Friday, March 25, 2011

Family Medicine: End of Lice to End of Life, We're There. What do You Think?

On top of my pile at the start of the day before seeing my first patient:  Someone calling this morning about their child, sick from school but they can't come in and mom wants a note from a physician faxed to the school saying the child can't go to school.  What would you do?

Next on the pile, a mom calls about two kids with head lice.  Please call in a prescription, is the message.  What would you do?

Next is someone calling to say they forgot to get their chronic disease prescription for their depression when they were here recently- acutely ill. What would you do?

I take a call from a hospice nurse who is concerned about a family not yet seeming to be understanding that the patient is going to die.  The patient is one day out of an extended care facility after a long hospitalization for severe heart and brain diseases with a terminal situation.  There are several medicines ordered for heart and brain diseases.  The patient told the family he wanted to be with Jesus. What would you say?

The first patient is here for chronic disease management:  hypertension, insulin resistance, hypertriglyceridemia, weight management.  We relate about the 3 months of winter being extremely cold.  The patient asks how the blood test results look.  I give him one copy of the results and point at a few elements on the file copy that look good.  "What do you think?" I ask.

"This doesn't look too good," he comments, pointing to the triglycerides of 187.  "What is this test?" he adds pointing to the Hemoglobin A1C of 6 which is in dark black ink usually indicating an abnormal lab value.  "It's like the cousin of the triglycerides, leaning in the direction of diabetes.  Notice that at 6.4 or above, the A1C is consistent with the diagnosis of diabetes.  Look at your last test, though and notice your triglycerides of 265 and A1C of 6.2.  You are doing something that's pushing back your diabetes potential.  What do you think that is?"

"Could it be the mall walking that my wife and I started two months ago? I guess the diet changes are helping, too.  And it's been easy to do since we met with the dietitian." "Those are important factors in what we're seeing. How are you doing it?" I ask.  He looks up and to his left, "We looked at our life and our health and our weight after the push from the last lab results and decided to act.  Now, I'm seeing a smaller me and both my wife and I are looking 5 years younger." What would you say?

I find Family Medicine to be  interesting, challenging and personally rewarding.  We deal with people and families in all stages of life and all contexts. What do you think?

Monday, March 21, 2011

Family Medicine: Collaboration at the Confluence with Family Nurse Practitioners

"Excuse me, Doctor, could you sign this prescription for me?", said the nurse practitioner quietly after interrupting my encounter with a patient in our Millersburg, PA rural training site.  It was 1977 when I was a second year Family Practice resident, and I had not seen a clinical nurse practitioner since medical school on a team oriented elective at a community health center in Arizona.  Now I was her clinical collaborator (?) and I was confused.  Was I supposed to be supervising her?  Who was she?  (Who am I as a family physician? wasn't even answered yet).  What does she know or not know?  What do I know or not know?

Fortunately, I was curious, like George (see post Could Curious George be a Family Doctor? ).  "I'm not sure what I'm supposed to do.  What's your diagnosis?  Can I see the patient?" I said to her.  "Yes, Doctor, it looks like otitis media in this eight year old boy," she said respectfully.  She led me to the other hallway and introduced me to the mother and the patient. 
The patient had an upper respiratory infection and otitis media (ear infection).  The prescription was for Ampicillin.  I signed it after verifying the diagnosis.  I remembered the Family Nurse Practitioner, Pat, in Marana, AZ during my medical student multidisciplinary team elective.  She was the leader of the health care team in that community health center with the transient National Health Service Corps physician, a general internist, trained at Johns Hopkins in Baltimore, MD.  This was a similar setting in many ways, but I was in a different role and needed training about that role.

