Human Centering: Mutual Respect Opportunity in Health Care

Human Centering (NHBPM Day 29)

(Published first by me in Wego Health NHBPM Challenge 11/30/2011.  Click link above for original post.)

As the stress mounts in the health care (non) system, involved persons such as patients and physicians will need enhanced communication skills to effectively communicate with each other.  Physicians are getting more distracted by technology and reporting mandates (also known as quality initiatives) while patients are getting more distracted by their fading finances and increasingly convoluted rules of third party payers such as insurance companies, employers and the government (tax payers).  

In the Family Medicine office setting, how is this enhanced skill possible?

One strategy is called human centering.  Since family medicine is relationship based instead of disease or part based health care, the human connection between patient and doctor is worthy of extra consideration. How does this dyad establish and maintain the patient-physician relationship?  One way is by focusing on the human aspects of each other first.

What values of the patient and the physician overlap?  How might they reveal their humanity before shifting to the role of patient and doctor?

First, it helps to realize that each member of the dyad shifts through a few different roles before, during and after the office encounter.  These roles might include human, learner, teacher, friend, patient, physician, consumer, consumer coach,  and others depending on the context and flow of the interaction.  

A simple greeting including eye contact, positive facial expression, verbal greeting which includes the name of the other person, and sometimes a handshake provide an opportunity for human sharing before therapeutic connection is established.  Assuming an attitude of respect and curiosity about the other person affords an opportunity to better share information.  "When did you start the beard, Dr. Jonas?" is specific enough to take Dr. Jonas out of his physicianly, trance-like state.  Using the person's name is a not-so secret approach to shifting the dyad out of focus to redirect it toward another subject.

Expressing appreciation for something done by the other or teaching the other person something are useful ways to seek human centering for the dyad.  As they learn from and about each other, they can build respect and appreciation for their individual and shared uniqueness.  As they expand their understanding of each other, their shared humanity becomes an anchor upon which to allow probing questions of each other, including expressions of doubt and fear.  This anchoring may give extra protection of the dyad from less desirable (money sucking or risky) encounters with the less useful aspects (such as unnecessary radiation exposure or avoidable expense) of the Medical Industrial Complex.

The humanness of the individuals in the dyad delivers the base on which enhanced health and patient safety allow better mutual exploration of subsequent confusing clinical information.  The initial human centering allows the dyad to become a decision making unit of considerable quality.  As patients and physician allow their humanity to mutually connect, human centering initiates a higher quality clinical interaction, decreasing the potential for harmful, costly or dangerous clinical decisions.

Family Medicine: Peer to Peer Review

First thing this morning, I called pharmacy review for a health plan Re: One prescription written for the last 2 1/2 years for one of my patients, their "client".  I called them last week to get permission to set up a time to talk to this person.  Patient was without chronic drug for one or two days at risk of serious symptoms, often requiring emergency care to treat.  "We don't cover that drug for the purpose of managing chronic pain."
That's interesting since my patient had no life potential on five other medications and now has a life on the drug you won't cover.

Me:  Here's her story, "...".
"OK, the drug is approved, in light of that information, for six months."
" How about a year since her condition is chronic and stable if she takes that medication?
"No, we only approve it for six months."
"I'll pray for her to get a miracle, otherwise, I'll talk with you in five months"
"OK, but then you only have to send in the appeal form you initially sent us for the prior authorization, including the information you just told me."
"That information was on the form and told to your staff three times in the last five days by me and my staff."
"Yes, but now we understand what you meant (by speaking the words my writing suddenly had meaning for them)."
"In Canada, my patient would have been approved for life for the medication."
"Yes, but we're different"

Soon thereafter, I entered the room of my first patient of the day.
Knock, knock at the door, which I answer,"Dr Jonas, there's a pharmacist on the phone about the pain killers for ........  They want to clarify a few things."
"Here we go again,"  I think.

Ten minutes later I re-enter the first patient's room and apologize for the second interruption in our meeting.
A friend of mine had over 75 patients with the need for him to beg to continue the first drug mentioned above.  He could call for about five patients at a time, even though he had a list with all their names and offered to submit the whole list.

Who will fix our broken, bankrupt system?

Humans Versus Technology: Who Wins?

"The most exciting breakthroughs of the 21st century will occur not because of technology but because of an expanding concept of what it means to be human."...Naisbitt and Aburdene in Megatrends 2000 (copyright 1990).

Did we get our concepts expanded?

So, twenty years later, we're seeing the next wave lean back toward technology as techno-wizards map our every behavior to identify our tribal membership and note our other "proclivities" to market items or lifestyles to us (from The Numerati by Stephen Baker). How is our "expanding concept" of humanity doing with that?

Even in health care, which used to be about health and caring, and now is deteriorating into healthcare (new business models, phony quality initiatives and ringing cash registers), we're deluged with new techno-geek strategies to de-humanize all former humans such as patients and physicians.   After all, healthcare has little to do with humans in the newer thinking. It can all be broken down into numbers and made efficient.  Those who are not getting more efficient will have to move out of the system.  And go where?

Those people will be expelled from the government system into socially or spiritually managed health systems, that will be devised by marginalized humans.  These humans will realize that Naisbitt and Aburdene were right about them, but not the vast majority of citizens who were swept up by technology.  The rejected people will be served by rejected physicians, nurses, mental health professionals, social workers, personal trainers, pastoral care professionals and financial advisors in cohesive teams of humans.  How will these inefficient people fare?

