Monday, May 31, 2010

Memorial Day : Grief and The Vietnam Wall. "Thank You For Your Service"

"Thank you for your service," the book store clerk said to me after asking if I'd been to Vietnam when she rang up a book about "The Wall" for me.  I am still sometimes embarrassed when people thank me for serving.  I felt more like it was my duty.  I got a full scholarship to West Point, an incredible education, and a lifelong sense of commitment to this nation and its people.  I owed you my service and I felt good about serving.

"My brother's name is on the wall," she added.  The family doctor in me knew that she wanted to say more.  "What happened to him?"  "He was killed in 1965 in a big battle with a lot of helicopters and artillery, but his unit was surrounded. " "Was that the battle in the Ia Drang Valley, the one made into a film with Mel Gibson?" She nodded.  "That was called a victory, but with devastating losses, only pulled out by using jets and napalm," I added. I thought of the song, "Mansions of the Lord", sung by the West Point Glee Club at the end of the movie and again by 160 of us in the West Point Glee Club Alumni Concert in 2007. Memories bounced around my brain as she and I discussed her brother and Vietnam.

I remembered serving on funeral details in Tennessee when I was a second lieutenant stationed at Fort Campbell, KY.  We related to the next of kin, played taps, folded the flag for the spouse or next of kin and traveled back to Ft. Campbell.  Most of the funerals were for older veterans, but two of them were for young men killed in Vietnam.  Those ceremonies were heavy with grief and tears.  Mothers were shaking, fathers and brothers felt empty.  At the cemetery, it was heavier until the playing of "Taps" and the presentation of the flag to the relatives.  They held the flag tightly, like it replaced one of the painful memories.  People pulled together at the church or family home for the gathering, always with food, after the funeral service.  Survivors turned off part of the grief with ritual, support and prayer.

Soon after Ft. Campbell, I was a student in the Army's Rotary Wing Aviator school in Mineral Wells, Texas when my roommate (trailer- mate, actually), Jack Gerke and I were informed that one of our company-mates (E-4) at West Point had died in Vietnam.  "Would we be pallbearers?"  We were off to Bunkie, Louisiana to meet the family of Lieutenant Denny Layton Johnson and represent our West Point class at his funeral.  Jack and I both already were headed to Vietnam as soon as flight school was over.  It was a very sad experience to hear about Denny getting killed in an ambush a couple months after his arrival in the non-declared war zone.  It was heartening, though, to hear the childhood and high school stories from his parents and brother.  His relatives were wonderful people.  Gracious, thankful Christians full of grief, but kind enough to welcome us and share.

I reflected later on my "inadequate" grief for Denny years later while looking at his name on the Vietnam Wall, realizing how my West Point training had me focused on mission accomplishment in a way that dropped grief skills way down the priority list.  Actually I don't think grief made the list.  One couldn't be looking back in combat.  It was all forward until it was over.  The Wall doesn't let grief hide, though.  It confronts you with your denial and death's reality in a humble way.  Each time I go to see the Vietnam Memorial, I realize more.  It is a patient teacher.  What a life Denny Johnson missed.  He didn't see his kids play little league baseball or graduate from high school.  He didn't even have a chance to get married. Every year, I feel more meaning to his loss. I now have grandchildren, a continuous message of love and a reminder of what others missed.

Twenty names on the Vietnam Wall are members of West Point's class of 1968, including Denny Layton Johnson.  "No task too great for '68" is our class motto.  Every year, class members gather at the wall for a ceremony honoring those who have died, especially those who were lost as a result of the Vietnam War.  West Point loses graduates in every war.  West Pointers study war, but we love peace.  We don't want anyone to die in war. We don't want anyone to experience death in combat or the loss of a loved one in combat.  We were trained to keep moving to accomplish our mission.  The Wall now silently tells us of another mission.  Stop and grieve.  Appreciate and honor the fallen comrade.  Appreciate yourself, too.
" Thank you for your service."