At sign out rounds with my faculty that day, Dr. William Hakkarinen, (the innovative rural Family Physician recently- 2/15/2011; Vol 41, No. 3 featured in a Family Practice News story "Family Physicians Reflect on Four Decades") I asked,"How does this work with the nurse practitioner?"  He explained how we collaborate with the nurse practitioners just like we relate to the physician assistants back at the main family practice center in our residency.  He trusted the judgment of the family nurse practitioner and was confident in her ability to know when to seek input.  She, however, couldn't prescribe on her own, so needed the physicians to review and sign her prescriptions.  We had a thorough discussion about all the implications and ramifications of collaboration with physician extenders, as they were categorized in our Department of Family and Community Medicine at the Hershey Medical Center of Penn State University.  (WHERE CHOCOLATE RULED).

In 1979 when I returned to my native Ohio to start practice as a Family Physician, I wondered why no one had a FNP or PA in their practice.  I was a supporter of the concept of physician extenders and a believer in the important role they could play in health care.  Fifteen years later, as President of the Ohio Academy of Family Physicians, I was fortunate enough to testify before the state legislature in support of the enabling legislation to allow nurse practitioners and physician assistants to be licensed in Ohio.  At that time I was also serving as Director of the Physician Assistant Program and Department Chair in the Kettering College of Medical Arts.  Now I work with Family Nurse Practitioners almost daily and teach Family Nurse Practitioners in my private practice office.  Our legal relationship with them in Ohio is described as "collaboration".  We need them.

At the confluence of the disciplines of medicine and nursing, we need to better define how we collaborate with each other as Family Physicians and Family Nurse Practitioners for the good of patients and our disciplines.  So what is collaboration?  What do I mean by confluence?  How might we connect for collaboration?  Who wins?  Who loses?
Here are definitions that may be helpful as we think of collaboration at the confluence of our disciplines.
Collaboration:  Definition from Wikipedia 3/19/2011
Collaboration is a recursive[1] process where two or more people or organizations work together to realize shared goals, (this is more than the intersection of common goals seen in co-operative ventures, but a deep, collective, determination to reach an identical objective) — for example, an intruiging endeavor[2][3] that is creative in nature[4]—by sharing knowledge, learning and building consensus. Most collaboration requires leadership, although the form of leadership can be social within a decentralized and egalitarian group.[5] In particular, teams that work collaboratively can obtain greater resources, recognition and reward when facing competition for finite resources.[6]

Confluence: Definition from Wikipedia 3/19/2011
In geography, a confluence is the meeting of two or more bodies of water. It usually refers to the point where two streams flow together, merging into a single stream. It can be where a tributary joins a larger river, called the main stem, or where two streams meet to become the source of a river of a new name, such as the confluence of Bell Creek and Arroyo Calabasas, forming the Los Angeles River. In a broader sense, the merging of any two streams is a confluence.[1]

Family Physicians and Family Nurse Practitioners are engaged at the confluence of their commitment to serve patients.  They are critical for the delivery of primary care in America.  As we collaborate in many settings with varying scopes of practice, the leadership and followership need will vary.  Our flexibility over the years has generally helped our ability to respond to patient needs.  With millions of patients wanting for basic primary care, we now aren't fulfilling the needs of our nation and face an overwhelming increment of more need in the near future.  Instead of blending at the confluence of our primary care scopes of practice to serve more patients, the two disciplines seem to be jockeying for power and financial position. In the era of health care reform as the payment reform discussions overshadow the access to care and basic services concerns, we family physicians and our family nurse practitioner colleagues need to move into creative collaboration mode.  

At the confluence of these two citizens of two great disciplines is the legal mandate to "collaborate" (at least in Ohio where this is written).  How this occurs is important but not included in the training or the literature of either Family Medicine or Family Nurse Practitioners.  When I asked 5 different Family Nurse Practitioners and 5 students in the field how much of their curriculum focuses on learning about and understanding collaboration with physicians, the answer is:  None.  Zero. Are we still in 1977?  Are we avoiding something that may be depriving our patients of health care?

