Tuesday, December 30, 2014

Healthcare and Vietnam: Loss and Grief

As a Vietnam Veteran and Family Physician, I'm noticing parallels that are bothersome.  Many times recently, I've thought, "This feels like Vietnam"  How?
By the discouragement in the physicians as the transformation of healthcare erodes their autonomy and sense of independence.  It has intensified and dragged down their quality and their spirit.

The "metrics" of the year or quarter or month or week are dumbing down the practice of medicine.  Just like the "metrics" of body counts in Vietnam killed the morale of the American soldier.  They weren't killers and rebelled against the concept of killing people just to have something to count.  We physicians aren't counters and coders as the EMR and a misguided group of programmers and MBA's/ MHA's have labeled and aimed us.

We care and work and serve much more than count and code, BUT we are selling out to the "Numerati" and other numbers/financial geeks.  How much time is left to care and work and serve?

I grieve the loss of the medical profession, just as I grieved for the deep wounds of the Vietnam Veterans, used as killers and body counters by misguided people in Washington, DC.

What do you think?

Direct Primary Care Informational Sessions Dayton, Ohio, Monday January 26 and February 23, 2015

Direct Primary Care Informational Sessions Dayton, Ohio.  

Family Physicians, General Internists, Pediatricians and Med/Peds Primary Care Physicians
and Primary Care Nurse Practitioners, Physician Assistants, Residents and Medical Students:

Monday January 26 and February 23, 2015 at 7:00 PM in the offices of Family Health Connections, Inc 
at 2633 Commons Blvd Suite 120 in Beavercreek, OH:   
Get the latest information about Direct Primary Care.

Sponsored by the Center for Innovation in Family and Community Health (CIFCH).

RSVP to 937-427-7540 (Medical office of Dr Jonas, President of CIFCH).

Is Direct Primary Care the business model to assure your career satisfaction in 
Family Medicine, Internal Medicine or Pediatrics (or Med/Peds)?

Wednesday, December 24, 2014

Pain News and Blog Reviews; Christmas with Autism -Weekly BTR Show

Hi Folks,
On my weekly Dr Synonymous Blog Talk Radio Show I covered several issues, drank coffee and encouraged people to come to the Bluegrass Jam at the BellHOP Cafe in Bellbrook this Saturday 7-10 PM.

I don't know enough about autism.  There is so much to know and so much still missing.  I'll push ahead with more learning.  You may also wish to know more, so I reviewed four sites with autism information and one mother's blog post about Christmas over the years with her son Matt.

Pain News, Family Flu, Christmas with Autism on The Dr Synonymous Show

Last weeks show covered different topics:

MTHFR, B Vitamins, EMR, Clinical Decision Making, Grief at Christmas on the Dr Synonymous Show

A link to the show is always available on this blog site, too.  You have to have a google ID to get into the site, though.

More next week on the Dr Synonymous Show.

(Over 200 shows are archived on iTunes so you can listen to me a lot, if you are so inclined.)

The Flu HURTS!

The Flu HURTS!  It is a PAIN SYNDROME!  That's one big reason to avoid it and respect it. People tend to have pain in their back, head and all over BEFORE the mucous hits their entire respiratory system on the second day.  IT HURTS!

And, there is too much mucous, AND fever every twelve hours or so with increased aches and pains.

And many people, in the midst of the mucous, aches, pains and fevers have the common thought, "if I died, it would feel a lot better".

The Flu is now moving into the Miami Valley  with five or more days of symptoms including sore throat, body aches/ pains, fever and cough.  On day four to six, the infection is often so annoying that the patient or parents seeks medical attention, convinced of the need for an antibiotic, chest x--ray or cough suppressant.

People with chest tightness from tiring muscles plus or minus wheezing seek relief from their painful misery.

Remember Henry The Hand and the principles of hand washing to minimize the spread of the flu.  AND, Don't touch your face!  http://www.henrythehand.com/

Some people just want to get a note so they can get back to school or work when well.  Employers just don't allow a good illness to follow its natural history without involving physicians.  If you know you don't need medical attention, can't you be trusted to decide when you're recovering or recovered?  Is it a covered benefit under your insurance to use a physician when not ill to get a note to return to work?  Can't your mother just write an excuse for your absence?  (No -according to many employer and school policies.  The now functional worker or student must go to a doctor to get cleared for their illness-caused absence, sitting in a waiting room with the coughing people, before their school or employer will believe them as to why they were absent.  What a waste of resources this type of distrust generates.)

- See more at: http://drsynonymous.blogspot.com/2011/03/family-medicine-is-it-flu-strep-throat.html#sthash.4waCI3HF.dpuf

Treatment:  Rest AT HOME!  Don't go anywhere!  You are a threat to others.  Honor yourself and them by keeping away.  Don't go to see doctors or urgent care or emergency rooms, either, unless you really need them for something you and your family can't handle.

Water!  Water! and Water!
Aspirin is a great pain killer for adults with the flu, but may cause death in children because of Reye's Syndrome.  Ibuprofen and acetaminophen may help both adults and children with pain and fever (a temperature greater than 100.4 degrees).  Above 101, the fever adds to the pain.

Cough suppressants, expectorants, decongestants as needed.  Vitamin C 1000 mg may be helpful. likewise echinacea (puerpuera, pallida and augustifolia)..  Vitamin D3 2000 IU daily may prevent the flu, as may the flu shot.  Unfortunately the flu shot only covers three of the many strains and the first one that has hit the area seems to be insensitive to the three strains covered by the shot.  Better luck next year.

I don't think much of Tamiflu, which may shorten the flu by one day- if started in the first forty eight hours of symptoms, but cause mental confusion with delusions or hallucinations at a relatively high cost.

If you have a serious condition and need to see your physician to clarify how to handle the flu in the midst of the serious condition, see your doctor.  You matter.  They can help to clarify how to handle your flu relative to your other disease and all of your medications.

If you see your physician for the flu, don't even think of asking them to handle any of your chronic problems or ongoing medications, etc. while there.  You only need to clarify your flu related issues and get home.  Minimize the exposure to the patients in the waiting room, the office staff and the physician.  

