Sunday, August 28, 2011

Human Centering: Veterinary Style with Our Sick Dog, Buckeye

Our ten year-old dog Buckeye was bleeding from a tumor above the right shoulder, below the neck.  It was a continuous flow from his repeated scratching at it with his right rear foot which was red with his blood.  The antibiotic spray from our vet was no match for his self-damaging scratching.  He looked tired.  Our washing and bandaging didn't stop the blood flow.  We washed him and wrapped his wound with gauze and a towel and headed for the 24 hour Dayton Care Center (for pets) listed on our vet's front window.

Buckeye is a big, gentle long haired half Collie who is very effective keeping deer away and fighting off raccoons that try to get in our bird feeders and Rebecca's plants.  He was in half Husky (his other half) heaven last winter when temperatures hit zero and he seemed to thrive on it. He loved the air conditioning, on the other hand, the last two months when it was sweltering outside.  He's been lying around a lot the last three months.  Old age seemed to be one factor, but the mass showed up with bleeding a couple days after he had an altercation with a raccoon.  Initially, we wondered if it was an abscess from the fight, but the vet noted that it wasn't related to the raccoon, but it was a tumor.

The front desk woman at the Dayton Care Center, Ann, asked about and clarified with us the problems our dog was having then gently took our dog's leash, addressed him by name, saying, "Come on, Buckeye" and walked him back to get his vital signs checked.  He walked slowly with her through the doors to the clinical area.  We had to fill out forms, then wait for the vet to clarify how she would proceed.  We watched the waiting room TV, on the food channel, featuring chef competition.  The vet, "Amy" B., came out to interact about Buckeye, offering us an opportunity to meet in a quiet room or right where we were in the main waiting area, where no other owners remained except my wife and I.  We said, it's ok right here if it's ok with you.  She was comfortable reviewing his situation, seeking guidance from us about how far to go.

She noted on examination that his gums were very pale, indicating a possible anemia, acute or chronic or both,  and he was wheezing in the right lung only which could relate to the anemia or the tumor or both or neither.  We sensed that she leaned toward doing an x-ray to clarify the lung situation and blood test to define the extent of the anemia could guide other decisions about what to do with our ten year old dog who had been slowing down for several months.  I appreciated the interpersonal skills of the vet who used vague, open-ended language in the early part of our engagement while she was allowing us to determine the extent of the work-up based on our sense of our dog's overall health and meaning to us.  She said, OK, we'll get those tests and then review the situation again with you.

Three courses of chef competition later on the show "Chopped", she came into the waiting area and asked us to come with her to review the x-rays.  I knew that they would be abnormal by the way she spoke, probably showing more cancer, meaning his life was near the end.  She said the anemia is severe and there are worrisome, malignant appearing lesions all over the lungs (but they could be signs of other problems like a fungal infection), pointing to circular areas of white where black would have been more normal.   She allowed us to comment on the findings and start thinking aloud what we thought that meant for Buckeye.  So his life is coming to an end, we mumbled.  After mentioning a few other aspects of his failing health with her, she told us that, if we wish, they could euthanize him right there.  We gasped for a second, then thought of our sweet, kind-hearted collie-husky dog.

"What if we had him home a couple days", my wife pondered aloud.  "I'm not sure he'll last very long and he'll still most likely be bleeding unless he has a large bandage and T shirt covering it and a covering on his right rear foot to avoid his intense scratching at the tumor", clarified the vet as she effectively shared her perspective.  "I don't want to be too blunt, but I want you to know the extent of his disease and how fast it's evolving.  I had a dog that was similar and no one told me, which was disappointing because I waited too long," she self disclosed to us (almost in those exact words).  We could tell that she loves dogs.  Her caring was helpful.

Twice during the engagement around the x-ray image on a wall-mounted computerized image viewer, she asked open ended questions seeking to clarify how we perceived our relationship with our dog and what we thought of the life of our dog.  She was very kind and respectful, not pushy in any way, letting us make the big decisions.  We realized that our dog would soon enter a mode of suffering by bleeding and wanting to scratch it and getting more and more exhausted until he couldn't stand and we would feel sad for his misery.  We suddenly understood that we should have him euthanized right there and so stated.  The vet said we could go to be with him just after we signed the papers for the procedure and burial at a local pet cemetery (if that was our desire).