                           

Autism People and Survival Activists are Good Antidotes to Football Blues

Football suddenly sucks out 50% of my mood with our Buckeye loss to Michigan, when we could have won it a couple times.  The new era is half way upon us with the coach and several players gone from the "tattoo and memorabilia" and "pay for no work" scandals. Intense game, though.  I went to the screened in porch to watch the birds, hide from the next wave of games and listen to non-sports talk on Blog Talk Radio (www.blogtalkradio.com).  Preparedness Radio is a great series on BTR about survival strategies.  Today they talked about grinding your own grains with various devices, one of which is a show sponsor.

Another show, Autistic People,  had a discussion about persons with autism spectrum disorders.  A very talented theater arts teacher/performer was the speaker who deftly engaged those of us in the chat room for some of our opinions.  She lives in Canada which has a different strategy for government support of persons with disabilities.  People "on the spectrum" and others will enjoy her insights and find her comfortable to share with.

My mood is returning nicely after a couple hours on the internet with my BlogTalkRadio friends.  They signed up as followers for my show (www.BlogTalkRadio.com/DrSynonymous).  There are hundreds of interesting shows for you on BTR or other internet radio channels.  I enjoy listening and learning.

Oh, I made rounds in one of my hospitals this morning.  It's always interesting to interact with other professionals in the hospital and see patients and their family members.  I have to decide how much in-patient care I want to do when the new Soin Medical Center opens in February 2012 next door to my office.

I'll make rounds again tomorrow after church.  Maybe we should go to Roosters for lunch on the way home and make a family outing of the opportunity.

OK Buckeyes, we're done with "Tattoo-Gate", let's move ahead with a new coach next season and Beat Michigan.  Maybe I should take up my banjo again and play on the porch during OSU football games to stay upbeat.  There haven't been any recent tattoo scandals in banjo players.

Better yet, I should shift my priorities toward the diverse array of important issues delivered through Blog Talk Radio free of charge, 24/7.  Learning more will be good for my health and that of my patients.

Family Medicine: Relationship Based Care for Patients with Chronic Disease

Family Medicine: Relationship Based Care for Patients with Chronic Disease

Family Medicine: Pain is a Ten Point Game

Pain Pseudo-Factoids from a prescription pad holder (physician):

1.  No Brain, No Pain

2.  Pick the right parents, or have more pain (and more risks with opiates- for dependency, misuse or abuse)

3.  If your pain is a ten out of ten and you are not writhing, doctors won't believe you

4.  If your pain is an eight out of ten and you grimace, doctors will probably believe you (see migraine exception #7 and Fibromyalgia Factoid #13)

5.  If you get IV Morphine or Dilaudid in the ER and your pain loses 4 points or more (e.g., 8/10 drops to 4/10 or less) and you so state, doctors will usually believe you (if you say "thank you" to the doctor)

6.  If your pain is a six, you should get at least 2-4 points less with hydrocodone/acetaminophen (Vicodin type generic), surprisingly to opiate fans- Ibuprofen 800 mg has equal pain killing potential for those who picked the right parents (see #2)

 7.  If you have migraine headaches (who decided to use the word ache instead of pain?, by the way made a huge mistake) and smile when you tell the doctor your pain is an eight, they will believe you if they or a close relative have migraines

8.  If you require huge amounts of dental "numbing" injections when you have a filling at your dentist, you may have picked the wrong parents (see #2)

9.  If your pain is a four in the doctor's office and a six at work or while carrying your baby, inform your doctor of the pain level variances to help them understand your pain range.

10.  Pain never stays at the same level continuously in the medical world.  If you give a doctor a range for your pain variation, you are speaking our language and we hear you better.

11.  At every doctor visit for chronic painful conditions, be prepared to deliver your pain numbers on a scale of 0-10, which more and more has to be written into any note that involves prescriptions of opiates and other pain killers.

12.  The fear of the pain may be equal to or greater than the impact of the pain on the pain sensations.

13.  If you have Fibromyalgia, 50-75% of physicians will be confused about how to respond to your pain  comments. (it used to be 99%)

14.  Blogging about conditions that include a chronic pain element helps the medical community to get a better understanding of what  life and activities are like with chronic pain. Thanks to all you bloggers with chronic painful conditions.

Family Medicine: What are We Doing? Why are We Late?

As a Family Physician (FP), I see miserable people every day.  They may be acutely sick with expectations of getting well soon, with some help from me (or just a note saying they can't work for a while).  After clarifying their history and doing a focused physical examination, I make some comments about the natural history of their affliction, negotiate a treatment plan- sometimes just validating their strategy  and congratulating them for knowing themselves so well.  Other times they just want me to be a leader or commander (less than 5% want commands now days- used to be 50-75% in the 70's and 80's- the "old" days) and advise a strategy and watch for their nod of agreement.  The strategy includes plans for any contingencies or follow-up appointment, their next appointment for any prevention or chronic health needs and a comment about an upcoming situation in their life ("I hope you enjoy your Florida trip to see your mother", etc.).

About 25% of my patient interactions relate to these acute illnesses as the primary reason for the appointment, with 98% of those patients adding extra problems of an annoying sort (to the patient) after they are in the exam room.  Those problems seem to be about 25% "reassurable" on the spot and 75% needing a more in depth evaluation, half of them needing another visit to actually evaluate and treat medically.  The patient often wants to push for the extra time immediately, giving me the opportunity to act medically (which has its own set of rules and legal implications) or engage in an often uncomfortable negotiation about the importance of practicing medicine in a medical way as the legal system and the profession expects.

The add on problems constitute the major reason for physicians in Family Medicine getting behind in their schedule, since many of the add-ons that the physician opts to respond to NOW are mental health issues which are complex and require extra listening.  Brain problems and life problems are the next major set of "time in the schedule" challenges.  These and the NOW issues usually relate to depression, anxiety, situational reactions, opiate use or abuse, substance abuse or dependency, chronic pain, grief reactions, marital distress, etc.  Our caring about people as people may often add to the "inefficient" way Family Physicians respond to these complex issues.