Especially if you are on chronic opiates for a stable pain syndrome, the flu visit is not the time to ask your physician to engage about your pain management.  That is a complex separate visit with all sorts of "quality" and regulatory overtones, way more complex than most people on chronic opiates are respectful of, which is one of the reasons fewer and fewer physicians are willing to treat pain.  People on chronic opiates OFTEN become manipulative and devious and desparate.  The FDA just multiplied by six the amount of time a person on chronic hydrocodone (Norco, Vicoden, Lortab) must visit their physician.  They changed those drugs to a Schedule II (similar to Percocet, oxycodone, oxycontin) which means they can't be refilled or called in to a pharmacy.

If you get a complication of the flu, see your physician.  A complication is whatever you think is a complication.  Especially difficulty breathing, exaustion from coughing, new fever after the fever stage is over, etc.

The flu feels great once it's over.  That's because the Flu HURTS

Monday, December 15, 2014

EMR: Physician Rants

OK, I've heard some physician rants about Electronic Medical Records.  Change isn't always fun.  Here are some rants, just in case you or your physician are all giggles about the EMR, so you know there are other opinions.

"The Electronic Medical Record (EMR) is as "medical" as Medical Marijuana.  But, it helps to maximize "medical" billing.  It costs too much.  It leads to markedly diminished time for patient care.  It is shameful that it was mandated by poorly informed non-physicians.  It is shameful that physicians went along with it.  The idea seemed good, but the EMR doesn't deliver the goods to help patients or hospitals or physicians to improve quality and decrease cost. The new quality isn't quality- it's whatever is measurable.  We sold out our profession and our patients on this misguided transformation.  The Electronic Medical Record is an Electronic Billing Record."

Benefits:  Billing.  Medication lists.  Prescriptions. Legibility.

Harm: Loss of time.  Patient quality.  Patient satisfaction. Physician quality.  Physician autonomy.  Patient-Physician relationship.  Cost of health care.

What do you think?

Tuesday, December 2, 2014

What is Family Medicine?

Medical students have to sort out specialties to be able to select one for their career. Here's the definition of Family Medicine for those who wish to understand how their career dreams compare to a career in this specialty.

"Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity." (1984) (2010 COD).....from the AAFP

During their Family Medicine clinical experience, they may wish to refer to this definition each day to notice what manifestations of the specialty they've experienced or observed.  They may ask themselves:  
"Was that continuity of care I just experienced?  As I see the same patient and members of their family am I developing a comprehensive picture of their health needs?  Working with the patient, are we developing a comprehensive plan for their health screenings and disease care?"

Further information from the American Academy of Family Physicians is the Scope and Philosophical Statement of Family Medicine:  "Family medicine is the natural evolution of historical medical practice. The first physicians were generalists. For thousands of years, generalists provided all of the medical care available. They diagnosed and treated illnesses, performed surgery, and delivered babies. As medical knowledge expanded and technology advanced, many physicians chose to limit their practices to specific, defined areas of medicine. With World War II, the age of specialization began to flourish. In the two decades following the war, the number of specialists and subspecialists increased at a phenomenal rate, while the number of generalists declined dramatically. The public became increasingly vocal about the fragmentation of their care and the shortage of personal physicians who could provide initial, continuing and comprehensive care. Thus began the reorientation of medicine back to personal, primary care. The concept of the generalist was reborn with the establishment of family medicine as medicine's twentieth specialty.

Family medicine is a three-dimensional specialty, incorporating (1) knowledge, (2) skill and (3) process. Although knowledge and skill may be shared with other specialties, the family medicine process is unique. At the center of this process is the patient-physician relationship with the patient viewed in the context of the family. It is the extent to which this relationship is valued, developed, nurtured and maintained that distinguishes family medicine from all other specialties.

In the dimension of process, the family physician functions as the patient's means of entry into the health care system and as the physician of first contact in most situations is in a unique position to form a bond with the patient. The family physician's care is both personal and comprehensive and not limited by age, sex, organ system or type of problem, be it biological, behavioral or social. This care is based on knowledge of the patient in the context of the family and the community, emphasizing disease prevention and health promotion. When referral is indicated, the family physician refers the patient to other specialists or caregivers but remains the coordinator of the patient’s health care. This prevents fragmentation of that care in both the outpatient and inpatient settings. The family physician serves as the patient’s advocate in dealing with other medical professionals, third party payers, employers and others and as such is a cost-effective coordinator of the patient’s health services.

Although all family physicians share a core of information, the dimensions of knowledge and skill vary with the individual family physician. Patient needs differ in various geographic areas, and the content of the family physician's practice varies accordingly. For example, the knowledge and skills useful to a family physician practicing in an inner city may vary from those needed by a family physician with a rural practice. Furthermore, the scope of an individual family physician's practice changes over time, evolving as competency in current skills is maintained and new knowledge and skill are obtained through continuing medical education. This growth in medical information also confers on the family physician a responsibility for the assessment of new medical technology and for participation in resolving ethical dilemmas brought about by these technological advances.

In summary, the family physician of today is rooted in the historical generalist tradition. The specialty is three dimensional, combining knowledge and skill with a unique process. The patient-physician relationship in the context of the family is central to this process and distinguishes family medicine from other specialties. Above all, the scope of family medicine is dynamic, expanding, and evolutionary.(1992) (2011 COD)".... from the AAFP

The personal experience of the students allows them to discern how well their dream and their sense of the specialty of Family Medicine align.  It's not for everyone, but it is the specialty for many.

Saturday, November 22, 2014

Chicken Pox, Vioxx and Goldilocks - The Song

Healthcare Healthcare Everywhere                     by Pat Jonas, MD

Chicken Pox, Vioxx and Goldilocks- Healthcare Just for you
A shot, a drug and a fairy tale, it’s just like a zoo
And if you have insurance, you won’t pay the bill
Just go into CVS, you can get your fill

     Healthcare, healthcare everywhere, more than what we need
     Cat scans, ER’s, MRI’s, Chemo used like tea
     More is better, “Let’s be sure”, “You’re a friend of mine.”
     Let me see your wrist ID to bill you one more time.