Nurses still care.  I believe that Family Nurse Practitioners still care, too.  Physicians need to be around people like that since our discipline is getting a bit jaded by the mechanistic aspects of healthcare reform and the reimbursement debate.  How do we enhance our collaboration skills?  I think we should start with our hearts.  It's a good way to overcome limiting beliefs, if we still have any doubts about each others position in health care delivery (Heart, Mind and Brain).  In Family Medicine, we have some big hearted physicians who care a lot but are getting bogged down with work responsibilities that detract from caring for and about patients. We can enhance our caring potential by working with Family Nurse Practitioners, who have nursing hearts (the biggest in health care, I think) and primary care clinical skills (each, as us, with one unique scope of practice).  Our teamwork in our health care teams over time will fill in the gaps of who leads and who follows- issue by issue, patient by patient.  Our primary care skills will support the merging of our streams of collaboration through recursive experiences, discussions and processes as we seek together to serve those who need primary care.

Who loses?  Those who would waste scarce, valuable resources in a misguided misalignment with the health care needs of America.  Who wins?  Everyone else, especially patients and their families, employers, Family Physicians and Family Nurse Practitioners.

Thursday, March 17, 2011

Family Medicine: Working and Caring are in Transition

Family Doctors have to "get the work done" while caring for people.  Sometimes the two responsibilities conflict.  How do you know if your doctor is working on your behalf so much that you don't feel like they care about you?  When they seem to be caring about you in a unique way, how do you know they're not being distracted from the work of gathering, analyzing and recording information about you relative to your chief complaint. 

Could they care too much and overlook important clinical information while you are feeling very pampered or special?  Or fail to record the pertinent information that enables their cross-covering physician to be able to treat you when your physician is on vacation?  Could they be overly concerned about the patient satisfaction survey you will fill out later (about their bedside manor) enough to miss an important clinical finding?  Could they be so concerned about you that they go out of their way to get your special tests at the most cost-effective site with good quality, saving you a lot of money?  Could they "forget" that the physical therapy office in the building next door is open 7A to 7P, allowing you to get your PT without missing work?  Could they remember to tell you that the hospital owned PT down the road is only open 8A to 5P and costs $500 dollars more for a course of physical therapy?

If the doctor is a bit mechanistic but very thorough clinically, can you overlook their logical, rational excesses?  If the medical assistant, nurse and receptionist are extremely friendly and calming, does that make up for the doctor's seriousness?  Can the overall work and care of the team suffice to meet your needs in those important areas?

Care and work used to fit well together.  Now they might get distracted at times as we transition to electronic medical records (EMR) and you ponder the addition of a personalized health record (PHR) for your personal use.  We care a lot while we work for you.  Most doctors also are employed by a bigger company that they are responsible to, so some aspects of the work include considerations of corporate rules and policies, adding to some of the distraction. 

All physicians want to help patients.  They also like to eat.  The balance between working and caring includes considerations for BOTH patient and doctor.  BOTH have to work and care.  Both have to eat.  That's how, together, we make it into the era of EMR's and PHR's, as humans committed to each other's success through caring and working.  It's not EITHER/ OR but BOTH/ AND.  Both patient and doctor have working and caring to do.

Caring and working.  Working and caring.  Every day, every patient.  Every patient, every doctor.  Work and care.  Both important.  What do you think?

Saturday, March 12, 2011

Family Medicine: Is it Flu, Strep Throat or a "Flep" or "Stru Throat"?

Lots of people are infected with something- coming out of three months of "real" winter in Ohio, during which people were trapped indoors breathing and coughing on one another.  Strep throat is going through the schools, high/ middle/ elementary and pre. Fever, painful throat- a continuous deep red section of redness, with tiny red spots on the rearmost aspect of the roof of the mouth but sparing the nose of redness or swelling in the over six group, are prevailing symptoms in our patients (although with the high numbers of people here with allergic rhinitis including swollen nasal turbinates and clear nasal mucous, it gets more challenging to find the pure presentation of strep throat). The kids under 6 years old may have the same findings as an  adult or deep red conjunctiva, nasal turbinates, pharynx and tonsils, usually without the misunderstood exudates that texts imply have some correlation with strep throat.  They also often have the tender anterior cervical swollen, tender lymph nodes ("glands" a few inches below the jaw bone high on both sides of the neck).  The adults I see with strep seldom have this finding.

