Wednesday, December 21, 2016

Care and Caring with My "New" Knee at The Soin Medical Center

I love the Soin Medical Center in Beavercreek, Ohio!

There is a great team of caring, competent health care professionals in the Joint Center in the Soin Medical Center.  My right knee volunteered to need their services with a total knee replacement.  Dr. Aram Donigian orchestrated the surgery with a very engaging and connected operating room team.

The Soin environment offers a small town atmosphere, which I love.

For the day of surgery, the nurses, doctors, nurse practitioners and OR personnel were highly focused and organized.  I noticed stainless steel hammers and other carpentry-like tools in the OR - then stopped looking.  I sort of didn't want to know too much.

The spinal analgesia calmed my entire being and the propofol gave me sleep and the next thing I knew, I was waking in the recovery room with Nurse Shelby, who exemplified the Soin spirit.  She was energetic, caring, honest, helpful, supportive and competent.  I had the laughter that wouldn't quit and no pain in my right knee.

Now on the mend with great nurses, PT's, OT's and Nurse coordinators etc., I am being discharged and continue to sing the praises of the Soin Joint Replacement Team.

What a great example of Resilience!

They help each other to get the job done. And they Care.  And they care.  And they care.

More later about other aspects of this adventure.  Here's my BlogTalkRadio Show about it: Click for more  Dr Synonymous New Knee at Soin Medical Center

Saturday, December 17, 2016

Vaccine Pot Pourri

Warning:  If you come to my medical practice, you may be exposed to un-immunized or "under-immunized" children. 

I believe that informed parents are the ones who make healthcare decisions for their children.  Ohio is one of about 13 states that allow parents to accept or refuse any or all recommended immunizations, so parents are in the drivers seat about vaccines.  "Informed Parents" is a key concept in this process.  Physicians are obligated to help the parents to understand the diseases and immunizations in question.  This is a process, not an event.  It is helped considerably by information access via the internet.  We can review information from the Center for Disease Control (CDC): vaccines and preventable diseases and who should not get these vaccines to clarify some of the basic information and go to many other sites to explore further information as desired by the parents.

These discussions are important but often very complex.  Many physicians are time constrained from going very far into the discussion.  A few are angered by parents who don't accept whatever is recommended enthusiastically.  Most parents are pleased to have the vaccines for their children.  Many want to hear more about the potential benefits and harms of the vaccines.  A few want to know more about the potential dangers (and benefits) of the diseases versus the risks and benefits of the vaccines.

I like vaccines for most people.  I like freedom of choice, too.  The concept of the "Greater Good" is a balancer in public health and in medical decision making about vaccine preventable diseases and vaccines.  These concepts go back to the principles of medical ethics, which I reflect on every day.  

  • Principle of respect for autonomy,
  • Principle of nonmaleficence,
  • Principle of beneficence, and.
  • Principle of justice.

I encourage you to look up the Principles of Medical Ethics for an array of definitions of these terms.  Decisions can be shrouded in gray from time to time and generate considerable discussion.  Vaccines versus genetic vulnerability to negative effects of vaccines is a challenging and complex discussion that is often overlooked or misunderstood.  The CDC is sensitive to this issue, but more front line genetic information is needed to identify the small group of vulnerable children and adults who need to stay away from certain vaccines.  The changing nature of microbes is another challenge, especially pertussis.  How do you immunize people from a disease that keeps evolving?

"The ideas that everyone has to get vaccinated for the “greater good,” and that it is acceptable for some children to be sacrificed for the welfare of the rest, does not feel quite right when one-size-fits-all vaccine policies end up targeting the genetically vulnerable as expendable."  From:

Barbara Loe Fisher

We are confronted with many diseases while we are blessed with some great vaccines and some great freedoms.  At the confluence of these, each individual gets to decide how to proceed.  Physicians, patients and parents have responsibilities to do our best to help each other and our society.

What do you think?

Wednesday, December 7, 2016

Know Brain Know Pain: From Genomics to Guts to Gardens

Here's the Power Point slides from my presentation at the pre-symposium Seminar for the institute of Holistic Leadership: Know Brain Know Pain

Here's the outline of the first few slides.  I'll review thers on my Dr. Synonymous Blog Talk Radio Show after my knee surgery calms down in a couple weeks.

The cannabinoid receptor agonists (health foods that stimulate cannabinoid receptors in the body) are promising for pain relief for many.

