Shame and Pride; Pity and Sympathy: No Match for Wholehearted Empathy

I'm forever grateful to David Aspy, EdD, now a mentor from heaven, who taught me empathy and more.  He had directed the National Consortium for Humanizing Education in the 1970's and wrote Kids Don't Learn from People They Don't Like with Flora N. Roebuck, EdD in 1977, among other works.  As a resident physician, I was looking for teaching strategies to help resident physicians improve their teaching skills as head of a workgroup for the AMA Resident Physician Section in 1977-78.

Al Vastyan, PhD in the Humanities Department at Penn State, Hershey an important part of the MS Hershey, knew of the project.  He called me one day with sudden enthusiasm about the project when he read an article by Dr. Aspy.  I read the article and called Eastern Kentucky University where Dr Aspy had relocated his work.  We talked a good while.  He sent me a packet of books including the one above.  I was hooked.  And excited about others of his writings such as Toward a Technology for Humanizing Education.

He invited me to Richmond, KY to learn more.  Dave spent two days teaching me about empathy, congruence and genuineness as applied to audio and video-tape analysis of teacher-learner situations.  He showed me the work of Robert Carkhuff, PhD about teaching and helping.  The Art of Helping, The Skills of Teaching:  Interpersonal Skills and the Carkhuff Interpersonal Skills Scale were included.

Two key pieces of the training were included in the Cognitive Functioning Categories Training Module by Dr.'s Aspy and Roebuck.  The Flander's Interaction Analysis rounded out the tape rating checklists and skill training scenarios.
Listen to my Dr Synonymous Broadcast to hear more:
Dr Jonas on BlogTalk Radio as Dr Synonymous

Thanks to Dave Aspy for his mentorship and message.
 
The transformation of medical practice has taken many physicians away from personalized patient engagement.  Accurate empathy has been shown to facilitate learning by students and patients.  Is it time to re-emphasize accurate empathy and even grade some patient-physician interactions for how we teach and learn from each other?  Has "Meaningless Use" and Bonus Based Medicine taken physicians away from empathy?  Can medical practice recover from our mis-alignment with societal and patient needs?

Should we have a National Consortium for Humanizing Medicine?  Health Care?

"More Than Words, More than Us"

I was struck by the words of the title for this post while listening in church today to Rev. Jay Rundell, the guest minister.  The sermon title, "Gratitude in Trying Times", was about the struggles of the Apostle Paul, in Philippians 4:4-13.  The sermon itself was about all of us and our struggles.  "Sometimes we need to listen," he said.

6  Be careful for nothing; but in every thing by prayer and supplication with thanksgiving let your requests be made known unto God.

7  And the peace of God, which passeth all understanding, shall keep your hearts and minds through Christ Jesus.

9  Those things, which ye have both learned, and received, and heard, and seen in me, do: and the God of peace shall be with you.

13  I can do all things through Christ which strengtheneth me.  14  Notwithstanding ye have well done, that ye did communicate with my affliction.

A lot of sermons have been preached using this section of Philippians.  A key point or two of the presenter today was the  "Praying with Gratitude" in verse 6, the "Doing" in verse 9, and the "Sharing" of the struggle with others and their "Connection" to the struggle in verse 14.

Part of the message was to "Pray, Do, Share and Connect".  Validate each other with action and shared struggles.  Be human.  Serve God.  Don't expect life to be all rosy.

Do = "More than words" ("More than prayer")
Share = "More than us" ("More than me")

As we dialog with God through prayer and act on our discernments, we should dialog/ share with others about our struggles and mutually connect to allow reconciliation of our struggles, losses and griefs.

I thought, there must be a hymn that uses those words in the title.  I'll look for it.  If it were already written, it might be something like this (or would it?):

I thought it was over, I thought life was done
So empty I shook with despair
I asked God to help in the name of His Son
But I couldn't tell He was there

I shared my dilemma with some of my friends
They listened and prayed for God's Love
To soften my heart and then never to end
Below can be just as above

I prayed and I listened and listened some more
The peace in the silence shone through
My heart beat was thankful for all He had done
God showed me just what I could do


Chorus:     The Heartfelt Joy of understanding
                   Deepest Peace that we can trust
                   God will touch us as we gather
                   More than words, More than us


(The last line of the last verse could say I or could say God or He, according to how it's perceived.)

(Rev. Rundell's wife is a Family Physician in medical education at my alma mater-The Ohio State University)

Direct Primary Care: Ohio

Ohio Academy of Family Physicians discussing DPC.  Some thoughts.

Click Here:  Direct Primary Care Defined

Click Here: DPC Coalition site

Prepare to aggregate information about DPC for members.

Collaborate with meetings about DPC.  Speak at meetings about DPC w/ OAFP perspective

Influence FMIG's, Departments of FM and residencies about DPC

Buffer movements that add unreasonable restrictions to DPC

Short may be better.  Watch out for restrictive language in def and/or legislation.

Less is better legislatively.

Family Medicine makes for great DPC physicians.

Legislation- escape from insurance.  Specifically exclude DPC from oversight  by insurance commish.

Avoid written agreements w/ patients unless you want it for all pts of all FamilyPhysicians.

Protect each physician's scope of practice.

Ask for same considerations of med profession as legal profession would get for practice.

Avoid phony quality initiatives.

Have pride in Family Medicine.  We're good.  We're well trained.

Don't let poor self esteem cause restrictions of DPC Docs legislatively.  We're good.

Search Dr Synonymous about DPC = >50 posts with lots of information.

Meaningful Use for Symphonies

I went to the symphony tonight.  I enjoy some classical music from time to time.  I remember playing the Barber of Seville record from the Reader's Digest Classic Collection in 1963 before each high school football game to get focused and fired up (it's true).  Chopin is another favorite of mine.

