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

Sunday, November 14, 2010

Family Medicine Leaders: Interview with Ken Bertka, MD: OAFP and AAFP Leader, EMR Expert, Family Man


Dr Synonymous Show November 9, 2010
Introduction: I’m Dr Synonymous, a Family Physician in Beavercreek, OH

Veteran’s Day is 2 days away and we want to salute them and their endeavors.  A Dr Synonymous salute to all veteran’s, (including me, I’m blessed to have had the opportunity to serve in the Army)

Disclaimer:  We’re not practicing medicine here.  That’s best done by your own family physician in the context of an ongoing therapeutic relationship.

Patient Blog:  The Positive Medical blog- when Treatments End by Chrysalis http://feedproxy.google.com/~r/ThePositiveMedicalBlog/~3/lLuadTPsAFg/when-treatments-end.html

Physician blog:  Medical Students- Future of Family Medicine: Medical Student Burnout and Unprofessional Conduct by mdstudent31 http://futureoffamilymedicine.blogspot.com/2010/11/medical-student-burnout-and.html

Physician blog:  Is it the End of Private Practice? By Brian Vartabedian, MD

Dr Synonymous blog:  Saturday, November 6, 2010  

Family Medicine: Saturday Morning in the Office http://DrSynonymous.blogspot.com


A few comments about “The Wall”, The Vietnam Veterans Memorial 

Interview with Ken Bertka, MD

From Toledo, OH;  just finished service on the Board of Directors of AAFP and is a Past President OAFP, Past Medical Co-Editor, Core Content Review of Family Medicine, etc.
Welcome, Dr. Bertka

Would you describe your current professional activities and positions for our listeners?
Would you point out for our listeners special family doctors in the Toledo, OH area, please, such as your wife, Dr Vickie Bertka, now a hospice physician and the late Les Huffman, MD, who also served as OAFP President and later became AAFP President, (installed in Boston in 1976 at my first AAFP meeting when I was a resident in FM at the Hershey Medical Center).

How was the recent wedding of your son, Brian?  Is your youngest son ready to follow suit?

What were the more interesting situations and issues you dealt with on the AAFP Board?
How does AAFP analyze the difficult decisions like how to relate to health care reform?
What’s going to help with the pipeline of medical students needed to enter family medicine training?
Are there other workforce issues of near and far future that are pressing for family medicine and our patients?

What are your thoughts about the PCMH?  The EMR and “Transformation”? How will it relate to Toledo?  AAFP?
Have you published the process and results of your transformation in the Mercy Hospital System?

Your ran for president elect of AAFP with a platform of 4 R’s, You weren’t  successful with your election campaign, but the four “Rights” sounded pretty good to me.  What are the 4 “rights” that the AAFP members should consider? Let’s discuss these a bit.

How will people in Ohio get good primary care?
What’s going to happen with funding for health care?   What is the future for family physicians?

You’re also into music through your church  what do you do in that area?

Next week on Tuesday at 8-9 PM, November 16,  we’ll  interview Tom Leaman, MD Founder of the Department of Family and Community Medicine at the Milton S Hershey Medical Center in Hershey.  The Founders of Family Medicine education were a special group of people.  Tune in next week to hear from a special founder, Dr Leaman who also became President of the Society of Teachers of Family Medicine. 

I’m Dr Synonymous, Good Night

Thursday, November 11, 2010

Veteran's Day Reflections: Finding our Spiritual Center

"Doing what you do well within the framework of a system of values that you respect can constitute a spiritual center."  ...Frederic Flach, MD in Resilience

Being a military veteran gathers more meaning as the years go by.  Serving a country we believe in, doing the work that we do well in a group whose values we respect allows us to get close to, or find, our spiritual center.  God often seems to join in, anchoring the spiritual center with affirmation and Truth.
I remember in August, 1970 experiencing my first mortar attack on our Viet Nam Headquarters for the 45th Engineer Group in Phu Bai.  I was holding the winning hand in "High Chicago" (seven card stud, high spade in the hole splits the pot with the winning poker hand) when Bam! Bam! Bam!, mortar rounds landed a few seconds apart and were "walking" into our position.  Suddenly, everyone ran from the plywood officer's club into the various bunkers around our living quarters. I ran across the street from the club and dove into the bunker next door to my "hooch" (plywood hut) and came up praying the Lord's Prayer.  My spiritual center was refreshed quickly when motivated by mortars.   My brain and heart reminded me of God's role in my life as I finished the Lord's Prayer and moved onto the 23RD Psalm.