I participated in a large strep throat research project in my Newark, OH office about 27 years ago that left a lasting impression.  My "strep mentor", Tennyson Williams, MD, who I interviewed on the Dr Synonymous Blog Talk Radio Show on March 8 and mentioned in the blog post on this site outlining the show,  was the principal investigator of the study based out of the Department of Family Medicine at Ohio State.  In the information gathering for the study, we noted the presence or absence of several findings in the ENT exam, among others.  The appearance of the nasal mucous membranes and the uvula held a lot of power when considering strep infection.  I still look up a lot of noses and carefully note the uvula in the back of the throat as key elements of upper respiratory infection differentiation.

The Flu is now moving in also with five or more days of symptoms including sore throat, body aches/ pains, fever and cough.  On day four to six, the infection is often so annoying that the patient or parents seeks medical attention, convinced of the need for an antibiotic, chest x--ray or cough suppressant.  People with chest tightness from tiring muscles plus or minus wheezing seek relief from their painful misery.  Some people just want to get a note so they can get back to school or work when well.  Employers just don't allow a good illness to follow its natural history without involving physicians.  If you know you don't need medical attention, can't you be trusted to decide when you're recovering or recovered?  Is it a covered benefit under your insurance to use a physician when not ill to get a note to return to work?  Can't your mother just write an excuse for your absence?  (No -according to many employer and school policies.  The now functional worker or student must go to a doctor to get cleared for their illness-caused absence, sitting in a waiting room with the coughing people, before their school or employer will believe them as to why they were absent.  What a waste of resources this type of distrust generates.)

So what if someone was exposed to strep and developed sore/ painful throat for a couple days then they got muscle pains and cough, and shift toward a flu presentation with their symptoms?  When we see folks with a mixed story like that and they have the mixed/combined symptom story with the combined physical findings, we are challenged to fully know which primary infection is driving toward whatever secondary infection might be present.  So we get the Rapid Strep test (throat swab plus five minutes for the test to reveal a positive or negative result) and the flu quick test (nasal swab plus 15 minutes waiting for it to "develop" with the potential to show influenza A or B or none).  I'm not prone to have persons with flu or strep or whatever infection go back to our waiting room until the tests yield their opinion, so we leave them in the exam room, eliminating one fifteen minute visit from happening on time due to the room being occupied.

None of the three tests is perfect.  There is a high chance they'll register the presence of the infection if the infection is in the patient and a high chance it'll be accurate if it implies absence of the infection.  BUT, the physician has to interpret the test and the meaning of the result in light of the patient's findings and story, including an analysis of the probabilities regarding accuracy of the tests and accuracy of all information gathered.  That's where the differential diagnosis further expansion and contraction is "completed."  The tests are not self explanatory and may mislead one to mis-interpret the results.  The information and test interpretation skill is one of the fun challenges in medical practice.  Statistical insights are one of the skills needed to get the best outcome.  Interpersonal skills and an understanding of the natural history of the infections under consideration are critical as the family physician considers how they each might affect the ongoing health of the patient in light of their chronic good, fair or poor health.  The family context and the health and activity of family members is an extra consideration for the family physician.

Yes, the flu finally made it to our area, but it's not showing up in a pure way.  The strep and other infections are clouding the image of the flu.  Is it flu or strep or "flep" or "stru throat", a nasty and confusing combination?