Know Brain
Nucleus Accumbuns
Caudate Nuclei
A Fibers
C Fibers

                             •Know Pain
Acute vs. Chronic
Wind Up
0 to 10
“Twin Towers” of Pain

                       •From Genomics
Human Genome Project
23 & Me, etc.
New Information
Front line usage clunky
Hopeful with IT/ EHR

                       •To Guts
Human Microbiome Project
Good Fats, Prebiotics, Probiotics
L. Helveticas, B. Longum
Wheat Belly, Grain Brain
Grains and Sugars
Skinny People Poop

Breakfast Via Ninja
Protein Powder & Greens
Flaxseed, Hemp Hearts
Super Collagen Powder
Maca Boost Powder w/Rhodiola, Ginger, Theobromo Cocao
Citrulline Powder
Berries, Almond Milk, Kefir

To Gardens (Or health Food Stores)
Only Response to Genomics
Medicalized by “Medical Marijuana”
All will know of Cannabinoids
And Endocannabinoids
And CB1R and CB2R and “CB3R”, etc.
Fermentation, Sprouts, etc.

          •Vitamins and Supplements
B Right, C, D3, Coenzymated MVI
Omega 3 fish, Cal-Mag-Zinc, K2
Selenium, Tri-Iodine, NAC,
Curcumin, SAMe, CoQ10, Pycnogenol,
DHEA (over 50)
Probiotic 10-20
          •“Medical” Marijuana in Ohio
Is NOT “Medical”
Will Cause Solutions to Opiate “Crisis”
Solution to “Obesity Epidemic”
Will drive physicians to Health Foods
Is Dangerous, too

          •Beighton score
Connective tissue Disorder Spectrum
EDS Ehlers-Danlos Syndrome
Marfan’s Syndrome

           •Brighton Criteria

Friday, October 14, 2016

Ohio Association of Free Clinics Annual Meeting Opening Session 10/14/16

I'm here as Board Chair and Medical Director of the Open Arms Health Clinic in Bellbrook, OH. This is a good group to get to know. 

A room pulsing with love and caring is what I sense immediately.  We had the welcome by Deb Miller, Executive Director - who knows how to help people know that they matter.  Susan Labuda Schrop did the Roll Call covering the whole state of Ohio.

Nicole Lamoureaux, CEO of the National Free and Charitable Clinics spoke of the “Changes in Free and Charitable Clinics Nationally”.   Thirty clinics have closed.  Six million patient visits annually were increased by 100,000 after the ACA was implemented.  Clinic missions changed as the “insured” turned out to be “underinsured” and continued to come to Free clinics.  The evolution was from a Free Clinic model to a Charitable Clinic model.  Now many have a sliding fee scale, a suggested donation, a free-will donation, Medicaid, Medicare, Private Insurance etc.  They remain flexible as the needs change.
Also many have evolved from the Free Clinic Model to a Hybrid Model.  Questions asked are “Why aren’t you an FQHC?’, etc.  Many opt to avoid the federal connection and remain “Independent”.
Some are wearing multiple hats such as being a FQHC three days per week and a Free Clinic two or three days per week.  Mix and match, flex and evolve is the name of the game.
Overall patient demand did not decrease with the implementation of the Affordable Care Act.  The underserved have changed some, but the numbers aren’t diminished.
A lively discussion about variations on populations served and evolving models of care was a who’s who of patient situations in the state of Ohio and an eye opener for those in the jam-packed room.  Screening patients for need is common.  Honoring the donors was another important fact for the free and charitable clinics in attendance.
EIghty-three percent of the patients are in the workforce nationally.  The numbers of veterans seeking care at these clinics has increased.   It is painfully obvious that the primary care workforce is woefully inadequate.
Problems:  Recruiting Volunteers, Fundraising and Development, Cost of Pharmaceuticals, Primary Care Volunteeer availability, etc.

Send us your stories!  Was the last message from Nicole.  You give something that our country’s missing.  Caring for those in need.

OSU and The Primary Care Workforce

I enjoyed a visit to Ohio State for my 40th reunion of the Class of 1976 from the College of Medicine.  I have intense concerns about the Primary Care Physician Workforce.  A big flinch for me came with a comment from Dr. Quinn Capers, Dean of students at OSU College of Medicine, my alma mater, at the Alumni Meeting, that 41% of the graduates go into primary care specialties.  The stats when broken down on the slide listed Family Medicine 8.7% which is pretty accurate and consistent with national percentages.  The other specialties and percentages were NOT accurate and not consistent with national percentages of actual practicing physicians.  The numbers were accurate as to the percentage of students matched into those residency categories.  It is widely known, especially by the Alumni office, that less than 5% of those entering internal medicine residencies enter primary care practice.  Less than 10% of those entering pediatric training enter primary care pediatric practice.  I assume that Dr. Capers wanted to just give the match stats for senior students, not actual practicing physician stats, but he didn't say so.