Now that Family Physicians are being sucked deeper into the Medical Industrial Complex, by corporate employment, to feed patients into the corporate profit centers, there may be increased efficiency and a lot less response to mental health and life stresses.  The owners of the contracts of those employed FP's are pushing for more numbers and fewer stressed patients. Time will tell if the MIC wins over the health needs of patients, or if the patients educate the MIC to respond better to their needs.  More later about the changing system, much of which is better than our current system, much of which is less safe, all of which seems more expensive to our society.

What do you think about current and future response to your primary care needs?

Family Medicine at Thanksgiving: I'm Thankful for People. They are Great

People are great.  I interact with 22-35 people individually or in groups of two or three (when several family members are present in the exam room) each day in my Family Medicine Practice.  This week is extra interesting because of Thanksgiving (TG).  These folks are fascinating. They each have a worthy life story, focused on the encounter with their family doctor to achieve a specific end point (less pain, more function, etc.).

During this month of November, I'm interested in how they will manifest, enhance or diminish their family strengths and values.  What are they doing for TG?  What will their role be in the family gathering?  Who cooks what and who does what as part of their various traditions for TG?  What roles are changing for our more senior patients at TG this year?

Who is infected and contagious for TG this year?  Who is still angry at their sister for bringing the sick baby to last year's TG, but possibly bringing an infected toddler to the family gathering this year?  Who feels bad about going of town, missing the usual gathering at their brother's home?

Who just got their flu shot and wants it to be effective for the Kentucky trip this year?  Who just had Flumist nasal spray for their flu immunization and wants to know how long they might be contagious since grandma is on chemotherapy for her breast cancer?  Who is on medication for Strep throat?  For Shingles?  Are they contagious?

Who is a great shopper, intending to shop at midnight on "Black Friday"?  Who is a great football fan that can't wait for the day after TG for college grudge games? (Ohio State vs Michigan, anyone?)

We Family Physicians get to hear about all these opportunities, risks and benefits of family life during this great American Holiday.   It's enlightening and sometimes challenging to respond to all the unique questions generated by our patients and their families.

I hope that you have a wonderful Thanksgiving Day and weekend, remembering to GIVE THANKS for your blessings.

What questions do you have (for your doctor)?

Becoming a Patient Again for the First Time

When you are a patient, how do you act?  What do you do?  What's changing for patients?

OK, so we all know how to be a patient.  Get sick, get worried that it's not going away or could be serious or could severely impact a chronic disease we already have or alter our life or work activity. Treat it with non-physician strategies.  Call for an appointment.  See the doctor.  Answer questions, get examined, listen to a treatment plan from the doctor, clarify ability to align with the plan, check out, pay co-pay, make next appointment for follow-up of this condition or chronic ones or prevention needs.

Think about how you'd be a patient if time and money were no object.  Think of the circumstances under which you would feel totally satisfied by your health and health care strategies.  Think of modern technology and modern communication.  Imagine how these might fit together to deliver you to your best health and well-being.

What health supports and attitudes would you expect from your healthcare professionals?  How do you want the system to best support your needs?

Do you want email, faxes, texts on your cell phone, Skype, YouTube videos or personal contact to be included in the array of health communication supports for your upgraded patient status?

What data about your health and healthcare do you wish to be shared with others so incentives can be doled our for "quality initiatives" for you, your health care team and others?

When would you like to know about the "end of life" and how your nearness to it determines some of the benefits of the system you are imagining to support your health?

Think on these things and post your comments below, as you wish.

Holistic Health: Thanksgiving Health and Eating Plan

Did you know the Surgeon General has declared (several years ago) that families should review their Family Medical History (FMH) on Thanksgiving weekend?  The Surgeon General's Family History Initiative is the ongoing program to inform and support families in their search for information about their medical history.  Here is a web site that included helpful information for families:  Family Medical History Initiative

I inform countless patients about this initiative by the Surgeon General, also suggesting the day after Thanksgiving for the family focus, to minimize distractions about disease and body parts on Thanksgiving Day, if possible.  "If someone spews incessantly about their intestinal problems while eating the turkey and dressing, it may help to remind them to save their comments for Friday at 1 PM when we'll all review the FMH",  I suggest to them.

Many lose track of healthful eating and disease prevention strategies on Thanksgiving Day.  To them I say, remember Five, Five and Five:  Eat five servings of fruits and vegetables and five colors of food daily. Remember five major prevention strategies:  Control your blood pressure, control your weight, control your cholesterol, exercise 30 minutes four days weekly, and reduce unnecessary stress.

Remember five and five and five and the Family Medical History Initiative of the Surgeon General to have a healthful Thanksgiving.  Happy Thanksgiving!

Patient Safety: Excessive Use of Radiation by Physicians on Patients

"

Dr Synonymous 1 year ago

"A key to decreasing excess use of CT scans is informed consent. Look for a consent form to inform a patient about the risks and benefits of the CT scan you are ordering or they are getting. You won't find one in the two hospitals I use for admissions, nor the local children's hospital. I've spoken with ED physicians, hospital admin people, radiologists, nurses and patients about this. Who will take responsibility for being more neighborly (honest) with our patients? 

The marketing team from Children's Hospital came to my office to market expanded CT scanning potential and I asked if they had the consent forms yet for parents to sign before CT scans on their children. "No", was their answer- two years in a row. "Please tell your radiologists, starting with the chief of radiology that I will not order any CT scans until I see a copy of the consent form that my patients parents will see and sign before their child receives radiation of that magnitude."