Wednesday, May 26, 2010

Tuesday in Family Medicine: Honoring Our Patients and Ourselves

We started the day with a team huddle.  Startled MA said, "what's that?"  I replied, "Meet me in the conference room and we'll plan the day."  She said, "OK, I'll see you in the break room."  I said, "It's the same room, depending on the intention of the individual.  In this case let's think of it as the conference room."  One MA off for family situation, FNP not here yet.  Other MA has to get the front desk with phones and people.  Small huddle today for the first one ever called a huddle.

"Let's look at today's schedule and figure out what's happening.  Do you have any MA patients this morning?"  She looked at the schedule and said, "No, no labs or treatments."  "OK, I don't remember my first patient, is she one of Dr. C's?  This patient at ten is better to see the nurse practitioner to review the lung status before I discuss the brain situation and family stresses.  Add her to the FNP schedule, as well as this little girl and this woman with all these problems. I'll wrap up with her remaining complex problems and a lot of issues about her home-bound husband.  We'll do three visits worth for this woman, since she can't get away from her husband very easily.  We make house calls on him every few months.  Pull his chart when you get hers to take her to a room.  The FNP is light for patients, so we can tag team with those three people.  We'll both see them."

"Hello." I greet our nurse practitioner and quickly summarize what I intended, if it worked with her.  She said, "How are you today?"  I had to shift my thoughts to think of me and remembered that I don't do that until everything is finished for the day.  She's a nurse and a family nurse practitioner, therefore caring about everyone all the time.  An asset for her and our patients.  I guess I should remember to remember me, but I get into other people's frame of reference and value systems all day every day and it paints my aura with their colors.  I want to help them to stay aligned with their life goals and dreams.

Recently, after input from my friend and colleague, a human systems engineer, I'm better understanding how to balance my values, goals and dreams with those of my patients.  I, like many family physicians, had de-valued me which, I'm learning,  doesn't actually serve them as well.

The first patient, an alternative practice believer, rarely comes in and it had been over a year.  The BP part was doing fine on the lisinopril that she finally agreed to after the headaches wouldn't abate with herbal therapy.  "This blood pressure medicine helps me.  I need another prescription."  I point out after examining her that the blood problem and lymph nodes weren't going away. She redirects the conversation, one of her 40 ish children was unemployed and moving back home with spouse, two children and one dog.  The patient, also, was between money making part time jobs.  We discuss her job market briefly before I note that the blood problem seems more medical to me than alternative.  We discuss boundaries between natural, supernatural, medical and alternative therapies.  She decides that the blood problem is still natural and alternative for therapeutic need.  She relates to God (the supernatural therapist) in her own way. 

She has two alternative practitioners, an herbalist and an energy practitioner, neither of whom promises her anything about the blood problem.  They speak to her of health and functional enhancement.  I agree that health maintenance is important and  she's wise to pursue it in a way that is consistent with her personal beliefs.  I present my position about what might constitute a medical urgency in light of her blood problem (weight loss, night sweats, persistent infection, etc.)  She nods and states a willingness to return if those things are happening.  I again edify the hematologist that she refused to see 18 months ago, just in case she ever has a need.  She smiles.

I am comfortable with our boundary discussion.  She is free to make decisions that may lead to her premature demise (the negative part of my physician-self thinks this) and I am obligated to inform her of "medical options".  She makes decisions, I give her medical information.  We respect each other and honor each other with listening.  I feel comfortable in my heart about her.  That is what I might call "evidence based" decision making.


Thursday, May 20, 2010

Health Care Non-System: Family Doctors Close Practices; 6000 Patients Scramble

Since May first, 2009, three family physicians in my community have closed their solo practices and started seeing patients at the Wright Patterson Air Force Base (WPAFB).  One of them was cross covering with me until a few months before he closed.  Another worked with me in our adventure in a local university, directing their campus health center while continuing our practices.  The third just announced her move to the air force base.  Two of them were recent presidents of our county medical society.  This is a clear message about the stresses of private practice and a jolt to the community that initially is not noticed.  Nothing appeared in the media about the loss of three physicians.  The base is lucky to get these doctors.

Another physician around the corner from me shifted into concierge medicine in MDVIP after 25 years in practice.  He now has a practice with 325 patients and is more relaxed and satisfied.  Total patients left without a family physician as a result of these four family doctors career decisions is about 6,000!! 