Less than fifteen  percent of medical students actually enter a primary care practice.  "The Dean's Lie" as it's known in Family Medicine, is saying otherwise.  The only excuse for this could be that the federal support for residency training reimburses hospitals for residency training, giving extra "primary care training" money for ALL internal medicine training slots, even though less than 5% of the slots will actually train a primary care physician.

The creation of hospital medicine specialists has created thousands of jobs caring for hospitalized patients.  Increasing amounts of medical student debt plus these jobs equals a great opportunity for career and financial satisfaction and fewer residents selecting to practice primary care internal medicine or primary care pediatrics.

I was disappointed that the Dean gave no indication that the COM is sensitive to workforce needs and the national and Ohio dilemma with inadequate numbers of Primary Care physicians.  Some things never change.

Wednesday, October 12, 2016

Family Medicine: Paradigm Lost

The new narrative in health care is here.  The alphabet soup of the next era is here.  Technology wins, patients lose.  
I remember the dream.  The dream of living in a small community and caring for its people as their Family Physician. The dream of helping people to be healthy.  The dream of knowing people, science and medicine at the same time in a useful way.  The dream of helping people to know that they matter. 
Then Family Medicine showed up:  "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."...American  Academy of Family Physicians.
It was billed as a relationship based specialty.  It delivered.  Over and over.
Then things changed.  It didn't secure its borders and its core.  It devolved with the so-called Patient Centered Medical Home (which could be called the Payment Centered Medical Home).  
It turned away from patients in favor of "Bonus- Based Medicine", aligning with misguided "quality" initiatives run through Electronic Medical Records.  It drooled over "Meaningful Use" bonuses.  It turned into a group of data entry clerks, far removed from thoughts of The Principles of Medical Ethics.  Patient Autonomy be damned.  Employers, insurers and Statins became more important than patients.
Family Medicine went on the defensive and stayed there (with the rest of medicine when the Affordable Care Act pushed medicine passively over a cliff).  
It was "The Counter Culture", a hope for the people to have good health care, pushing against the technology and subspecialty driven approaches that now are bankrupting our nation.
Family Medicine:  Is it time for a Hospice consult?

Or is it time for Direct Family Medicine?  The Family Medicine version of Direct Primary Care?  The New Counter Culture?
It's time to get a paradigm that's on the offensive.  There is only one of them:  The Direct Primary Care Movement.  

Saturday, October 1, 2016

OSU College of Medicine: 47% Non-Ohioans--Why?

I was blessed to get to attend the best medical school in the world at the time -- The Ohio State University College of Medicine in the Class of 1976.  About 90% of us were from Ohio.  At our Homecoming and 40th Reunion Celebration weekend, we received the traditional update from the COM administration during the COM Alumni Association meeting.  The demographics of the current student body were impressive in their response to inclusivenes with 26% under-represented minorities, 54% women, 46% men.

I flinched, though, at this statistic:  53% from Ohio and 47% from out of state.  When questioned, Quinn Capers IV, MD, the Dean of Admissions answered that the College needed to get that many out of state students to get the type of diversity (cultural and other) they want.  I strongly disagree. What is missing in Ohio born applicants?  What is missing in the culture of Ohio?

What do pre-med students from Ohio think of being denied 100 (of the 202 or so) entry level medical student slots at Ohio State?  What do the state legislature and the tax payers of Ohio think of this approach to admissions?  What do alumni think of this approach to admissions?

Saturday, September 17, 2016

Blogcation at Home

In spite of having a continuous flow of bloggable situations and information, my blogging is diminished for a while.  My time allocation is changed while we care for my Mother in Hospice in our home.  She's taking her time.
I haven't broadcast/recorded a Dr. Synonymous Show this summer, either.  I didn't retire or quit being a Social Media Geezer.  I'm pacing myself.
More later.

Monday, September 5, 2016

Death, Grief, Duty and Prayer

Death.  Prayer.

Grief.  Prayer.

Duty.  Prayer.

Someone dies.  Unexpectedly.  Young.  Way before their time.
Then -- confusion and feelings of inadequacy.  Why?  Why did it happen?
How do I go on?  How does anything go on?

We pray.

How do we understand it?  What will make the feelings go away?  Maybe we should feel like this for the rest of our life to honor the meaning of the person in our life?

We pray.