Fellow physicians, wouldn't it help if the public knew ahead of time about radiation, so gradually they would have a better understanding of benefits and harms of diagnostic imaging?"

My comments above from 2010 in response to a Kevin, MD blog post are still a call for better informed consent.

As the new Soin Medical Center opens in February 2012, will they lead the way in the Dayton, Ohio market with informed consent for CT scans done in their ER?  Or fall in line with others who let the patient find their own lists of benefits and harms of the CT scan they are about to receive without giving informed consent?  I hope the leadership of the Soin MC take the high road for Patient Safety.

Breathe Life into an Aging Health Care System One Relationship at a Time

 It's time to move ahead with patient training to help get health care into the next era.  I submitted this overview of a workshop for a conference with Breathing as the main theme.

A Workshop with A. Patrick Jonas, MD, Holistic Family Physician

Introduction:  There are many dehumanizing aspects of the modern health care system. People in the system need to reconnect with people as humans first, patients second.  Patients can take the lead in rejuvenating the system one interaction at a time.  Starting with their humanity, they can avoid the patient role until they connect as equal humans to their health care connection person, such as a physician.

What breath strategies may lead to a better Health Care System?

What about shared breathing, two persons at a time.

Healthcare human dyads which breathe together in peace may become patient and doctor in a cocoon of shared problem solving and planning that creates the next era in Health Care.  Human centering through breath can launch trusting, empowered health dyads to lead the way, from human to human.

Dr. Jonas will Review the current situation in health care and patient-physician relationships and explore perspectives of attendees from their recent experience.

He will overview a Human Centered Process to breathe new life into patient-physician dyads.  Attendees will connect to the six step process via discussion, role play and dyadic interaction.  They will expand their ability to

Breathe to increase their ability to:

Respect:

 Self, others and systems

Protect:

            Self and others

Connect:

            Self with others

Detect:

            Alignment and Misalignment with values, goals and dreams

Correct:

            Misalignment

Reflect:

            On self, others and helpful processes

Blogging in Bed

Avoid blogging in bed.  Back pain, laptop slides around, arm fatigue.  Short post today, folks.
What's going around?  A flu-like virus, new insurance plans, hypothyroidism, ill people at parties.
Duck if you're around parties.
More later.  Pillow wants me asleep.
Thanksgiving Day in 9 days. Don't forget to review your Family Medical History the day after Thanksgiving, per the Surgeon General's recommendation.
Goodnight!

Family Medicine: Night Call

On call tonight.  Someone calls, tells their story and I make a recommendation for home action, we clarify the plan and agree on it.  I call the ER at  the hospital closest to the patient to let them know that my patient may be coming.  I speak with ER physician, letting him know something unique about my patient in the context of sharing clinical information.  I ask ER physician if they are seeing similar patients with these symptoms.  He notes that he's seen four tonight and he'll take care of my patient.  I am pleased.

Another calller with concerns about their adolescent child. I ask some questions after listening to the mother's observations of her teen the last few days.  I need to clarify the level of intensity of the illness and the threat to the patient's life, parts, ability to go to school tomorrow, need for follow-up, etc.  Does he need to be seen tonight or tomorrow?  Is he safe?  If tonight, which ER or urgent care are we suggesting?  If tomorrow, do I have a specific time to offer an appointment?

Sign of the times:  both callers left a cell phone number on our answering system.  One of them didn't answer, so I left a message that I would call back in 3 minutes.  I called back in 3 minutes- no answer again, so I left another message.  In 3 minutes, when I called again, they answered, so we conversed about the situation with the illness.

Sometimes when I'm on call, people will call our number, leave their message on the voice mail and forget to leave their number.  Sometimes one of us will lose phone contact due to holes in the phone coverage.  Lots of interesting cell phone situations occur.

Sometimes the caller is trying to convince a very sick loved one to go to the ER late in the night.  Often we can be of help by talking to the sick person and informing them of our relationship with the ER doctors, providing a little continuity message to the patient and transferring the patients trust to the emergency department physician and staff.

The advent of videophones could make night call more effective in those situations in which the patient has a viewable problem, like a rash.  Technology will help us to be more and more effective, leaving more time for patient interactions on night call.

Holistic Health: Breathing and Patient Care

While taking several classes in holistic health techniques, I noticed that breathing was a component of many skills as a step or continuing element in the particular therapy.  There are hundreds of complementary and alternative practices used around the world for various health purposes, many of which include a breathing element.

As a Family Physician, however, I'm not generally in a complementary or alternative practice mode.  I'm relating to people of all ages about their life through their five senses and the biopsychococial model in a family context.  Some aspects of breathing, though, fit nicely into a lot of what I do in relation to my patients, even in a mostly "normal" family medical practice.

What role does breathing play in my daily practice activities?

Preparation.  Focus.  Connection.  Rapport. Relationship.

Preparation:  Take three deep nasal breaths, focus on the heart, while allowing the abdomen to expand with inhalation and then appreciate something external to you, such as a situation, a past experience or a future experience.  Those three steps, from www.Heartmath.com allow a calmness to float through my medical countenance.  My blood pressure and heart rate are reduced.  Then I shift my thoughts to the next patient.

Focus is easier, especially shifting to the next patient.  Breathing with the patient's pace of breathing can enhance rapport by entrainment of rhythms.  All of these steps support the patient- physician relationship.

