Farewell 2012: You Bounced Along the Path of Our Lives

OK, the year is ending, and I'm glad.  The path of life lies ahead, informed by the experiences of 2012.

My activities of interest beyond Family and God at the end of 2012:  "Get on the Ball with Jesus"  a toning and fitness program using the exercise ball (Swiss Ball) in a group of Christians at my church (Bellbrook United Methodist Church.)  I bounce almost every day.

Learning to play the didgeridoo via Didgeridoodojo.  Enhancing my ability to be "wholehearted" via www.heartmath.com using my emWave Desktop.

Books I'm reading/engaging at the end of 2012:

Journey of the Heart by John Welwood (The Path of Conscious Love)  "When love comes down to earth it gains depth and power"

This is Your Brain on Music by Daniel J. Leviten "Young children start to show a preference for the music of their culture by age two,...  Researchers point to the teen years as the turning point for musical preferences.  As adults, the music we tend to be nostalgic for, the music that feels like it is 'our' music, corresponds to the music we heard during those years."

The Healing Power of Sound by Mitchell L. Gaynor, MD  (Recovering from Life-Threatening Illness Using Sound, Voice and Music.)  "The same principles of harmony and entrainment that operate within the human body are also dramatically apparent when human beings communicate with each other."

ChefMD's Big Book of Culinary Medicine by John La Puma, MD and Rebecca Powell Marx (A Food Lover's Road Map to: Losing Weight, Preventing disease, Getting Really Healthy) "I'm going to help you learn to see food as your body sees it."

A Brief History of Everything by Ken Wilbur "...a universal smorgasbord of human possibilities, all arrayed as a shimmering rainbow, an extraordinary spectrum of your own deeper and higher potentials."

The model introduced by Wilbur is extremely helpful to me as I seek to further clarify the path of a Family Physician and hone the Human Centered Health Home model.  There is hope in delving into the human condition and sharing intimately with others to clarify our individual and shared humanity.

God did well in our creation.  Will we honor Him on our paths?  (I ask of me and you and us).

Peace to all as we follow the path of 2013.

Christmas Day in Our International HQ

Merry Christmas to Dr Synonymous readers who celebrate Christmas.

This year we're starting in my home in Sugarcreek Township just east of Bellbrook, OH (Spring Valley mailing address-sometimes confusing).  Today we'll also visit in Dayton,  Liberty, Springboro and Columbus with Christmas cheer.

It's always special for me.  Last year, we celebrated in Chapel Hill, NC.  In other years: Liberty, OH; Granville, OH; Columbus, OH; Hershey, PA; Manhatten, KS, Milford, KS, Farmersville, OH; Greenville, OH; Hilliard, OH; and Vietnam.  There was no hope for snow in Vietnam and little hope for snow in Chapel Hill, but the many white Christmas days had a special flavor.

The Birth of Jesus, understood in so many ways, holds so many hearts at peace while challenging the Christian mind and soul with a message of love and forgiveness.

May His love hold and guide your heart forever.

Snoring : Be gone- Join the Didgeridoo Hullabaloo

The didgeridoo Hullabaloo is coming.  Fight snoring.  Avoid sleep apnea.  Get your Didgeridoo now!

The Didgeridoo Store

How to play the didgeridoo.

Get your starter kit and get ready for the Didgeridoo Hullabaloo- coming in January, 2013.

Further information will be announced on the Dr Synonymous blog site and the Facebook page of The Center for Innovation in Family and Community Health and IFGHealth.com.  Stay tuned.

Comment below when you have started to learn to play the didgeridoo or when you are playing four days a week.  YouTube submissions of Hullabaloo participants are welcome (even before the formal starting date for the Hullabaloo).

Don't feel like you have to be as good as Didgeridoo Drummer, Andy Graham, to reduce (or prevent) your snoring.

Didgeridoo Drummer- Andy Graham

Direct Primary Care in Blufton and Beavercreek, OH

The Dr Synonymous Show December 18,2012

Coming up in the Dr Synonymous Show on Blog Talk Radio Tuesday December 18 at 9 PM is another interview about Direct Primary Care featuring Dr Sam Heiks of Blufton.  Direct Primary Care (DPC) is a business model that is catching on fast as a way for Family Physicians to refresh their practices and careers.  As I've noted before, www.DPCare.org is a good site for orientation to the concept of DPC.

Dr Sam Heiks of Blufton is a Family Physician who has started DPC at his Creekside Family Practice, recently featured in an article in the Lima News: Dr Sam Heiks .  Author of the article, Kate Malongowski, did a good job of accurate reporting about Dr Heiks and his practice.

She also quoted me accurately about DPC and my approach to it in Beavercreek.  We use the DPC business model in our Direct Family Medicine practice approach at Family Health Connections, Inc. The DFM is the newest aspect of our non-traditional-"Families Only"- Practrice.  It affords us a fresher approach to our new patients who don't use health insurance to cover their Family Medicine needs.  That's right, to be a new patient in our practice, you can't use your health insurance to pay.  Similarly, you can't use your auto insurance to get your car serviced at a dealer or Valvoline.

We'll discuss many of these issues on the show to further clarify how DPC works in Blufton and in Beavercreek.  We'll also mention Direct Ohio Care, a new network for primary care physicians interested in Direct Primary Care in Ohio, similar to the Health Access Rhode Island physician network with seventeen member practices.

Dr Heiks has an interesting background, involving Kansas, Wisconsin and Ohio.  Tune in to hear how he's adding to Family Medicine in Ohio.

Don't worry if you can't tune in live on Tuesday night.  It's saved as a webcast for later download or listening 24/7.

Christmas on the Ball at the BellHOP Cafe

Christmas on the Ball” at the BellHOP Café on  Saturday, 12/8/2012

Public Invited: Bring your exercise ball or just your self for a toning, movement and fitness session.

“Introductions and Welcome by Pat Jonas of BUMC and Heather of BellHOP Café

Overview of Session including Health and Safety Warning and Disclaimer

               Make a Habit of toning, stretching and movement first- fitness later.  PACE YOURSELF

               Standing, Sitting on the ball- with/without bouncing, lying on the ball, lying on the floor

               Helps Heart, Upper Body, Core, Lower Body, Spine and Mood

Opening Prayer

Breathing on the ball.  Without- five whole breaths and five with bounces.