Ann was sadder than before as she introduced the forms and the bill which we signed and paid before going in with Buckeye.  We both started to cry when we saw him lying on a blanket with two towels around his neck, already soaked in blood at the site of the tumor.  He was tired and still kind.  We petted him and touched him and talked to him.  He quietly enjoyed our touch and our words of love and farewell.  He seemed to be relieved as he put his head down and rested for his trip to dog heaven.

I was comforted by the style and demeanor of the front desk assistant and Dr. Amy B., the veterinarian.  They allowed us to progress through some difficult decisions by allowing the time and openness to reflect on who we are and what we believe about our dog. I am thankful to them for their caring and skill.  I also appreciate whoever contributed to their training.  It isn't easy to engage strangers about personal relationships with their pets.  Thanks to them for being so human centered while caring so much for pets and their owners.

Thursday, August 25, 2011

The Dr. Synonymous Show 8/23/2011: Patient, Med Student, Doctor Blog Tweet and Medical Review

Dr Synonymous Show on BlogTalk

Click  Here for the show with blog reviews and discussion, starting with Pissed Off Patient  Exercise Blah Blah blah , then Dr. Fatty Finds Fitness Crazy Catch-up Post followed by the medical student blog: Adjacent Possible Medicine about Social Media Risks for Med Students .

Next is a JAMA article review of how TV watching is leading to increased tyope II diabetes, heart disease and all-cause mortality followed by a Tweet Review of ten current tweets on Twitter, including a link to a JAMA article about home-going meds in patients leaving hospitals.

Eat more nuts, soy and plant sterols to lower LDL cholesterol is the message from an NPR blog.  House Calls: a review article from the American Family Physician is then reviewed, leading into comments about Dr Synonymous post about house calls in April 10,2010  House Calls: Paid in Full Plus Tips.

Dr Jonas then reviews Dr S most recent post Family Medicine:People Time and Money  before signing off with a quick comment about his Set Our Hearts at Liberty blog West Point Glee Club Reunion which included a YouTube link to his recent West Point Alumni Glee Club reunion concert in July at West Point.

Listen in 24/7 since the show is saved as a podcast.  The live show is from 8-9 PM ET Tuesday nights which includes a chat room.  I'm happy to curate several blogs, tweets, a monthly interview and the Family Medicine literature.  Check it out.

A. Patrick Jonas, MD

Sunday, August 21, 2011

Family Medicine: People, Time and Money

"Any new stressors in your life?" I inquire of many patients, assessing the context in which their symptoms arose and persist.  Many make an expression or comment that seeks clarification, so I add, "Like people, time or money?"
Recently, many folks just respond, "All three."  Relationships with people are strained in their homes where someone may be out of a job and someone may be a caretaker for an ageing parent or grandparent while someone may be contending with the struggles of a teen or an adult child (who moved back in with two children and a dog after divorce and job loss).  There are too many people in their lives with too many problems for all to go well.  The multi-generational family is making a comeback, with unpredictable outcomes.

Time is working against my stressed patients.  There is not enough time for everything they have to do.  At work, many are doing more work due to budget cuts that result in others being terminated.  They have the added stress of learning new computer/business systems and certifications for their new skills.  Some don't have enough time with family or time in bed to get needed rest and sleep.

Most don't seem to have enough money.  They are trapped by the job loss or having to be present at a job that results in neck or back strain without the ability to afford to take time off to recover or get physical therapy.  Many want us to "drug" them so they can work while injured and in pain.  Lack of money adds to the home stress.  If one income is gone in the two earner family, stress and tension mounts with the bills.  Each shows the stress a different way, sometimes making the financial problems worse.

Several people in their twenties don't seem to mind moving back home with Mom and Dad, but Mom and Dad feel the stress, according to what we're seeing.  Mom and Dad often don't have the extra money to support the adult children.

