Wednesday, June 29, 2011

Family Medicine: Learning from Stress in the Military- Can We Forget the Tiger?

"Stress" is a concept that we all can relate to, but each has their own set of stress definitions.  How does the US Army understand Stress?  Here is an excerpt from the section on "Stress and Combat Performance" from the US Army Combat Stress Control Handbook (Lyons Press 2005, pp 33-35).  Does any of this sound like your life?:

"Stress is an internal process which presumably evolves because it helps the individual to function better, stay alive, and cope successfully with stressors.  However, there is an optimal range of arousal (or motivation or stress) for any given task.

     a.  If there is too little arousal, the job is done haphazardly or not at all because the individual is easily distracted, makes errors of omission, or falls asleep.  If arousal becomes too intense, the individual may be too distractible or too focused on one aspect of the task. He may have difficulty with fine motor coordination and with discriminating when and how to act.  If the individual is unfamilial with his own stress reflexes and perceives them as dangerous (or incapacitating, or as a threat to self-esteem), the stress itself can become a stressor and magnify itself.

     b.  With extreme arousal, the individual may freeze.  Alternately, he may become agitated and flee in disoriented panic.  If stress persists too long, it can cause physical and mental illness.  Extreme stress with hopelessness can even result in rapid death, either due to sympathetic nervous system over-stimulation (such as stroke or heart attack) or due to sympathetic nervous system shutdown (not simply exhaustion).  An individual giving up can literally stop the heart from beating.

     c.  The original purpose of the stress reaction was to keep the person alive.  The military requirement for the stress process is different.  It is to keep the soldier in that range of physiological, emotional, and cognitive mobilization which best enables him  to accomplish the military mission, whether that contributes to individual survival or not.  This optimal range of stress differs from task to task.  Tasks which require heavy but gross muscular exertion are performed best at high levels of arousal.  Tasks that require fine muscle coordination and clear thinking (such as walking point on a booby-trapped jungle trail or distinguishing subtle differences between friendly and enemy targets in a night-vision gun sight) or that require inhibiting acrion (such as waiting alertly in ambush) will be disrupted unless the stress process is kept finely tuned.  If the stress process allows too much or too little arousal or if arousal does not lessen when it is no longer needed, stress has become harmful."

I underlined the one phrase about "whether that contributes to individual survival or not".  In the military, sometimes mission accomplishment results in loss of life.  In the REHEARSAL for D Day in 1944, there were about 800 deaths.  This is way beyond what is supposed to happen in our work places, but many times our bodies are reacting as if a tiger is about to attack us.  Our body then gets an intense stress reaction.  Once we know we can respond successfully to tiger attacks with learning and maturity, we don't need as many tigers.  Can't we get away from the tigers?  Can't we find ways to reduce the pressure on each other and become more human-centered?  Isn't it time?

In Family Medicine, we have opportunities to help people to identify their stressors and upgrade their coping skills.  We know how to help people to clear up their view of their personal tigers and balance their stress without having a heart attack.  Stress can be helpful, as noted by the US Army, but also dangerous.  We don't have to be soldiers and experience combat to develop a variety of responses to stress.  Human to human, not tiger to tiger, we can move ahead with more balanced stress responses.

What do you think?

Tuesday, June 21, 2011

Human Centered Health Home: Reflecting on Patient Values, Goals and Dreams

During the last major process of the patient-physician engagement in the Human Centered Health Home (HCHH)- Reflecting, a primary aspect involves patient goals.  The patient relates with the physician to remain in line, or re-align with, personal values, goals and dreams.  Various aspects of these elements may be clarified over time in the context of the patient-physician relationship   During each engagement, either party may seek to clarify how health or health problems may relate to long and/or short term life goals.  While reflecting near the end of the encounter, long and short term values, goals and dreams of either or both parties may be reviewed to facilitate better short and/or long term decision making.  Past posts have given specific examples and future posts will give more examples of how to do this.

The physician has already shared their perspective with the patient using a process such as "get, give, merge and go." (see explanation here)  The patient now has the satisfaction of having a mutually agreeable perspective relative to their chief concern since they participated competently with the physician.  The physician is relating to the content of their clinical note for recording recommendations and agreed to decisions already discussed.  They may be using the format of the eventual final note to guide their comments and give the engagement another reportable element.

There may be a lot of probabilistic commentary during this section, as the physician comments on the probabilities that the patient will achieve their goal(s) using various diagnostic, therapeutic and educational strategies.  The patient may clarify their goal(s) as this discussion progresses.  The driving value of most concern to the patient may be mentioned, clarified and recorded in the note as having influenced the decision process to be able to remind the participants of that value and its importance.  Reflecting on patient (and physician) values in recorded media (the medical record) enriches the human alignment potential for both parties.

These values may be physical, intellectual, emotional and/or spiritual relating to any aspect of the biopsychosocial model, from the biosphere to the subatomic level.  The physician must remain mindful of patient safety and costs throughout this element of the engagement.  They may also be reflecting on their own biopsychosocial values and their own humanity during the discussion and while assuming various roles throughout the relationship with the patient.  The vast array of considerations is dependent on respectful, honest communication by both parties and timely recording of key components of the discussion and decisions.