After the usual warm-ups, the conductor focused the symphony by raising the baton and leading them.  They proceeded to play eight perfect scales.  The conductor bowed.  We applauded.  He enjoined the symphony to stand and bow.  We applauded.

They sat down and played another scale perfectly.  And bowed.  We applauded.  The conductor bowed again and walked off the stage.

The master of ceremonies entered, "That's our concert for tonight, Ladies and Gentlemen.  I hope you enjoyed our first concert to honor the medical profession and the physicians in our community.  We followed their lead and demonstrated Meaningful Use of our instruments.  We hope you enjoyed it. We appreciate the attendance of our government regulators tonight, too.  They will judge our Meaningful Use quality and let us know within three months when we get to do another performance,  in a Meaningful way.  Goodnight"

BTR Show: Hybrid DPC Can be Done- It Ain't Easy

My Weekly Dr. Synonymous Show on BlogTalk Radio: Reviews primary care payment evolution and options from cash pay to insurance to direct pay monthly and others.  IT makes it possible to relate in the current complex system (s) in ways that are still sensitive to patient and physician needs.  Here is the link:

Click Here

Hybrid DPC- Can Be Done, BUT Harder than New Pure DPC

Dr Jonas, your host on the Dr Synonymous Show will discuss some aspects of Hybrid Direct Primary Care that are challenging hurdles for those with an existing practice who want to continue with their current patients while adding Direct Primary Care.  It doesn't have to be either/or for everyone.

Generally DPC is for private practice physicians.  That's who I'm talking to in this show.

Next is a commentary about Osteoporosis in Men as presented in the Journal of Family Practice in September.

A blog and tweet review follows.

Other items on this show will include a review of two medicare ads for patients.

Family Medicine: Thank You Emergency Physician for Caring

He called about my patient in the Emergency Room.  She had a pile of co-morbidities.  He was working his way through them, and her specialists and her personality.  He cared.  He heard her request for admission.  He was working to get her in.  Thanks -Dr ER Doctor Who Cares.

Interview with Casey Babbitt, MS4 WSU BSOM

We discussed the career and interests of Katherine Marian "Casey" Babbitt, MS4 at Wright State University Boonshoft Schol of Medicine during the first hour of the Dr Synonymous Show on 9/22/15.  Click on the link to listen to the show on BlogTalk Radio.  The general line of questions folows:

How is medical school going?

What is the most fun in med school?

Where do you go next?

What do you notice about the culture of medical practice during these years of transition?

What are med students saying about their careers these days?

Etc.

Let's talk a bit about the people with hypermobility and Ehlers Danlos Syndrome since you did a special project about the when you had your Family Medicine clinical rotation with me.

What is Ehlers Danlos Syndrome?

What did your project entail?

How has it impacted what you've done since the project?

I have used the form several times with patients and in speaking to the Dayton Zebras last week.

Etc., Etc.

What's next for you through WSU BSOM?

etc.?

Interview with Casey Babbitt, MS4

The last 20 minutes of the show reviewed and discussed my blog post about vaccines:
Leadership and Vaccines: From Presidential Candidates to American Families

What do you think?

Leadership and Vaccines: From Presidential Candidates to American Families

I watched the Republican Presidential Candidates Debate on CNN Wednesday night (September 16th) and noted when the vaccine fuse was lit by asking Donald Trump about how he would relate to the CDC on the issue of vaccines.  I knew his response would light up Twitter, the CDC, Public Health professionals and 99% of Primary Care Pediatricians.  He answered like a concerned first time parent dressed up in a Donald Trump costume with a Donald Trump attitude.  He said they stretched out the immunizations for his children and "it worked out".  He referenced the child of one of his employees who had a horrible reaction to an immunization.  Ben Carson, MD showed his Neurosurgeon stripes by responding meekly on the subject and generally agreeing that there are too many injections and they might be spaced differently.  Rand Paul, MD (Ophthalmologist) expressed his support of vaccines AND, on the other hand, his love of freedom (of choice on immunizations).  It was polite commentary.  The medical community response wasn't.

I reviewed a few Twitter streams and blogs which spewed anger and disparaging comments about Mr. Trump primarily.  The name calling and insults were aimed also at the Republican Party. Evidenced-Based civility was lacking.

Vaccine discussions seem to melt into name calling, in general, after one or two shared comments - all over the internet.  One group attests to the safety of immunizations, strongly implying that there are no studies stating otherwise.  The other group attests to the dangers of vaccines and the harm that many children have suffered from one immunization or another.  Passion abounds.  They all care deeply.  They are doing the best they can based on what they believe.
Candidates Guide
I appreciate Chad Hayes, MD - the pediatrician who wrote "The Presidential Candidates Guide to Vaccines".  Notice the 114 comments including the types I mention above.

These comments cover the opposing opinions pretty well.  The world of either/or covers a lot of territory.  The gray world, where the Family Physician and individual Families often live can be more challenging and confusing.
Have vaccines saved lives?  Yes. They are safe for most persons and helpful for our entire society.
Did anyone ever have a reaction to a vaccine that resulted in permanent injury?  Yes.  Death?  Yes (everything we prescribe has the potential to have a fatal reaction, but with vaccines, it's extremely rare.) But we're not supposed to let you read such a comment because it may cloud your judgement.
Other problems from vaccines?  Look at VAERS, the government site where physicians report serious reactions to immunizations:   Serious reactions from date of injection

We know that the percentage of serious reactions is tiny compared to those with the usual reactions like local pain, fussiness, fever, etc.  And tiny compared with the benefits for individuals and society as a whole.

Is there some information in the CDC site that we should hide from you?  Should we be like the old time GP who kept the secrets and just "had to be trusted"?  Are many parents angry about not knowing about the VAERS or the huge amount of information about vaccines and vaccine preventable diseases on the CDC web site?