Barcode reader in my hand leads to good health care
Patients lying in the bed will notice that I’m there
“Yes! A nurse someone who cares, perhaps I won’t be killed”
“OK, I can hear your cares, after you’ve been billed”

Family Doctor, what is that? Someone we don’t need.
ER, that’s the place to go when I start to bleed
Just bill my insurance, please, for more and more health care
Co-pay’s all I need to pay for everything that’s there.

I recently gave a talk titled "Chicken Pox, Vioxx and Goldilocks:  Avoiding Avoidable Care" at the Institute of Holistic Leadership Annual Symposium (see previous blog post with that title).  Included was this song which we sang together.  Just a spoof on some aspects of healthcare.  The tune is similar to the Mr. Clean song (but not quite).  Enjoy.

Friday, November 21, 2014

Family Medicine: Compassion Equals Vulnerability

"Long term relationships lead to a build-up of particular knowledge about patients, much of it at the tacit level.  Because caring for patients is about attention to detail, this knowledge of particulars is of great value when it comes to care....On the whole, our tendency to think in terms of individual patients more than abstractions is a strength...but can make it difficult for us to feel comfortable in the modern academic milieu, where diagnosis and management are more usually seen in generalizations than particulars.  The risk of living too much in a world of generalizations and abstractions is detachment from the patients experience and a lack of feeling for his suffering."
The ideal for all physicians is an integration of the two kinds of knowledge: an ability to see the universal in the particular.
     The most significant difference between family medicine and most other clinical disciplines is that it transcends the mind/body division that runs through medicine like a geological fault line". ...Ian McWhinney, A Textbook of Family Medicine

I love that last sentence more every time I read it.  But it is also sad that most of the rest of medicine employs, as Dr McWhinney notes:  "a clinical method that excludes attention to the emotions as an essential feature of diagnosis and management.  Another is the neglect in medical education of the emotional development of physicians."

Important to Family Physicians is compassion.  We care enough to hurt.  When we hurt for our patients or our relationship with them, we show our vulnerability as humans.
Compassion = Vulnerability.
When we celebrate with our patients, our enjoyment can equal our caring.
Enjoyment= Caring.

It's fun to transcend the mind/ body fault line and be a Family Physician, vulnerable and caring..

What do you think?

Wednesday, November 19, 2014

Family Medicine: Life is Not Medical, It's Human

So many initiatives make up the current healthcare transformation.  Many are fad-like IT adventures that appear exciting on the surface but detract from health care, especially as it applies to individuals.  The life of the individual is being sucked into a medical abyss by some of these initiatives such as "Meaningful Use"  which measures "measurables" and calls them "quality".  These initiatives are billed as vital and may lead to bonuses for physicians (or their employer) or labels for patients as "non-compliant".  Overall, they are leading to the Medicalization of life and a denial of the Humanity of life.

Is life just Medical?  Are we Human Beings or Medical Beings?  Is managing cholesterol the essence of Family Medicine?  Is a good Hemoglobin A1c the measure of the patient-physician relationship?  As Peggy Lee once sang, "Is that all there is?"

The Direct Primary Care DPC) movement says, "No!"  There is more.  There is the power of the patient-physician relationship to validate the humanity of both patient and physician while identifying and treating medical conditions.  There is the shared wisdom of patients and physicians that clarifies the meaning of the illness and the beauty of life.  DPC offers new freedoms and challenges to Family Physicians via more time with patients and family. The time factor allows for richer differential diagnoses and clinical decision making.  It also allows for a deeper understanding of what it means to be human.  It's not perfect and it's definitely not for everyone.
What do you think?

Friday, November 14, 2014

Direct Primary Care Informational Session Dayton, Ohio

Family Physicians, General Internists, Pediatricians and Med/Peds Primary Care Physicians and Primary Care Nurse Practitioners and Physician Assistants:

Monday November 17, 2014 at 7:30 PM in the offices of Family Health Connections, Inc at 2633 Commons Blvd Suite 120 in Beavercreek, OH:   Get the latest information about Direct Primary Care.

Sponsored by the Center for Innovation in Family and Community Health (CIFCH).

RSVP to 937-427-7540 (Medical office of Dr Jonas, President of CIFCH).

Is Direct Primary Care the business model to assure your career satisfaction in Family Medicine, Internal Medicine or Pediatrics (or Med/Peds)?

Check it out Monday November 17th.  You may be surprised to know that practicing medicine can be fun again.

Wednesday, November 12, 2014

Family Medicine: Loyalty

I noticed a loyalty rating of physicians in some hospital literature recently.  I cringed.  My patients came to mind when I read the word loyalty.  I am loyal to them.  They are loyal to me.  (OK, it isn't perfect loyalty, but often it is "Til death do us part").

I have no similar category for hospitals.  Some might say they are generic marketing units, with the "best practices" (me-too sales pitch of the week) noted in their marketing pitch in such a way that one might think they actually had an original "service line" or product idea.  I've not seen recent evidence of their inclusion of my specialty, Family Medicine, in any of their "best practices" or product lines.

When Ohio eliminated the corporate practice of medicine act, thus allowing non-physicians to employ physicians, the medical profession became mis-directed toward not being a profession any longer.  A profession is allowed to exist by the citizenry through our legislature if the profession agrees to police its own member and enforce its own ethical code.  With the shameless enabling of the bankruptcy of millions of Americans through unnecessary and over priced practices, we have bailed out as a profession.  Is our loyalty shifting to hospitals?

I am a member of the American Medical Association.  Here are the Principles of Medical Ethics from the AMA for members:

Principles of Medical Ethics


The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

Principles of medical ethics

I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
V. A physician shall CONTINUE to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
IX. A physician shall support access to medical care for all people.
Adopted June 1957; revised June 1980; revised June 2001.