How do they cope?  When asked they comment about "going shopping", "exercising", "prayer", "church", "TV", "friends", "family", "grandchildren", "eating junk food", "reading", "meditation", "pets", "political activity".

People, Time and Money.  Imagine your stressors and coping strategies.  People, Time and Money have a lot to do with both.  How do you cope in these interesting times?

Sunday, August 7, 2011

Family Medicine: Naive Enough to Believe

I just attended the Ohio Academy of Family Physicians (OAFP) Annual Members Assembly in Dublin, OH (Columbus suburb) for many reasons.  Seeing friends who are Family Physicians from all over Ohio, their families and the staff of the OAFP is meaningful and reaffirming.  We know and care about one another.  It works.  Staying connected to Family Medicine and getting updated were other goals for me at the annual celebration.  The effectiveness of the experience is made possible by the outstanding OAFP staff, who are experts in professional organization and support.  Things seem to happen miraculously when they are involved. 

Finding the "Edge" of Family Medicine and its interface with all that is not Family Medicine is another focus for me.  Usually there are "Edge" people at every OAFP meeting who help me to understand how it looks and feels at and beyond the "Edge".  I enjoy hearing about what's happening in every part of the state. 

The "Center" was easy to find at this event (actually several events):  Patients are always at the heart of Family Medicine.  They weren't necessarily invited formally, but their essence and spirit are the hub around which the OAFP is organized.  They are the strength and the weakness of Family Medicine.  Caring for them is what we do and what gives us meaning.  Over and over at this meeting, patients were mentioned and pondered and honored (and cursed?).  We love you, Patients.

Special consideration at the meeting was Practice Transformation.  Big message:  Without PT, Family Medicine will not survive. Family Team Care was introduced as a workable model by Peter Anderson, MD, a solo family Physician in VA who transformed his practice into a PCMH.  The Patient Centered Medical Home (PCMH) was featured last year at this meeting and continues to generate interest and fear.  The state of Ohio is pushing forward with a PCMH project that has promise and clout since Ted Wymslo, MD, who developed legislation to promote the project, is an OAFP member/leader and current Director of the Ohio Department of Health in Columbus.  Ted spoke about the project and the Office of Health Transformation  and change.

The business meeting was notable by its lack of resolutions and lack of controversy.  A Memorial Resolution for Gene Wright, MD OAFP Past President was a special moment.  Jean, his widow, and his children were present to receive a tribute. He was a beloved Leader of OAFP and several aspects of health care in Lima, where he practiced and started a community health center.  He played a critical role in AHEC education for medical students from the Medical College of Ohio and was recognized by OAFP years ago as Educator of the Year.  Gene, though, was a big hearted, fair-minded friend to OAFP leaders and members for decades.  He was loved by his family, his patients and his community, all of which he served with love and compassion.

Collette Willins, MD delivered her President-Elect speech with energy and enthusiasm, followed several hours later by her induction as President and swearing in by AAFP Board member, Reid Blackwelder, MD.  Dr Blackwelder, gave a delightful overview during the business meeting of national issues being addressed by the AAFP.  He aptly noted the dynamic changes in Washington and the various strategies of AAFP to provide continuous input on behalf of Family Medicine.  The SGR and RUC were mentioned along with other reimbursement concerns of family physicians and the AAFP.  Our Academy is working to represent us in a challenging time.  The outcome is uncertain.

The Town Hall Meeting was a very open opportunity for any OAFP member to voice concerns and express opinions about many situations.  Survival issues for the specialty were mentioned in numerous ways, including the workforce pipeline with medical student debt being a threat to students selecting our specialty, increasing employment of FP's by non-physician entities that aren't aligned with patients in the way we would want, reimbursement, regulations and mandates, the economy, etc.  Visiting officers from Illinois and Wisconsin commented on situations in their states and Dr Blackwelder contributed the AAFP perspective.  Many reflected again on the wonders of practicing Family Medicine and the joy of caring for patients, while lamenting the business model that we're trapped in that is mis-aligned with our survival and our patients best interests.

