Thursday, July 29, 2010

Thursday in Family Medicine: Odds and Ends

Several messages to read/answer on walking in door.  Hospice nurse calls, we discuss patient and clarify next nurse visit.  I ask MA to call Mrs. X to get afternoon appointment for sick husband who called at 7:15 AM through our pager system.  I notice family nurse practitioner is only working half day (AM).  Greet her with comment about what she's up to this PM (teaching).  Thank her for willingness to cover next Sat AM.

One of AM patients:  Thyroid follow up, weight gain, medication side effects- palpitations, oral ulcers, medication off the market- now back on and maybe worth retrying.  Hormone therapy from other doctor -several questions.  Snoring conversation- it's worse.  Multiple allergies.  Bone health. Back pain.  Non-coverage of massage by insurance.  This was scheduled as 15 minute visit (took 40 minutes).  Note to self to continue quest for optimal scheduling wisdom.

Examine patient, driven by aspects of the probabilities of various diagnoses considered during the history, narrowed into a short differential diagnosis that varies as we clarify higher or lower risks with clinical information gathered by listening, questioning and examining.  This is the essence of physicianship in the clinical domain- thinking clinically in the context of the patient-physician relationship.

Knowing the population that we serve, we know the type and prevalence of illnesses/ diseases that are possible.  This varies by age, gender, season, occupation, heritage, exposure, etc.  Each area examined further clarifies and leads to changing or validating the differential diagnosis.  The uniqueness of the current patient keeps filtering all the clinical thoughts and findings of the physician.  A lot of information is flying through the conscious and unconscious mind. The context for their life keeps coming into play as a critical filter for every bit of information.  Gradually, we family physicians know our patients lives first and diseases second.  Life is powerful. And limited.

Note to self:  these people (aka, my patients) are fascinating as we (our team and I) get to know them over time.  The relationship is the driver for the engagement and it becomes more and more powerful. This is still fun after 152,000 patient encounters.  Thanks for the opportunity folks.  More later...

Wednesday, July 28, 2010

The Human Centered Health Home: Protected and Neighborly

As a child, I always felt safe. Growing up in a neighborhood of unlocked homes where every kid could enter any house to play with other kids as allowed by the neighborhood mothers. The moms watched over the children and kept us safe and in line. They also had occasion to use branches from the same weeping willow tree as a switch. I remember hearing,"Go get me a switch from the willow tree and it better not be too small," on a few occasions, as did my playmates. In this environment, we were safe and everyone was neighborly.

I wonder if our medical care system could explore becoming more neighborly. Shouldn't people be safe in the system? Shouldn't we have a safe area where we could rely on a simple set of rules and personal relationships to deliver honest communication about important issues? What about expanding a neighborhood health care concept? (without willow trees).  What about timely information sharing in the context of ongoing  relationships?

Would it be neighborly to work together toward mutually beneficial outcomes?  Would it feel comforting if we would apprise each other about risks and benefits of our considerations?  Would we expect mutual revelation of reasonable estimates of pain, suffering and expense?  Would we find an "adult" switch to provide respectful feedback to keep each other in line?  Would we try to protect each other, our friends and our families from undue hardship?

Would it be neighborly to use sociotechnical innovation such as social media via cyberspace to relate in a timely manner?

A Human Centered Health Home (HCHH) could be a step in the right direction.  Humans first, caring and neighborly, is possible as we head toward the next wave of health care.  Just imagine...

July 27, 1970: Departure for Viet Nam 40 Years Ago

As I wrote my first prescription today, I noticed suddenly the date July 27, 2010.  Fortieth anniversary of my departure for Viet Nam as a Captain in the US Army and new army aviator with new rotary wing aviator pilot wings.  I left my wife of seven months at the Cincinnati airport to fly to Oakland, CA and depart form US Air Force Base at Treasure Island.  My sister-in- law was in labor with her second baby when we departed for Anchorage, AK.  After arrival in AK and a delay for engine trouble, Matthew was born before we left for the Far East.

After refueling in Kubota, Japan, we were off to RVN, landing in Saigon for further assignment to be determined at Long Binh HQ.  We new pilots filled out forms and waited in a bar drinking Budweiser beer.  Someone posted a list of assignments on the bulletin board and we read our fate.  I was surprised and pleased to be assigned to the 18th Engineer Brigade in Cam Ranh Bay.  Wow! An engineer officer getting an aviation assignment with an engineer unit.  I laughed and had another beer. 

The next day, I flew to 18th Engineer Brigade HQ in Cam Ranh Bay where I reported in and participated in a volleyball game and cookout with other pilots and crew members.  I felt some guilt if this was to be my view of the War in Viet Nam, but the next morning I was assigned to their 45th Engineer group in I Corps (northernmost part of South Viet Nam) and 24 hours later, headed for Phu Bai (Land of the Dead) home of the HQ 45th Engineer Group.  The land around Phu Bai was pockmarked with grave sites which from the air looked like bomb crators.

I reported in to HQ and was escorted to the Aviation Section. We had seven helicopters, two UH1H's (Hueys) and 5 OH-58's (Kiowas) and several pilots and crew chiefs and one technical inspector.  I next met my hooch-mate (roommate) and got introduced to the officers club (a plywood hut).  We ate roast beef (an almost daily main course for supper) and went to the club to play cards and get refreshed.  In case the drinks at the club weren't enough, we had a ration card for alcohol.  Each of us could buy two bottles of liquor, five (or was it six?)  bottles of wine and six cases of beer monthly.

This was Viet Nam forty years ago.

