Family Medicine: Prove the Patient Right

"Since I've been on that flaxseed, my knees don't bother me.  I've canceled my surgery.  I can't believe it!  They hurt so bad for so long.  Now the pain is gone!"
Five years later: "I feel better now that I got my knee replacement.  I should have done it earlier."  Very interesting.

"I can't take sulfa drugs for infections." "What happens if you take sulfa?"  "I don't know, I just know my mother gets a rash if she takes Sulfa, so she told my sister and I to never take sulfa since we might get a rash."

"I can't get a flu shot, because I got one in 1972 and later caught bronchitis. I don't want the bronchitis again.  I always respond well to Vick's Vaporub.  My grandmother used to rub it into our upper chest whenever we caught a cold.  They seemed to be milder and resolve faster with the Vick's ."

Things change, times change and so do patient beliefs.  We all have both positive/ enhancing and limiting beliefs of one sort or another.  Family Physicians get exposed to them every day from patient to patient and their family members.  Sometimes, it's our limiting beliefs (yes, the family physician's limiting beliefs) that get in the way of patient success. Sometimes, this surprises the patient, just as we're sometimes surprised at their positive or limiting beliefs.

How do we contend with our respective limiting beliefs that may deter clinical success?

I have a strategy called, "Prove the Patient Right."

Whatever their theory about what might happen should they follow a particular course of action, I add it to my considerations and treat it equally.  We deal with a lot of small probabilities already in Family Medicine, so what's the problem with adding another consideration to our differential diagnosis or treatment plan?

We have our experience and the medical literature to refer to for insights.  They have knowledge of themselves and their family plus personal knowledge of many health and medical situations and conditions.  Together, we can integrate our theories and share information to get the most favorable conclusion.

If I'm thinking their story, signs and symptoms could be a serious heart condition, I want them to be right with their theory that they had palpitations because they took too much over-the -counter cough syrup.  On the other hand, if they are afraid that their symptoms indicate they might have cancer of the bone, I want them to be proven wrong, but know I have to mention the bone cancer concern as I discuss the meaning of the symptoms and signs relative to the various tests for causation.

Together, we can share our theories, concerns and fears as we pursue their best health.  Prove the Patient Right and Prove the Doctor Right are helpful strategies for healthful lives.

Family Medicine: What Happened?

Something happened.  Medicare patients are now admitted to hospitals by strangers, discharged in 2.2, or so, days and readmitted 20-30% of the time within 30 days.  Both admissions are paid by Medicare.  Sounds like a good business model if you like to maximize profits.

We family doctors used to admit them ourselves if they needed it.  They might be in for four days, but not readmitted.  We wrote or gave the admitting orders for hospitalization and orders every day in the hospital.  At the time of discharge, we wrote the list of discharge medications and the prescriptions for any new ones.  The patient saw us in our office in 3-7 days to clarify their progress.  The admitting history and physical was our work, as was the discharge summary.

What happened?  We left private practice, opting for employment with reduced hours and responsibilities.  Hospitalists were invented as a consequence, to have someone to do the inpatient work in hospitals.  Five or six new processes are used to replace what we used to do, as the system strives for the quality we used to have.

Replacing Family Physicians has been very profitable for many.  Now it's going to get expensive, as the government initiates penalties for re-admission within 30 days.  Profit is the quest of the Medical Industrial Complex, but America is paying dearly with, by some accounts, 195,000 deaths yearly generated by medical errors.  What happened?

Is it fixable?

Dr Synonymous Show: Social Media Geezer

At the Family Medicine Education Consortium, Inc. (FMEC, Inc.) Annual Meeting in Danvers,  MA four of us will present:  "Social Media Nuts and Bolts: For Geeks to Geezers".  It creates an opportunity to reflect on my social media "career" and skills.  This blog post is an overview of much of the content of my part of the presentation.  I will talk about it on my Dr Synonymous Blog Talk Radio Show Tuesday October 18 live from 8-9 PM ET, by clicking on the link below. After that time, the show can be heard as a podcast by clicking on the same link.
The Dr Synonymous Show

My show starts with a welcome, an introduction and a disclaimer.  Who am I? What can you expect/ not expect from the show?
I'm Pat Jonas, MD, a Family Physician in Beavercreek, Ohio.
Background of my show and blog name- Dr Synonymous.   A.P. Jonas ("I am Apple Pie Jonas, synonymous with motherhood and the American Flag")
"Helping YOU to be synonymous with your best health!"

