Tuesday, July 29, 2014

Reflections on Family Medicine in Dayton since 1952 from One Perspective

"Count backward by ones starting at 100," the doctor said as he put the ether bearing mask over my six year old face in preparation for my tonsillectomy and adenoidectomy at Miami Valley Hospital.  It was 1952.  I was excited because I could eat all the ice cream I desired and stay up late each night for a week, watching "I love Lucy" on our new black and white TV. I loved the hospital, the smells and the attentive people.  I thought highly of George Martin, MD, our Family Doctor, whose office in Miamisburg smelled of vitamins.

Other than an occasional "check up" for milestones like starting the first grade or going to Boy Scout camp, I only saw Dr Martin when I was infected.  he seemed to only have one response to my infections: a penicillin injection.  He would say Hmm, Hmm while looking in my ears, nose and throat and listening to my heart and lungs. then leave the room, returning several minutes later with one hand behind his back.  I knew there was a syringe in the hand that he hid.  He would announce that I needed a little shot.  I would say words to the effect that it was going to hurt.  He would say, "I bet you a nickel it doesn't hurt."  I would shake his hand and say OK.  I t would hurt which ever hip received it and he would pay the nickel when I pronounced that I won the bet.  How did he know I would gamble?  Did my mother consent to my gambling with my doctor?

Highlights for Children was my other continuing memory of my Family doctor's office.  I loved to read it and work the puzzles and find the hidden objects while waiting.  We waited a lot since Dr. Martin was extremely busy, even on Saturday mornings, when we would go to the bakery for cream horns (one of my alltime childhood favorites) after the doctor visit.  Philhower's pharmacy was another major stop in Miamisburg, not for prescriptions, since Dr. Martin dispensed the medication from his office, but for odds and ends after going through the "dime store"- Woolworth's.

Fast forward beyond 177,000 patient visits (of mine) and I still love to go to Dr.'s offices, although they don't smell like vitamins now.  And they don't give many penicillin injections, since we have a wide variety of antibiotics and we understand viral respiratory infections better.

Now, Dayton has its own medical school at Wright State University which can inspire medical students to be like Dr. Martin or his modern day equivalent.  How do they accomplish that?  They have a Department of Family Medicine.  The specialty didn't even exist until near the end of Dr. Martin's career.  Now the Department routinely gets awards for having a high number of students select Family Medicine for their specialty.  (Although there is a recent down-turn in those numbers).

True confession of author bias- I'm on the clinical faculty of The WSU BSM Department of Family Medicine and I teach students in my office every year since 1994.  That's when I arrived back home to Dayton after a decade of private practice in Granville and four years on the full time faculty of The Ohio State University College of Medicine in their Department of family Medicine.  I was hired into a WSU faculty role through the Kettering Medical Center which had worked with Dr Mark Clasen, Chair of Family Medicine for WSU, to establish Family Medicine Education at KMC in connection with the Family Medicine Residency at Good Samaritan Hospital.

Larry Ratcliff, MD was the Founding Director of Family Medicine Education for KMC in 1993 and Associate Residency Director of what would be eventually renamed, The Dayton Community Family Medicine Residency.  As former Residency Director for Family Medicine at the Grant Medical Center in Columbus, Dr Ratcliff was skilled at setting up programs, recruiting residents and teaching medical students and residents.  He succeeded at KMC via the WSU relationships with the passionate help of Lee Jean Jordan (later Heller) who was tireless in her KMC innovations and her liaison activities with the GSH residency staff.

A unique champion for Family Medicine at KMC was the Director of Medical Education, Robert Sutton, PhD who had the vision for Family Medicine that delivered the people and the budget to make it happen.  He was continuously supportive and understanding of the role of Family Medicine Education in the big picture for the KMC and the broader Dayton Community.