Tuesday, March 8, 2011

Show Outline of Founders Interview: Tennyson Williams, MD Founding Chairman Department of Family Medicine, Ohio State

The Dr Synonymous Show March 8, 2011

8 PM ET Tuesday Night on Blog Talk Radio, Internet Redio
Click above to listen while you follow the outline below.

Introduction:  I’m Dr Synonymous, a Family Physician practicing in Beavercreek, OH.

Disclaimer:  We’re not practicing medicine tonight on this show.  Your medical care should come about through a therapeutic relationship with your own Family Physician.

Show Overview:  Tonight we’ll start as usual, honoring patients by reviewing a patient blog first:
Grieving Dads

Next we’ll have a special interview with a Founder in Family Medicine:  P. Tennyson Williams, MD the Founding Department Chair of Family Medicine at The Ohio State University College of Medicine. 

I have to add that I am a graduate of OSU in 1976.  I was a clinical faculty member from 1979-1990 when I became full time faculty until 1994 when I joined the Wright State faculty at the Kettering Medical Center.  So I may show all kinds of bias in this interview, but you’ll know where I’m coming from.  You may wish to read some of the background of Family Medicine at Ohio State

Dr Williams will now join us:  Greetings.

Let’s dive right into the founding of the Department of Family Medicine: How did you do that?
Who was involved?
What were you leaving to start the department?
How many years did you practice before OSU?  How did you decide to do General Practice?  How was that viewed in your medical school back then?

Which hospital did you train in?  What did that consist of?

You had a reputation as a curious physician, doing studies in your office to modify practice.  What kind of projects/ studies did you do?

What did your family think of the Ohio State move?
What feedback did you get from other GP’s? 

How were you involved in the establishment of the specialty of Family Medicine?  Who else worked on that in Ohio?
What other Family Practice leaders did you work with in the establishment of the specialty?   
How did the “House of Medicine” view Family Practice?  How supportive were the other specialties?

Back to Ohio State:  How did you select the first faculty?
How did you develop a curriculum?  How did that fit into the medical school?

When did you start the Family Practice now Family Medicine Residency?
Who were the first residents that stayed around OSU to practice?  Ohio?

What kind of challenges did you face?  How much fun did you have?  What do you see as your legacy at OSU?
How many years were you at OSU?

What are you doing now? I commented on your wonderful article about Left and Right Brained people and how they fit into Family Medicine (primary care) and otherwise.
How much fun are you having these days?

The conversation may include some or all of these questions as it flows.

We’re running out of time so I’d like to again thank Dr. Tenny Williams for his accomplishments and his willingness to be interviewed on the Dr Synonymous Show.

This is Dr Synonymous, we’ll connect with you again on March 13 at 8 PM ET.  Good Night.

Friday, March 4, 2011

West Point Lessons for Medicine: Duty Honor Doctor

Duty, Honor, Doctor                                      

West Point Teachings Applied to A Medical Career

West Point, formally known as The United States Military Academy (USMA), is one of the unique places on the planet.  It also is an institution that exists to develop leaders of character to serve this nation and its people.  As a graduate of West Point in 1968,  I served in the United States Army as an officer in the Corps of Engineers, a rotary wing aviator, instructor pilot, and maintenance officer in Viet Nam with the 45th Engineer Group Headquarters and in the "Big Red One" 1st Infantry Division as a small unit commander, rotary wing aviator and instructor pilot at Ft. Riley, KS.  I also earned my Airborne Wings from jump school at Ft. Benning, GA, Ranger tab from Ranger School based at Ft. Benning and Flight Wings from Rotary Wing Aviator School in TX and GA.  In these military experiences and continuing through Medical School at The Ohio State University College of Medicine, Family Medicine Residency Training at The Hershey Medical Center of Penn State University,  and through 31 years as a Family Physician, I have applied principles and teachings from the Academy to help me to better serve and lead.  