A lot of medical practice revolves around the concept of "normal".  What is normal?  From Ian McWhinney's A Textbook of Family Medicine:
"To identify individuals at high risk requires an understanding of the meaning of normal.  In the history of medicine, few errors have led to so much harm as the failure to be precise about the meaning of the term.  Although present when the physician is assessing and treating illness, the risk of harm is especially great in preventive medicine, for here the physician is identifying abnormalities in patients who have not come for treatment of symptoms or who have come with symptoms that bear no relation to the identified abnormality.  Identification of the abnormality may then lead to treatment that has risks and costs.  At the very least the patient will have an anxiety he or she did not have before.
To think clearly about normality, the physician must have an appreciation of human variability.... individual variation (and)...variation between individuals,...partly genetic but also partly the result of adaptation of individuals to different environments."

So when recommending immunizations, individual variability should be considered.  Who is at risk for what?  What is the context of their current health situation?  What might be their genetic predispositions relative to vaccine preventable diseases?  What sensitivities might they have to specific vaccines?  Is the CDC recommended schedule right for them?  Do they need a consideration for an adjustment to the usual schedule?  Look at the schedule for infants, adolescents and adults and note the variations for persons with chronic conditions, etc. Immunization Schedules

These are simple and complex schedules.  Vaccines are a complex issue and decisions about vaccine preventable diseases are complex.  It is a challenge for parents to be informed about the diseases and the vaccines.  The CDC web site is informative and overwhelming, but important.  The information form about each immunization is both summarized and deep depending on where you look in the site.
CDC Vaccines

Your physician is also very helpful, but short on time for in depth teaching about immunizations. Families generally have to work together whenever there is a new infant in the home.  Later immunizations require updates about vaccines to make the most informed decisions.

I believe that each individual family will have to make their own informed decisions about vaccines. We Family Physicians can provide a lot of information and show them the recommended and required (for Ohio schools) vaccines and they have to make what they consider to be their best decision.  Parents have many sources of information and should be able to consider the context of their child's life and theirs as they think of all the ways that vaccines may help.  They will also think of ways they may be harmful.
Enter the Principles of Medical Ethics:
1.  Respect for Persons/Autonomy: Acknowledge a person’s right to make choices, to hold views, and to take actions based on personal values and beliefs
2.  Justice: Treat others equitably, distribute benefits/burdens fairly.
3.  Nonmaleficence (do no harm): Obligation not to inflict harm intentionally; In medical ethics, the physician’s guiding maxim is “First, do no harm.”
4.  Beneficence (do good): Provide benefits to persons and contribute to their welfare. Refers to an action done for the benefit of others.

These considerations should be continuously in the mind of the physician.  Yes- the patient has the right to make choices about immunizations.  For several years most parents in my practice opted not to get the chicken pox immunization, assuming their child could get it like they did- from an infected friend or classmate, until they realized that no one seemed to get the chicken pox anymore.  Times change.

Some parents opt for no immunizations or to delay until the child is an age to be determined (two seems to be the age they pick).  About five families in my practice were "fired" by pediatricians for refusing one or all immunizations.  Four of them were shocked at the anger/ rage of the pediatrician at their desire to alter the immunization schedule for their infant (including having no immunizations)  I believe they own their children and they have an obligation to make informed decisions relative to their health, in the context of their lives (including their community).  Objections to them having the freedom to choose are well argued in the comments to the Presidential Candidate Guide above.

A tiny group of individuals and families are genetically predisposed to have adverse reactions to certain immunizations.  The PBS special about immunizations mentioned one such mutation.  Many families with autism are concerned about methylation mutations such as MTHFR or BH4 or CBS mutations leading to vaccine reactions in some.  Our Human Genome Project was supposed to give us more tools to discern those risks, but those options are not at the front line yet.  With IT and EMR's they are closer.

I love immunizations.  They have saved lives.  I enjoy gray, too.  Each patient is uniquely one of a kind.  Their biological variability is important and worthy of consideration, curiosity and respect, as are their values, goals and dreams.  Knowing and honoring that is the essence of being a Family Physician.

Family Medicine: Humans Want Meaning- Even Physicians

As a FamiIy Physician, I'm encouraged every day by being a part of people's lives.  Our relationship is a force that seeks a creative tension to help us grow-- and it often happens.  It's about meaning. People want meaning.  In Family Medicine, we want to help people find meaning.   And we want meaning in our lives, too.  It's like the historical physician who comforted patients, while learning from them.

We are still doing it.  BUT. Sinister forces are driving the practice of medicine into mechanistic strategies to overemphasize guidelines and treat everyone as if we are 100% certain that they are all the same.  The Electronic Medical Record is being used as a weapon to enforce the denial of biological variability and give bonuses to doctors who agree that everyone is the same.  This generates a lot of moral distress in physicians, nurses and patients.

AND, it thwarts the quest for meaning.  It's a de-humanizing approach to money management, not health or disease management.  Physicians are being de-humanized, too.  I see it in my colleagues frequently.  I read about it in their writings on the internet.  I hear it when I converse with them. They used to enjoy what they get to do.  That enjoyment is disappearing.  Yours might be disappearing, too when you are somewhere in the healthcare system.

You are getting to experience it when you see your physicians.  What do you think?

@apjonas Twenty Doctors to Follow on Twitter List?

20 Doctors You should be Following on Twitter

Being the humble servant of the human condition that I am, I get confused when I'm named one of the top twenty this or that to follow on Twitter.  I admit that I love it when it happens.  It's reassuring that the "Social Media Geezer" has made some sort of impact.  On Twitter I'm @apjonas.
Here, I'm Dr. Synonymous- likewise on my BlogTalk Radio Show "The Dr Synonymous Show"
www.blogtalkradio.com/DrSynonymous and a Google account get you into the show.