In 1994, Larry Bauer, MSW, MEd who had been Director of Organizational Development in the DFM at OSU and I were recruited to join Dr. Ratcliff at KMC.  Larry was also a key player in setting up the OSU Sports Medicine Fellowship which was directed by Dr. John Lombardo, also Chair of the DFM at OSU and graduate of UD and the Dayton St. Elizabeth Family Medicine Residency.  My position at OSU had been Vice Chair and Director of Clinical Services which included the direction of the OSU Model Practice (with 29 physicians, several nurses and two mental health professionals.) and oversight of the hospital services for the department.  We both had teaching (and publishing and scholarship) responsibilities with sports medicine fellows, medical students and residents in family medicine.  I also served as liaison to campus health centers at OSU, Otterbein and Denison (which I had directed for a decade) for placement of our sports medicine fellows.

Since KMC had no teaching practice for Family Medicine, I started one called The Indian Ripple Family Health Center with budget support from KMC on Indian Ripple Road in a strip mall in a failed internal medicine office site.  It was located at the confluence of four different types of populations which worked out well for practice variety and teaching students and residents.  We established the use of video technology in the IRFHC so each learner could be videotaped within their first week on site and during their last week and as needed in between.  We saw some great patients and students.  The site eventually qualified as an official/certified satellite of the GSH FM Residency.  It also scored 100% for the JCAHO site visit. We did some good stuff, folks.

Toni Clark, DO was the first physician faculty recruited to practice and teach with us at IRFHC.  Phil Whitecar later "transferred" his practice from the Fred White Center at WSU to IRFHC to join our faculty for the IRFHC, KMC and GSH team (yes, it could be confusing at times with so many masters).

Larry, Larry and I also became the management team for restructuring the Kettering Medical Center Physicians, Inc., the physician network of faculty (KMC is a major teaching center for multiple medical and surgical specialties) and purchased practices.  As the KMCPI project progressed, Dr Ratcliff became the Director of KMCPI and I became the Director of Family Medicine Education for KMC.

In 1995, we had opened the  IRFHC site that would later expand and house our official satellite training site for the Dayton Community Family Medicine Residency.  In 1996, at the request of the Kettering College of Medical Arts, I became Professor and Chair of the Physician Assistant Department and Director of the PA Program.  This enabled integration of some of the clinical training of medical students from both Loma Linda, WSU and the PA students of KCMA on site at IRFHC.  Scott Massey, Associate Director of the PA Program joined the faculty at IRFHC and WSU DFM faculty were contracted to teach PA students at KCMA.  (OK, it may get confusing, but I'm a proponent of team training and teaching).  We taught Pastoral Care residents at IRFHC, also. I was on the advisory committee for their training.   They were great at helping patients with advanced directives and stress and prayer needs.

Further team teaching happened through the Multiprofessional Course of WSU taught through Wright State and including Medicine, Nursing, Dental Hygiene (from Sinclair), PA's (from KCMA), Social Work, Psychology (and one more that I'm forgetting, but I taught in the course for several years along with faculty from the other six schools, including my good friend and colleague, Kate Cauley, PhD, Director of The Center for Healthy Communities.  It was extremely rewarding).

As the Satellite at Indian Ripple was integrated more fully into the DCFMR, merging of tasks and courses and personality alignments (or misalignment) lead to Larry Bauer and I splitting away from Family Medicine Education and IRFHC to start The Center for Innovation in Family and Community Health which remained a part of Family Medicine Education at KMC.  The CIFCH was to produce academic products and services, which we did by developing electives for residents in Behavioral Health (that psychiatry residents could also take), Family Medicine (another one that psychiatry residents could also take), and Practice Management. After one year, Dr Sutton had left to take a position in Michigan and KMC restructured their financial reporting and software, resulting in budget confusion through the whole KMC system.  Dr. Phil Whitecar became the next Director of Family Medicine Education and Medical Director of the IRFHC.

Our CIFCH was not funded for 1999, in spite of making a profit for the KMC. Larry Bauer's position was not funded and I resigned my faculty position, seeing it was my time to leave.  I started another private practice in Beavercreek, taking the CIFCH with me.  I noticed recently that I have a bottle of vitamins that smell like Dr. Martin's office.  I've not yet taken up gambling with my younger patients about th epain in injections.  Maybe that's next.