We grieve.
We reconcile the new reality of the loss with our reality.  We integrate the meaning of the deceased person into our continuing life.  We become our "next self".

We pray.

We act.
On our duty to honor the deceased person and their meaning to us.  And their meaning to the world. Again and again.

We pray.

Thank You, God, for the gift of this person and the ongoing and evolving meaning of their life to us.
Thank You, God, for understanding.  Please help us.

Saturday, August 13, 2016

Physician Burnout: More than Half!?

I'm listening to a presentation about this topic at the Ohio Academy of Family Physicians Annual Members Assembly in a room full of brilliant people- Family Physicians. Are 63% of them burned out, as the Mayo Clinic study indicated in 2015?  If so, how does that impact their ability to help people?  To lead an organization?  To innovate enough to find solutions to health care problems and physician burnout?

Practicing Family Medicine is an incredible privilege.  It's still fun.  Medicare administration and other insurance administrative overload is killing it for more than half of family physicians.

Many physicians are looking for relief.  Mostly in the wrong place, since more are getting burned out (was 51%, now 63%).

Is there hope?

Thursday, August 11, 2016

Thankful and Grateful: Practice Makes Perfect

I thank God frequently.  I'm thankful for the blessings I've received.  I'm grateful for parts of things. I'm grateful for people.
Even this computer--I'm grateful for it.
I practice being thankful and grateful, which may lead to improvement.
I'm even grateful for "Yes, But" .people, as long as they speak in the middle of a meeting and not the end.

And flowers, music and children.
And old people.  And the republicans and the democrats and Hillary and Donald..I'm  thankful.

What about you?

Wednesday, July 27, 2016

Departure for Vietnam 46 Years Ago

It seems like a long time ago, because it was- 46 years ago today, I left for Vietnam.   Forty-five years ago, I came back- changed.  Connected permanently to a phenomena-  Vietnam Veteranhood.

I Am A Vietnam Veteran.

I wear a hat to remind me and you of Vietnam Veteranhood.

Vietnam Veteran 2016

It means a lot to me.  The Wall comes to mind.  The mirror speaks.

It reminds me of Phu Bai, where I was stationed initially in Vietnam.

A poem/song came from it:

Lately I've Got Phu Bai on My Mind

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.                        

Now back in Ohio.  Being a Vietnam Veteran.

Friday, July 22, 2016

Family Medicine: This is Still Fun! (After 40 Years)

I'm in my office Friday morning.  I get to see these fascinating people and help them and learn from and about them and the contexts for their lives.  It doesn't get any better than this.
A child for Pre -op physical, two patients with rare diseases, evaluation after auto accident, lumbar disc disease with back pain, insulin dependent diabetes for more than 50 years, poison ivy, allergies, sinusitis, chronic low back pain, plus four more acutely ill people who will call in this afternoon.

Storm just started.  Heat index over 100 tomorrow, breathing problems expected.

Still having fun after 190,000 patient encounters and 40 years.

(I just have to re-align the dominant business model that we use and relate to.  Insurance is something to think about eliminating in favor of Direct Family Medicine.  We are meeting with other physicians to discuss the Direct Family Medicine model further for Greene County.)

Saturday, July 9, 2016

Now the Morphine

Mom is getting a bit “gaspy” with her breathing.  Occasionally, she coughs.  She frequently breathes fast, but claims to have no breathing problems.  The Hospice nurse gave her another dose of morphine today to help her get through all the movement associated with her bathing and changing from the Aid who came a bit later.  Mom was very relaxed five hours later and breathing more comfortably.
The morphine will help her to relax and breathe easier more and more often over the next few days as it becomes harder to breathe and harder to relax due to the congestive heart failure and recurrent micro-aspiration of food and liquids into her right lung.  She has no complaints, though.
We the living or We the survivors have more problems than she does.  She has no worries or stressors anymore.  Her mind seems to be dissociating from her weakening body, not noticing its maladies.  Heading toward the end.  Still on course, on glidepath toward her heavenly future.

Wednesday, June 22, 2016

Glidepath to Heaven

"On glidepath," I remember hearing during instrument flight training in the Army.  Glidepath was the radar assured safe line from the sky to the runway.  Watching my mother as her body dies reminds me of the glidepath concept.  Her body has been "on glidepath" for months as it slowly shuts down, and surprisingly isn't finished yet.

Mom is on the glidepath to the hereafter, or you might think of it as the glidepath to Heaven.  Her body is on a mission to part with her spirit, giving it eternal freedom.  Eternal wholeness is the reward.  The glidepath to heaven ends with forever.  The slow deterioration of the body parallels a slow increase in services and personnel needed to support the failing body.  That could be referred to as the caretaker glidepath.