Standing:  Five reps each of twist (p117)*, front bend and side bend (p118), hug and 30 seconds of drape over ball (p115)

Recovery for two minutes

Sitting:  100-150 bounces with music, Hip Release (124), Pelvic tilt (p34), crunch (p36), back stretch (p35)

Water, fluids, bathroom break, ball repair/ reinflation 5-7 minutes

Health Tip:  Dr Synonymous (aka, Dr Jonas) Stress Reactions, Cortisol, and the Ball

Lying on ball: back toner (p50), rise and shine (p52), push up (p46)

Lying on floor: five reps each-lower body toner (p68), lift ball, squeeze bal

l

Sitting on ball: 2 minute bounce with music

Recovery, refreshments from BellHOP menu, fellowship

Next formal session 7 PM January 10 at BUMC (followed by 7PM Jan 14^th at BUMC)

Next informal session:  Your place- three times weekly 2-3 each standing, sitting, lying (five reps or 30 seconds-depending). Bouncing 2-4 minutes depending on energy and comfort.

More exercises at www.Ball-Exercises.com

We'll see you in Bellbrook!

*From Sculpt Your Body with Balls and Bands by Denise Austin, 2004 by St Martin’s Press

Weekly Reflections of Dr Synonymous on Blog Talk Radio

December 4, 2012 Dr Synonymous show Dr Synonymous Show

After introductions and the usual disclaimer, Dr Synonymous (aka, A. Patrick Jonas, MD) noted that he has an acute upper respiratory tract infection with sneezing and rhinorrhea (runny nose).

This resulted in a viewing of Dr Will Sawyer's award winning site Henry the Hand for a quick refresher on infection control.  Interestingly, this is National Handwashing Awareness Week , which is very timely as Family Physicians are seeing more patients with respiratory infections at this time of the year in the colder states (I don't know what's happening in the warmer areas).

Patient blog via Medical Mojave's blog site was Final Trick, with Ehlers Danlos Syndrome and more.  The featured blog in my review  What's in Your Gut

Dr S/J mentioned articles in Family Practice News of November 15 including the SGR (Sustainable Growth Rate) formula that determines physician reimbursement under Medicare (which also is used by many other health insurance carriers to determine reimbursement) which mandates a 26.5% reduction in physician reimbursement on Jan 1, 2013.  Fourteen times in the last ten years, a temporary fix was passed by Congress to avoid the SGR "Fiscal Cliff".  Many fear that we will go over that cliff on Jan 1st with the nation riding the same wave downward on the larger Fiscal Cliff. www.Familypracticenews.com

Dr Jonas reviewed the weekly American Medical News making comments about employed physicians and independent physicians (36%).  The employed physicians who work for hospital systems are being squeezed and the AMA delegates approved five Principles to Address Conflicts of Interest.

Letter to Board of Directors of American Academy of Family Physicians  from Dr Mike Sevilla of Family Medicine Rocks fame (and the "King" of social media in Family Medicine)

Another important story is "Insurance Exchanges Emerge as Red vs. Blue" commenting on the insurance exchanges mandated by the Affordable Care Act that have to be ready for open enrollment on October 1, 2013.  Many states opted in, many opted out, many are confused and many want to split the responsibilities with the federal government.  All Americans will be affected by the exchanges in one way or another. www.amednews.com

Importantly, Direct Primary Care is an approved component of the exchange system IF combined with an indemnity (hospitalization) policy.  Many physicians are adding a DPC component to their practices as mentioned in this blog and on my Dr Synonymous Blog Talk Radio Show.  Newest in Ohio is Dr Sam Heiks,  a Family Physician in Blufton.  There was a nice article in the Lima News sritten by Kate Malongowski (a thorough, accurate and delightful reporter/journalist) about Dr Heiks DPC activity, including quotes from Dr Jonas (with reference to my Direct Family Medicine model of DPC)  Dr Sam Heiks and Direct Primary Care

The Dr Synonymous Show continued with a review of Dr Kenny Lin's blog Common Sense Family Doctor and "In Health Care Little Details Make all the Difference"

Dr Jonas further mentioned A Brief History of Everything by Ken Wilbur, interesting book about a model for everything in the universe, including the mind of God.

Lastly, this is Army-Navy week culminating with the Army Navy football game on Saturday.  Go Army!

We lost a great West Point graduate last week- Jay Tieber, class of 1957.  RIP Jay.  Our prayers are with Maxine and your family. Jay Tieber, obituary

Interview with Nick Hirth, MSIII WSU BSM Interview

Click on date for Weekly Dr Synonymous Blog Talk Radio Show  November 27, 2012

After greeting, mentioning the coffee from the BellHOP Cafe and commenting on the new issue of Family Medicine from the Society of Teachers of Family Medicine (STFM), Dr Jonas introduces Nicholas Hirth, MSIII at Wright State University Boonshoft School of Medicine.

Nick speaks of his background including undergraduate studies at Ohio State and home town of Grove City, OH.  He discusses the WSU strengths and some aspects of the curriculum.  He reflects on the satisfaction he has interacting with patients and the emphasis WSU put on the patient-physician relationship from the start of medical school.

He mentions his desire to stay in Ohio for training in a Primary Care specialty and future practice (Ohio is blessed to have such a knowledgable and dedicated future physician- a tribute to the wisdom of the WSU BSM admissions committee).

Nick mentioned his Family Physician father who practices in Grove City and differences in the training then and now in medical school.  He also comments about how distant a lot of the health policy and healthcare funding issues seem to be from third year medical student activities.  The medical school offers many organizations to help students connect to the breadth of the medical profession.

It's always fun to interview medical students, who give hope to aging physicians.  Thanks to you medical students for giving us hope for the future of the medical profession.

5-5-5: Strategies for a Healthy "Eating Season"

                 
                  The Dr. Synonymous Show November 6, 2012 

                  5-5-5: Strategies for a Healthy "Eating Season"

Dr Synonymous discusses the 5-5-5, meaning a recommendation to eat five colors of food daily (not counting M & M's), five servings of fruits and vegetables and to control four health issues (weight, blood pressure, cholesterol and stress) and to exercise.  He elaborates on each of these issues and introduces listeners to the Center for Disease Control Nutrition site, which gives each individual formulas to plan their eating strategies. 