Throughout the KMC adventure, our people remained active in the Department of Family Medicine.

KMC eventually closed the IRFHC and stopped training Family Physicians.                                                                                                                                                                                          

That's a piece of my perspective.

A. Patrick Jonas, MD

Thursday, July 24, 2014

Human Centering: Enhancing Success in Health Care Situations

Presentation at The Institute of Holistic Leadership  with Pat Jonas, MD  August, 2014

Introductions: Megatrends, Avoiding "Non-Compliance"

Centering: Patient, Payment, Physician, Hypnotherapist, Health System, Public Health, Human

Human Centering:            What it is

                                             What it Does

                                             Why it’s important
Where and/ or when human centering may be beneficial?
How to do it:  Notice how you use your five senses.  Which one leads?
               Become Wholehearted by balancing the autonomic nervous system (“The Mommy Heart”)
P O L A R to another person in dialog  whole (sort of) wholehearted
Notice:   Assumptions, Context of them and you, Process of them and you
Human Centered Health Home (HCHH) Process for dyad
Holistic Strategies for Human Centering
               Mind-Body Therapies
               Body Work
               Energy Work (Overtones – one of the secrets)
How to use Human Centering
               In Health Care Engagement as patient/client or practitioner (working and caring)

               In HC System as visitor- e.g., in a hospital (working and caring)

               With a friend who has health problem

Human Centered Health Care (HC)2
               Context of dyad

               Process of R P C D C R

Heart to Heart Rapport
               Trance A to Trance B
               Rapport: Human to Human, Heart to Heart
               Dialog: Wilber’s Four Quadrants from A Brief History of Everything by Ken Wilber
               Human Connection: P O L A R to Explore, Understand and Act   P I E S x L L W
The Art of Health Care by Bill Anthony, The Art of Helping by Robert Carkhuff
The Structure of Magic Volumes I and II by Richard Bandler and John Grinder
Consulting with NLP by Lewis Walker
Hands of Light by Barbara Brennan, Wheels of Light by Rosalyn Bruyere
HeartMath.com for Quick Coherence Technique

WWW.DrSynonymous.Blogspot.com numerous blog posts: HCHH and process of care in Family Medicine

Tuesday, July 22, 2014

Non-Compliance Soon to be Top Diagnosis

Within three years, the top diagnosis in EMR's will be non-compliance with medical therapy or dietary therapy or exercise recommendation, etc.  (My opinion)  Patients and physicians are now trapped by the Electronic Medical Record.  The plan of care must include the recommended therapies for the diagnosis or the physician loses bonus potential.  There must be proof that the medicine was prescribed and the pharmacy dispensed it or the physician and/or the pharmacy may lose quality points or bonus dollars.  Just watch.

Information Technology tightens the system and decreases choice.  We used to be forgiving about patients that would sometimes decide not to fill prescriptions or sometimes decide not to take the medicine when they did fill the prescription.  Often, their judgement may have been better than ours as we came to realize.  Over time, we got to understand each others perspectives as our patient-physician relationship developed. Physician and patient learned how to honor each other's judgement.  The quality of the relationship depended on it.  IT initiatives now risk the patient-physician relationship, a central aspect in the quality of health care. The patient has to align with the "Patient Centered" decision of the EMR protocol that aligns with "quality".

Unless they want the diagnosis soon to be number one: Non-Compliance.

What's "Patient Centered" about that?

What do you think?

Thursday, July 10, 2014

Many Patients Assigned to New Doctors

Several of my current patients called my office this week on receipt of information assigning them to a new physician (not me).  They are insured via a medicaid managed care product such as Care Source, but two other companies won the Miami Valley area bid to provide medicaid managed care.  We are not a "participating provider" in either of the new plans, so our patients will be assigned by a computer to another doctor.  We'll lose 50-75 patients in this part of the healthcare transformation.  We have meaningful, ongoing relationships with our patients and these losses hurt on the personal side, too.