The caretaker glidepath remains earthbound, with slow progression toward the Hospice "crisis team" for "crisis care" and final peace.  There is no "crisis" except the need for another billing term to differentiate a different level of care.  "Heavenly Landing Team" might be a more fitting title.

Mom is on the glidepath to Heaven.  Slowly moving toward eternity.  She's content, happy, pleased.  Way to go, Mom.  Let's pray for a safe landing.

More later.

Friday, May 27, 2016

Home With Hospice

We were looking at various options for Mom.  Now, later, etc.  How long is now and how soon is later?  We looked at long term care options and realized that later is now.  At each place we discussed end of life care and hospice options.  If we could get some assurance about transfers from bed to wheelchair and wheelchair to commode, Mom could come home (to our house where she has lived for six months.  We had the home care company already with PT, OT, etcT (all the T's) options.

I called hospice to clarify options and decision points along the way.  Later IS now, I found out.  The hospice nurse/ boss explained the how, when and why of how they relate to a person like my mother. Wham!  They had connectors to our "A" team for PT, OT, Nursing, etc. and financial coverage in
areas where her personnel might be needed.  I realized that "Home with Hospice" was best for Mom. She could be here and they had respite care if we crashed and need relief.

The cat and dog really took a liking to Mom and will be excited to see her come back.

This will be another chapter in Mom's life, and the last one.

The hospital bed, bedside commode, hospital tray holder and one other item arrive tomorrow.
Mom arrives the next day.

We have a three day Holiday Weekend to get all settled.

Here we go!

Friday, May 20, 2016

Decision Time Nears for Mom's Nursing Home

Mom's running out of steam.  Dementia and deafness, a bad combination.  Mobility impairment. Weak legs.  Falls.  Fractured hip- surgically repaired.  Getting rehab. Hit a rehab plateau.  Can't transfer on and off the commode without lifters.  Stuckness is near.

I'm a doctor.  Still torn by this decision.  Afib, warfarin, diabetes, weakness, urine problems, recurrent infection.  Where's the cure button?  A nursing home is getting closer.  Not yet ready for hospice.

Sorry, Mom, we can't take you back home unless your legs work better.  We don't have two lifters at the house.  OK, God, how about some help, according to your will.  Amen.

Family Medicine: Time for Radical Innovation. Are We Up to It?

The innovation which is needed to get through the modern healthcare mess should be radical, not incremental. Currently, healthcare is money oriented and data driven.  Patient autonomy seems to be ignored via "Bonus-Based Medicine" driven by financial incentives and misguided "Quality Initiatives".  The calling to be a physician who served patients in a relatively sacred patient - physician relationship has been replaced by the job, secured by the contract, cluttered with consumer-clients (formerly called patients).

Don Berwick, MD wrote recently in JAMA that the current data driven era in healthcare should be replaced by the "Moral Era".  The Moral Era needs medical stewardship, appropriate use of scarce valuable medical resources.

G. Gayle Stephens, MD, one of the founders of Family Medicine, wrote of the importance of the counter-culture role that Family Medicine should play in the academic medical centers.   "But the constant is the skill of patient management.  One cannot be a Family Physician without highly developing this skill.... the sine qua non is the knowledge and skill that allows a physician to confront large numbers of unselected patients with unselected conditions, and to carry on therapeutic relationships with patients over time."

Dr. Stephens also warned of the current era of healthcare years before it happened.  "Recent developments are inimical to the role of the physician as healer.  We are developing an erroneous assumption that health care is a product and that the health problems of the population are remediable by medical technology."

It's time for Radical Moral Innovation--Medical Stewardship!

What do you think?

Sunday, May 1, 2016

Family Medicine: Working the Free Clinic with God

The vaccuum just turned off.  I turned in my prescription pad and loaded up the computers, picked up my all-purpose valise filled with confusing information about a vast array of projects.  We were finished with another night at the Free Clinic.
"Dr., there is one more patient back there.  She just got here."  I looked back the hallway, put down my case, found the prescription pad, put the stethoscope around my neck and walked down the hallway.  A door was closed and I could hear voices.  I knocked and entered to find our nurse taking the blood pressure of the patient.  (Yes, I was pressing the clock a bit since the pharmacy where patients filled our prescriptions was closing in twelve minutes).
I recorded the blood pressure as the nurse stated her findings. She was done with her part.  I read the reason for the visit and saw the list of six prescriptions requested, plus the two problems on top of the four chronic diseases.  Plus the 8 months since the last visit at which the patient agreed to get a lab test one month later.  Where had she been?  This could be challenging to beat the clock, if it was in play for the patient.
How can we help you tonight?  "I need my refills"
(OK, I sometimes get irritated when patients say that.  I practice medicine and prescribe medications if indicated.  Pharmacists give refills, I write prescriptions- a difference of some importance to me.)