Family Medicine: The Quest for Wholeness

Many times in our lives, we'll seek wholeness or a sense of oneness with who we "really" are.  These identity quests can be enlightening, overwhelming, devastating, and/or satisfying.  As we interact with other people, we would like to deliver our whole self to the engagement.  Unfortunately, that is seldom the case.  Mis-alignment with our whole self speaks to the numerous distractions that we notice almost continuously.  Our whole self often eludes us when we'd like to show our best self (or at  least, put our best foot forward) to others for special situations.

A case in point is people who go to doctors and want to look, sound and act sharp for their physician.  In my Family Medicine office, we often have people call to cancel appointments because they are "too sick" to see me (their family doctor).  "I'll call back and reschedule my appointment when I'm feeling better," they say.

My medical training offers lists of ways to seek wellness via good medical prevention:  Exercise for 30 minutes five days weekly, eat five servings of fruits and vegetables daily, control your blood pressure, control your cholesterol and your weight (now we may comment on your body mass index, which is about the same thing).  I most recently heard an excellent talk to this effect by Dr. Colin Kopes-Kerr in which he reviewed the science behind these five main recommendations for good medical health, which is the best way to prevent early demise from common chronic diseases.

The World Health Organization has another perspective on the meaning of health.
Definition of Health by the World Health Organization :
"Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."  The word "complete" in their definition makes it beyond what I could commit to as a Family Physician.  The patient may commit to COMPLETE physical, mental and social well-being, but it's not covered by their medical insurance.  That definition, though, would get closer to wholeness.  It is a goal that is achievable from time to time for brief periods.  It is not a medical goal, it is a personal health goal.


Beyond these concepts, the wholeness I refer to is physical, intellectual, emotional and spiritual (PIES).  Patients may have strengths or needs in any or all of these four parameters, but seldom function at their ideal (personal goal) levels in all four at once.  Physicians may be able to interact with patients about these factors, especially as they relate to their health goals and needs.  Patients may emphasize a physical problem and comment about the emotional impact of it, but seldom mention spiritual issues (often thought by physicians to be a sense of purpose or meaning) unless prompted by the physician.  Patients and physicians both can be trained to better relate to these issues separately as they relate to patient health.


"When is the last time you were yourself?" I often ask patients.  They (adult patients) usually seem to know. That state of being they refer to in response to my question may be as close as I get to hearing about the oneness they once had.  Exploring how they perceived their five senses in that state of wholeness helps me to facilitate their quest for realigning with it for the health benefits.  Still, that may not be "whole" wholeness for many.  


Many patients describe unique states of well-being in their prayer lives, especially some who describe times when they felt one with God while engaged in a religious or spiritual experience.  That experience of "ultimate" oneness is beyond any medical or WHO definition of health.  I marvel when I hear about it or experience something similar, but humbly recognize "real" wholeness as beyond the scope of my medical skills.   

Veteran's Day: Warriors for Peace and our Nation

America and Veterans are friends, partners for peace and warriors for our nation.  This Veteran's Day is special since it includes the most famous Veteran's Day date ever:  11/11/11.  (Even more special at the moments of 11:11 AM and PM.)   The date focus offers an anchor to remember this Veteran's Day for a long time.  Let's make it as special as the unique date.

"The Warrior is the archetype of leadership.  We come into our leadership skills by staying in our power, by showing up and choosing to be present, by extending honor and respect, and by being responsible and accountable."... The Fourfold Way by Angeles Arrien, PhD.

In Arrien's writings she comments that "the challenge of every Warrior and leader is the right use of power."  Warriors have the power of presence, communication and position.  They carry forth mental, physical, emotional and spiritual intelligence that defines their presence.  They communicate with sensitivity to content, timing and context and they are willing to take a stand.

Please note that Warrior is not synonymous with "killer", as many might fear.  The Warrior's willingness to take a stand for what they believe in may inspire others to do likewise, even though they have beliefs that differ from those of the Warrior.

The Warrior mentality is one aspect of officership that is taught at West Point, along with the knowledge and skills to be servants of the nation, leaders of character, and members of a time-honored profession.

At West Point we learned about "Duty, Honor, Country".  Duty offered challenge and tested our strength of conviction.  Could we do what we are supposed to do?  As we became Warriors, Duty became our middle name.  Honor raised our standards and commitment to "choose the harder right instead of the easier wrong".  Country reminded us about our homeland and its citizens, worthy of our efforts.

Veterans had an opportunity to become Warriors as a result of attributes that are taught and used during military training and service.  The role of Veteran adds more to our Warrior mentality and potential to be of continuing service to the nation. This expanding opportunity to serve the nation as Veterans has never been more important than now.

Veteran's Day is a reminder of our opportunities, commitments and obligations as Warriors. Our nation needs more people who will stand up for their beliefs and still show respect for the beliefs of others.  Many are humbled by seeing the levels of sacrifice offered by our soldiers both in modern warfare and over the centuries. The camaraderie, cohesiveness and presence of our Warrior Veterans might be what America needs more of to get a course correction for the confusion invading our nation.

If you need a Warrior, ask a Veteran.  If you need help, ask a Veteran.  If you need a leader, ask a Veteran.  If you need prayer, ask a Veteran.

11/11/11:  Remember and honor our Military Veterans.  Pray for lasting Peace.

Family Medicine: Coherence and Connecting with Patients

Establishing rapport between patients and Family Physicians is an important step in every clinical engagement.  One of the more powerful ways to do this is by using the "Quick Coherence Technique" from Heartmath in Boulder, CA.  The simple three step process is reinforced by self training on electronic training devices such as emWave or emWave-PC.  I have both the handheld and computer-based units.  I just used the emWave handheld device to get "coherent" before writing this post.

