Wednesday, October 31, 2012

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.

Saturday, October 27, 2012

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.

Tuesday, October 23, 2012

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 (

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.

Saturday, October 20, 2012

Family Medicine: Time to Warrior-Up!


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?

Friday, October 19, 2012

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?

Tuesday, October 16, 2012

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.

Friday, October 5, 2012

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.

Tuesday, October 2, 2012

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.