"What kept you away?  We haven't seen you since last summer."
"Two jobs.  Prison. Court orders, daughter is in prison again for 30 days.  She gets violent with me, but I'm all she has.  She's only 16.  I don't know what I'm going to do."
"How do you cope?"
"I pray.  I work"
"Who loves you?"
"I guess my daughter does."
She was overwhelmed and near empty, but still human.  Someone loves her.  a someone who beats her occasionally, but a someone.
Hearing the story unfold, I listen for hope.  I ask about hope.  In her medical record she listed her religion as Christian.
I silently pray, "God we need help.  In the name of Jesus, please touch her heart with your love.  Please touch her daughter with the healing power of your love."
"And thank you, God, for bringing this woman here tonight to remind us all why we have the Free Clinic.  Please help us to show your love for her as one of your children.  Thank you for loving us as you have and leading Mary Ann Stone, RN, our "Founding Nurse Mother" (now leading from Heaven) to found this clinic."
I quickly examine her and write the prescriptions, all of which are indicated for her chronic conditions and situation.
"You're showing your daughter a Mother's Love and God's Love.  You're doing your best.  That's all you can do.  Thank you for what you're doing and what you're being.  God Bless You."

We clarified the prescriptions and her time frame for getting them filled and options for follow-up visits.
She smiled.  She left.
I cried for her. I cried with thanks that we can relay God's message to people like her and for the Hope that seemed present from the Creator of us all.  God is a great Free Clinic worker.

The names, dates, genders, exact circumstances, etc. of any references to patients are shifted to prevent identification of individuals.

Saturday, April 30, 2016

I Am a Family Physician

Yes!  I am a Family Physician!  I feel blessed to have had the opportunity for 37 years.  I'm also excited that I'm just warming up.  Practicing, practicing and practicing.  Developing discernment, insight and understanding.  The Human Condition meets Biological Variation and God steps in. Wow!  Every day these people share with me about their lives, their biology, their pathology, their variations, their values, goals and dreams.

I am a Family Physician because of the patients.  Who they are, what they do and what they have. They have trusted me with their bodies, their families and their stories.

I remember many lessons learned, unlearned and relearned, thanks to the repetition of patient care. From the first physical exam patient with migrating paresthesias at Mt. Carmel Hospital as an OSU medical student to the first inpatient at Riverside Methodist Hospital who died on the last day of the rotation when I was propping him up for a stat chest x-ray, I learned.

From the child with splinter hemorrhages on his eye exam to the one with a rare degenerative and terminal disease of the nervous system I learned at Children's Hospital of Columbus.  The openness of Marana, Arizona with the National Health Service Corps Clinic and its multi-professional health care team including a Nurse Practitioner, Pharmacist, Nurse, and Internist fresh out of residency training in Baltimore at Johns Hopkins was enlightening.  Adding the first immunizations I ever administered to children on the Pima Indian Reservation and use of the mobile health clinic used by the Marana Clinic to reach small villages expanded my perspectives about health care and medical practice and teams.

In the Department of Family and Community Medicine of Penn State University at the Milton S. Hershey Medical Center in "Chocolatetown, USA" - Hershey, PA I learned in the Family Medicine Model Unit on my own patients and in the Medical Center Hospital on patients of other physicians how to think like a Family Physician and how to act like one.  A wonderful faculty taught us about our specialty from multiple perspectives.  Tom Leaman, MD was our Department Chair who had founded the department and the Family Medicine residency training program before the specialty actually existed.  He was a great leader and role model for what we residents wished to become.

House calls, nursing home rounds, the rural clinic in Millersburg, PA and the inner city Hamilton Health Clinic in Harrisburg were other parts of the Hershey training.  I added a public health rural experience studying small town rural health centers in 3 Pennsylvania locations.  Chocolate and the Hershey Park with Hershey Chocolate World rounded out the residency experience.  Mentors like Dave Aspy, EdD somehow showed up, too.  Relationships with patients, colleagues, friends and family were at the center of the learning and growing.