The principles of Medical Ethics simplified:  There are four basic principles of medical ethics. Each addresses a value that arises in interactions between providers and patients. The principles address the issue of fairness, honesty, and respect for fellow human beings.
  • Autonomy: People have the right to control what happens to their bodies. This principle simply means that an informed, competent adult patient can refuse or accept treatments, drugs, and surgeries according to their wishes. People have the right to control what happens to their bodies because they are free and rational. And these decisions must be respected by everyone, even if those decisions aren’t in the best interest of the patient.
  • Beneficence: All healthcare providers must strive to improve their patient’s health, to do the most good for the patient in every situation. But what is good for one patient may not be good for another, so each situation should be considered individually. And other values that might conflict with beneficence may need to be considered.
  • Nonmaleficence: “First, do no harm” is the bedrock of medical ethics. In every situation, healthcare providers should avoid causing harm to their patients. You should also be aware of the doctrine of double effect, where a treatment intended for good unintentionally causes harm. This doctrine helps you make difficult decisions about whether actions with double effects can be undertaken.
  • Justice: The fourth principle demands that you should try to be as fair as possible when offering treatments to patients and allocating scarce medical resources. You should be able to justify your actions in every situation.
            from Medical Ethics for Dummies by Runzheimer and Johnson

With increasing evidence of loyalty to hospitals instead of patients, we have to refresh our professional insights and realign with our patients.  Our approach to clinical guidelines leans away from autonomy toward "Bonus- Based Medicine".  "First do no harm" doesn't align well with all the CT Scans we're administering (80 million 3 years ago) that will contribute to 29-30 thousand cancers annually soon.  Etc., Etc.

Is there a way out of our disastrous mis-direction as a (pseudo)- profession?

I'm a bit old fashioned and my loyalty is with my patients.

What do you think?

Tuesday, November 11, 2014

How to Thank a Veteran: Do Your Duty

 How do you thank a Veteran?  We reflect on this more and more these days.  It seems that the whole nation has a sense of gratitude for our service.
One message of our service is that we had a sense of duty.  Duty- doing what we ought to do.  It's a simple concept, sometimes exacting a high price.  What ought we to do?
In military service, we may get a more direct opportunity (or many) to answer this question.
On one end of the spectrum is the cold answer:  Kill someone if necessary.  Another is to risk one's life for a comrade in arms, or a civilian, or a town. Sometimes, the choices overlap, sometimes they conflict.

I'm a Vietnam Veteran.  We had a confused mission at times.  Enable the South Vietnamese to defend themselves and become independent of North Vietnam- easy to understand.  Kill as many enemy as possible to get high body counts as a "quality" measure of warfare- harder to adjust to becoming a killer just for quality control.

Harder still if ordered to kill innocent bystanders by a confused commander, which happened at My Lai, a dark incident which cost many Vietnamese their lives and a few Army leaders their careers.  A helicopter pilot, Hugh Thompson,  saw what was happening and put himself and his helicopter between the "killers" and the "victims", risking his life to do what seemed right.  Military troops sometimes get in these situations suddenly and act quickly.  The rest is history.  Duty.

Many veterans refused to follow illegal commands in Vietnam.  Many followed the illegal orders.  Many careers ended suddenly.  The military duty seemed to conflict with the Human Duty.  What is right? Judgments over the years allow those individuals and situations to be clarified.  Some people have peace of mind because they did their Human Duty when confronted with the opportunity.  Duty calls our humanity to attention and to action.

Veterans often have stories to share of others doing their duty.  The stories don't include music in the background to make them more dramatic like many of the war movies.  .They tell of human decisions under duress.  The characters had flaws.  The situation wasn't clear, but the decision was.

You have opportunities to do your duty.  Honor a Veteran on  Veteran's Day by doing your Human Duty. Do what you ought to do.  Yes, align with your conscience.  Yes, it may mean quitting your job.  Sometimes that's the right thing to do.  If doing your job means harming people personally or financially, maybe it's time to quit.  God will know.

Thank a Veteran by Doing Your Duty!

Friday, November 7, 2014

Neighborly Family Medicine Now Open for Direct Family Medicine Patients

Neighborly Family Medicine
A. Patrick Jonas, MD
Rebecca T. Cherry, MD
@ Family Health Connections, Inc.
2633 Commons Boulevard, Suite 120
Beavercreek, Ohio 45431
Updated 7/02/2017

Direct Family Medicine is our version of Direct Primary Care (DPC), a popular business model for practice.  This is not insurance. It is medical care from Dr.'s Jonas and Cherry, both graduates of Ohio State University College of Medicine and board certified in Family Medicine.

We provide Basic Family Medical Care:
Acute Problems
Chronic Conditions and Diseases
Prevention/Physicals such as well child, well woman w/female exam, sports, etc.
Traditional After Hours On Call Physician Coverage

We are Family Fanatics!  Families ONLY can sign up:
You must agree to sign up the whole family (household)
and pay the enrollment fee for the whole family at your first visit.
There are monthly fees that are due at the end of each month.  Families may dis-enroll with written notice after three months of membership.  If they return, another enrollment fee will be charged.
There is a per visit fee which is due at each visit.   Our basic fees do not include laboratory tests which are charged at a discounted rate for most common tests.  Immunizations materials are separate charges. Imaging fees are the patient's responsibility but discounted fees are available.  Money doesn't sound very warm sometimes, but Neighborly Family Medicine is warm-hearted.

If you have Tricare, Medicare, ANY type of Medicaid (Caresource, Molina, Buckeye, UHC medicaid, etc.) or any other government-sponsored insurance, you are NOT eligible until 2018 when the practice expects to have terminated our contracts with government and commercial insurance companies.

We expect that patients will find a catastrophic health insurance plan to cover their emergency, hospital, cancer and other more expensive aspects of their medical care.  Many uninsured patients won't have that luxury and we'll try to help them find affordable care as possible.  The health care system is changing rapidly and we're convinced that Direct Family Medicine is a better business model for Family Doctors.

This model of care was recently reviewed positively in Forbes magazine: DPC Trumps the ACA for Value, Quality and Satisfaction

Costs:                       Adults     Children 2-17     Infants 0-2

Enrollment                    $80         $40                 $60
Monthly Membership   $70         $40                 $50
Per Visit Fee                 $20         $20                 $20

If you qualify, you will be asked to provide the information at this site: 

DABBLE with Your Holistic Health

I like to DABBLE with holistic health.  Here's a simple outline for you.