The Dr Synonymous publishing is about Family Medicine and the human condition.  I love my medical specialty and enjoy doing Family Medicine and being a Family Physician.  It's worthy of sharing.  So I do.  I learn so much about life and medicine from interactions with patients.  The social media gives me the opportunity to reflect on those learnings (but not a freedom to write anything about specific patients)>

You are reading my blog.  And, I'm on LinkedIn for professional connections.

I have a personal Facebook page and one for my medical practice-Family Health Connections, Inc. and one for my high school graduating class and one for my high school alumni association.  I run another Facebook page for The Center for Innovation in Family and Community Health.

So... I love the social media and the enhanced ability to connect in various aspects of my life.  It's a nice shortcut, too.  I peruse fifty to 100 tweets daily and about fifty Faceebook entries.  I review blogs and tweets on my BlogTalk Radio show.  It's fun and rewarding.

Dr. Synonymous: A Wild Time in Family Medicine

Dr. Synonymous Show

Dr Jonas your host for the Dr. Synonymous Show will give the usual disclaimer about not practicing medicine on the show and wade into the intense energy focused on October 1, 2015.  The blog and tweet review will reflect on numerous other authors. Click above to listen to the show.

Dr Jonas, your host for the Dr. Synonymous Show, will give the usual disclaimer about not practicing medicine on the show and wade into the intense energy focused on October 1, 2015.  The blog and tweet review will reflect on numerous other authors.

The Ehlers Danlos support group, the Dayton Zebras, will have a presentation by Dr. Jonas next Thursday night September 17th about methylation, MTHFR- from the Genome to the Garden to the Health Food Store.  He presents about "Getting a NAC for Health" next Wednesday morning at the BellHOP Cafe in Bellbrook at 9 AM (the public is invited).

  

How do we survive the next wave of change in health care?  Direct Primary Care will be mentioned as one part of the solution.

A mention of Liberty Health Share and Liberty Direct and Civic Health will be included as they are interesting companies with timely products.  Dr. J gets no money to mention them, by the way.

The Dr Synonymous Blog will be reviewed somewhere in the show.  We'll have fun.  But starting late for several reasons.

He will mention the dilemma about board certification decisions by near retirement physicians and others. 

Your comments are welcome.

Loose, Floating Energy in Health Care

3 Trillion dolllars in Health Care.  Everyone wants some of it.  Who gets it?
I'm getting one contact per week from someone who wants a piece of the pie.  "I have a piece of software that should get me a piece of the pie.  Can I show it to you?," they say.

Yes, I'll look.  I'm curious.  A Scholar of Family Medicine.  A Warrior for Family Medicine.  A Visionary for Family Medicine.  A Teacher of Family Medicine.  What do you have?

What I want to hear/see is Human Centered and Neighborly.  NOT patient centered or Evidence Based, which have become empty, self-serving and often phony AND superficial.

"Human Centered"  --- We all matter.  Neighborly- we're not trying to sell you something you don't need.  And we respect you.

Come on, Folks.  Let's get more Human Centered and Neighborly.

Just my opinion.  What do you think?

End of Summer in Family Medicine: A Reflection

Dr Synonymous InternetRadio Show: Summer's End in Family Medicine

Getting back to the roots of Family Medicine, Dr Jonas- the host of the Dr Synonymous Show, will expound on end of summer activities in one Family Medicine office.  Families in transition is a  common theme.  Teaching a Medical Student or a Family Nurse Practice student is another common office happening.  Listen in and we'll also go over a few of our usual blogs and tweets.

I love Family Medicine.  Immunizations, how's and why's also discussed in this end of summer reflection.  I love immunizations and the science behind them, while worrying about the profit motive that clouds some of them at times.  College health, sports physicians, back to school physicals are part of this recording, too.  Families, Families, Families also come up a lot.

"I Want to be Numb Now" Plea of many leads to song by Dr S (Plus Medical Care)

Direct Primary Care Ohio "Unsummit" Review and Doctor Spew

Check out my BlogTalk Radio Show.  The Dr Synonymous Show August 25, 2015

Dr Jonas, the host of the Dr. Synonymous Show, will review the DPC Ohio "Unsummit" that was previewed on last week's show.  Lots of energy and ideas flowed as the enthusiastic participants shared their situations, dreams and plans.  The Presdent Elect of the Ohio Academy of Family Physicians, Ryan Kauffman, MD announced his DPC leanings and represented the OAFP well with an update of OAFP DPC perspectives and acting as the "price police" for our meeting.  He introduced the rules about prices being taboo and clarified, a couple times, the importance of the rules for fairness and protection of all involved in meetings and presentations.

Dale Bellis, Executive Director of Liberty Direct was a well received participant who had a back end plan that's affordable and off the grid of ACA administered by Liberty Healthshare, a non-profit organization of Gospel Light Mennonite Church Medical Aid Plan, Inc. that is recognized by the US gov't as a healthcare sharing ministry, exempt from the ACA.

Mike Strickland, MD, trained in the AtlasMD DPC system, and Ryan Kauffman, MD, soon to go to Brian Forrest, MD's bootcamp for DPC presented about "pure" DPC practice while Phil Whitecar, MD and Dr. Jonas presented about their hybrid practices in Beavercreek.  Will Sawyer, MD from Cincinnati, who operates a subscription practice in Cincinnati, reviewed the legislative situation in the nation and Ohio for DPC.

We had fun. Dr Jonas will also add some comments and review the Dr. Synonymous blog about "Grain Gonads".  

From Wheat Belly to Grain Brain to Grain Gonads

OK, low gluten fans (like pretty much everyone should be), after you read Wheat Belly by William Davis, MD you'll peruse Grain Brain by David Perlmutter, MD.  With so much information about the evils of grains you trade them and most sugars for nuts and seeds. You also eat some prebiotics and probiotics and fermented foods and feel better and better.  Your migraines, brain fog, insomnia, irritable bowel and myalgias disappear.  What about your polycystic ovary syndrome?  It should reverse also.  Anything else?