Two of the problems in the Viet Nam Conflict were  the lack of support by the American people and the misdirected strategy to use enemy body counts as a measure of success.  In part, this lead to atrocities, dishonesty and burnout that manifested as alcohol and drug abuse, disobedience and mental illness including depression and Post Traumatic Stress Disorder (PTSD) for many.  There were no parades to welcome us home.  The spiritual center was damaged for many.

Perusing my alumni magazine, The Assembly and Taps, from the West Point Association of Graduates,  I page back to the alumni news from the class of 1968 (my class) by Dave Gerard.  Many photos and updates of classmates/spouses activities follow as Dave tells our class story.  Starting with the wedding of the daughter of John and Gayle Frinak at the Plumbush Inn across the Hudson river, Dave next notes that John wrote the memorial article for classmate Johnnie Miller, a lifelong aviator who died in June, 2008.

Then more somber realities are noted with the death of Steve Bowman, PhD, a noted military historian and classmate who died in September, burial of Dick Flynn in April, 2010 attended by several classmates and the report from the Memorial Day Ceremony in Alexandria, VA.    Friend, classmate and fellow Cadet Glee Club alumnus Henry Spengler, who died when his helicopter was shot down in Viet Nam, was honored that day, among others.  Several smiling photos later, Dave notes "Sadly, we are one less, again.  "Bullet Bob" Henderson died peacefully on the morning of 15 July, 2010 in Salt Lake City of a horribly painful and debilitating disease- surrounded by those he loved and who loved him."
I went to Salt Lake City, as did Jim Stanley and Malcolm Murray where we three L-2/E-4 alumni from USMA '68 met up with classmate and SLC retiree Bob Brace and his wife Jo, our friends and hosts.  We told stories about Bullet Bob, West Point, Viet Nam, etc. while consoling and partying with the Henderson clan.  Marguerite, Bullet's ex-wife was a "saint" for Bob.  His children and grandchildren are special people with some great memories of Dad/Grandpa, the SLC attorney known as the "Bull Dog" in the courts.  I'll always remember how Bob was against the Conflict in Viet Nam before Sen. Fulbright, not an easy position to defend at West Point where all of us expected to serve in the conflict.  We'll miss Bullet, his brilliance, his sarcasm and his incredible smile.  He had to run the Wasatch 100 Mile Endurance Race about 16 times to keep a balance in questing for the spiritual center that he seemed to solidify in his last days.

Over fourteen million Americans served in World War II.  Over 415,000 died in service to our great nation.

Pray for Peace.  Get it fixed in the spiritual center of America.

Thank you, Veterans, for your service.

Saturday, November 6, 2010

Family Medicine: Saturday Morning in the Office

Patients are different on Saturday morning. Family physicians often have Saturday morning hours which serve many purposes, including timely service to patients and minimizing the total calls to the physician on call for the practice.  It also serves a quality enhancement purpose by allowing the "Saturday physician" to see the patients of the other physicians in a cross covering role.  This keeps us aware of how we compare in our treatment patterns of various conditions and diseases and allows us to become familiar with some aspects of the families of our colleagues.  I've been doing Saturday hours since I started my family medicine residency training at the Penn State Hershey Medical Center. 

We try do avoid doing complex disease management on Saturday due to limited staffing and partly out of consideration for the physician's need to focus on acute illness and recover from the sometimes more chaotic weekday work.  Complex thinking about multiple diseases and therapies is done all week, but less of a priority on Saturday when the acute illnesses, especially infections, abound.  A very sick person with pneumonia who "crawled through" a work week while having shaking chills and shortness of breath could present the doctor with a very satisfying encounter involving a blood test (cbc w/ differential white blood cell count and possibly a basic metabolic panel), nebulizer treatment with albuteral, injection of Rocephin and maybe an urgent chest x-ray to clarify presence or amount of pneumonia.  That's fun because of the opportunity for quick improvement and positive vibes for both patient and physician .

There is "special needs" time on Saturday also for more time consuming discussions with patients and families, such as end of life discussions with a roomful of people about grandma or "Pop" when more relatives are available to interact.  Sometimes this is the best time to see persons with quadriplegia who may need more time for a vast array of concerns.  A complex hospital follow up, due to list clarification of drugs and specialists, may best fit on Saturday AM. The type of visits are driven by staff availability to assist with patients and procedures.  Doctor engagement and thinking is balanced against staff availability and mental energy of all concerned.  One long family visit for detailed engagement fits nicely but two may exhaust the team and disappoint the participants.