Dream   Allow  Become  Become again  Listen  Enjoy

Dream like Goldilocks (that's a good start)

Allow like a great teacher allows their students to succeed/ fail/ learn

Become yourself with honored parts (if awakened by bears, run like Goldilocks)

Become your next (near) whole self again

Enjoy it like the (near) whole you, as your parts allow

As you imagine wholeness and fulfillment in your future, supported by personalized healthcare that aligns with your values, goals and dreams, how content might you feel as you visualize or sense your future self?

What is your dream?
If you wish to have success (as you define it), it may be more readily achieved by:
     Defining your Dream
     Having a Burning Desire to achieve it
     Believing you will reach it

Allow an honest assessment of yourself at regular intervals

     In your Living, Learning and Working Contexts (If you like grids, make a 4 x 3 grid giving 12 boxes to reflect on).
     Does your honest assessment yield strengths and needs conducive to actions that better align you with your values, goals and dreams?

Tuesday, November 4, 2014

Vioxx and Trust

Vioxx was a great medication for thousands of people with osteoarthritis.  It was great for pain relief.  Many persons, though got serious side effects.  Heart attacks and strokes.  Here's some of the initial background information:
In VIGOR, a study in 8076 patients (mean age 58; VIOXX (rofecoxib) n=4047,NAPROXEN n=4029) with a median duration of exposure of 9 months, the risk of developing a serious cardiovascular thrombotic event was significantly higher in patients treated with VIOXX (rofecoxib) 50 mg once daily (n=45) as compared to patients treated with NAPROXEN 500 mg twice daily (n=19). In VIGOR, mortality due to cardiovascular thrombotic events (7 vs 6, VIOXX (rofecoxib) vs NAPROXEN, respectively) was similar between the treatment groups. (See CLINICAL STUDIESSpecial StudiesVIGOROther Safety Findings: Cardiovascular Safety.) In a placebo-controlled database derived from 2 studies with a total of 2142 elderly patients (mean age 75; VIOXX (rofecoxib) n=1067, placebo n=1075) with a median duration of exposure of approximately 14 months, the number of patients with serious cardiovascular thrombotic events was 21 vs 35 for patients treated with VIOXX (rofecoxib) 25 mg once daily versus placebo, respectively. In these same 2 placebo-controlled studies, mortality due to cardiovascular thrombotic events was 8 vs 3 for VIOXX (rofecoxib) versus placebo, respectively. The significance of the cardiovascular findings from these 3 studies (VIGOR and 2 placebo-controlled studies) is unknown. Prospective studies specifically designed to compare the incidence of serious CV events in patients taking VIOXX (rofecoxib) versus NSAID comparators or placebo have not been performed.

How did we miss the intensity of the medication's effects beyond the 45 of 4047 patients mentioned above?  45 of 4047 is bad enough, but it was even worse.

We physicians are gullible.  Fifty percent of major medical advances are disproven within five years. We refer to post marketing reports to understand the effects of medications on a broader population than those initially studied.

We lost some patient trust with Vioxx and similar drugs.  How do we get it back?

Monday, November 3, 2014

Chicken Pox

In "the old days", parents expected their children to catch chicken pox.  Everyone got it.  It was not considered to be a big deal.  Starting with red spots, then blisters on the trunk, it could evolve into hundreds of blisters all over the body.  It itched.  It sometimes scarred.  It took several days for the rash to get crusts and be declared, five or six days later, non-contagious (suitable for return to school, church, scout meetings, etc.).  If there were several children in a family, they could get chicken pox sequentially and result in prolonged absence from work by the care-taking parent(s).  Schools might experience a prolonged period of absenteeism as the infection went through the grades.  

The Center for Disease Control has a web page for the public about chicken pox (varicella virus) here and the chicken pox vaccination here.  A more detailed report for health care professionals is here, starting with this paragraph:  "Varicella (chickenpox) is a febrile rash illness resulting from primary infection with the varicella-zoster VIRUS (VZV). Humans are the only source of infection for this virus. Varicella is highly infectious, with secondary infection occurring in 61%-100% of susceptible household contacts.[1-5] Transmission occurs from person to person by direct contact with persons with either varicella or herpes zoster (shingles) lesions or by airborne spread from respiratory secretions or lesions of persons with chickenpox. The incubation period for varicella is 10-21 days, most commonly 14-16 days. Varicella is characterized by a pruritic, maculopapular vesicular rash that evolves into noninfectious dried crusts over a 5- to 6-day period."

So, what's your approach to chicken pox?  The initial vaccine is recommended for one year olds with a booster later per the CDC schedule.  A lot of people just want their child to get the chicken pox "naturally", which is hard to do when the majority get the vaccine, so they wait for them to get exposed.  If they don't get the chicken pox, they may decide to go ahead with the immunization, or they may decide to download a form from the Ohio Department of Health to submit to the school nurse opting out of the vaccination.  Ohio is one of thirteen states that lets parents opt out of any or all immunizations.

The decisions about chicken pox are simple and complex.  We study a lot about infectious diseases, the immune system, immunizations and human behavior to help people with decisions about vaccine preventable diseases. Chicken pox is a good example.

What do you think?

Saturday, November 1, 2014

Patient Enrollment in Direct Family Medicine aka, Direct Primary Care- Family Medicine Style

When figuring our charges for Direct Family Medicine (using the Direct Primary Care business model), we consider the context in which we relate to our patients.  Family Medicine is a relationship based specialty defined by the American Academy of Family Physicians (AAFP) as :  "Family medicine is the medical specialty which provides CONTINUING, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity." (1984) (2010 COD)

The specialty has been cut apart by the current nit picking approach to physician reimbursement that distracts both patient and physician.  The relative value units used to determine billing codes is a key element of the distraction.  The DPC business model, generally anchored by a monthly payment after an enrollment fee, frees patient and physician from many distractions related to the RVU's and the Electronic Medical Record. The focus of clinical encounters is dependent on the relationship of patient and physician instead of physician and reimbursement rules, EMR and employer.  The patient doesn't have to be concerned about their insurance company preventing them from acting on the plan agreed to with the physician.