Dr Jonas, aka Dr Synonymous gives support to using the exercise ball for tone, movement and fitness.  He gives listeners several ideas about use of the ball also to reverse or prevent insulin resistance, which he explains in detail.  Dr S reviews stress reduction strategies and their impact on weight, blood pressure, and cholesterol.  

Listen in for holiday strategies for a healthy "Eating Season."

Childhood and Adolescent Depression; Tweet Chats #CHSOCM

The Dr Synonymous Show October 30, 2012  Here

 Dr Synonymous aka, A. Patrick Jonas, MD starts with comments about tweets on Twitter, then 

 "Treatment of Childhood and Adolescent Depression" from the American Family Physician, 

Sept 1, 2012 issue by Clark, Jansen and Cloy from the University of Mississippi Medical Center.  

The risk factors and diagnostic criteria are well reviewed along with screening tools.  

Helpful comments about therapies are reviewed.

Tweets followed by Dr Jonas are perused with a focus on a tweet chat by #CHSOCM, including their opening prayer.  

Blog reviews include one by Meredith Gould about book authorship processes and one by Kenny Lin about support for Family Medicine as written by Richard Young, MD.

Last is some expansion by Dr S about his upcoming chat session at the BellHOP Cafe in Bellbrook on Saturday morning November 10 at 9AM.

Dr Synonymous Show 10/23/2012 Humble, Collaborative Docs IBS & Blogs

Starting with information about the issues in the upcoming Presidential election, Dr Synonymous then reviews some information from JAMA about Peripheral Artery Disease (PAD) and correlation with risk factors for CAD. Then comments on a JAMA article reflecting on small studies showing large effects being exagerated due to sample size.  A  study about parachute jumps with and without a parachute that will never be undertaken was used to make a point.  Large studies seldom find large effects.  Docs should be collaborative and humble about uncertainties.

Diagnosis and treatment of Irritable Bowel Syndrome is discussed next from The American Family Physician 9/1/2012.

Introduction of Intellectual Disabilities, At Your Fingertips by Carl Tyler, MD and Steve Baker, MS.  Good looking content and very useful for Family Physicians in the office.  Thanks Carl and Steve!

Blog reviews: Medical Mojave, A Chronic Dose and two books by Laurie Edwards, and Dr Synonymous- announcing his chat at the BellHOP Cafe in Bellbrook, OH November 10 at 9 AM.

Dr Synonymous Show October 23, 2012 on Blog Talk Radio

Dr Synonymous at the BellHOP Cafe November 10th

Dr Synonymous at the BellHOP Cafe November 10, 9-11:30 AM

Chat with Dr Synonymous at the BellHOP Cafe in Bellbrook (OH) on Saturday November 10, 2012 from 9-11:30 AM.  Come early, eat breakfast and enjoy some coffee in a relaxed, informal setting.  Map to BellHOP Cafe

A. Patrick Jonas, MD a Holistic-Minded Family Physician is Dr. Synonymous on BlogTalk Radio (internet radio) and through his Dr Synonymous blog (www.drsynonymous.blogspot.com).

During the first hour of the session at the BellHOP Cafe, Dr Synonymous will review:
                                       
                                           "5-5-5: Strategies for a Healthy Eating Season"
                                         
                                           "Successful Visits to your Doctor"

                                           "Heart Health and Bone Health"

In the second hour, after a short break, Dr Synonymous will answer questions from those present about health, healthcare, illness and dying with dignity.  He will interact with the audience frequently during both hours.  He still has fun practicing medicine and enjoys learning from and about patients, even after 170,000 patient encounters since 1979.

Expect to hear about Family Medicine, healthy habits, vitamins, supplements, respect for self and others, protecting yourself from harm in the medical system, brain health, stress and coping, God, prayer, family, love, relaxation, massage, the five senses, medication, the placebo response, the nocebo response, America, the Medical Industrial Complex, cost, respect, misguided quality initiatives, awesome people, and how doctors think in comments made by Dr Synonymous.

Disclaimer:  Dr Jonas will not be practicing medicine on those in attendance.  They should not expect to solve their personal medical problems in this session.  Nothing in this session is intended to replace the medical care currently being received by those present from their personal physician or other medical specialists.

We'll see you at the BellHOP Cafe November 10th at 9 AM.

Family Medicine: Time to Warrior-Up!

Warrior. 

There, I've written the word.  What images does it generate in your brain?  What thoughts?  What feelings?  What sounds?  Any smells?  Or tastes?

Or FEARS?!  (Yes, many feel afraid when they hear or read the word warrior).

In the Four-Fold Way by Angeles Arrien, she describes the Way of the Warrior:

"The Way of the Warrior or Leader is to show up, or choose to be present.
Being present allows us to access the human resources of power, presence, and communication. We express the way of the Leader through appropriate action, good timing, and clear communication.":

Family Medicine needs more warriors (Uh Oh, warrior in the same sentence with Family Medicine- meek, soft spoken, please everyone, don't make waves, sacrifice for the poor, ignore the rich-Family Medicine)

Family Medicine needs more warriors.  A little bit louder now, and proudly- with enthusiasm:  Family Medicine needs more Warriors!

We are complicit with the misaligned behavior of The Beast- the Medical Industrial Complex- that is shamelessly bankrupting America.  Can we Warrior-Up and re-direct it?  Can we Warrior-Up and protect our patients from its darker side?

Warrior-Up, Family Medicine.  We owe it to ourselves and our patients.

What do you think?

Context and Reflection in the Human Centered Health Home

“The central tasks of a physician’s life are understanding illness and understanding people.  Because one cannot fully understand an illness without also understanding the person who is ill, these two tasks are indivisible.”…McWhinney in Family Medicine

Also, a physician should understand him/her self and their own worldview.  Context is powerful in the patient-physician relationship, including that of the patient, the physician and their relationship.  Yes, the confluence of the worldviews of the patient and the physician is important.

The last post referred to clinical decision making in the Human Centered Health Home (HCHH).  After Respecting, Protecting, Connecting, Detecting, and Correcting, the dyad of patient and physician finish their engagement by Reflecting.  This may include Reflecting on the current engagement, the relationship, the decision making process, the future, etc.

Part of the Reflecting by the physician includes recording the clinical encounter note.  Eventually, this may be partly written by the patient.  Both parties may eventually have a separate note about the engagement that has a merged component and is shared for the Personalized Health Record (PHR) owned by the patient and the Electronic Medical Record (EMR), controlled by the physician.