Personally distressing situations sometimes warrant a formal response to re-balance the spirit.  I can use several strategies to re-balance, but only the Heartmath instruments give me the message electronically, validating my coherence when I need it validated.  I wrote about it for The Ohio Family Physician magazine last winter for their technology edition.  (It's endorsed by the PGA, too, for you golf fans).  The Ohio Family Physician- Technology Edition (page26)

Check it out at www.heartmath.com.  I love it and you will too.
(I'm not on their payroll either-just love the products they developed.)

Family Medicine: Caring and Working are Clashing

Family Physician (FP) perspective:  Patients call for appointments with Family Physicians for lots of reasons.  They may be acutely ill, chronically ill or chronically well.  The lines between the categories are often blurred.  They blur more when the patient arrives for the scheduled appointment.  The patient has many needs and wants, many of which are "extras" in the eyes of the physician but "mandatories" in the life of the patient and the system in which they live and work.

The FP wants to make a difference in someone's life each day, to help patients to know that they matter.  The doctor wants to feel satisfied that they are still aligned with the desire to help people, not detoured by the avalanche of ever-increasing administrative and regulatory demands on their time (and soul).

The physician is hopeful that the daily schedule will flow nicely, allowing the work to be done.  Helping versus working.  It's becoming an "either/or" for the physician instead of a "both/and", losing instead of winning.  The FP knows that the patient has many expectations, some of which align nicely with the physician's expected work flow, some of which don't.

 How many times a day will the physician feel heavy hearted at not responding to the extra needs expressed by the patient during a scheduled appointment?  How many times a day will the physician respond to a need of the patient beyond that expressed when the appointment was made?  How much guilt and disappointment will the physician build up by the end of the scheduled work day as they get "behinder and behinder" (sometimes getting an extra jolt when the last patient asks for a bit of time to call the spouse about picking up a child at sports practice or day care, etc.) ?

The physician and office staff care about the patient, which sometimes aligns with the work flow and sometimes doesn't.  Caring isn't as "schedulable" as working.  Working and caring sometimes fit like a hand in a glove, and sometimes they clash viciously.  Financial issues, which I've mentioned in numerous previous posts, drive the squeeze.  Big hearts may forget schedules and go the extra mile for the patient.  The push of this era in healthcare (one word = the financial part as opposed to two words- health care which = the human/people part) is often stressful and sub-sensitive.

How might the Family Physician get back on track with actual patient needs as health care transformation happens?  I've posted numerous times about the Human Centered Health Home (HCHH).  The Patient Centered Medical Home (PCMH) is the current national strategy, which has lots of merits.  I'll post more about it later.

What do you think?

Family Medicine and the Human Centered Health Home

What's going to happen in health care as we try to find ways not to bankrupt America with the wrong model of care?  As a Family Physician, I know we need to continue our relationship-based connection with patients, their health and their diseases.  The Medical Industrial Complex seeks to further "widgetize" healthcare into numbers, computers and financially "suckable" elements, ignoring important human elements of patient care.  


The Human Centered Health Home (HCHH) is the broad model I’ve been developing with colleagues in our Center for Innovation in Family and Community Health (CIFCH).   Many holistic skills and the relationship driven aspects of Family Medicine fit nicely into the HCHH.  


The five senses connect the human dyad that assumes the patient-physician roles.  The overlapping energy fields of the dyad allow further connection. 


How do they develop and enhance the healing potential?  What type of partnership evolves for the dyad that grows to neighborly proportions, powerful enough to protect the pair from the unsafe aspects of the Medical world?  How does the pair allow exploration of new and unusual strategies for health maintenance and responses to chronic and sometimes fatal conditions?  How do they learn to respect and honor each other in the context of their shared and respective life quests?

How can a human in the patient role quickly realign a physician into a mutually beneficial relationship?  How will a person in the patient role know when they should sever a potentially harmful relationship with a physician?

I’ll blog about this the next couple days to circle the potential in the HCHH model for use by activists .  I’ve written and spoken about holistic strategies for clinical survival for medical learners and holistic strategies for dealing with chronic pain for patients and practitioners.

Together, as humans, we can connect in a healing dyad of patient and physician, protected from the unsafe, financially destructive aspects of the Medical Industrial Complex.

Can this happen to help those with chronic diseases?

What do you think?

Submitted for day 7 post in #NHBPM  on Twitter and Wegohealth.com.

Family Physician: Fabulous Five Life Changers

The blog focus proposed by National Health Blog Post Month on day 5 is to write about five "things" that were life changers for the blogger that relate to their development as a health activist.

What are five phenomena that changed me to be a Family Medicine Health Activist? This is what I might expand on and make a good case.

1.  My Family:
     a. Of origin b. Of marriage c. Spouse role d. Parenting role
2.  My Spiritual Development
     a. Formal Religion b. Faith Quest
3.  Education
     a. Principles and 3 R's b. West Point c. Army Training
4.  Vietnam helicopter pilot and leader
5.  Family Medicine
     a.  Training b. Patient Relationships c. Patient Care

Reality, though, is probably a bit different.

1.  My maternal grandmother who lived across the street from us had severe rheumatoid arthritis.  My mother was her caretaker for many activities.  I never saw her walk.  She had the classic steroid induced facial features and classic severe RA changes in her hands.  But, she knitted, painted and drew pictures.  She was my own Grandma Moses.  We played marbles when I was a small boy and made Christmas ornaments together.

2.  I loved the smell of Dr. Martin's office (my Family Physician) and felt a curiosity about medicine from a young age.  I admired the doctor and the personal nature of his practice in Miamisburg, OH.

3.  My mother got polio when I was a child which affected her legs and trunk, leaving her mobility impaired for a few months before an almost complete recovery.  Then she got depression (before antidepressants were invented) and was hospitalized for several months.