I love being a Family Physician.  I love Family Medicine.  I wanted to write about Family Medicine and couldn't really get it done when I was in an academic or pseudo-academic setting.  Now in private practice and through on-going affiliation with people in FMEC, The Center for Innovation in Family and Community Health (CIFCH) and The Ohio Academy of Family Physicians (OAFP), I write something almost daily.  I have two blogs, one about Family Medicine, Dr Synonymous and one about life in the small town and community in which I grew up, Set Our Hearts at Liberty.

Patient blogs are the first part of my broadcast each Tuesday.  Without patients, doctors are useless, so I like to honor patients through my writings and my show.  A list of individual patient blogs that I read regularly is on my Google Reader, including Warm Socks Warm Socks, Pissed Off Patient Pissed Off Patient, Dr Fatty Finds Fitness Dr Fatty Finds Fitness, Sea Spray Sea Spray-Its a Wonderful Life,  RA Warrior  RA Warrior and others.  Group blogs representing specific types of patients are included on my show, including The Genetic Alliance The Genetic Alliance/, Grieving Dads Grieving Dads, 100 Best Sites for Fibromyalgia, etc.

Medical student blogs are next, often including Future of Family Medicine and Adjacent Possible Medicine.
Physician blogs follow, often including Common Sense Family Doctor and AFP Community Blog both by Kenny Lin, MD, and The Singing Pen of Dr Jen. by Jennifer Middleton, MD.  Lastly, I include my post(s) from Dr Synonymous.

Mike Sevilla, MD (aka, The King of Family Medicine social media) was a major role model for me to learn about social media.  I followed him on Doctor Anonymous and Family Medicine Rocks/ on his blog and on Blog Talk Radio.  He helped me to understand how to play, learn and teach through social media. Facebook was my first social media entry point, followed by LinkedIn, Twitter, My Space, Blog Talk Radio, UStream, Military.com, OSMA, etc. on to Google +.

Twitter.com/@apjonas is where I learned about Twitter and Tweeting followed by Tweetchats (first by #hcsm on Sunday nights, then #MDChat, then by starting up #FMChat with @MikeSevilla, @mdstudent31-now @BernieMD31, @RichmondDoc and hosting the chat once).

LinkedIn caught my membership in 2006, but I didn't populate it with my information until 2009 and integrated it with my tweets and blog in 2010.  Now I use it for professional connections across many career fields, including Family Medicine, hospital, college and medical school connections.

I'm speaking about these items and more as a legitimate "Social Media Geezer" on The Dr Synonymous Show, this blog post, on Twitter, LinkedIn and in Danvers, MA this weekend.  I hope you'll join me.

Family Medicine: Observations by a Family Doctor

Observations by a Family Doctor in my office:  Shingles in retired parent giving Chicken Pox to adult offspring.  Strep throat presenting as conjunctivitis.  Diabetic addicted to starches causing increasing HgbA1c.  Low Vitamin D3 levels in over 50% of patients tested in my practice.  Renal Insufficiency in a lot of patients after treatment for edema of legs with diuretic.  Lisinopril causing a lot of people to cough or to have elevated potassium. 

Warts, papillomas, skin tags, cuts and abrasions abounding as the weather becomes more tolerable.  Sinus congestion with mucous excess from "ragweed day" on August 15 until the first frost.

 Some aging couples are so close as to be almost inseparable.  When one of them dies, the other becomes empty and miserable, sometimes leading to the demise of that person.  Loneliness isn't good for human health. James Lynch wrote a book about this subject titled, The Medical Consequences of Loneliness, which validates the title well.  People need people.  People need responses from other people.

Children like to imagine and play, if given the chance.  We have a child's kitchen/cooking station with oven, microwave, plastic food items and a baby in one large exam room.  Three to ten year old children tend to actively engage in play around the kitchen activities.  Some children manifest a deep caring for others with an intense desire to share.  After age twelve, it's rare to see or hear of these traits in the children I see.  A clear exception is the home schooled children.  They continue to engage, plan, imagine and speak of it somehow in the course of a well child exam.

Two or three times a month I see a "stay at home" Mom.  Once every four months, I see a "stay at home" Dad.
  