As the "Socio-Technical Neighborhood" is further developed, audio and video elements of the note will be shared for Reflection in the PHR and the EMR.  Arrangements for confidentiality, HIPAA, and consent to use information by either party will require further clarification.  It will become more and more popular.

What do you think about the context of the patient physician engagement?  How do you like to Reflect on the engagement and the relationship? What aspects of the "Socio-Technical Neighborhood" should be developed?  Will be helpful?

Clinical Decision Making in the Human Centered Health Home

The Dr Synonymous Show October 16, 2012

Dr Synonymous reviews clinical decision making in the Human Centered Health Home (HCHH) using models of thought and care that may be used in Family Medicine. 

 After a person identifies that they need their physician to help with a problem, they make an appointment of one type or another.  An appointment may includes human centered greeting comments, then use of SPIT, a model for considering Serious, Probable, Interesting and Treatable causes of the patients chief complaint. 

Next is Identifying Information that personalizes/humanizes the patient, including a Living, Learning, Working model with  physical, intellectual, emotional, and spiritual components of the patients life through CODIERS (another model).  

Dr S  next comments on  using the Biophychosocial Model to expand the differential diagnosis further.  A further filtering, expanding and narrowing process next mentioned is the consideration of systems and processes that may relate to the patients primary problem.  

The dyad engages the HCHH process by Respecting themselves and each other, unconsciously committing to Protect each other, then by Connecting in a mutual problem solving dyad.  As they explore the above information in the context of the patients life, the physicians life and the system in which they engage, they seek to Detect the causes of the patients misalignment (chief complaint) with their life/work plan.  

The physician then undertakes a physical exam of the patient considering the differential diagnosis throughout the process. 

The dyad, after the patient repositions, then shares their perspective and clarifies the assessment. 

Next they share in developing a plan to Correct the situation causing the chief complaint.  The plan may include Diagnostic elements such as imaging or laboratory tests, or even the test of time.  It may include Therapeutic elements including dietary measures, exercise, medication, physical therapy, massage, vitamins, etc.  Patient education is the last formal component of the visit followed by a human/human departing action/comment.

Each patient and physician engage differently, so models such as those mentioned may or may not be used by individuals in any clinical engagement.  I like using the models, especially the HCHH process for training and personally use them in my daily practice every day.

Re-Introducing Human Centering in the Health Home

Two years ago I was learning about Human Centering from Steve Deal, Human Systems Engineer among other talents.  I am reposting one of the blog posts about human centering which is the center of the Human Centered Health Home (HCHH). I get to do this every day and it's fun.  There is fun in Family Medicine!

Wednesday, November 30, 2011

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.

The Human Centered Health Home: Respect Revisited

I'd like to revisit and upgrade the Human Centered Health Home model of care, developed through the Center for Innovation in Family and Community Health (CIFCH) and years of practice and collaboration with others, especially Larry Bauer since our days at the Hershey Medical Center.

Here's the original first post about the HCHH:

Friday, July 2, 2010

The Human Centered Health Home: Start with Respect

Aretha Franklin sings of one kind of R-E-S-P-E-C-T and Rodney Dangerfield joked about not getting another kind of respect, but the underpinnings of the patient-physician relationship is another kind of respect.  As transformation in health care moves forward,  we must continue to remember the respect that is the basis of our current interactions and future successes.

The Patient Centered Medical Home (PCMH) has been proposed by employers,  governments and organized medicine to help "bend the cost curve down" by shoring up a crumbling primary care base with more money and more tasks.  Proposals and demonstration projects so far make it look like the "Payment" Centered Medical Home instead of the "Patient' Centered one.  There is too much connection with the Medical Industrial Complex (MIC) for the PCMH to really get to the point about patient centered care.  It is a good start, but too bogged down with issues about the electronic health record, reimbursement, "quality", time management, cost, "meaningful use", power and control to leap into a future needed by patients.

Our Center for Innovation in Family and Community Health (CIFCH) proposes that we re-emphasize the human aspects of the patient and the physician to refresh the PCMH model into a more meaningful one that we like to refer to as the Human Centered Health Home (HCHH).  The human to human dyad of the patient- physician relationship allows "neighborly" discourse that protects the pair from some of the distractions and intensity of the MIC.  Their mutual respect allows a better understanding of the context of each other's lives, allowing a better focus on the work at hand.

Start with respect for each other, for the system in which we both function, for our teams, for our colleagues, for our families, for our information systems and so forth. In a context of human to human respect, our other roles of consumer, steward, teacher, leader, warrior, visionary and so forth can be allowed and understood. We spell it the same as Aretha Franklin, maybe even flashing back to hear "RE, RE, RE, RE, RE, RE, RE, RE Respect". Then hearing "Just a little bit. Just a little bit." If we only have a little bit of respect we might only get the "Payment" Centered Medical Home instead of the Human Centered Health Home that patients and Family Physicians both deserve.

NOW, in October, 2012:  Respect is even more meaningful as we move ahead into healthcare transformation.  If the human dyad of patient and physician respect the context of their engagement and each other, that may be a good start.  Respect may allow enhanced communication and understanding of their relationship-based, shared endeavor.  It may enable a mutual honoring of the attributes of the other and the self in their shared roles.  The respect may lead to increased commitment to protect each other and their medical neighbors, even if it means standing up to the Medical Industrial Complex and its money sucking ways.

R-E-S-P-E-C-T

Family Medicine Paradox: Wholeness Interferes with Quality

"The Paradox of Primary Care" by Kurt Stange, MD PhD and Robert L. Ferrer, MD, MPH is a perplexing but telling article in a monograph from the Annals of Family Medicine in 2010.

"Quality of health care most commonly is measured by the application of disease-specific, evidence-based process-of-care guidelines.  This evidence fairly consistently shows that primary care clinicians deliver poorer quality care than specialists.

Evidence from the Medical Outcomes Study assesses care of patients with several chronic diseases.  The study finds that patients functional health status outcomes are similar for care rendered by specialists and generalists but that generalists use fewer resources.  Similar outcome at lower cost represents higher value.

A growing number of studies show that for patients with chronic somatic and/or mental illness, shared care between specialists and  generalists is optimal.