OK, you may be sensing less clutter in the office visit.  In fact, the office visit doesn't have to be the center of the activity.  Without the focus on  RVU's and traditional coding and billing, the office may be omitted from being the venue where we solve many problems.  Many follow-up visits may be accomplished online, or on the phone or via home visits.  With fewer patients, more time and less office "lock", more home visits may fit in.

The enrollment fee allows the physician to have some front money to prepare for patients and to offset the Ohio end of the month mandate for the monthly membership charge.  They cannot prepay or we would be seen as an insurance company and arrested for not following the Ohio rules.  Each state has the potential for making similar unusual rules that may stifle this business model.

What if patients enroll and never pay the monthly fee at the end of the month?  Or only pay for one month and never show up again or pay again?  We require a three month initial enrollment to get the relationship established and to guard against doctor shoppers or people who may not appreciate the value of Family Medicine and the patient- physician relationship.  If the patient drops out after the initial enrollment, we figure that they gave it a good try and it just didn't work out.  If they re- enroll, they are charged the enrollment fee again and signed up for a minimum of three months.  They are allowed to drop out and re-enroll twice unless there are unusual circumstances (such as, they moved and came back).

Another twist for our practice, Neighborly Family Medicine, is that we take "Families Only" as patients. That means the whole household has to enroll as patients or we con't take any or them (I've done this for 34 years- it works well).  It also means they'll be paying enrollment fees for multiple persons.

To make this process smoother, we have a member management platform company that allows online enrollment for Neighborly Family Medicine.  Patients can read about Direct Family Medicine and our philosophy of care and various practice policies on the site at www.Hint.com and apply with their information and credit card number.  Yes they apply and we review their information to clarify that they actually qualify for our Direct Family Medicine path.  It detracts slightly from the beauty of this process when we have to review their information before accepting them.

We're a hybrid practice with about 2500 "traditional" patients from all sorts of insurances and government plans that preclude us offering this path to them so we have our original Family Health Connections, Inc. practice that houses them (but with the same tax ID number as Neighborly Family Medicine).  Insurance rules and contracts combined with our current confusion about Direct Primary Care type payment strategies make it challenging to do something that enhances healthcare and the patient- physician relationship.

So, there you have a bit of information about one DPC hybrid practice: Family Health Connections, Inc. and Neighborly Family Medicine and our enrollment process.

What do you think?

Friday, October 31, 2014

Direct Primary Care = Direct Family Medicine, Direct Pediatrics & Direct Internal Medicine

Direct Primary Care is a business model for medical practice that is gathering momentum with a boost from the American Academy of Family Physicians (AAFP) through the "Health is Primary" Campaign. See it here Find definitions of Direct Primary Care at www.dpcare.org

My practice, Neighborly Family Medicine in Beavercreek, OH, uses the DPC business model to practice Direct Family Medicine (DFM).  Notice that I'm differentiating the business model from the specialty practice.  The semantics are important, but take a while to understand.  Direct Family Medicine helps me to understand what I'm offering to patients.  I assume that a pediatrician would deliver Direct Pediatrics, while an internist would offer Direct Internal Medicine.  A Med- Peds physician would do Direct Med-Peds. Clarifying how the DPC business model is applied can be very helpful for patients and doctors.  The term Direct Primary Care comes up short of adequate clarification when patients seek care.  I love doing Direct Family Medicine (and saying it, too).

Direct Internal Medicine and Direct Pediatrics are needed.  The physicians in those specialties deserve to have the fun and freedom of using DPC to support their specialty.  We need a lot more internists and pediatricians in a DPC business model.  Join the movement, Folks.  We need you.  There are not enough Family Physicians to meet the care needs for America at the primary care level.  Let's team up and shift the cost curve together.

Patients:  Introduce DPC to your pediatricians and internists.  They'll love Direct Pediatrics and Direct Internal Medicine.

Tuesday, October 28, 2014

Teaching Direct Primary Care: Here We Go!

Direct Primary Care is all the rage.  It's been anointed in the "Health is Primary" initiative as a key business model for success by the AAFP (American Academy of Family Physicians).  The initiative was launched by the AAFP last week in Washington, DC.

A keynote presentation by Erika Bliss, MD CEO of Qliance at the Family Medicine Education Consortium (FMEC) in Arlington, VA two days after the AAFP announcement wowed the students, residents and even some faculty at the FMEC meeting. One big question from the students and residents:  Where can I get DPC training?  One big question from the faculty types:  How do you teach it?

Personal reflection as a DPC innovator, DPC Hybrid private practice owner and Family Medicine educator: Direct Primary Care is the only element in all of medicine that is moving ahead on the offensive.  The rest of medicine is otherwise on the defensive, hunkered down waiting for the next mis-directed initiative.  The AAFP is willing to take the risk of helping Family Physicians and their patients by going against the status quo and endorsing the DPC business model.  The "Health is Primary" Initiative allows Family Physicians to get some reassurance about the Future of Family Medicine.

How do we teach DPC along the entire Family Medicine workforce pipeline?
1.  Define our Dream (and help each individual to define theirs)
2.  Have a burning desire to achieve it (and cheer for each other as we get "fired up")
3.  Believe we can do it (and validate/reaffirm the belief of each other)

Dialog will be one of our powerful resources for spreading the word about DPC.  We are good at it.

The DPC pioneers have paved the way for the model to be accepted, proven and recommended.
The "Health is Primary"  initiative will add energy, deliver AAFP introductory workshops during the next year, and facilitate the DPC Member Interest Group which will help interested members to learn more.

Departments of Family Medicine can be pivotal in promoting DPC by updating faculty on the Health is Primary Initiative and the DPC elements in it.  DPC oriented faculty and clinical faculty and preceptors should be asked to orient faculty and departmental staff to DPC.  A Champion for DPC should be identified by interested Departments.

State Chapters of AAFP should be contacted for information or assistance with DPC resources and contacts.  The state chapter web site should connect with the AAFP "Health is Primary" initiative and its DPC elements.

Family Medicine Interest Groups (FMIG's) should get DPC speakers to introduce DPC elements to the student members at FMIG meetings.  FMIG advisors should find the online DPC info which is plentiful.  Pre-doctoral directors in Departments of Family Medicine should identify their DPC resources such as preceptors, clinical faculty and full time faculty, and social media resources for medical student use.