How about low testosterone?  Yes, Low T can be grain driven.
It's easy to remember the PCOS as a grain driven entity.  I choose to remember the gender unbiased nature of the effects of grains with the term "Grain Gonads".

We're seeing more 30-40 year old males with Low T as a result of Grain Gonads.  Dr. Davis refers to the Low T and ED (erectile dysfunction) in Wheat Belly.

Just call it Grain Gonads.  Lose the wheat, lose the weight.  Lose the wheat, help your gonadal functions.

What do you think?

Agenda: Direct Primary Care Ohio "Unsummit" III August 22, Beavercreek, OH

Direct Primary Care Ohio “Unsummit” III

3210 Beaver Vu Dr Beavercreek, OH 45434

Saturday, August 22, 2015

8:30 to 8:59 AM

Registration and Reception

Saturday, August 22, 2015

9:00 to 9:30	Welcome Introductions, Disclaimers and Price Taboo Guidelines  Direct Primary Care Definitions and History  Pat Jonas, MD;  President, Center for Innovation in Family and Community Health (CIFCH)
9:15 to 9:30 AM	Ohio Academy of Family Physicians Actions and Role w/DPC                           Ryan Kauffman, MD President- Elect
9:30 to 10:15 AM	Pure DPC Practice: Why and How    Ryan Kauffman, MD and Michael  Strickland, MD
10:15 to 10:45 AM	Leaving Faculty and Starting a Hybrid DPC           Phil Whitecar, MD
10:45 to 11:00 AM	Break
11:00 AM to11:15  11:15 to 11:35 AM	Legislation: Issues and Update                                  Will Sawyer, MD  Student and Residents: Teaching, Curriculum                  Phil and Pat
11:35 TO Noon	Panel for Q & A                                                Will, Ryan, Michael, Phil
Noon to 1:00 PM	Lunch on your own

Saturday, August 22, 2015

1:01 to 1:45 PM     WS 1:45 to 2:15 PM     PW	DPC National Tour                                                    Pat Jonas, MD DPC “Nitch” Hybrid:  Challenges and Pitfalls            Pat Jonas, MD
2:15 to 2:45 PM    PW	Direct Pay in Cincinnati                                         Will Sawyer, MD
2:45 to 3:00          PW	Statewide Network Development                             Pat and Will
3:00 to 3:45 PM   APJ	Townhall Q & A                                                        All Presenters
3:45 to 3:50 PM   APJ	Wrap up and Announcements

Direct Primary Care Ohio "Unsummit" III Dayton, Ohio August 22, 2015

A. Patrick Jonas, MD

Philip Whitecar, MD

Will Sawyer, MD

will present at the DPC Ohio Unsummit III in Beavercreek (Dayton Suburb) on August 22, 2015.

These Family Physicians have studied Direct Primary Care and play with it daily.  Dr.'s Jonas and Whitecare have Hybrid (traditional and DPC) practices in Beavercreek.  Dr. Sawyer has a subscription practice in Sharonville.

They will expound on DPC Nuts and Bolts and their personal situations relative to DPC in interactive sessions that allow attendees a personalized opportunity to interact about DPC and get lots of questions answered.  We'll address student and resident issues including curriculum and practical experiences.  Legislation will be an important discussion.

What won't happen: Mention or discussion about prices.  This keeps us on the right side of the FTC.

All primary care physicians, NP's, PA's, Office Administrators, Office Staff are welcome.  Medical Students and residents are welcome.  Other stakeholders such as medical societies, holistic practitioners, general surgeons, imaging centers, laboratories, wellness companies (such as Gemcare Wellness) and special insurances (such as LibertyHealthShare, etc.) may wish to sponsor and attend.

9 AM to 4 PM at 3210 Beaver Vu Drive, Beavercreek OH.  That's the Chamber of Commerce Conference Room.  Just N of Rt 35 East of I675.  Across street from Beaver Vu Bowling Alley (bring your ball and shoes for more fun).

This is a big WiFi type meeting.  DPC is all over the web.

$150 to attend ($125 subsequent person from same practice). Medical Students $25    Residents $50.

Make checks to CIFCH  and send to CIFCH 2633 Commons Blvd Suiite 120, Beavercreek, OH 45431 or pay at the door after registering on Facebook as below.

More information: Pat Jonas, MD or Rebecca at 427-7540 or email apjonas1968@gmail.com

$250 to sponsor with a display table.

We'll see you on August 22 (and later in 2015 for Ohio Unsummit IV).

Registration via message to Center for Innovation in Family and Community Health on Facebook.

Vietnam Departure 45 Years Ago: "Lately, I've Got Phu Bai on My Mind"

July 27th 1970, I left my wife of seven months at the Cincinnati Airport (actually in Kentucky) and headed for Vietnam.  It was a long journey which never ends.  A young Engineer officer with new helicopter pilot's wings flew to Travis Air Force Base in CA, then to Alaska, where I learned that my nephew Matthew had just been born (Happy Birthday Matt- and Mike, his brother who was born July 27th two years before).  Then off to Japan for fuel enroute, then to the Saigon area.

I filled out a "dream sheet" of the types of aviation units I might wish to fly with at Army personnel headquarters at Long Binh and waited with other pilots in my rotary wing aviator class for the assignment sheets to be posted on a bulletin board.  We drank beer and chatted.  Then the postings.  I was assigned to the 18th Engineer Brigade.  I would fly for the Engineers.  The orders said to go to Cam Ranh Bay to the unit HQ. I was there for one day, played volleyball with some other pilots and learned the next day that I was being assigned to fly with the 45th Engineer Group HQ in Phu Bai (which means Land of the Dead) in I Corps, the northernmost of the four sections of Vietnam used for military planning.