In further contrast, ecological studies comparing states in the United States find that a greater supply of generalists and a lower supply of specialists is associated with greater quality of care on multiple disease specific quality measures....more primary care is associated with better population health and lower cost and greater equity.

Thus, the paradox is that compared with specialty care or with systems dominated by specialty care, primary care is associated with the following:  (1) apparently poorer quality care for individual diseases, yet (2) similar functional health status at lower cost for people with chronic disease, and (3) better quality, better health, greater equity, and lower cost for whole people and populations."
 ...Stange and Ferrer

I see a couple key words to ponder:  diseases and whole people.  We (I am a Family Physician) do better taking care of whole people than specific diseases (although we do that pretty well, too).  We understand patient personal values and integrate them into clinical decisions.  We value their wholeness, which we consider one of the outcome goals of a disease process.  We want our patient to be whole and able to live the life they've intended.  The disease is not the major focus of their life and is considered in the context of the patient's goals and dreams. 

If we measured quality that means wholeness instead of measuring a narrower disease focus that is less likely to align with wholeness, we might be viewed as having high quality across the board. Maybe the paradox disappears when we use patient driven quality indicators of wholeness.  What do you think?

FMEC 2012 Cleveland: Med Students Care to Serve

What a delightful dinner I had tonight listening to the career dreams and goals of three medical students from Wright State University Boonshoft School of Medicine.  These three women didn't know for sure what specialty they would select, until a moment when they suddenly understood what their future would be:  Family Medicine.  "I took the JI (junior internship) and I knew it was "family" for me.  I didn't really know it until it hit me."  She commented further to the effect: "I enjoy taking care of patients.  That's what it's about.  I mean, isn't it?  Taking care of patients.  I love it."

I was touched by the passion and caring and love of Family Medicine.  (Way to go-Wright State!).

There is Hope at the FMEC meeting.

FMEC: The Innovator's Network Tweaks the Future of Family Medicine

I'm at the Family Medicine Education Consortium, Inc. annual meeting pre-meeting session called The Innovator's Network.  Wow, Folks!  Exciting and somewhat overwhelming.

People, health, Family Doctors, money, semantics, rejection, bureaucracy, innovation, energy, caring, holistic, integration, affordable, government, data, large numbers, small numbers, micro practice, collaboration, efficiency, effectiveness, patient satisfaction, physician satisfaction, legislation, legislature, insurance exchanges, health system change, non-system of health care, super utilizer, inclusion, exclusion, technology, workforce, nurse practitioners, physician extenders, funding, market, upgrade, friendship, loneliness, isolation, admission, re-admissions, Medicare penalties, Medicare, uninsured, Medicaid, EHR, patient, enrollment, social media, exam room, waiting room, intervention, legal, tinkering phase, iterative loops of finding efficiencies, awsomeness of tinkering, capacity, Hepatitis C, CHF, CAD, risk management, workforce pipeline, other providers, other primary care physicians, access, panel size, senior citizens, falls, delirium, independence, billing, core values, emergency room, urgent care, discounts, wrap-around insurance product, brokers, squeezede, home visits, bonus, etc.

Direct Primary Care:  What happens when it's all about the Patient and Physician?; Elder Power!  A program that helps seniors remain in their homes, connected to their Families, Friends and Communities; Sharp Health Care:  Advanced Illness and End Stage Disease Management; Project ECHO:  Strengthening the Capacity of Primary Care by building a Collaborative Relationship with Sub-Specialty Clinicians; The Oxbow EMR:  Designed by and for Family Physicians; The Super Utilizer Project were presented in the first part of the day.  The room suddenly overflowed with young FMEC meeting attendees at the start of the Super Utilizer presentation by Jeffery Brenner, MD.
Onward for innovation! 

Saying No to Authority: Black and White and Gray Perspectives

About 100,000 people die each year due to errors in health care according to the Institute of Medicine.  We have a lot of fixing to do to reduce the chance for errors that lead to those deaths.  People in health care will have to confront each other, seek clarification, forgive each other rapidly and move ahead.  When and how do we need to push back to save lives?  Who may be disappointed or angry about the tension induced by pushing back?

“Captain, I need you to fly me to these coordinates to check in with one of my companies,” said the Engineer Battalion commander near Khe Sanh in Viet Nam in 1971 during operation Lam Son 719.  I was a helicopter pilot in the engineer group headquarters flying support for one of our three battalions on that day.  I called for a clearance to fly to his unit and received word that it was a no-fly zone since an F-4 jet was just shot down in that area.  (Let’s see, if the enemy can hone in on a jet that flies really fast, they might have no problem aiming at an OH-58 (Kiowa) helicopter that flies a lot slower, keeping me from getting the  Lieutenant Colonel to his objective and eliminating us and our helicopter from the war zone- and the earth).

“Sorry, Sir, but we’re not allowed to fly there temporarily.  It’s been designated a no-fly area since a jet was just shot down there.”  “Captain, take me there immediately,” he responded.  “I’m sorry, Sir, but I don’t have clearance by our security to fly there.”  He made a couple angry, grumbling comments, sort of venting his frustration at me.  He was a leader, committed to his people,  who was willing to do whatever it took to get the job done.  His unit was not actively engaged in a fire fight or other situation that required immediate command presence for life and death decisions.  He wasn’t satisfied with my answer. 

“Sir, Let me get you the Colonel (Group Commander) on the radio so you and he can clarify our options.”  The colonel reaffirmed our inability to get to those coordinates until the no-fly was lifted, after clarifying mission issues with this battalion commander. He still was annoyed with me and not pleased.

We flew to another of his companies first after which we were cleared to fly to the previously off limits coordinates.   

On return to his battalion encampment area and before landing, I noted puffs of white smoke inside his perimeter, consistent with white phosphorus from artillery fire and, since the enemy didn’t have any white phosphorus rounds, I knew it was from our own troops.

I told him on the intercom, “Sir, your position is receiving friendly fire, we can’t land yet.”  He responded briskly, “That’s bullshit, we are not taking fire.”  “Look out your window, please, Sir.”  He exploded with a few expletives about who was attacking their unit with friendly fire, etc.  I had his unit frequency waiting for him to communicate, while I called artillery coordination to report the friendly fire.  No one was killed, fortunately.  After the white puffs stopped, I was able to deliver him back to his troops and his headquarters.