Raising children of our own became an important part of my understanding Family Medicine. Rebecca and I had one son in the Army at Ft. Riley, KS, another at Ohio State and the third at the Hershey Medical Center.  I had insight about childhood growth and development, family systems, family life cycle and family structure and function from experience in my own home.  Teething, immunizations, holidays, birthdays, family vacations and grandparents were part of both the personal and professional education.  Three Mile Island was an added educational bonus since we were seven miles from the nuclear reactor that had a partial meltdown in March 1979.  Maybe God wanted us back in Ohio.

We moved back and enjoyed Granville, Ohio for 15 years before coming to Bellbrook for 21 more years of practice. Many ups and far fewer downs added to my Family Medicine skills and attitudes and insight.  Missing a brain tumor in a child was a significant developmental scar.  Many subsequent patients of mine have benefited because of what I learned painfully through that failure.  We care and we hurt and we learn.  That's part of being a Family Physician.

A woman stepped into an elevator in Licking Memorial Hospital in Newark, where I admitted my patients, and looked at me, the only person in the elevator.  I recognized her as a patient from several years before and remembered her story.  "I bet you don't remember me."  Before I answered, she continued, "You saved my life.  My husband almost killed me and you helped me to understand what was going to happen next.  I left him because of your help."  "Thank you," I said.

I've grown in my appreciation of the Creator and the creation, including people.  I speak of God with patients in the course of our conversations daily.  One of my main responsibilities is to make sure that people know that they matter.  Like they say in My church, they are "children of God".

Patient encounters in one setting or another number about 190,000 for me.  They are still teaching me and inspiring me to learn more.

Somewhere along the way, I became a Family Physician.

Stories from the journey are sprinkled in my more than 500 blog posts as Dr. Synonymous and more than 200 Dr. Synonymous Blog Talk Radio Shows.  Hits on this Blog will number 150,000 in the next few days.  I'm thankful for the opportunity to share some insights about Family Medicine and the human condition and God.

Thanks to the patients I've been blessed with since 1973 when I started at OSU, I am a Family Physician.

More later.

"Medical" Marijuana May Disrupt Medicare and Medicaid

The Ohio legislature, like 23 legislatures before them, intend to pass a "Medical" Marijuana law soon.  There is nothing "Medical" about marijuana, by the way, as I already blogged two weeks ago.

What happens when thousands of primary care office appointments are taken up by patients wanting approval for their "Medical" marijuana?

Disaster!  Primary care physicians are pretty much operating with full schedules.  There is no room for thousands of marijuana seekers.  Assuming that those visits won't be covered by "medical" insurance, and since they involve a controlled substance, they are longer visits.  They will be billed at a separate charge, paid at the time of the visit (how desperate might someone be to get their marijuana?).  The OARRS report must be consulted, etc.

A cash business line for these special patients will generate lots more revenue than Medicare and Medicaid, without the hassles and onerous "quality" initiatives and penalties.  Thousands of Medicare and Medicaid patients will be suddenly without a physician or without the ability to get timely appointments.  More physicians will see the "Medical" marijuana law as an opportunity to dump Medicare/Medicaid and help our marijuana friends for more financial stability.

Hassle Free Marijuana patients may start to look more appealling than Hasselful government funded patients.

What do you think?

Wednesday, April 20, 2016

Guidelines are Not Policies but Should Get Consideration

I confess that I am annoyed when someone writes or says that medical guidelines must be followed.  I disagree.  Guidelines are reminders of what one should consider.  Biological variation is so vast that each unique human warrants individual consideration.  I like guidelines as reminders of what could or should be considered in clinical situations.  I've never thought them to be policies or mandates.

An over reliance on guidelines as mandates could be disastrous for many patients.  One size does not fit all.

What are your thoughts about guidelines?  What are your experiences?

Saturday, April 16, 2016

Nurse Practitioner Marijuana

I believe that the words "Medical" and "Marijuana" are mutually exclusive.  A plant such as cannabis may not be prescribed in plant form by physicians.  We physicians can prescribe four cannabinoids ("Any of a group of closely related compounds that include cannabinol and the active constituents of cannabis") as legal, FDA approved pharmaceuticals.  They are not plants of 160 or more chemicals, as is the cannabis plant.  The contents of a puff of marijuana smoke are not exactly known, since there are so many chemicals in dosages that are not known.  That's beyond anything we are licensed or trained to prescribe.

Our profession is defined and limited.  We are being used by parties interested in legalizing smokable marijuana to ignore our profession and become shills for misguided legislators.  There are thousands of medications that I may prescribe as a physician.  There are hundreds of recommendations about vitamins, supplements and foods that I may make professionally if I make the patient aware of the potential limitations of the specific product.  None of these are whole plants.  Many are derived from plants and made into tablets, capsules, IV solutions, etc.