Just a few observations.  People are always interesting, even in a Family Doctor's office.

Family Medicine: Patience

Patient 1. Married to the pushy fellow who only comes in when forced to see the doctor to get his prescriptions.  That's right, he is just using the doctor, he doesn't want me to think, just write and don't talk (but we hope for an opening to be helpful and we're helping his wife).  Usually, if we stay committed to his well-being, we'll get to know each other a bit and we'll connect.  Patience.

Patient 2. Oops, she forgot her husband, supposed to be  two persons coming in today, but husband, barely able to function after cancer surgery one year ago opts not to come along.  What to do?  I thought we were responding well to his fatigue with disability recommendation and parking placards for disability parking.  I want to see him, examine him and recommend strategies to get the realignment with his life that he was desiring.  Patience.

Patient 3.  I open chart, see vitals and chief complaint:  HTN, Allergies, Cholesterol.  Abnormal EMG and NCV.  Does he have diabetes ?  He tells a huge story about a work situation which is being cared for by an occupational medicine physician.  OK. Can we clarify what your reason was for making this appointment?  We need mutual agreement on his goal for this visit.  OK, the purpose is his concern that his test result means that he's becoming a diabetic.  "When is your next health oriented regular office visit?", I ask.  I'm trying to clarify our focus and boundaries for this visit.  We'll get there.  Patience.

One patient at a time, we learn to have patience.  Patience for our patients.

Family Medicine: Simplifying Complex Decisions for Complex People

While interacting with my first patient of the day, a knock at the door interrupts us.  "Dr., there's a doctor on the line from the hospital."  I excuse myself from the patient engagement and take the phone line off hold, noticing the quick greeting by the hospitalist caring for one of the sickest people in my practice.  We have a discussion about the dire prognosis and challenge of getting the patient to engage in a discussion about end of life decision making.  My patient already would qualify for hospice services, but she blocked the discussion about end of life decisions when I brought it up three or four times previously.

My hospitalist friend and I agree on a plan for my patient to consider.  I've spoken with him on several occasions about challenging patients and clinical decision making.  He's very enthusiastic and intelligent, which I appreciate, as do my patients.  And he cares about them as people.

Since we can't be everywhere at one time, we have to share medical decision making with others, especially including the patient.  How does that happen when they're exhausted and confused in a hospital bed?  How might we humanely move ahead with an end of life discussion when the patient might be delirious and the personal physician has handed off the acute care of the patient to the hospitalist?  How might the complexity of the patient-physician relationship over several years be transmitted into the discussions between patient and hospitalist?

It's difficult, but it's what humans do in our complexity- be human as the major simplifying strategy.  Humanity serves as a simplifying concept in situations such as this.  We care and we share in the context of our mutual humanity.

Family Medicine: Trends in My Office

1.  Immunization Discussions:  Getting longer. Parents (Usually Moms) who had delayed initiating immunizations for a child are signing their child up for vaccines, building into the required immunization schedule starting with one or two combination immunizations, with sensitivity to family history and context issues (who is on chemotherapy, pregnant or otherwise vulnerable?).  None ever mentioned any concern about the British publication about MMR.  Many don't agree with the varicella vaccine mandate (chicken pox shot) due to their personal and family history of a benign experience with the chicken pox.  Well child visits are expanding in time needed for education about vaccine preventable diseases.

2.  Increased Numbers of Thyroid Abnormalities:  More men with elevated Thyroid Stimulating Hormone (TSH) than usual and increased numbers of women.  They were experiencing fatigue, hair loss, dry skin, swollen neck and fluid retention.  It seems that they reduced their salt intake leading to decreased iodine ingestion.  Recent surveys of salt products found lower levels of iodine than expected.  This is a key ingredient in thyroid hormone production.  Many patients had shifted to use of sea salt for cooking.  Sea salt typically doesn't contain iodine.  Sea salt and iodine advised the patients who had decreased iodine intake to take kelp tablets which are loaded with iodine.  An excellent article from Life Extension magazine October, 2011 issue just happens to discuss this problem.
The Silent Epidemic of Iodine Deficiency

3.  Unusual diseases:  About 9% of patients in a family physicians practice have unusual or rare diseases.  These are interesting and often challenging.  One interesting site to use for reading about rare diseases that have a genetic basis is OMIM, listing over 12,000 single gene disorders. Online Mendelian Inheritance in Man.