Who is next?  Could it be your doctor?  (or me?..I wonder how the system works at the base?  Do you get to follow a panel of patients with continuity or just urgent care? Do they have whole patient families?-I'm a family fanatic. How much free time?  What do they pay family physicians at the base?  What do they pay for medical liability insurance (aka, malpractice insurance- we pay about $19,000 yearly)?  Could I admit to the base hospital and refresh my hospital skills that will fade as we aren't having many admissions to care for until the new hospital is built next door to our office?)

Oops, I almost forgot how I own my practice condo (mortgage of about $5300 monthly and about $12,000 in taxes yearly to help the community) and have 9 employees who are delightful, committed people.  We're still having fun helping people with their health and life issues.  At the end of the day, I sometimes feel a bit tired pouring through the stack of clinical information such as lab results, imaging results and letters from consultants, not to mention emergency forms to fax to the power company so people don't have their power shut off.  Then there are a few prior authorization forms to beg for medications needed by my patients instead of the one that made them ill or didn't help.  I find myself wondering about the end of the day pile of forms at the air force base (is it smaller?)  Just a thought- not really serious. 

We can't predict what happens next in health care.  Stay tuned and stay healthy please.  Dr Synonymous

Monday, May 17, 2010

Friday Morning in Family Medicine

The office staff members are laughing, with the youngest standing in the center with hair down and others interacting about her appearance. "Are we converting into a salon?," I ask. I look at the patient schedule, noting the first two have chronic pain, one with a congenital musculoskeletal condition, another with remote history of occupational disaster and ensuing pains and dysfunctions. 3 slots open in AM for acutely ill people followed by a luncheon for staff and physicians from a local hospice.

A glance at my work area, where action items can be piled for same day perusal, yields notice of a thick chart: "he had fasting labs drawn, what tests should we order?"(I wonder why the mystery on the tests. Looking into his medical record, I note one no-show for this "diabetic in denial" since his last visit five months ago. He was having fatigue and concentration problems, noted by his wife, due to financial struggles from the untimely purchase of a new house before selling his first house. He opted not to take the antidepressant I offered to prescribe and had no time for counseling.  Now he is catching up to his health with the blood test, hoping to have a great HgbA1c to avoid a discussion about the financial stress and his depressed mood.) 

I next see a note from a mother of two teens asking if their sports physical can be used to approve and sign their summer work physical forms. Yes, with the usual form and doctor has to review the physical and peruse the risks noted in his medical record fee. We're no longer able to work for free, so we have charges for our services.

The first patient is here for medication and right arm pain according to the note written by my medical assistant.  His vital signs are normal except for heart rate of 105.  I knock, enter the room and shake his hand, make eye contact and ask, "how's it going?"  "OK, how have you been, Doc?  How is your leg?"  He remembered my infection (celllulitis) and expressed his wishes for me to heal completely.  Then he spoke of his sadness that someone had beaten his son, who went to the ER for evaluation, stitches and x-rays.  His son's girlfriend had a miscarriage after the beating.  He was saddened by the loss of his first grandchild, but he expressed concern that the baby might have been too much  for two seventeen year-olds to care for.

We did the medical part of the encounter with examination, clarifying questions and prescriptions.    His heart rate was down to 88 as he reflected on the coffee and cigarettes he had just before coming to the office. Then he showed me the words to a song he had written to honor his lost grandchild.  He plays the guitar, smokes and talks like Johnny Cash (bless his soul).  The words and the heartfelt compassion he had for the parents and their deceased child touched me.  "I'll see you next month, where are you riding your Harley this month?" I asked.  "I'm riding around Kentucky with a buddy.  That'll help me to forget what's happened."

The next patient room houses a couple including one of the "pain" patients and his lifemate (who was terminated from the practice years ago for misuse of benzodiazepines twice). "What are your plans for the summer? How is your walking and stretching going this spring? What are you doing for Memorial Day weekend?", are questions I asked during the visit. In his responses to my questions, I hear many aspects of his functional status and pain medication use.  "How is your back doing?  How does your hip feel?" are the type of open ended questions that I start with to clarify aspects of his pain and management.  Further questions yield specifics about the pain and the treatment.  A knock on the door interrupts my prescription writing after my examination of  ENT, Neck, Heart, Lungs Back, Hips, Strength, Nervous System, General Demeanor and Gait (he added that he was sneezing and coughing a lot since the grass and cottonwood trees had partnered to assault his mucous membranes, so I added those elements of history and physical to evaluate the respiratory symptoms).