Sunday, July 4, 2010

Independence Day: Freedom and Underwear

On July 4th, 1964, a fifty gun salute sounded from West Point up and down the Hudson Valley, reverently honoring the fifty states and reminding those within earshot of Independence Day for those states, our nation and its people. The assembled "New Cadets" in the class of 1968 held their rifles vertically in front of their chests for the entire salute, which included the reading of each states name before its cannon added the loud retort. I remember the pride in our nation, a sense of satisfaction that I was at West Point with an opportunity to serve it and the pain in my arms as the M-14 seemed to gain weight with each firing of the cannon. I felt good about my home state of Ohio, but pained over South Carolina and was wobbly by the time Vermont was honored. The honor, pride, opportunity and pain were a message about our future of service to the nation.

The Class of 1968 had connected on July 1st with a quick orientation to military and West Point traditions, vigorous and thorough haircuts, a review of marching, intense practice of standing at attention, parade rest and saluting. Then we were marched behind the West Point Band which introduced us to many of the parade songs we would hear for four years (including Onward Christian Soldiers, which I appreciated from my church and choir experiences) past our proud (surprised/ shocked) parents and many girlfriends (including Rebecca, my girlfriend- now my wife- who thought I looked like "an alien") to Trophy Point for a ceremony that ended with our swearing in to the United States Army.

"To support and defend the Constitution of the United States against all enemies, foreign or domestic…" are words that imbedded in my brain on that day (See Oaths of Enlistment and Oaths of Office online for fascinating history of oaths back to the revolutionary war).  The meaning of the oath has evolved over the years as I've experienced honor, pride, opportunity and pain across forty-six years of service (five on active duty in the Army) to our nation and its people. The surviving members of the class of 1968 continue to serve in many ways, but all remember that day at Trophy Point. We committed to serve the cause of freedom as we understand it, even to go to war for it, even to die for it, as twenty of our classmates did in Viet Nam. The well known class of 1915 took a similar oath to "support and defend…" resulting in a victory in World War II. President Eisenhower, a member of that class now known as "the class the stars fell on" because of all the generals, was one of those unique people who defended against both foreign enemies in war and domestic enemies as President.

General/President Eisenhower returned to West Point in 1965 for his 50th class reunion which resulted in amnesty to cadets for all punishments, endearing him to the classes of the late sixties almost as much as his comment in a documentary about him essentially saying, they cared too much (at West Point) about trivial things like folding underwear. We cadets in the movie theater at the time gave his comment a standing ovation. We didn't like folding underwear either. BUT, could folding underwear while intensely disliking it have made a difference in Ike's decisions leading up to D Day? Could he have been more able to interact with Congress about challenging legislative initiatives? Could following a series of legal orders like, "You must fold your underwear exactly this way for inspections of your room to be satisfactory," lead to an ability to follow legal orders with which one may have disagreement later in life/ career as a president or as a citizen? If we can fold underwear without complaining (after time for desensitization), can we do our duty without complaint when the stakes are bigger? Has West Point protected our freedoms better by repetition that enables leaders such as Eisenhower to understand when to act and when to refuse to act?

Somehow, a Kansas boy launched by West Point grew into a great general. One who had pride in his troops and his country and was honored with the opportunity, knowing the pain that it would bring to so many and the freedom it could bring to the world, to say to his troops on the dawn of the D Day invasion:

"You are about to embark upon the Great Crusade, toward which we have striven these many months. The eyes of the world are upon you. The hopes and prayers of liberty-loving people everywhere march with you. In company with our brave Allies and brothers-in-arms on other Fronts, you will bring about the destruction of the German war machine, the elimination of Nazi tyranny over the oppressed peoples of
Europe, and security for ourselves in a free world."
Dwight D. Eisenhower

"Freedom has its life in the hearts, the actions, the spirit of men and so it must be daily earned and refreshed - else like a flower cut from its life-giving roots, it will wither and die."
Dwight D. Eisenhower

Friday, July 2, 2010

The Human Centered Health Home: Start with Respect

Aretha Franklin sings of one kind of R-E-S-P-E-C-T and Rodney Dangerfield joked about not getting another kind of respect, but the underpinnings of the patient-physician relationship is another kind of respect.  As transformation in health care moves forward,  we must continue to remember the respect that is the basis of our current interactions and future successes.

The Patient Centered Medical Home (PCMH) has been proposed by employers,  governments and organized medicine to help "bend the cost curve down" by shoring up a crumbling primary care base with more money and more tasks.  Proposals and demonstration projects so far make it look like the "Payment" Centered Medical Home instead of the "Patient' Centered one.  There is too much connection with the Medical Industrial Complex (MIC) for the PCMH to really get to the point about patient centered care.  It is a good start, but too bogged down with issues about the electronic health record, reimbursement, "quality", time management, cost, "meaningful use", power and control to leap into a future needed by patients.

Our Center for Innovation in Family and Community Health (CIFCH) proposes that we re-emphasize the human aspects of the patient and the physician to refresh the PCMH model into a more meaningful one that we like to refer to as the Human Centered Health Home (HCHH).  The human to human dyad of the patient- physician relationship allows "neighborly" discourse that protects the pair from some of the distractions and intensity of the MIC.  Their mutual respect allows a better understanding of the context of each other's lives, allowing a better focus on the work at hand.

Start with respect for each other, for the system in which we both function, for our teams, for our colleagues, for our families, for our information systems and so forth. In a context of human to human respect, our other roles of consumer, steward, teacher, leader, warrior, visionary and so forth can be allowed and understood. We spell it the same as Aretha Franklin, maybe even flashing back to hear "RE, RE, RE, RE, RE, RE, RE, RE Respect". Then hearing "Just a little bit. Just a little bit." If we only have a little bit of respect we might only get the "Payment" Centered Medical Home instead of the Human Centered Health Home that patients and Family Physicians both deserve.