More later.

Family Medicine: Pain

The Family Physician cringed mentally as he wrote the prescription for Percocet 5/325 #240 (two hundred forty).  Take one or two every four hours as needed for severe pain.  The patient had five years of low back pain, two before the surgery and three after, with numerous therapies and medications initiated and many rejected as inadequate or overly generous with side effects.  Long acting opiates yielded unacceptable brain side effects for the patient, not noted with short acting opiates.  The patient lost jobs and insurance coverage three or four times during our five year engagement so far.  Three trials of physical therapy seemed to be thwarted by the low back pain, loss of insurance and missed appointments.

Allodynia, hyperalgesia, palpable muscle spasms quadratus lumborum and paraspinous muscles.  Mid line tenderness is minimal at L4-5 with right sided tenderness of sacroiliac joint.  Straight leg raise positive on right at 45 degrees.  Deep tendon reflexes - 2 plus and equal knee jerk bilaterally.

The physician reflected on the low back pain in the patient's father, also a patient in the practice, who followed a similar course with low back pain in 1995, including several years of opiate therapy and two years of total disability.  How did his father get out of the pain situation?  He experienced a sudden priority change when his father died and mom needed a caretaker in his family home of origin.  Within two months he was off the Percocets and into fitness, church, vitamins and supplements.

Many Family Physicians are frustrated by patients with chronic pain who become "energy vampires" or get stuck.  Many are also tired of doing the "tough love" by confronting the behaviors of patients like the first one above to finally get them into physical therapy or other supportive strategies or even terminating their relationship if appropriate.  How will the next era deal with these patients?  And these doctors?

What experiences have you had with either side of the patient-physician chronic pain relationship?  How can it improve?

Family Medicine: Do Consumers Need Consumer Coaches?

When I'm with a patient, I'm a human first and a family doctor second.  I consider them to be human first and patient second.  As they shift their roles, I'm often a consumer coach, a safety advocate and a small business owner.  How do we get anything done shifting through several roles during encounters with patients?  Does each member of the dyad know which role they are manifesting at each moment?  I don't think so.

Should we both have signs that identify our roles as we progress through each office engagement?  Will we each understand the other better if we know when roles shift along with expectations of each other?

The identity confusion is one of our problems in Family Medicine these days.  We are generalists who care deeply about people.  How should we address this issue?  Do consumers need consumer coaches (concurrent with family physician role or separate)?

What do you think?

Family Medicine: Pancreatitis, Gallstones and the Differential Diagnosis

The patient has severe abdominal pain and nausea after supper.  It's unbearable so they get the spouse to drive them to the local ER.  In the ER, the patients pulse rate is 110, BP is 136/82, Temperature is 99.4,  weight 152.  The 46 year old patient appears to be uncomfortable, holding the upper abdomen and moaning intermittently.  The physician notes a normal physical exam except for some perspiration on the forehead and upper lip, the tachycardia (without gallop or murmurs) and epigastric tenderness without rebound or guarding.  Rectal exam is negative for occult blood.  Past Medical History is significant for Rheumatoid Arthritis, currently on Sulfasalazine (ssz) orally and  Methotrexate but recently tapered off prednisone over a prolonged period of time.

The ED physician orders some lab tests, IV fluids and opiates (as needed for pain),  and an abdominal CT scan.

IV morphine relieves the pain from 9/10 to 3/10.  Lab results include elevated amylase, lipase, ALT, AST, BUN and WBC (13,500).

The examining physician gets the CT report from the physician in Australia who reads night imaging studies from this hospital.  The report notes several normal elements and comments on several gallstones present in a normal appearing gallbladder without thickening of its walls or other evidence of inflammation of the gallbladder.  The pancreas appears normal, but the mid-portion is blocked from view by overlying intestine.

The patient is admitted to the hospital and undergoes evaluation by a gastroenterologist, a general surgeon and a hospitalist, who was the admitting physician. The rheumatologist does not come to the hospital, but was called by the hospitalist to discuss the status and treatment of the RA.

Five days later, the patient sees the family physician in the office and relates the story of the hospitalization.  "Have you ever had an NG tube in your nose, Doctor?"  The patient begins.  "And people analyzing everything coming out of your body for exact fluid content?  Do you know how inefficient hospitals are?  Three different people asked me the same questions on the night of my admission.  It was like the clipboards from Hell.

