrals, and the usual doctor's office stuff.  It is already gone at the moment the word Vicoden crosses their lips.  The family doctor knows that it'll take another 15 minutes to clarify how and why our patient is taking an opiate without our involvement.  How do we clarify that we don't have the time to get the history and physical examination to arrive at an opiate level decision for the problem they decided not to involve us in until they accidentally came in for the ear pain.  The "incidental" issue is about four times more challenging to effectively explore, diagnose and treat than the ear pain.

Will our curiosity pull the family physician into making the next patient wait another 15 to 30 minutes (confusion sometimes abounds with the self referred chronic pain person who doesn't believe in "citizenship" in the medical system)?  Or will the FP comfortably respond to the request with, "I'm happy to explore that with you in another appointment, since we're out of time and opiate prescribing implies a complex situation with added risks."?  Stay tuned.  Stay Curious.

"Curious George" sees another patient scheduled for an acute visit: Patient called this morning for a visit today acutely ill with sinus pain (see other blogs noting that Dayton, OH area is the worst allergy city in America- Numero Uno for total allergic mucous per capita), and moans a bit when describing pain in face and right ear for 3 days off and on.  Now they have coughed up some yellow mucous (Yes, it is the "Yellow Victory" noted in one of my April blog posts) and wish relief for sinuses, ear and upcoming Thanksgiving holiday with family (is it going to get worse? Am I going to get pneumonia?)

After my examination of the affected areas,sharing my perspective on diagnosis and ideal treatment and answering questions, the moaning stops and my patient energetically asks, "can  you take over prescribing my Wellbutrin, I don't think I need a psychiatrist any more?"  I notice the moaning somewhere again, oops-it's me.  When is your next appointment for your diabetes, hypertension and acid reflux?  "I don't have one."  States the patient who agreed to have an appointment for those conditions two months from when she saw our family nurse practitioner four weeks ago.  The room feels too warm.  "Excuse me a second while I check the heat control right outside the door, it feels too hot in here, I said warmly." 
"Doctor, your next patient just called to reschedule, her mother is having a stroke".  I turn the heat down two degrees, re-enter the room with renewed energy and curiosity.  I think, I wonder how many problems my patient will drive through this visit if I just go with the flow, Wellbutrin and all.  SEVEN!  We had seven diagnoses and four more prescriptions and a blood test conquered before I started to close by noting the number of problems we've dealt with in the time allotted for the acute visit plus the rescheduled patients time.

Sometimes I feel like Curious George and get carried away with curiosity about people.  They are all interesting and different, but I have to remember the flow of the schedule and how to relate to acutely ill persons and differently to chronic disease management folks (different rhythm, flow and focus).  The patient agreed to schedule a chronic problem visit for the other four problems that I deferred.  We could have done ELEVEN problems, we get paid as if we handled four at the most.  So my curiosity gave away payment for treating three problems or so.  Not the best behavior for the business side of the practice, which is squeaking.

We love our patients and the interaction with them.  Sometimes that doesn't balance well enough with the financial survival side of things in family medicine.  Now we face the planned Medicare reimbursement reduction again for the fourth or fifth time this year (21.2%) soon to be followed by a 5 or 6% reduction in reimbursement in 2011.  The other four times, Congress extended current payment levels at the last minute or retroactively when in May (or was it April or June?) they passively instituted the cuts for two weeks before reinstating the former reimbursement, which is 2001 levels of reimbursement.

All notes on Medicare Advantage Plan patients are reviewed by an outside reviewer, so we do a lot of copying so they can tell if we're defrauding the  government.  Patients covered by Medicare are generally older and have more complex problems per visit than any other patients, but their reimbursement per problem is generally less than all other patients.  And we expect the reimbursement to be slashed.  Hmmm, should I try to recruit more Medicare patients?  How curious am I?

We have concerns about _______ (insurance) company and we're not sure what our relationship with them will be after January 1, 2011.  This sign is in all our exam rooms and our waiting room with the name of an insurance company in the space where the blank is.  Some times one company or another scares us with their behavior and we drop back or out of a business relationship with them.  It's a sign of the times.  Hopefully, we're not curious enough to go out of business financially by relating to the wrong folks.  Stay tuned.  Stay Curious, just like George.

Monday, November 15, 2010

Family Medicine Founders Interview: Tom Leaman, MD, Founding Chair, Dept of Family and Community Medicine, Hershey Med Ctr of Penn State University

Dr Synonymous Show November 16, 2010 8-9 PM ET  www.blogtalkradio.com/drsynonymous
Introduction and Disclaimer
Patient Blog: http://bit.ly/9F9uak
Medical Student blog:  The Future of Family Medicine  http://bit.ly/cYY861
Dr Synonymous: his training in the 70’s in Hershey, PA under Dr Leaman & Residency Dir Ted Kantner, MD

Introduction of Special Guest, Tom Leaman, MD Founding Chair, Department of Family and Community Medicine, Milton S Hershey Medical Center of Penn State University

Thanks again for an incredible experience for me and my family in Hershey, PA from 1976-1979!
How did you decide to start the first clinical department in the new Hershey Medical Center?  Why Family Medicine first?

What sort of practice did you have before moving into the Medical Center?
What was the feeling that lead to all this happening in the little town of Hershey?  How was the town before and after the arrival of the Med Ctr?

How did medical care in Hershey change during the transition? How did the local physicians respond?
Who were the people supporting this new adventure?

How did you get faculty for the Department?  How did everyone adjust to an academic environment?
How did the town react?  Your patients?  Your family?
How did it all evolve? (to deliver the wonderful training experience to me and my peers and many others)

What were the fun aspects of starting the Department and moving into the Med Ctr?
What kind of difficulties were there?  Was budget development fun?
How long did you continue in the Department?

You served as President of the Society of teachers of Family Medicine, too?  What was that like?
What other founders did you know?  Did they all share in the adventure?

Anything we should fix about family medicine or FM training?
How are the founders and their vision remembered?
What does it mean to you to have a career as a family physician?
Other comments or thoughts, Tom
Thanks again for your service to humanity, patients, students, residents, physicians, and your community!
We'll continue to introduce the Human Centered Health Home next week on Tuesday night at 8 PM on BTR