After the operation was complete, all pilots in our group HQ unit who supported his battalion during Lam Sanh 719 were recommended for, and received, the Army Commendation Medal, except one- me.  I am pleased to have not received that medal.

We do the best we can and seek clarification, but time marches on, so decisions are made, actions taken and forgiveness offered.  In health care, we will have to push back a bit more often in the name of patient protection.  Sometimes, feelings will be hurt and nerves frayed, but hopefully forgiveness will be offered rapidly and lives will be saved.

Family Medicine: God, Please Help Us

The patient sobbed and winced, accurately showing the misery of an untenable relationship violence trap.  The Family Doctor listened, and listened and listened.  No medical therapy could lift the patient back to a "human" from their sub-human prison.

"It's not your fault," the doctor pleaded, "It's not your fault."

He listened as the patient repeated an endless spewing of misery.  The tightness in his chest and upper body echoed the tension in the patient's story.  He allowed his brain to settle into the background, empty of solutions for this human suffering that was pulling him into a pit of despair. No strategy for temporary resolution allowed her to move forward intact.

The clinical decision making skills, insightful differential diagnostic abilities, awareness of clinical guidelines paled in comparison to the patient's need.

"God help her," he prayed silently.  "And help me."

He listened some more.  He waited for Heart to arrive.  Brain could think, but Heart had to connect energetically to Heart.  A transfusion of God's Grace calmed the doctor's Heart into caring mode which linked to the patient's wounded Heart and decompressed some of the tension in the room.  The nearness to death from loss of humanity faded just enough to let the tiniest ray of hope arrive.

"Thank you, God," He thought.

He offered a temporizing medical strategy that may allow a calmer review of options tomorrow.  The patient had enough energy and humanity to agree that another visit tomorrow would be OK with her.

He walked into his office, felt a surge of human emptiness draining him acutely and intensely of emotion.  Back from the abyss of human suffering, he cried.

Family Medicine: Heart to Heart with America on 9/11

Today we're heart to heart with our fellow Americans.  Prayerful and open-hearted, Family Physicians reflect your concerns about your values, goals and dreams on this unique day in American history.  We're with you. We hurt, too, but less and less each year as we start to reconcile 9/11/2011 with other aspects of our lives and those of our patients, their families, their communities and our nation.

This used to be the anniversary of Pete Rose record-setting 1492nd hit to break Ty Cobb's record.  We're remembering Pete's hit again 27 years later, but through the national 9/11 "filter".  It's slowly becoming the anniversary for other events.  My son and daughter-in-law were married on this date two years ago, painting the date with young love and commitment.  And other lives move ahead.

Each will live today in their own way, most through the memory of a shared American experience that touches us forever.  Peace.

America: 9/11/2001 Plus 11 Years

The calls from our patients came pouring in to today, Monday September 10, 2012.  I wonder if our patients are feeling the 9/11 falling mood of America.  The re-runs of 9/11 related shows started a couple days ago.  The planes are flying into the World Trade Center again.  We have to reconcile it as a reality and accept it as part of our identity as Americans.  Every year at this time, we'll get our visual reminder and reflection opportunity.  How is it going for you?

Prayer helps.

Peace to all.

Family Medicine: Replacements are Lacking for Aging Docs

OK, I'm creeping toward retirement in a few years.  My hospital(s) have committed verbally to help recruit a replacement Family Physician and another and maybe another to help us grow to three physicians.  Eight years ago we were included in their search process.  My replacement hasn't shown up, though.  One candidate did interview and agree to work with me as a full time Family Physician seven years ago.  She called a week later and apologetically withdrew her acceptance of the position because the job she really wanted had suddenly come available.  I agreed with her that she had to go with her heart and wished her well.  Oops!, she said when she called back a week later saying she made a mistake since the "dream job" she went to finalize wasn't exactly what she thought it was.  And... was the position in my office still open for her.  I reaffirmed that I thought her heart had spoken to the effect that she really wasn't supposed to be coming into my practice and something else would be the real "Dream Job".

Six months later, a very good Family Physician interviewed with me as a result of the system ad.  She was about to deliver her second child and wanted to work three days weekly.  She started a few months later and is still in the practice, along with a part time Family Nurse Practitioner, who just got a four day a week job in a geriatric house call company and will reduce her work at our practice to one day weekly.

Since then (five years), no other qualified applicants have been identified by the search process being used by my hospitals.  Eight Family Physicians have left our county and two have been replaced, one in a hospital owned practice and one in a large group practice.

I met with our hospital physician recruiter today.  It looks relatively hopeless for them to recruit another physician to our practice.  The only persons responding to their ads in Family Practice journals and online want a permanent employed position with a fair amount of security, not a small private practice, such as ours.

We are "Family Fanatics".  We only take families as patients (entire households).  It's been fun for me these last 32 years and I suspect that it would appeal to another Family Physician, as it has to the woman practicing with me.  We also just started a Direct Family Medicine track for uninsured new patients who want a "Medical Club".  They pay $80 to enroll, $60 at the end of each month and $20 per visit for basic Family Medicine (in office acute, chronic and preventive care with flu shot included, but there's a separate fee for other immunizations, outside laboratory tests and surgical procedures).

I've posted before about the inadequate number of medical students selecting Family Medicine for their specialty training.  Also, I've posted about how the two flagship hospitals for the two local hospital systems both closed their Family Medicine Residency Training Programs.  They don't even train primary care internists in my hospital system, even though they have several residency programs in several specialties.  Overall, the primary care base for the health care non-system is shrinking.  Duck.  Here come the wrong specialists to provide your primary care services.

I wonder if we are too much of a fossil practice to get a young Family Physician to join us?  I wonder if we have to find our own recruit since we're possibly lumped in with the wrong group of practices seeking another physician (hospital and large group)?

What do you think?

Family Medicine: Promoting Civil Discourse

With the start of the Republican National Convention in Tampa, political intensity is rising.  As Family Physicians, we repeatedly communicate in a mutually beneficial way with patients.  Can we demonstrate and promote this in the political arena.  Let's role model our engagement with, and respect for, patients skills in other venues, to show people how to engage and listen to others.  Let's lead the way to demonstrate and promote civil discourse during and after the campaign season.

What do you think?

Dr Synonymous Blog Talk Radio Show August 28, 2012

Here's the overview for the content of the Dr Synonymous show on August 28, 2012.  