Serving patients aligns well with the mission of the Academy, affording medical alumni an opportunity to better focus on the needs of the persons we serve in the context of their unique lives and situations.  In reflecting on those aspects of my experience at West Point and my continuing relationship with the Academy and its graduates, especially the members of the class of 1968, I have listed some of the important elements of West Point training that have influenced my career as a Family Physician.  After 160,000 plus patient encounters, I still employ daily the fruits of learnings gleaned from the elements and experiences in the following list.  Over the next few months (or years if I get too nostalgic), I (and maybe other USMA grads with medical careers) will expand on these elements for readers to perceive how medical graduates of USMA and other medical professionals may derive benefit from the teachings of The United States Military Academy at West Point.  Many will quickly notice how many of the teachings apply broadly to leaders and followers in other endeavors.

Duty, Honor, Country
The Long Gray Line
The Corps
The Cadet Honor Code
The Cadet Prayer
The Cadet Chapel(s)
Bugle Notes
The Cadet Glee Club
Guides and checklists
Gloom Period
More Repetition
More Teamwork
Planning and Organization
                Small Unit
                Larger Units

Thursday, March 3, 2011

The Dr Synonymous Show 3/1/2011

The Dr Synonymous Show March 1, 2011        Listen to the show here:  Dr Synonymous on BTR

Disclaimer and Introduction:  I'm Dr Synonymous, a real family physician practicing in Beavercreek, OH.
Overview of tonight's show

Patient blogs:   The Difference Between Doing and Watching by Seaspray

 Fog be Gone  :  The Great Lyme Debate by Penelope

Breakfast tips from The Glycemic Load Diet by Rob Thompson, MD

Medical Student Blog:  Sebastian wrote about how to advocate for a cause while separating one's profession in:  The Future of Family Medicine: The Social responsibilities of Wisconsin Family Physicians

Marcus Welby, MD makes a house call from House Calls by Thomas L. Stern, MD

Physician blogs:
Another Commercial Touting Specialist Care by The Singing Pen of Dr Jen

Common Sense Family Doctor
by Kenny Lin, MD writing about use of the PSA test that isn't good for screening (asymptomatic men)

Family Oriented Primary Care:   Working with couples (from Mcdaniel, Campbell and Seaburn)
Dr Synonymous blog: Hippocrates, Hope and Heart      

Next Week March 8: Founder’s Interview with Dr Tennyson Williams, founding department chair Department of Family Medicine, The Ohio State University

I'm Dr Synonymous:  Good Night

Wednesday, March 2, 2011

Family Medicine: One Morning for One Family Doctor

Alcoholism, Depression, Generalized Anxiety disorder, Caretaker Stress, Insulin Dependent Diabetes Mellitis (IDDM)- uncontrolled, Hypertension, Hypercholesterolism, Non-Insulin Dependent Diabetes Mellitis (NIDDM)- uncontrolled, Dietary Non-compliance, Hypothyroidism, History of Thyroid Cancer status post partial Thyroidectomy, Hypertension- Essential-controlled, Hypertension, NIDDM- controlled, Coronary Artery Disease s/p MI with Congestive Heart Failure s/p Cardiac Arrest, Generalized Anxiety Disorder, Hypothyroidism, Hypertension- uncontrolled, Mild Dementia-Multi-Infarct, Depression, Dependency, Pharyngitis, Insulin Resistance, Hirsuitism, Abnormal Menses, Pre-Menstrual Syndrome, No-Show Hospital Follow-Up, Acute Intestinal Obstruction s/p Colon Resection, Chronic Renal Failure, Atrial Fibrillation- controlled, Call No-Show. Chronic Anticoagulation- Stable, Patient Education RE: Human Papilloma Virus and Vaccine to prevent same.

Lunch Break: Water, Chicken Noodle Soup, 2 Tablespoons of Peanut Butter.
Check Facebook, E-mail, Twitter, Blog Posts. Review lab reports and correspondence, write recommendations for medical therapy. Sign forms.

Rinse and Repeat.