The Ohio legislature is intending to propose "Medical Marijuana" soon.   Ohio Marijuana proposals 
I am against so-called "Medical Marijuana", for which there is no Medical definition.  What if the legislators step in a different direction and call it "Nurse Practitioner Marijuana"?  They have sought independent licensure in Ohio, free of physician encumbrance.  Would the legislature pass a Nurse Practice Marijuana bill as part of a deal to grant them their request?

Would the newly independent nurse practitioners welcome the Nurse Practice Marijuana and dive into setting up the practice network that enables Ohioans with appropriate problems, as defined by legislators, to be treated by their independent nurse practitioner?

In New York there are complaints (Compassionate Marijuana Use Law in NY ) that they haven't registered the needed 30,000 patients that would enable financial success of the vendors.  How many physicians are they expecting to leave primary care practices to prescribe the plants (aka, marijuana)?  We have a huge shortage of primary care physicians in America.  Why ask them to make it worse by spending practice time dealing marijuana prescriptions?

Save the primary care physicians!  Legislate the Nurse Practitioners to be independent marijuana prescribers. Physicians will still prescribe legal cannabinoids and retain the professional identity and some of the integrity of the profession.

OK, I don't really want the nurse practitioners to be used by legislators in this way.  The professions may want to stand together on this issue, although I predict they will both sell out.

What do you think?


Sunday, April 10, 2016

West Point: Two Books, a Ring and Friends

Rochester, New York was the site of another West Point Class of 1968 L2/E4 gathering.  The occasion was the 70th birthday of Jack Gerke.  Great party, great guy, great family and great friends. Six of us came from Virginia, Maryland, Florida, Ohio, Texas and Montana with two wives- Ann Laughton and Sandy Tucillo- to celebrate Jack's 70 years.  (OK, a total of 7 L2/E4 graduates from 1968 were together at one time) Don Davis, Alan Aker, Steve Frushour, Nellie Laughton, Ralph Tucillo, Pat Jonas and honoree Jack Gerke shared stories (including Norm Miller, BG Weeks, Howard McElroy and especially Stosh Parker but also Ollie, Toz, Nick, George G, Bullet Bob, Tom, Jon, Denny, Malcolm, Frank, Mike K., Bill M, Rich, Joe, Jim M, Mike G, George Z).  Not to mention Smiling Art, Al Haig, Norm Schwartzkopf, Gen. Bennett, Bernie Rogers, Maj Waters, The Long Gray Vine, etc.

Mary Ellen Gerke and daughter Sam (proud Purdue grad and mother of an eight month girl who is included in the photos) and son Steven pulled off a great surprise for Jack and we added by singing On Brave Old Army Team as we shocked Jack with our entry to a party already packed with Jack's family and friends.  A Bullet Bob antic couldn't have surprised Jack more than we did with the E4 spirit (and even Nellie sang).

Of course, I spilled the beans about Jack's 6 month confinement and 144 Punishment Hours and reduction in rank from cadet lieutenant to private for owning a car, driving it on post before it was allowed, running a stop sign and trying to evade the MP's.  He got a standing ovation from the entire Corps of Cadets in 1967 when the punishment was read from the "poop deck" at supper.  His pent up energy was put to good use on our company football team (that I humbly coached) which almost won the regimental championship, until someone broke our quarterback's arm.

Mary Ellen and Jack were surrounded by family and friends as Jack was serenaded by a special song written by Mary Ellen, covering Jack's entire life to the tune of "Davey Crockett".  His sister Alice reflected on how Jack was as a big brother.  All present were honoring of Jack's humility, loyalty, dependability, mentorship, etc.  He also laughed at jokes told by others-- for decades.  Thanks, Jack.

The L2/E4 accolades for Jack also emphasized the uniqueness of our West Point friendships.

What makes it special is the glue that holds us together as Brothers.  How did it happen?  An array of shared experiences, many under the unique duress of West Point.  Much of that experience is symbolized by two books and a ring.  Two books that we were given on arrival at West Point July 1, 1964.  A ring that was earned by perseverance and commitment.

While the Bugle Notes contained the history of West Point and the United States Army and all the information that we had to memorize, The Holy Bible ("presented by The American Tract Society to the Fourth Classmen at The United States Military Academy") topped it with a message of increasing importance at West Point and beyond.

A ring with our Class Crest, The West Point Crest and the central message of the United States Military Academy: Duty, Honor, Country is our daily reminder.