I flew for a year and returned home, meeting my wife in Cincinnati for a few days before coming home to visit in Liberty and Farmersville where my parents and her parents lived.  Then we toured the western US and set up in Milford Kansas, just outside Ft. Riley where I was to finish my Army career as a pilot and instructor pilot and small unit commander.

45 years after leaving for Vietnam, I'm still learning about the meaning of the whole Vietnam experience.  I read about the background of the war and the decision processes that kept it going and ended it.  Very complex and very human processes that led to a lot of confusion.  Twenty of my West Point classmates died as a result of their service in Vietnam.  I think of them often.  I think of Phu Bai, too.

Lately, I've Got Phu Bai on My Mind
                                                    by CPT Pat Jonas 45th Engr Gp
                                                                    Aviation Section

Lately, I've got Phu Bai on my mind
Thinking now of all we've left behind
Like friendly fire and innocence
And fears that won't unwind

Lately I've got Phu Bai on my mind
Black smoke blowing gently in the wind
Mortars stopped the card game my first week in the war
Winning hand in High Chicago went right out the door

Lately I've got Phu Bai on my mind
Mortars weren't being very kind
Diving in the bunker just outside my hooch
"Our Father Who art in heaven", coming from my lips.

Lately I've got Phu Bai on my mind
All clear sounds, let's get back to my hand
No one cares to sit back down
A buck of my winnings is gone.

Lately I've got  Phu Bai on my mind
Blowing Agent Orange dust into the wind
Flying out to Rakkassan, Tomahawk and Nancy
Visiting our  Engineers, nothing really fancy.

Lately I've got Phu Bai on my mind
Floor show, Cold Duck mixing really fine
Flying to the DMZ to let off Donut Dollies
Rolling on the River mixes well with Buddy Holly

Lately I've got Phu Bai on my mind
Navy tried to make me land downwind
Ducking friendly fire at Khe Sanh and beyond
Bridge Over Troubled Water on AFVN.

Lately I've got Phu Bai on my mind
Cross the river down the coast again
Flying low along the beach- beautiful clear water
Calling into Castle base weather getting hotter.

Lately I've got Phu Bai on my mind.                        

Click here for the video/musical version with banjo

Preparing for the West Point Glee Club Alumni Reunion- Nostalgia

Dr Synonymous Show: Nostalgia Via West Point Alumni Glee Club Reunion

Dr Synonymous, aka Pat Jonas, MD- West Point Class of 1968, is travelling to West Point for a Glee Club Alumni Reunion (his third).  "I love these experiences.  The music is great, the people are great, the place is beautiful."

Listen as Dr Jonas reviews the agenda for the weekend and reflects on his days in the West Point Glee Club, life as a cadet and after.  He'll  reflect on a few songs and  even sing a few bars here and there and review a few Glee Club Memories.

The concert will be July 15th 7:30 PM- 9 PM at Trophy Point on the post at  West Point.

The Dr Synonymous Show Discusses Direct Primary Care and Ohio "Unsummit" III

Let's talk about Direct Primary Care for a while.  What's going to happen at the Third DPC Ohio "Unsummit"?  DPC is happening slowly but surely. Getting better and  better.  Are you Fed Up with getting the run-around in healthcare?  Do you want a doctor who will listen to you?  Do you want to step away from the annoying, artificial financial pressures of your insurance company?

Maybe you should look into Direct Primary Care.

Physicians: Do you want something different?  Do you miss getting to spend time with patients helping to solve their problems and treat their diseases?  Do you want more independence?

Maybe you should look into Direct Primary Care.

Dr. Jonas discusses  DPC and introduces the DPC Ohio Unsummit III scheduled in Dayton, Ohio on August 22, 2015 on The Dr Synonymous Show:

DPC and Ohio DPC "Unsummit" III .

Here is the information about the "Unsummit":  Facts about the "Unsummit" and Registration

Follow the Facebook page of The Center for Innovation in Family and Community Health for more information as the schedule unfolds.  Mark the date now if you want to get ready to practice in a DPC setting.

My Blogs from July 9 and 11 are reviewed, finishing with a Didgeridoo solo.

Why Are So Many Physicians Afraid?: The Coward to Warrior Ratio Seems Huge

From coward to warrior, physicians come in all shapes, sizes and attitudes.  Or do we?

It seems that lots of physicians are afraid to be a professional.  They are afraid to disagree with the financial decision makers in their institutions (that employ them or with whom thy're contracted). This is rampant behavior.

We represent an ethical position that our patients and communities expect.  They don't know it's not happening like it used to.  Yes, it used to be common behavior for physicians to vehemently disagree with hospital administrators over a principle involving ethical decision making.

It looks like we were for sale.  We were bought.  We're saluting the hospital flag and altering clinical judgement to the massive expense of our patients and our society.

We sold out to the EHR which was billing software slightly altered for clinical purposes.

We sold out to do massive numbers of CT scans in ER's of questionable utility.

We sold out in rehab facilities to maximize reimbursement.

Were we always for sale?

Were we always cowards?

What are we afraid of?

Do our patients and communities know?

Let's tell them.  That's informed consent.

(Better than what they get in ER's when they aren't informed about the potential benefits and harms of all the CT scans.  Look around your ER for a consent form to do a procedure like CT scans that can cause cancer. You won't find one.  Shouldn't a patient know? )

Breathing, Snoring and the Didgeridoo

Here's the outline for my presentation at the Institute of Holistic Leadership for July 9, 2015
Yes, I'm teaching the didgeridoo to attendees for fun and that they may have diminished or no snoring.