Students could introduce the DPC business model to preceptors for discussion during their clinical rotations. A list of online resources explaining DPC and its variations should be available on FM Department and FM Residency web sites.  Medical students could refer preceptors who are naive to DPC to these sites.

Residencies that identify how they will teach DPC should quickly add a DPC section to their web site and promotional materials.  Similar to the sports medicine, geriatric, perinatal, genomic initiatives across the last couple decades, the DPC aspect of practice management could be in place within two months for aggressive programs.

A champion for DPC should be identified for each section of the "Family Medicine Pipeline" and connected via social media.

Objectives for practice management training should be quickly modified to add a DPC component.  One key aspect of DPC in practice management is the learners attitude about business, money, commerce, ethics (business and medical), and the patient-physician relationship.

The Family Practice Model Units should explore a DPC track for patients and employers, which is doable (FYI-I was Medical Director of a University and a Community FM training practice- multiple payment models fit nicely.  None of them are inherently evil, but some faculty wondered if something they were unfamiliar with was dishonest--like capitation or fee for service.)

Residencies:  Students are hungry for this model.

All of us:  We're part of the problem as a citizen of the Medical-Industrial Complex.  Let's re-direct the ship around the iceberg with "Heallth is Primary", including DPC and what we learn as a result of having to teach about it.  How will it fit with "The Dream".

What do you think?

Friday, October 24, 2014

Family Medicine: The Myth and the Tension

What do patients expect of their Family Physician?  What do we expect of them?
As we relate to each other, one or the other may seek better connection.  They may press to create more tension to enable a more meaningful engagement.  Relationships, like poems, need tension.

Hopefully, patient or Family Doctor creates the tension to enhance the communication or someone may not get a fair consideration from the other.  Creative tension may enhance the relationship, too.  It can get toned over several engagements to allow high quality communication and better alignment with mutually beneficial values, goals and dreams.

The expectations of each party may be based on a mysterious myth about who the other person is and what has (or hasn't) happened before.  Our profession has some mythical qualities with many patients, especially those with positive expectations.  We may remind them of a TV Dr. like Marcus Welby, MD or Richard Kildare, MD (OK, these were a long time ago) or one of the newer physicians on Gray's Anatomy.  Those myths may be helpful for the patient and the doctor to accomplish their goals.  They believe in something beyond the current situation, and make it through.

What kind of tension do you create?  Or run from?

What myths might you believe about patients, Family Medicine or your Family Doctor that may help or harm your health?  Or your career?

More later from the FMEC meeting in Arlington.

Monday, October 20, 2014

FMEC Meeting: Reunion of "Geeks and Geezers in Social Media" #FMEC2014

Calling all Social Media Geeks and Geezers alumni. Starting at the Hershey FMEC meeting, several of us launched a social media era for FMEC with a session called, " Social Media for Geeks and Geezers".   Mike Sevilla, MD and Kenny Lin, MD and I noted that, after our Seminar, several blogs were initiated.  "The Future of Family Medicine" blog by Kevin Bernstein (then medical student on the AAFP Board) MD and "The Singing Pen of Dr Jen" by Jennifer Middleton, MD were among them.  Numerous persons started a Twitter account at that meeting.  It was a nice start.  After two similar sessions at subsequent FMEC meetings, including Jennifer Middleton, MD, Michael Smith, MS, Kenny Lin, MD and I in various faculty roles more people started to Tweet and blog and use social media in all sorts of venues.

Kenny Lin, MDCommon Sense Family Doctor
A. Patrick Jonas, MDDr. Synonymous
Jennifer Middleton, MD The Singing Pen of Dr. Jen 
Larry Halverson, MDFrugal Family Doctor
Mike Sevilla, MDFamily Medicine Rocks
Kevin Bernstein, MD/Andrew Lutzkanin, MDThe Future of Family Medicine

In Arlington, VA, we're inviting Geeks and Geezers to be Social Media Ambassadors via Twitter, Blogs, Facebook, LinkedIn, and Internet Radio, etc. throughout the FMEC meeting.

We'll have a breakfast discussion table for Geeks and Geezers on Saturday morning to celebrate and launch interested persons with their own Twitter, Blog, etc.

The hashtag for the meeting will be something like #FMEC2014.

Many of our tweets will also be sent to #FMRevolution #DirectPrimaryCare and others.

As we turn the corner to become "Solutionists", think about what might be the next hashtag for
what's happening in Family Medicine.  We'll discuss #the nexthashtag at the meeting, maybe in the bar Saturday night.

Who's a Geek and who's a Geezer?  Your mirror has the answer.  Mine said, "You are a geezer."
Onward to #FMEC2014


FMEC Northeast Regional Meeting: "Health for the Nation and the World: Putting People First"

Come to Arlington, VA October 23-26 and learn with the Family Medicine Education Consortium team of educators.  Medical students, residents, faculty and others involved in Family Medicine Education will celebrate together the challenge of transforming the health care system in a way that better serves individuals, families and communities.

In a time of disruption, no one knows where the healthcare system is headed or how to get it going the "right" way.  It costs too much and is misdirected,  mired in "Meaningless Use" and "Transformationitis".

Who cares enough to risk anything to do what's right?  The FMEC for one.  The meeting includes preconferences such as the Innovators Network which already has played a key role in upgrading the Direct Primary Care movement.

I love this meeting.  Medical students from the northeastern United States, Residents from fifty or more programs with displays about their programs and Family Medicine faculty from the Northeast- like five hundred people who are excited about Family Medicine.

Breakfast tables to discuss interest areas and solutions, keynoters about healthcare solutions and educational dilemmas, space to sit down and talk with others who have common interests, book authors to sign and discuss their book, Door prizes for students at the Residency Fair.

FMEC 2014 Meeting Facts                Final Program FMEC 2014 Annual Meeting

Check it out!

Monday, October 13, 2014

Is CVS too Aggressive? Customers or Patients?