4.  Several musculoskeletal injuries and one repaired nasal septum in HS and at West Point refreshed my curiosities about medicine.  I kept thinking of becoming a physician.

5.  Medical school at Ohio State and Family Medicine training at Penn State in Hershey, PA taught me about individual and public health needs, from rural farms and nursing homes to small towns and Indian reservations in Arizona on a special multi-disciplinary elective experience with pharmacy and nursing students.  Special populations in PA, death and dying, Legionnaire's Disease, Three Mile Island with a partial meltdown of a nuclear reactor all added to my activist motivation.  Advocacy in organized medicine resulted from my desire to improve medical teaching and to enhance radiation safety.  It was a good start.

Family Medicine: Teens, Times and Texting

"How many  texts are you doing each month?" I asked my teenage patient who was sitting on the exam table texting during his annual teenage health visit.  "Ten thousand", he responded.

Later in the same visit, I gave my usual micro-lecturette on  health risks for teens:  "There are six things that can kill teens or make them wish they were dead- alcohol, drugs, cars, sex, violence and texting."  He flinched at the last one, but wasn't visibly concerned about the first five.

Parents and grandparents now routinely send text messages to teens, many alleging that the ringing or buzzing phone is never answered by the teen.  When I was a teen, I wouldn't dare ignore the calls from my parents on my cell phone.  In fact, cell phones weren't invented.  In fact, our phone had a dial.  OK, caller ID, call forwarding, answering machines and satellite/cable didn't exist either.

In those times, we barely used the telephone, unless we had a girlfriend (in my specific situation).  The girls never called the boys- gentlemanly behavior dictated that decorum.  We may seem way behind the times, but we made it.

When I saw the family doctor, they never mentioned alcohol, drugs, cars, sex or violence- all of which had been invented.  That wasn't part of their training.  Prevention was up to the parents, the churches and the schools- in that order.  Hell was one of the prevention strategies frequently invoked as a deterrent to outrageous teen behaviors.  Marriage was another prevention strategy that was invoked for mis-adventures of teenage sexuality.  Times have changed.  Teens have changed.

OK, I never saw my family doctor for prevention of anything after I was six years old.  Sports physicals were done enmasse lined up for a six second heart listen and six second hernia check by one of the GP's who had a son on the team.  It was free.  We had no prevention guidelines for sports, health or life that physicians used.  There was no money for medical care let alone prevention.  DUH! There was no health insurance, only hospitalization insurance.  Life was not a medical adventure, it was a physical, emotional, intellectual and spiritual one.

Teens and Times have changed along with the lifestyles (a relatively new word) of Americans.  I was well suited to a less electronic teen lifestyle with minimal invasion by the medical profession.  Now, in the age of health insurance, I am an invasive Family Physician who speaks comfortably of alcohol, drugs, cars, sex, violence and texting to teens and their parents every day.  I have a superphone, use social media and even text someone once or twice a month.

Family Medicine: It's Time to Upgrade Dr. Marcus Welby

"Doctor, we'd like to make a TV show about your life and medical practice," They messaged me on LinkedIn. I'm skeptical.  But, curious.  I fire back an e-mail.  Can we talk?, I ask in my e-mail response.  Yes, here's my cell phone number, comes back via cyberspace.

"We want people to better understand Family Medicine", Doctor.  "Good idea," I respond.

"We've reviewed the Marcus Welby, MD shows from the seventies.  Is it still like that?"

"No," I reply.

"Well, tell us how it is now," they plead (sort-of).

"Now, it's about humans who are sometimes in the role of Patient, and sometimes in the role of Family Doctor." I proclaim.  "If we're both humans, we have much more respect for each other, and we can bond together in a caring relationship that increases health and decreases over-all expense."

"Start the TV show with an emphasis on human relationships and their impact on health care quality and expense.  We can proceed from there to patients and doctors.  Then we go back to the human relationships"

"Whatever you say, Doctor,"  They reply.  Cut and wrap.

Family Medicine: Saturday Morning in the Office

I signed up to participate in NHBPM as a blogger, learner, reader, sharer.  

Here we go. The event is described below:

"It’s National Health Blog Post Month! Day 1

by Amanda

Happy November! Today we’re officially kicking off our month-long health blog challenge. Join us in posting every day of the month (yes, even weekends!) about health. In case that sounds too daunting or you’re worried you can’t come up with any ideas – we’ve created a prompt for every day. You can feel free to grab a prompt and run with it – take it wherever it inspires you to go. Whether you’re participating in the challenge or  just want some ideas to get their creativity flowing – feel free to reference the prompts.

Pretend you’re writing a book about your life, your health community, your condition, or Health Activism. What would you want to say? What type of book would you write? Is it a collection of short stories, a fictional novella, personal essay collection, or memoir?"

Saturday Morning in The Family Doctor's Office    by A. Patrick Jonas, MD

The office is rather quiet.  Only one Medical Assistant and one Receptionist work with one Family Physician who covers Saturday morning hours.  A couple of patients are already scheduled for follow up of an acute illness seen earlier in the week.  Another is coming in for continuing care of chronic conditions such as diabetes, hypertension, lumbar disc disease with low back pain, etc.  The rest of the six to nine patients I will see will call in with acute illness or injury.  Several patients are also scheduled to have blood drawn by our MA.

The patients are all unique with problems to discuss, lament, solve or treat.  Our relationship is the key to our interaction.  Many are unsure of their human worth and seek validation.  The trust that we develop in each other becomes an anchor to allow sometimes challenging explorations of difficult situations with concurrent human sharing and respect.