"The hospice nurse is on the phone,"  she notes.  I excuse myself and the couple grants me permission with polite comments.  I only have one patient in home hospice at present, so I prepare to interact with the hospice nurse about the patient I'm thinking of.  I have a standing order for the hospice nurses to call me whenever they are in my patient's home, so we're talking one to five times weekly.  We have about six minutes of discourse, during which I listen to her nursing perspective and share my medical perspective with her.  We agree on next steps in testing, treating and reporting, including aspects of weekend communication between her cross-covering nurse and my cross-covering doctor.  I congratulate her on doing a wonderful job.

I knock on the door of the room before re-entering (this shows respect and prevents embarrassment for the couple in rare situations) and enter.  "It must be Friday, I'm sorry for the interruption, but I always speak with hospice nurses when they call."  They acknowledge that it's probably a good idea and refocus on my comments.  I congratulate the patient on his priority of stretching and walking, recognizing how difficult it is to balance the pain versus the health and fitness.  Too much fitness work may result in too much pain and dysfunction, leading to confusion about optimal therapy.  We discuss their grandchild and how "love is the drug of choice" in families.  Five prescriptions are written as fast as I can, checking those for controlled substances twice to see that the extra information is included.  "I'll see you in a month, have a good holiday with your grandchild."

I read the note and vital signs before knocking and entering the next room.

Thursday, May 6, 2010

Captain "Sully" Sullenberger: Safety Messages from the "Miracle on the Hudson"

I was excited to listen to a safety presentation recently by Chesley B. "Sully" Sullenberger III. The room of about 400 healthcare personnel from the Kettering Health Network (KHN)was silenced as Captain Sullenberger showed a National Transportation and Safety Board (NTSB) recreation of the flight path, instrument readings (altitude and airspeed), and actual pilot and air traffic controller voices concluding with the dramatic landing on the icy cold Hudson River (captured on film). As a former Army helicopter pilot and instructor pilot, I could feel myself becoming tense as I listened to the rapid communication from tower to pilots and even tenser as the altimeter neared two hundred feet with the airspeed at 130 knots (more than 130 miles per hour).

The pilots no longer responded to the tower that just before impact suggested yet another alternative landing strip- eleven minutes away! Truly,they were on their own with no engines in a heavy object being pulled to the earth's surface by the force of gravity. The view on the screen suddenly changed to live video of the plane showing up on the right, about thirty feet above the water and splashing down like a huge sled, sliding rapidly along in a continuous spray of its own making. It disappeared out of camera view and the room of viewers felt a sense of relief. Even though I'd seen the splashdown a hundred or more times on TV, I still felt uneasy about the outcome until our speaker calmly reported how they felt as the passengers and crew were helped off the plane onto the wings and suddenly converted passenger ferry boats in a busy section of the Hudson River. They survived again!

The emergency landing riveted us to the concept of safety, Captain Sully then shifted to 200,000 medical deaths yearly, noting that many may have been premature due to errors. In aviation there used to be a death rate of 1 person per one million hours of flight, now it's 1 person per 10 million hours of flight. The improvement comes from safety improvements. So what are we to do in medicine? Get safer! How do we get safer? Use checklists and practice our routines. Sully pointed out how the use of operating room checklists at a Pittsburgh hospital dropped their peri-operative infection rate to zero.

He pointed out that the use of checklists promotes teamwork, leadership and followership. It also generates the flexibility to face the unexpected, he stated as he referred back to "The Miracle on the Hudson", giving details as to how the use of checklists and crew practice enabled two pilots who just met three days earlier to pull off an incredible landing. He repeatedly emphasized that the entire crew of their flight had performed admirably and succeeded because of a deep understanding of the routines they had practiced.