Health Care blog, tweet and medical review and discussion, starting with patient blogs including Dr Fatty, Medical Mojave, Brass and Ivory:  Life with MS and RA and Rheumatoid Arthritis Warrior.  Resident physician blog post in The Future of Family Medicine.  Tweets from Molly Tally of PAFP and Mike Sevilla, MD.  Lastly, Dr. Synonymous blog posts:  Family Medicine:  Superhero Needed and Healthcare, "Obamacare" and Vietnam.

Click here to listen  Dr Synonymous Show 8/28, 2012

Health Care, "Obamacare" and Vietnam

I'm a Family Physician, at, what many would call, the "front lines" in health care.  I'm also a Vietnam Veteran, former Army officer, helicopter pilot and a graduate of West Point, Class of 1968.  My reflections on health care cause me to reflect on Vietnam.  How do the two relate?  Both were non-declared wars.  We won the major battles in both.  We lost or are losing both wars.  Why?  How?

In Vietnam we were confused about the overall strategy, but our tactics won every major battle.  One could say the same about health care.  We have no overall strategy, but our weapons to fight disease are superb.

Morale in Vietnam deteriorated when front line troops were instructed to become killers instead of soldiers.  Body counts replaced mission accomplishment as the focus.  The troops found a way to hide from their role as "killers" in illegal drugs, from marijuana to heroin, and mental health problems such as PTSD.

Health care is starting to fade into numbers instead of patient care.  Misguided quality initiatives follow IT installations in which billing software is modified into Electronic Medical Records (EMR)for clinical use, resulting in patients and their narratives being ignored into a sea of numbers.  Nurses hang onto bar code readers instead of holding onto patient hands and hopes.  Caring professionals are becoming despairing professionals.

Patients are being turned into numbers and bar codes.  Their hopes and dreams, which should be the basis of "Quality" measures, are being ignored.

Robert McNamara, Defense Secretary for Presidents Kennedy and Johnson was the leader behind the Vietnam body counts which devastated troop morale.  The Patient Protection and Affordable Care Act (PPACA), also referred to as "Obamacare", has now taken the lead with numbers-oriented policies and protocols that will move us closer to the demise of health care. 

"Meaningful Use" (which I sometimes refer to as "Meaningless Use") is the term used to refer to the government mandates for approved Electronic Medical Records, which may reward primary care physicians with taxpayer dollars (up to $56,000 per compliant physician).  The numbers game is polluting the push for developing the Patient Centered Medical Home (PCMH), which is supposed to help patients, into the development of, what I refer to as, "Payment Centered Medical Homes", with over-emphasis on physician reimbursement to try to "buy" medical students into Family Medicine and other primary care specialties.

Family Medicine is a relationship focused medical specialty.  The patient-physician relationship is the heart of Family Medicine.  It is our essence.  It is being ripped out by the current direction of health care.

Is health care becoming another Vietnam, with massive expenditures and worsening outcomes?  It feels that way to someone who's been involved in both wars.

What do you think?

Family Medicine: Superhero Needed

I still remember the excitement I had when Robert Rakel, MD, Chairman of Family Medicine at the University of Iowa (and, eventually, editor of one of the top two texts in the field of Family Medicine) spoke at the National Rural Health Annual Meeting in Detroit in 1974 to medical students attending the meeting.  He introduced the relatively new specialty of Family Medicine with a charismatic presentation which included the Kerr-White diagram, showing that almost no-one who gets sick goes to a university hospital for their diagnosis and treatment.  They were going to Family Physicians.  They still do.

We are America's specialty:  A group of generalists who relate to patients regardless of their problem or need.  Family Doctors are doing well at taking care of much of America.  I'm still proud to be a Family Physician after more than 170,000 patient encounters, but things are changing.

I'm worried about Family Medicine now.  We need 30 % of medical students to select our specialty in order to have enough of a workforce to care for an aging population and to prevent premature demise from preventable or treatable diseases.

An over-emphasis on numbers is leading to increasing patient dissatisfaction with their care.  An  over-emphasis on money is leading to "Market Medicine", ethically insensitive business practices that lean toward profits instead of patients.  An over-emphasis on technology is leading to overuse of expensive technology instead of efforts to balance "High Tech" with "High Touch".  The money that follows the over-emphasis seems to pull medical students away from Family Medicine.

Bob Rakel, who was sometimes referred to as "The Rakel of OZ" was like a Superhero to me.  Family Medicine could use a Superhero to "fight for truth, justice and the American way of life", or at least the patient-physician relationship.  Be on the lookout for a masked someone with a big "FM" on their Superhero shirt.  We need them.

Male Wellness, Leg Cramps, Limb Movement, Human Trafficking

Here's a summary of the main elements of my BlogTalk Radio broadcast August 21, 2012.  The show covers a variety of health care blogs, tweets and medical review articles with some discussion.  Starting with an introduction and disclaimer, Dr Synonymous (A. Patrick Jonas, MD) notes an exception to the usual show format.  Sea Spray's patient blog about children, a dog and POOP is the only patient blog tonight.  Medical articles from American Family Physician and The Journal of Family Practice are the main focus, starting with an AFP overview of the "Adult Well Male Examination".  Discussion moves to Nocturnal Leg Cramps, then to Periodic Limb Movement Disorder and their diagnosis and treatment.  Brief comments about a Food Allergy slipped in to introduce a topic that I'll cover in a week or two.

Dr Jonas lastly comments about Human Trafficking, a modern slave industry with shocking dimensions.  Motivated by Pastor Terry Heck of Bellbrook United Methodist Church who is active in trying to eliminate this human disaster, Dr Jonas reviews the definition of Human Trafficking and gives an introduction to the topic.  I believe that Family Physicians have a role to play in prevention of Human Trafficking, starting with awareness. Addressing the issue of pornography, especially on the internet is another prevention strategy.  Human Trafficking in the sex trade leads many to become trapped in chemical dependency, prostitution and depression.  What do you know about the problems we have in Ohio and the rest of the nation in Human Trafficking?

More will follow.