Young athletes are another good group of folks to see on Saturday AM, since they usually need to know what's wrong, how to get better and when they can practice/play again.  They sometimes want to find a way to stop playing, if they are misplaced in a sport or not getting to participate.  In family medicine we help them to identify the meaning of their situation and to move ahead accordingly.  Parents "own" the young athlete and I enjoy helping the family with their need to understand the whole set of options relative to their "child".  Having x-ray availability can make this part of the practice even more fun with the diagnosis and management of simple fractures (or the ability to quickly rule them out when the doctor needs imaging help).

Each office of family physicians decides how they wish to address the opportunity for Saturday practice, hopefully deciding on strategies that are of mutual benefit to their patients, their family/career and their community.

Thursday, November 4, 2010

Family Medicine: Innovation and "The Hershey Conversation"

The Dr  Synonymous Show November 2, 2010
Family Medicine:  Innovation and "The Hershey Conversation"
Listen on Blog Talk Radio at this link 24/7.
Introduction and Welcome
Congratulations to my hometown of Dayton, OH being named the Number One Worst City for Allergy Sufferers in the US.  

Disclaimer- I am a practicing family physician, but we're not practicing medicine on the show.  Your best way to get good health care is through your personal family physician.

Patient honoring: We're only doctors because there are patients.  Let's always honor them.
Patient Blog:  That's What She Said "Inflammation and My Hippie Ways"

Physician Blog:  Musings of a Distractable Mind by Dr Rob 11/2/10.  Election Reflection.


My blog: Surprised at the geography covered by readers. 
The Family Medicine Education Consortium NE Regional Meeting in Hershey, PA

The Healthcare Innovators Network- a Pre-conference session
Several speakers with special messages from :
Alan (Chip) Teel, MD Elder Power to help Seniors remain in their homes www.Lincme.net
     started in Damariscotta, ME. High Touch, High Tech Senior Support.
Seven Dollars Can Change Lives by Edward G. Zurad, MD. Improving employee health and saving health dollars.
Patient Broadcast Network by Shawn Moyer, MD of Pinchot Med Center, Pinchot, PA (Small,  successful family practice using OX Bow EMR- unique and family medicine friendly)

Co-Ops for Medicine by Cathy A. Smith, Using Farm Concepts to help people survive together- one vote per person.
Patient Centered Medical Home Presentations abounded.  Geisinger Health Center and others.

TV coverage of FMEC Meeting:  Notice the medical students. Emphasis on the pipeline to deliver good family doctors.

Challenged kids dance and arts program:  Reach USA with 400 youth involved.  Enthusiastic group danced at FMEC meeting. See photos below
More Reach USA photos

Other Important Presentations:  Social Media by Kenny Lin, MD; Doctor Anonymous, Dr Synonymous well attended, well received update on various uses for social media in Family Medicine.  PAFP students started a blog, tweeted and used facebook and YouTube at the meeting.

Roland Goertz, MD, MBA President of AAFP "The Time Has Come" A great leadership talk with emphasis on where we're headed.  Special comments for medical students about a career in family medicine.

Coaching for Performance by Anton Kuzel, MD and Will Miller, MD Great leadership session about coaching and leading.

Beyond the PCMH: the Consumer-Oriented Human Centered Health Home (HCHH) by Steve  Deal, MS; Rosemary Ramsey, PhD; and Pat Jonas, MD.  A step in the right direction.

Aligning Primary Care Workforce and Infrastructure in an Era of Reform:  New Data and Online tools from the Robert Graham Center. Important data about primary care workforce from each medical school and residency.

Book Signing by authors in attendance:  Behavioral Medicine in Primary Care by Julie Shirmer et al.  The section on physician burnout is compelling. We need to take better care of ourselves.

So many great aspects to FMEC NE Meeting 2010. Overall a highly motivating experience and a breath of fresh air about the future of family medicine and health care.  It seems like we've started "The Hershey Conversation" about hope for health care and for people, like our patients and our selves.

My opinion of FMEC:  Important Organization. Stay tuned.

Go to twitter.com and search for #fmecnet  for tweets from the meeting.  Notice the tweets from med students, especially those from the PAFP.
Next week at 8-9 PM Tuesday night on BlogTalk Radio, I'll interview Ken Bertka, MD past president of the Ohio Academy of Family Physicians (OAFP) and recently a Board member of AAFP about family medicine, healthcare reform,etc.