A book could be written about each one of my patients.  If I were writing a book, I would include them, since they make me the Family Physician that I am.  But wait, the rules of confidentiality preclude me writing too specifically about them. They aren't allowed to be identifiable by readers of my book.  That's sad.  They are so worthy of written honor as citizens of the human community.  I offer a silent tribute to them as I hear their stories, validate their importance and celebrate our mutual humanity.

I am a Family Physician.  I love it!  I am so blessed to witness the power of the human spirit and the beauty of human connection.  "Love is the treatment of first choice," I tell many patients.  There are many natural and medical therapies that complement love in promoting healing and wholeness for the many situations and conditions that manifest in my patients.

Saturday, here I come.  I review the schedule of patients and their reasons for their appointments, then walk to the first exam room (the "East Room", so named because of the decor in the room consisting of items from the Far East, such as the calendar and framed tapestries) where I take the paper chart out (the Electronic Medical Record- EMR arrives this month) of the rack outside the door and peruse it.  I note the patient's name, their chronic problem list and demographic data and the data and note just written by our medical assistant (MA) including the vital signs, body mass index and their current situation that constitutes the reason for the visit (or "Chief Complaint").

I usually have lots of thoughts about the patient and the context of their life from previous encounters.  I also relate to the rest of the family (we are family fanatics with a special family based practice model) so I may think of them also before using the information at hand to expand my thoughts about the cause and possible treatments for the main patient's current problem.  I ask myself if I'm ready to see this patient.  If so, I knock and enter.

Saturday is officially under way.  I'm greeting the patient and those in the exam room.  Another chapter in my secret book is unfolding.  Title: Love is the Treatment of Choice.

Starbucks, Hospice and Visiting Nurses

I'm writing this with my new laptop, back on the screened-in porch, a few weeks after my previous laptop crashed. OK, I spilled water on it and THEN it crashed. It's raining now on a  cool, fall evening.  Coffee about ready for brand new Soin Medical Center Cup.    Starbucks never tasted so good.  I’m tired.

I received three calls from visiting nurses at lunch time today.  I always take calls from visiting nurses and hospice nurses immediately.  These situations are fairly complex and involve multiple persons beyond the patient.  I like to hear the nurse’s professional opinion after I give an overview of the patient, their life and family situation.  I want to get their perspective and give mine, then we clarify and make decisions.

 

One visiting nurse just met my patient today and told their family that Hospice could help them, before I ever spoke with the nurse.  Then the family member who is POA for healthcare called me to express their shock that their mother might be needing hospice.  It took a while to reassure them that their mother was not in a hospice mode, but recovering from the illness that lead to her hospitalization.  Very interesting.

Two days ago another  visiting nurse called about another patient and wanted to get an order to send out a social worker to review end of life advanced directives.  This patient has been in the hospital twice recently and already reviewed the information, to the extent she wished- not at all.  Her son with the Healthcare Power of Attorney takes care of that since she is mildly demented.

 

Two end of life pushes in one week from a hospital owned visiting home health company gets me curious.  It’s never happened before.  I wonder if they had a presentation from hospice about how they now take care of all sorts of patients.  (I wonder if they got excited about transfers of their company’s patients to hospice.)  I wonder if they know the extent to which end of life conversations have been started and how far they have progressed with each patient and their family already with their family physician (me).  I wonder if I should advise these patients to get a different home health organization.

 

OK, I will advise them to change home health organizations.  I'll call the company and express my surprise at the aggressive, premature and inappropriate Hospice suggestion their employee made to my patient, just out of an acute care hospital.  Then, I’ll inquire about the patient with mild dementia and why they suddenly are pushing these decisions onto patients and families, sometimes before knowing the patient situation and before discussing the patient with their personal physician.  I’m skeptical about the origin of these situations.

What might be next?

Another cup of Starbucks coffee in my special Soin MC cup.

Family Medicine: They Made Me an Offer

Wake me up, I must be dreaming.  They made me an offer.  Should I take it?  One monthly check for some or all of my daily office schedule patient time slots.  Every day paid for in part or in full.  I continue to own my own practice.  We move away (at a pace to be determined later) from insurance companies.  It has a nice ring to it.  How about the six weeks of paid vacation, one week for continuing medical education, health insurance and medical liability insurance?

Why would a Family Physician consider selling some or all of the slots in the daily patient care schedule to a non-insurance entity?

Maybe because we're being buried in an avalanche of forms and paperwork and requests by more and more patients for us to provide administrative support for various needs.  Reimbursement for services is going down and auditing by the government of all Medicare chart notes seeks to take back 12.5% of money paid out in our region.  My "legibility challenge" could cost us the whole 12.5%.  It's just another way we're hugged by Medicare to inspire us to take more Medicare patients.  Could they do it any worse?  A Medicare freeze in primary care reimbursement for three to five years or 29% reduction in reimbursement happens in January, 2012.

It's tempting to take the offer, since I haven't had a real vacation in nine years.  My health insurance plan goes out of business at the end of the year.  My office coordinator/wife who works 65+ hours in the office weekly is way overdue for some time off.  About $120,000 of various practice debts would like to be paid off.  The federally mandated transition to the Electronic Medical Record and the Patient Centered Medical Home (PCMH) could be accomplished smoothly.  Hmmm.

Someone in Ohio knows the value of Family Medicine.  Should I respond favorably to their offer?

They arrange for all the other service contracts-mental health specialists, medical specialists, laboratory, imaging, hospitals, etc.

But wait, what if they buy up all the Family Medicine independent physician time slots?  What do all the insured patients do who go to those doctors?  What happens to the patients who are not related to their business model?  What happens to the hospitals?

Wake me up, maybe it's just a dream.  More later.

Is this real?