The "Academy Awards Dinner" is always special for me with the passing of the gavel from the out-going President to the new one and the recognition of new officers and (the highlight for me) the recognition of the Fifty Years in Medicine Family Physicians.  Dave Garrety, MD was a special honoree to me in that group this year.

Sarah Sams, MD, outgoing President did a marvelous job during her year as our Leader. A unique surge of Sarah's special energy has lifted the organization through a sea of change, seamlessly.  Her Yellow Brick Road quilt was raffled off (Jeff Susman, MD, Dean of NEOUCOM won it) at the dinner setting a standard that no future President will probably match.  She's come a long way from Pork Queen of Iowa to Quilt Queen and Past President of the OAFP.  Thank you and Way to go, Dr. Sams!

Special moments at the meeting involve the personal relationships formed over the years.  Changes including loss, death, grief, new babies or grandbabies, career advancement, disappointment and satisfaction were all open for hugs, laughs and tears among OAFP friends.  The Family of Family Medicine is alive and well.

In spite of many negative situations that surround us, one could still feel the optimism that something is going to get us through this era.  Family Medicine will survive, was the message.  We don't know how.  We do know why it should survive.  We just believe.  I could feel the belief, but didn't hear how it is going to happen.  It reminded me of a motivational tape I once heard which referred to being naive enough to believe.  It recognized that sometimes knowing too much detail might just get in the way of success.  That may be where we are in this era.  We don't have access to all the information we need to guarantee our survival.  We are "NAIVE ENOUGH TO BELIEVE" that we will.  I think we're right.
What do you think?

More information on the Ohio Academy of Family Physicians Members Assembly from Dr. Mike Sevilla:
Dr Mike Sevilla Post on Ohioafp Meeting Day One

Dr Mike Sevilla Post on Ohioafp Meeting Day Two

Tuesday, August 2, 2011

Blog Review and Interview with Shaina Gerad, MSII WSU Boonshoft School of Medicine

Dr Synonymous Show August 2, 2011 on Blog Talk Radio Click Here for podcast

Introduction Dr S, Show Content, Shaina Gerad, MSII, WSU Boonshoft SOM

Disclaimer:  We are not practicing medicine here tonight
Patient blogs: MamaSick Being Neighborly

 and Pissed Off Patient   Pissed Off Patient
Dr Jonas Glee Club Reunion at West Point July 28-31

Med Student Blog: The Future of Family Medicine: Shared Decision Making is Two Way

Interview with Shaina Gerad, MSII WSU, a solid physician in the making.
                Hello, Miss Gerad, is the sound OK for you? HIPAA check, are our lips sealed about specific patients?  OK, we may proceed.
                How did you decide on a medical career?
                What prepared you for medical school?
                Tell us about your family’s involvement in health care and what influence that has on you as you start  your second year of  medical school.
                Tell us about the summer course through the Area Health Education Consortium (AHEC) that you were fulfilling in my office for the last four weeks.
What kind of experiences were interesting to you during that AHEC experience? Would you care to comment on your Social Media Project?
What seemed to be challenging about the experience? Etc.
What is the main focus of each year of medical school at WSU?
How collegial are the students in your class?  We hear that doctors have to get along better with each other and clinical and administrative team members.  Have you seen or heard of curricular elements that will deal with teamwork and multidisciplinary studies?
What are you learning about the Health Insurance Reform and Health Care Reform in medical school, if anything, at this early career stage?
There is a huge shortage of primary care physicians, contributing to the lack of access to health care for millions of people and extra expense for these patients who go to Emergency Rooms when they don’t have a doctor.  What are you seeing and hearing about student attitudes toward physician workforce issues such as specialty maldistribution?
How are the students going to deal with the debt they incur during college and medical school? How might that affect what they do?
What are you looking forward to in your medical career? In medical school? Etc.
Shaina, thanks for spending time with us tonight to catch us up on your career and some aspects of medical school through WSU.

This is Dr Synonymous.  Next week we’ll review the Ohio AFP annual meeting and comments about issues in the health care system, and, as usua,l patient blogs etc.
Til next Tuesday at 8PM ET, I’m Dr Synonymous, hoping that you are synonymous with your best health.  Good night.