Just got a call from a CVS pharmacist in Dayton, Ohio.  She identified a "gap in therapy" for one of my patients with diabetes.  "Don't you want to protect their kidneys with an ACE or an ARB?"

The patient did not meet any criteria for a "mandatory" ACE or ARB. Preventing kidney disease from ADA :  "Diabetic kidney disease can be prevented by keeping blood sugar in your target range. Research has shown that tight blood sugar control reduces the risk of microalbuminuria by one third. In people who already had microalbuminuria, the risk of progressing to macroalbuminuria was cut in half. Other studies have suggested that tight control can reverse microalbuminuria."

I pointed out to the pharmacist what the medical literature says about kidney considerations for diabetics, after she told me "there is one study" that said an ACE or ARB might be indicated.

I told her about guidelines and considerations and mandates and policies and the practice of medicine and the actual medical literature which is fairly vast in the area of diabetes.

She said, "I want my patients to get the best care possible"  After asking that "her patient" be prescribed an unnecessary drug.

What's up with CVS?  Are they foisting partially informed pharmacists on their customers (or "patients") to enhance sales?  Clearly CVS would have been the benefactor of the sale of the unnecessary drug.

Isn't there a slight conflict of interest in CVS pushing unnecessary drugs onto persons with chronic diseases in the name of "a gap in therapy"?  Or is it really a "gap in profits"?

What do you think?

Sunday, October 12, 2014

West Point and Medicine: Duty, Honor, Doctor

As a West Point graduate, I have applied learnings from the Academy during my career as a Family Physician.

Duty, Honor, Country.  The motto of West Point resonates in my brain and challenges my heart frequently. What is my Duty?  What is the Honorable thing to do, or not do?  How do I best serve my Country?

When I ask myself these questions, I often refer to the Cadet Prayer for clarification and connection to God.

"O God, our Father, Thou Searcher of human hearts, help us to draw near to Thee in sincerity and truth.  May our religion be filled with gladness and may our worship of Thee be natural.

Strengthen and increase our admiration for honest dealing and clean thinking, and suffer not our hatred of hypocrisy and pretence ever to diminish.  Encourage us in our endeavor to live above the common level of life.  Make us to choose the harder right instead of the easier wrong, and never to be content with a half truth when the whole can be won.  Endow us with courage that is born of loyalty to all that is noble and worthy, that scorns to compromise with vice and injustice and knows no fear when truth and right are in jeopardy.  Guard us against flippancy and irreverence in the sacred things of life.  Grant us new ties of friendship and new opportunities of service.  Kindle our hearts in fellowship with those of a cheerful countenance, and soften our hearts with sympathy for those who sorrow and suffer.  Help us to maintain the honor of the Corps untarnished and unsullied and to show forth in our lives the ideals of West Point in doing our duty to Thee and to our Country.  all of which we ask in the name of the Great Friend and Master of all."

This post is an introduction to a series of posts titled "Duty, Honor, Doctor."  

Saturday, October 11, 2014

Family Medicine: Are We there Yet?

I celebrate the youth and energy of our new and future leaders of Family Medicine.  You have the reigns. The AAFP meeting in Washington, DC launches the next phase of the transformation of Family Medicine. Health Is Primary.  Energy will abound. Direction will be agreed.  Movement will continue.  Then we will say, "We have arrived."


We never quite "arrive" because our patients never quite "arrive".  We are with them or we don't feel like Family Physicians.

We may be content about our near "arrival" for a moment and then remember patients who haven't "arrived" yet. We lament their situation.  This "unsatisfied contentment" is a point of pride in Family Medicine.  The celebrations are short lived because we feel obligated to help more people.  Fairness is important to us. People are important to us.

Even more than statins, bonuses, quality initiatives, CT scans, EMR's, etc.

People, People, People.

Patients, Patients, Patients.

What do you think?

Friday, October 10, 2014

Family Medicine: October

October in Family Medicine in Ohio brings another set of problems to the office.  The new Medicare year starts October 1.  Typically, on the business side of the practice, Medicare makes changes that result in delayed payments for a couple months.  Cash flow gets stuck.

The ragweed season downshifts to the damp and moldy season outdoors and dust and mold indoors. Somehow allergies beget acid reflux and respiratory infections, aided by the start of the school year which traps coughing children in tight quarters.  Upper respiratory infections sometimes make too much mucous to be tolerable and inability to breathe through the nose which causes insomnia.  The URI finds the lungs and adds lower respiratory tract infection to the code list.  Then the cough lasts 12-15 days, which can be really annoying (and good for business).

Added problems this October include the FDA labeling hydrocodone a Schedule II drug which makes it similar to Oxycodone in how we have to handle it.  One month at a time.  Patients no longer get any refills on the hydrocodone pain meds and they have to see us once monthly to get evaluated and prescribed again.

Flu shots are on more patient's minds since the threat of the Ebola virus is looming.  Airport workers may become more concerned about the Ebola uncertainty as they process passengers from Africa.

Welcome to October.

Friday, September 26, 2014

Patients and Family Doctors

Where are we doctors without you?
You are a health expert.  You know how to get sick.
You know how to take care of your self.
Up to a point.

You know our office staff.
You know our magazines.
You know Dr Google and Web MD
You do self care well.
Up to a point.

You know your story.
You know your support system.
You know how you cope with illness and adversity.
You know what we do.
Up to a point.

We know our medical system.
We know how to doctor.
We know how to care.
We know how to comfort.
Up to a point.

We know medicines.
We know hospitals.
We know other specialists.
We know laboratories.
We know imaging centers.
Up to a point.

We know that you matter.
We know that you may need help when you're ill.
We know how to listen to your story.
We know how to validate your worth.
Up to a point.

Together, we find meaning.
For our lives.
For our illnesses.
For our coping strategies.
For our ultimate demise.
Up to a point.

We comfort each other.
We honor each other
We confide in each other.
In our own way.
Up to a point.

At the point of connection.
At the point of respect.
At the point of shared humanity.
At the point of wholehearted contentment.
At the point of God's Creation
Within which we share as patient and doctor,
Human and human, teacher and learner,
learner and teacher, steward and steward.
Heart to heart.
There is a piece of God.