The doctors said I had pancreatitis.  I survived and got the tube out of my nose.  The surgeon wanted to blame my gallbladder for the pancreatitis, but the gastroenterologist gave it a clean bill of health, at least for now.  The surgeon suggested surgery and the gastroenterologist suggested changing one of my RA drugs.

I'm not excited about surgery and I feel horrible if I don't get that drug.  The rheumatologist said there was an extremely low likelihood that the drug caused the pancreatitis.  What do you think?"

Health System time out: The Family Doctor used to do all their own admitting, but the hospitalist movement and increasing employment of family physicians by hospitals has dramatically decreased the percent of doctors admitting their own patients.  So the patient doesn't know the admitting physician or the consultants.
    
This decreases the patient's trust and belief in the information received.  The stress of the situation from abdominal pain, the NG tube in the nose and down the throat, the loss of privacy with the counting of intake and output of fluids, the excessive repetition of the same administrative/billing questions, and the general sense of uncertainty about what's going to happen is overwhelming, increasing the patient's discomfort and fear.

So how does the personal family physician of this patient respond?  First is to show respect for the human who is also the patient and to reaffirm the patient-physician relationship which already includes an element of trust because of past interactions.  Next is to listen to the patient's story, honoring their humanity and recognizing their suffering.  Responding to the feelings expressed during the story helps to protect the patient from flashbacks to loneliness and fears experienced initially in the hospital and validates their view of their experience.

The family physician has already seen the hospital reports and the discharge medication list in the fax or EMR via the hospital relationship.  They now think of the natural history of all the pathologic processes and phenomena noted in the hospital as well as the RA.  They seek to detect where the patient is on those natural history time lines, determining further information needed by way of further history, physical exam, laboratory testing and imaging if indicated.  They know that it's not over for this episode of sickness.

While the pancreas has calmed down, the gallstones aren't going to disappear, so the physician will inquire about the patients impression of the surgeon's comments about the cholelithiasis (gallstones) and gallbladder, later comparing that information with the final discharge summary dictated by the hospitalist. "Cholelithiasis" is added to the patients problem list by the family physician for future reference.

All of this information is filtered through the patients personal values, goals and dreams in their living, learning and working worlds.  Yes, it is complex, challenging and even fun.  The patient gets to make the decisions, so the family doctor has to do this medical mental work (including the development of an ongoing differential diagnosis for both the pancreatitis and the cholelithiasis- maybe using SPIT) in the overall context of the patient via the biopsychosocial model, explained in a post last year.  Using the Biopsychosocial model to detect.

The family physician has seen thousands of patients and filters the patient situation through many similar experiences and their understanding of the medical literature to offer their best insights about what may happen with each of the patient's options relative to this illness.  Their knowledge and experience becomes a resource for the patient, whose interaction with the physician in the context of a trusting relationship enables a refreshed perspective on their options.

Human to human, patient to physician communication enables the dyad to move ahead to develop a follow-up plan.  What do you think?

Family Medicine: The Differential Diagnosis

How do Family Physicians analyze patient complaints?  Traditionally, the Chief Complaint (CC) is the driving force in the patient's and doctors minds.  The physician will listen to and expand the patient's story to develop a differential diagnosis, a list of possible causes of the CC.

I like to start with a four component acronym to cover four types of possible causes for the CC:  SPIT, which stands for Serious, Probable, Interesting and Treatable.

What is Serious (potentially causing loss of life, limb or a significant life function) that could cause the CC?
What is Probable (given the patient's life situation, age, gender, work, exposures, etc.) that could cause the CC?
What is Interesting (unique or novel from the physician perspective or the patients theory of causation- very important if they have a theory about the cause) that might cause the CC?
What is Treatable (responsive to a known therapy) that might cause the CC?

How does this fit into the Human Centered Health Home (HCHH) that I've promoted in this blog?  Here's an expanded explanation from a post in November of 2010:   Using SPIT in the HCHH

From the simple SPIT Acronym, the thinking may get more focused before expanding again as the physical exam is performed to further clarify possible causes of the patient's CC and lead to revision of the SPIT list.  Many other mental models and decision aids are used by Family Physicians from time to time as they engage a wide variety of patients.

How do you like to think about causes of symptoms, illness and disease?