This synthesis of phenomena is usually concurrent with record keeping, including the filling out of forms that relate to elements of the shared decisions (lab slips, prescriptions, encounter forms, physical therapy orders, etc.) which usually are the purview of the physician, but may change via use of the Electronic Medical Record (EMR) and the Personal Health Record (PHR).  The distraction potential during this content rich reflecting period is high, with patients often comforted enough by the process to suddenly bring up more problems for their family physician to consider, instead of celebrating the progress made as the physician might desire.

The mutual respect of the dyad may need a refreshing nudge at this time to stay focused on the main purpose of the encounter and the ongoing nature of the relationship.  Shifting back to roles of "human to human" may be one useful strategy that enables conclusion of the "clinical" engagement and a moment to honor their shared humanity.  This process is very complex and requires training and trial and error to achieve comfort and confidence.  Humans can do it as they remember to honor their shared humanity.  An over emphasis on patient or physician roles could mire the engagement in sludge, resulting in dissatisfaction for both.

Remember to GO HUMAN in the Human Centered Health Home.

Wednesday, June 15, 2011

Family Medicine: Can Willie Nelson Write Us a Song?

"The last thing I needed the first thing this morning was to have you walk out on me," sings Willie Nelson.  I reflect on those words from time to time as I feel a sense of betrayal from one aspect of the health care system or another.  Many other Family Physicians (FP's) feel some of the emptiness as they reflect on the "rock and hard place" forming the bookends for their potential demise.

Their patients are vulnerable to misleading health care marketing about the "scan of the month" or the "ultra-center of excellence" for one of their parts at the hospital.  The money they need for survival is controlled by parties not aligned with their patients needs, maybe even their employer.  If the employed FP's are pushed to see 24-28 patients every day, many patients are sent on for scans, tests or subspecialist evaluation who otherwise would be served by their Family Physician.  This increases the overall cost of care and the profit for the healthcare system.  Do employers understand that their local hospital is a "frenemy"?

How about it, Willie, would you write a song for Family Doctors and Family Medicine?  What would the title be?  "My Heroes Have Always Been Family Doctors"  "Family Doctors Flying too close to the Ground"  "We Tried, We Cared, We Faded"  "Unsustainable" "I'm Using My Last Tongue Blade"  "Stethoscope for Sale"  "We Love You More When We Get Your Copay" "Don't Drop Your Copay on the Ground"  "Too Much Debt to Fight" "We Didn't See it Coming" "Would the Last Patient Please Turn Out the Lights?" 

What titles can you think of for Willie to write for Family Medicine?

Tuesday, June 7, 2011

The Human Centered Health Home: Reflecting on the Patient Encounter

After Respecting, Protecting, Connecting, Detecting,and Correcting, the last element of the encounter between patients and physicians in the Human Centered Health Home is Reflecting.  This usually occurs at the end of the office clinical encounter or just after it's over.  Reflecting also includes completing the record of the encounter and the information needed to satisfactorally bill for services rendered.

Using the standard S-O-A-P format for recording the note helps immensely with this step.  The note may be written in the room as the patient tells their story and the physician expands and clarifies via mental models, some of which are mentioned in the earlier HCHH writings (see previous posts).  As the physician explores and narrows the possibilities, the note is developed, the assessment determined and the plan is shared.  The P- Plan includes the  diagnostic aspects, therapeutic elements and patient education including the timing of the follow-up for the current situation and continuous care/ prevention.

There may be a lot of probabilistic commentary during this section, as the physician comments on the probabilities that the patient will achieve their goal(s) using various diagnostic, therapeutic and educational strategies.  The patient may clarify their goal(s) as this discussion progresses. The physician may say, "With our findings here, there is a very high probability that you have a kidney stone passing from  your kidney through your ureter toward your bladder." 

"With the CT scan of the abdomen which bills at $2300, there is a 30-50% higher chance you'll know the exact size of your kidney stone (primarily if it's smaller than 4mm, which usually passes spontaneously) than with the renal ultrasound which bills at $550 and accurately shows stone size if 4mm or greater (the size that has a higher chance of not passing spontaneously).  The CT scan involves radiation exposure similar to about 500 chest x-rays and has a 1-2% chance of causing cancer 20 or so years later.  The ultrasound has no radiation and no cancer risk.  Overall it will show stones that may not pass, but less likely to show the size of stones that will pass spontaneously.  Generally, neither imaging study is necessary unless the stone, diagnosed clinically with the history, physical examination and urinalysis, is painful for too long.  What questions do you have about those options?"

The physician helps the patient to frame the situation and explore the options, sometimes shifting into teacher, learner, consumer coach and values clarifier.  Information resources in person or online may be very useful in this segment of the clinical encounter, as contingencies are developed and explored, before final decisions are made.  Sometimes there is further clarification about financial burdens of various medications and testing strategies before  working decisions are agreed to. 

Reflecting also includes context considerations for the physician.  Am I comfortable with this type of patient and this symptom complex?  What is enjoyable about this patient?  How does this type patient and problem inform the physicians career about likes and dislikes in family medicine.  As the physician reflects on the encounter, what did he/she learn?

Reflecting may include a vast array of considerations which will be expanded further in future posts.