Breathing, Snoring and the Didgeridoo                                  Pat Jonas, MD

July 9, 2015                       Institute of Holistic Leadership

Breathing                           First exercise                    Three Deep Breaths

Didgeridoo First Demo                                                Dr J

Breathing

               Baby 44, Adult 14-18 breaths per minute

               Oxygen Dissociation Curve, Sports Medicine

               Usual Breathing

               Diaphragmatic breathing

Breathing Exercise Two                                               The Stimulating Breath (Bellows Breath)

Nasal Breathing                              Heating, Cooling, Nitric Oxide

Breathing Exercise Three              The Balancing Breath                  Dr. Laskow

               Left Brain, Right Brain Issues

Didgeridoo Second Demo

Breathing Exercise Four                               The 4-7-8 (Relaxing) Breath      Dr. Weil

Break

Snoring Study 85% at 5 mos

The Didgeridoo                What it is  rhythm, What it does,  History   

               Grab your Didge:  The raspberry and the sweet spot

               The Drone

               Vowels                A-E-I-O-U

               Consonants        B-C-D-T

               Kazoo Effect

               Circular Breathing

Lip Buzz, Dizzyness        Dying Cow               YouTube Lessons

Buying at www.Didgeridoostore.com

Didgeribreathing Exercise

Questions?

Independence Weekend 2015

Independence Day is actually Independence Weekend most years and 2015 is no exception.  Friday the third of July we had some patients to see and closed at two PM. Before a special weekend like this I ask most patients what they are doing for the holiday. Many of them will have an altered experience due to the affliction that caused them to see a doctor.  Others are "a threat to society" because of the contagious nature of their infection.  Vomiting with abdominal pain is especially important to keep away from other people.  Most will be shedding viruses for a few days after the vomiting stops.  (Don't let them breathe near you).

When people mention their holiday plans, they are often sharing information about their values and dreams.  Who, What, Where, When, Why, Who are often included.  This information helps me to understand them and issues that relate to their health.  It also informs me about what people in general are doing these days.

One of the roles of the Family Physician is to act as a public health agent-- identifying issues that affect the health of the public enables us to contribute to prevention efforts and share trends with other physicians and public health officials.  Our generalist role in health care gives us a perspective about health system trends that may be helpful or harmful to patients.  We have to stay aware of our duty to inform and protect people (you and us - we have a duty to help each other).

Warning to you:  Currently the healthcare system seems out of control and constitutes a threat to the financial survival of individuals, families and communities-  in fact it's a threat to the nation.  More, more, more is what we say about everything.  More tests, more medication, more mandatory prescribing, more "quality" bonuses for health plans and physicians.  There is no realistic plan to do otherwise. There are superficial efforts to reduce certain tests and procedures.  I just saw a letter from one of the area practice networks advising their male patients to have the PSA test, which actually is no longer recognized as a screening test for prostate cancer.  It's only supposed to be used in symptomatic males- which is a diagnostic test--not a screening test (for non-symptomatic persons).  How is a patient to know that?  I was shocked and disappointed.  But I can blog about it and tell the people about it and mention to physicians about how the PSA test is supposed to be used.

I'm looking into programs like Samaritan Ministries and Liberty Healthshare as a consideration for our Direct Family Medicine (Direct Pay)  patients to have hospitalization outside the Affordable Care Act.  They are for Christians, but I assume that each religion has some special waivers relative to the Affordable Care Act, although I haven't researched it.  

Huge changes are coming in the next three years.  Stay tuned.

Independence Day.  I love America.  I love patriotic music.  I love the Boston Pops Independence Day Concert and A Capital Fourth both with the 1812 Overture.  I'm getting ready for the third ever West Point Glee Club Alumni Reunion Concert on July 25th.  I sang in the first two.  I'm looking forward to 3 days of the Hudson River Valley, nostalgia and patriotic music.  God Bless America.

Family Medicine: Solutionists or Inflictionists

Now you can add Solutionists to the list of novel ways to think of focused medical professional activities.  Direct Primary Care seems to be driving the invention of new terms.  Many see it as "THE Solution", so Solutionist isn't far behind.

Since we have so many pressing guidelines and protocols, I propose that we recognize the Inflictionists.  Those physicians who inflict so much on patients with inadequate regard for the patient's chief complaint or reason for the encounter should be called "Inflictionists".

I hope your doctor is a Solutionist.

Doctor Transitions- "Goodbye, Folks" Coming to Your Town Soon

OK, Folks- a message from the near future.  Here's what will be happening in communities across the nation.  Doctors will be sending out letters like this.  You will be surprised. Your primary care doctors aren't being replaced and they are leaving practice in droves for retirement or hospital employment.  In California, the hospitals can't employ them, so they just go to another state.  Since the hospitals aren't training new ones as much as they used to, you'll look to the urgent care in Walgreens, CVS, Krogers, etc. for your healthcare.  It'll seem OK for a while.

"Dear Friends and Colleagues in Healing,

I am saddened to have to announce that I will be leaving ................ It has been my pleasure to get to know you. I know this result is a big disappointment for us both. My work here has been a source of great satisfaction for me. The practices in  have been the best practice situations I have worked in. The relationship with my patients has been warm, rich and varied. The staff who have supported me have been wonderful to work with and exceptionally diligent. I believe we have practiced very good medicine together. The pace has been just right, allowing enough time to get to know you. I admire the mutual commitment to doing the best we can with less, since we don’t have all the fancy medical technology or specialists.

This place is wonderful. I have been fortunate to live in a wonderful house just a block away from the hospital. I have cherished being able to do most of my errands with just a brief walk to the store or the bank. Wherever I go, I see people I know. Every time I step outside, no matter where I am or what the season, I feel exhilaration with each breath of fresh air and every fresh vista.

The most frequent questions I have had over the year have been “Do you like it here?” and “Are you going to stay?” I want every one to know that I have loved it here. That has nothing to do with my decision. It was my hope and wish that I would be able to make this my long-term home and that I would be able to slowly wind my way into retirement over the next ten years.