Dr Synonymous on BlogTalk Radio August 21, 2012

Health Care: Radical Innovation Needed

I looked at the pile of reports about my patients at the end of the patient encounter schedule. Twenty or so patients are represented in the information that I review and direct for action or filing.   While working through the schedule of 15-20 patients each day, I also process information about six to ten other patients by responding to questions, signing prior authorization forms so patients with drug allergies might be authorized to get a medication that won't make them sick, evaluating and signing referrals, interpreting crisis lab values, responding to power company intentions to turn off the power of patients who were unable to pay their bill with a waiver form if they are dependent on electrical devices for their medical care, and responding to calls from hospice nurses and emergency room physicians.  

The intrusions that might distract me from focusing on the patients in each exam room have been increasing as "administrivia" increases in medical care.  Family Physicians are tiring as unfunded mandates pile up on the specialty with the broadest array of response repertoires to patient needs.  How do we get around the "sludge"?

Innovation.  Innovation.  Innovation.

Human Centered Innovation-  Not Payment Centered!  Not Physician Centered (Not even Patient Centered which leads to dehumanization and disrespect for physicians).

Radical Innovation- Not Incremental- Not Predictable.

How?  Start with a human perspective.  Stir with some IT.  Fold into apps.  Give them to humans.  Launch and leap ahead.

Check out IFG Health (www.ifghealth.com) and their apps that "protect people's humanity as they navigate the healthcare system."

Human centering starting on the patient side of the patient-physician dyad delivers a radical strategy to level the healthcare playing field.  The context of the patient's life may connect to the context of the physician's situation better with the IFG Health approach.  

Steve Deal, CEO of IFG Health has an array of skills and experiences as a systems engineer with an aggregate 14 years experience- eight years in satellites and simulation, six years in human systems.  He and I published a human systems article about the HCHH and another for The Ohio Family Physician.  I add 39 years of medical experience including 13 with the Center for Innovation in Family and Community Health and serve as the medical innovation advisor for IFG Health.  

Co-founder Rene Rafael Vogt-Lowell serves as chief technology officer.  He has a combined 14 years of service in many sectors of IT including management of emerging technologies for Sinclair Community College’s Distance Learning department and development of eLearning software applications and simulations for both mobile and desktop platforms.

OK, my piles at the end of the day won't disappear this week from one  innovation company.  No one strategy or company will solve the healthcare dilemma, but IFG Health is a radical innovation that feels right.

DOC (Direct Ohio Care) Launches Soon

Direct Ohio Care (DOC), an Ohio based network of medical practices, will enable Ohio Family Physicians and other Primary Care Physicians to offer Direct Primary Care (and what I like to call Direct Family Medicine) to their patients.  Direct Primary Care is a membership-based practice model that is included in the Patient Protection and Affordable Care Act as allowable in the state health insurance exchanges. HR3315 would also make it available to persons on Medicare, currently not allowed.

Direct Primary Care Coalition

HR3315

DOC will launch soon.  More later

The Olympics, Patients and the Human Spirit

Twitter goes wild with Olympic Tweets.  Staying up until 2 AM leads to sluggishness the next day.  Gabby Douglas, the gymnast has 51,000 fans on Facebook as of August 1st. Now that she won the gold medal for all around best female gymnast.  Patients have their favorite Olympic situations and great pride in America via the Olympic Gold Medalists and many others.  Swimming events and women's gymnastics are the most notable so far.  The running and jumping events start tomorrow.  More stars, glory, victories, disasters, failures.  Stay tuned.

We're getting a few more patients who can't pay or don't pay.  A few more are unemployed and can't find the next job.  Smoldering joblessness generates fatigue and stress.  Families are being squeezed.  People are tired.  They will rally, though.  I've seen the stamina of their spirit, and felt it.  It's impressive and heartening.  It becomes part of the heart of family physicians.  They show us again and again.  We love it. Thanks, folks.

Direct Family Medicine: Too good to Be True- So Far

How are we doing with the conversion to Membership-based Direct Family Medicine?  After three weeks of being closed to all insured new patients, we have no takers for Direct Family Medicine.  Several reasons are likely:  My staff may not "buy" it yet, or it's too confusing to quickly tell new patients how it works, or they don't like the concept, or they have insurance and don't qualify.

What do we do next?  Market to a specific group of people who don't want their insurance to include Family Medicine care.  Who are these people?  We aren't sure, since we can only take 200 of them in family units, or about 65-75 families.  We'll figure it out this week.

Our friend, the Center for Innovation in Family and Community Medicine is working on setting up a network such as Health Access Rhode Island to connect like minded practices.  There are at least four Direct Primary Care practices in Ohio so far.

More later.

July 27, 1970 Departure for Vietnam: Memories

Several times today, I reflected on July 27th, 1970- my day of departure from the United States for Vietnam. My wife went with me to Cincinnati, where we said our goodbyes (and may have felt strangely unusual this time with the slight potential of never seeing each other again- pangs of war's effects).  I flew to Oakland, CA then cabbed to Travis Air Force Base, where I reported in to someone and was assigned a flight to Vietnam via Alaska and Kubota, Japan for fuel stops.  Before I left Alaska, I got word of the birth of my nephew, Matthew, who timed his birth on his older brother's birthday (and my departure day), so I remember their July 27 birthdays easily.

I blogged about this subject on the 40th anniversary in 2010 here.

The Vietnam thoughts have many layers of meaning to me.  The War (never declared), flying helicopters (initially from our aviation section- see photo above of our building- in Phu Bai until moving to Danang in Dec., 1970), mostly in areas of I Corps- northernmost military designation of Corps I-IV, friends, playing cards, serving the Army and the nation, planning, solving problems, Operation Lamson 719, OH-58 training in Vung Tau (top photo above) and later instructor pilot training in Vung Tau.

The Bob Hope USO Show (above photo includes Bob Hope and The Golddiggers) flying along the beaches of the South China Sea (two of photos show aerial view and beachfront view of HQ 45th Engineer Group after December, 1970), flying for the 45th Engineer Group to engineering sites (in above photos) and to the northernmost Army outpost in South Vietnam to take "donut dollies" to entertain the troops (Was it to Camp Fuller?  We could see the North Vietnam Flag across the DMZ, by the way) , and R & R in Hawaii with Rebecca (seeing the Don Ho Show).  R & R in Sidney, Australia and a trip to the Sidney Zoo.  On and on with memories, stimulated by hundreds of photos of the experience on my laptop computer.  Coming home, meeting my wife in Cincinnati and going to the zoo.  Trips to "The Wall".  More next July 27th.  Peace to all.