So, I'm thinking of my days as a rotary wing aviator (the Army term) and using checklists for starting and preparing for takeoff and landing. I used a checklist for every flight in Vietnam and flying out of Ft Riley, Kansas. I remember how shocked I was to find in medical school in the 1970's (at The Ohio State University College of Medicine) that doctors did not use checklists. I thought that engaging a human body was much more complex than a helicopter, especially since the body also had a person inside. And so, we memorized and practiced, making sure that the patient never saw us refer to any checklists that would harm the interaction.

I flashed back to the head of surgery at OSU who had left a gauze sponge inside Woody Hayes, the famous football coach for the Buckeyes, and made the front page of The Columbus Dispatch. I remembered an angry, cursing, verbally abusive plastic surgeon at OSU berating the operating room nurse repeatedly, rising to threatening intensity as the sponge count (even without a visible checklist, every surgeon called for the sponge count before closing up the surgical incision) came up short one sponge. He vehemently insisted that all the gauze sponges were out of the patients massive facial cavity where a huge malignant tumor had been present. He was wrong and found the bloody gauze stuffed into a corner of the winding wound. She confronted his behavior and stated her intention to report it to her and his superiors. He was known for intensity and verbal abuse in the OR. I was very pleased that the nurse had confronted him (after he had closed the now spongeless wound) and reported his behavior. Could a checklist make a difference in situations such as these?

As Sully noted in his talk, behavior that detracts from the team is bad for quality outcomes and bad for the bottom line of the institution. He also pointed out that practice with a checklist enables the team to better understand each other and to clarify roles, enhancing or establishing mutual respect. I know that he was primarily referring to hospital safety, but I began to reflect on family medicine offices. My office team could benefit from a few procedural checklists for training and a daily team meeting with a checklist to get the patient care day started. Thanks Captain Sully for an excellent motivational talk to enhance our potential to improve quality and patient safety!

Sunday, May 2, 2010

Love is the Drug of Choice

"Healers in all major traditions recognize that the power of love is the most potent healing force available to all human beings."...Angeles Arrien in The Four-Fold Way.

People need people and people need love. In Family Medicine, we see people with a wide variety of problems and symptoms. These problems and symptoms are generally context sensitive. Often it seems that context is everything, especially to the extent that love exists for the patient. To the extent that love is missing in the patients life, the family physician may find signs and symptoms that try to fill the void. We may feel challenged to help the patient to find the human caring connection that prevents the loss of love or replaces the lost love. Some people may find a pet or even a plant that is a surrogate for human love. Love is the drug of choice!

Healers "recognize that the greatest remorse is love unexpressed." (Arrien) So, do family doctors have to become lovers to help our patients heal? Maybe. At least we can stay fresh in our love of humanity and the human condition. We can honor our patients as fellow citizens of the human condition, remembering to respect ourselves for the same reason. That shared humanity may allow the patient to feel the love, even if they smoke, eat too much, align with disappointing philosophies or political parties, or have an unusual aroma. Love is the drug of choice!

Toward the end of a patient care day in our offices, can we still feel love for us and them as we find ourselves hoping (and feeling guilty about it) that the lonely, talkative and WWII veteran senior citizen will finish the story about the awesome visit to the WWII Memorial in Washington, DC? Is it love or stress that has us humming the Jeopardy Theme Song faster than usual while watching the Rapid Strep Screen for the hyperactive six year old boy whose grandma is barking continuous commands to the lad? (Should we spin it clockwise or counterclockwise to make it register faster?) Have we already decided to treat the boy no matter what result the test yields?

In the same last four patients of the day sprint, do we breathe a sigh of relief as we break away from the chronic fentanyl patch, but worker's comp disabled fellow, who falls down all the time from his ineffective, system ignored unoperated spinal stenosis, who is actually there to follow-up from the ER visit associated with his vaccuum-like depressed mood, which we quickly dispatched with starter samples of vinlafaxine and a three week follow-up appointment? Does the sigh change into something else when he pronounces with a suddenly renewed energy, "They all have great respect for you in the ER. They said that you are the king. Thank you for being my doctor." As we say thanks, turn away and feel tears well up in our (needing to be dry for the remaining patient, a teen who missed a menstrual period) physician eyes we are honored and thankful that our patient remembered and reminded us that: Love is the drug of choice!