We'll have to replace those patients, many of whom I've cared for for 6- 15  years, with direct pay patients, who will not have interference by insurance companies or government intervention.  The business survival of thousands of independent Family Physicians is touch and go for the next couple years.  This is a  very rough time in health care for patients, too, as they lose insurance and get a different plan with a $3000- $5000 deductible that they can't afford.  Many can't pay their doctor bills with the higher deductible and eventually lose their physician again.  Duck.

More later.

Tuesday, July 8, 2014

No More Screening Pelvic Exams for Women

Annals of Internal Medicine | Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of PhysiciansScreening Pelvic Examination in Adult Women

On July 1, The above article was published in the Annals of Internal Medicine, adding guidance to a frontline transformation in medical practice.  Family Physicians and Obstetricians have performed millions of pelvic exams in non-symptomatic women, noting in recent years that fewer pap tests were indicated, fewer mammograms were desired and other countries weren't performing near the amount of pelvics per capita as done in the U.S.  Some technological advances have led to better care for symptomatic women and a better understanding of cervical pathology.

The cancer screening for women still includes an annual breast exam, not annual pelvic, not annual pap test, not annual mammogram (but close).  Please understand that "screening" means a test or procedure performed on a person with NO SYMPTOMS.  No Symptoms.  No Symptoms.  Please remember that.

They now may have an annual or less often evaluation and therapeutic intervention session, more focused on their life, goals and dreams and parts.  With less time used up by the pelvic exam, women's health should improve.  (My opinion)

Most women over 40  have a symptom or two in one area or another.  Usually not in the pelvis.  The new guideline does not apply to them. They may more readily schedule an evaluation by their physician without getting distracted by issues of pelvic health.

Let's see how it goes.  What do you think?

Saturday, July 5, 2014

Independence Day: Fifty Years After Fifty Gun Salute

July 4th 1964 is a distant memory, expounded on in my post in 2010:
 "Independence Day: Freedom and Underwear" Blog Post from 2010

I was a New Cadet at West Point.  The fifty gun salute, shared with my classmates in the great class of 1968, is my main memory of that day.  I note the photos today on Facebook of the New Cadets at West Point in the Class of 2018.  We are their 50 Year Affiliate Class.  We are connecting with them in various ways over the next four years in a flashback and "flashforth".  I wish them well.

Independence Day 1971 was special, too, since I celebrated it in Vietnam.  No fireworks.  No war that day, either since it was a holiday.  I don't know if the enemy honored it throughout South Vietnam.  Our 45th Engineer Group HQ officers celebrated in the beachfront officer's club which we visited each night to play cards, get refreshed and, on special occasions, sing.  I was one of the song leaders, Kurt Sins (now an attorney in New Orleans) was the piano player.  We sang every patriotic song we could think of on the Fourth of July.  And we did toast America with our favorite beverages.

Independence Day 1976 was another special one.  I had just started my Family Practice Residency in Hershey, PA at the MS Hershey Medical Center of Penn State University. The Governor's Convention (of the United States) was held in Hershey that week, so VIP's were in town and the fireworks from Hershey Park were special for the 200th Birthday of America.

This weekend, I played the CDs of our West Point Glee Club Reunions (2007 and 2011).  I love the music.  I love the meaning of the music.  I love the patriotic songs.  I cry more now as I reflect on some of the people we've lost and those associated with America and its music.  I'm especially touched by America the Beautiful as performed by our West Point Glee Club with a historical narration and The Battle Hymn of the Republic.
 Vietnam, the Vietnam Veteran's Memorial and my friends and classmates who served in the Army occupy my nostalgic reflections.  Twenty members of the great Class of 1968 (No Task Too Great) are honored with their names on "The Wall", reminding us of their deaths from their service in Vietnam.

Independence Day, from the British.  What a commitment the signers made.  We endorsed it at West Point with our Oath on the first day and reaffirmed it  as Army (mostly, but some went into other services) officers with our Oath on graduation day.

Independence is worth celebrating.  Fireworks, singing, gatherings of friends and family.  Way to go America.