The reason that I cannot is solely due to the economy and the limitations of  ... law on practices in settings like this.  this is not working out. As everyone knows, the state legislature and the Federal Medicare program have put a near stranglehold on small rural health care systems like ours. .   

Due to these restraints I am leaving at the end of the month. I will miss you all and this special place very much. I have been very blessed to have shared this last year with you."

Sincerely,

Way too many family doctors

Impending Disaster in Healthcare

Big pressures mount for the new ICD-10 coding system starting October 1 that will be a disaster for patient care.  Concurrent is the realignment of Medicare reimbursement with new systems of care called Accountable Care Organizations.  Most ACO's are unsuccessful.  

More onerous initiatives driven by IT are flooding our office every day.  If you are "late" filling your prescriptions by a few days, we get a letter about your "non-compliance".  If you are not prescribed specific meds with certain diagnoses, such as ACE inhibitors and statins for people with diabetes, we get a letter about the "gap in your care"- repeatedly, even if we send in something saying that you are allergic or have other reasons not to take the medication.

Primary Care is folding under the pressures.  Dr's are moving around, quitting or leaving in preparation for the coming mess. Med students see the piles of useless drivel and shift their specialty selection to specialties that have less hassle and more money. About 3,000 new Family Physicians are produced annually while there are more than 17,000 job openings for Family Physicians, and getting worse.

Both Dayton flagship hospitals don't train primary care physicians since there's not enough profit in it.  The new health plans initiated by the Exchanges from the Affordable Care Act have lots of enrollees, but don't have enough physicians to care for their primary care needs.  We see many of these insured patients in the free clinic I work with in Bellbrook.

We have to consider walking away from all insurances to survive.  Yes.  All independents have to get survival plans ready for the next wave of initiatives- none of which helps health.  You should think of what happens if you have no primary care access in the next few years.  We have to find a survival strategy for the short haul.

We may be shifting our practice style in October.  

Family Medicine: Let's Dialogue to Fight Impending Healthcare Disaster

Healthcare: Disaster of Inadvertence

What's up (or down) in healthcare?
I discuss it on my Dr Synonymous BlogTalk Radio Show at the link above.

I review a blog post by Dr Elaina George that expresses some of the dilemmas facing us in healthcare.  A bleak near future is coming.  Let's hang on AND develop radical strategies to bypass the "inadvertent" mess.

Dialogue is one of the keys to health care success.  Family Physicians should help patients to dialogue about their uniqueness in the context of their individual lives.  Patients should dialogue with persons in healthcare with whom they have contact.  We all need to share what's really important to us and seek to discern meaning in our health/ disease situations. The uniqueness of our individual identities must be clarified and honored in our interactions- both in life and in healthcare situations.

The dishonoring of  human values in the healthcare system is rampant and must be countered with dialogue.  Exposure to unnecessary testing, especially radiation via imaging such as CT scans is generating about 30,000 cancers per year according to the American Cancer Society.

"The rise in radiation exposure due to medical imaging is a cause for public concern because of cancer risk. Imaging techniques that use ionizing radiation (such as CT scans) have the potential to cause cancers to form, and because of the increased use of these techniques over the last two decades, some estimates predict that 2 percent of all future cancers will result from current imaging use.

In their study, Smith-Bindman and her colleagues examined the health records of millions of patients in several western and Midwestern states who participate in six large integrated health care systems. This was the first major study to look at how radiation exposure has increased within these private systems. The collaborating health care systems are all part of a consortium of 19 HMOs across the United States and in Israel called the HMO Research Network, which has made a commitment to conduct research to improve the health care they provide to their members.

To the researches’ surprise, for patients in these systems, just as in the rest of the U.S. population, the average amount of radiation has increased over the last two decades. The new study showed a doubling in imaging rates, and by 2010, for every 100 adult patients, around 20 CTs were performed. Older patients underwent even more CT scans. For every 100 patients age 65 to 75, around 35 CTs were obtained."  From the UCSF newsletter 2012

Physicians routinely don't get informed consent from the patient to perform most CT scans.  Won't this come back to bite physicians and hospitals when the public realizes the harm done?

The principles of medical ethics reminds us of patient autonomy.  "First of all- Do No Harm" is a central tenet of medical practice.  Thirty thousand cancers sounds pretty harmful to me.  Not getting informed consent for a test that can lead to cancer doesn't sound like patient autonomy to me.

Dialogue is needed.  Let's get it going, Folks!

Fun in Family Medicine, Direct Primary Care, Free Clinics and Advance Care Planning

Fun in Family Medicine, Direct Primary Care and Free Clinics

The Dr Synonymous Show May 26, 2015.

Dr Jonas, your host for the Dr Synonymous Show, will reflect on how much fun he has as a Family Physician.  He'll lament about some of the intrusions on the fun and note how Direct Primary Care and Volunteer (Free) Clinics counter the lamentable intrusions.

Insights on Advance Care Planning from the BellHOP Cafe session on May 20th.

Patients patients, patients.  The heart of Family Medicine is the relationship with patients.  Seeking a Win-Win while the rest of the healthcare system seems to be driving toward Lose- Win or Lose-Lose strategies.

Join us via live broadcast or podcast of the show.

Advance Care Planning Presentation at BellHOP Cafe

Advance Care Planning:  Starting a Conversation in our Community

Sponsored by Open Arms Health Clinic at the BellHOP Café May 20, 2015;  9 AM

Pastor Ralph Vencill, PhD, Pat Jonas, MD

Introductions  People, Ohio DNR Form

Advance Care Planning:                      What it is

                                                             What it does

                                                             Why it’s important

                                                             How to do it

UD/MVH Symposium in March

               Dying in America

               Respecting Choices program in Wisconsin

               Honoring Choices program in Minnesota

America Bar Association

Centers for Disease Control

Tool Kits

What about us?

Pastor’s Perspective

Panel

Next Steps