Duty, Honor, Country: Motto for West Pointers

Duty      Honor      Country

Those three words constitute the West Point motto.  They are included as part of The Academy Crest which is a component of West Point class rings.  I see that crest as well as my 1968 class crest daily when I put on my ring. Below are a few reflections about how those three words have come to have unique meaning to West Pointers.

The history and traditions of West Point, the Corps of Cadets and the United States Army are summarized for incoming cadets in a book called Bugle Notes, much of which we had to memorize as plebes (first year students).

The Cadet Prayer becomes a significant reminder about the three words in the motto and their meaning:  "O God, our Father, Thou Searcher of human hearts, help us to draw near to Thee in sincerity and truth. May our religion be filled with gladness and may our worship of Thee be natural.

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

Amen"

Duty:  What one ought to do.  The essence of duty is explored and understood and acted  upon during the cadet years and throughout a lifetime of service to the nation.  Oughtness is a compelling anchor for the study of the human condition.  Duty is an easier concept than oughtness to ponder/discuss.

Honor:   "Strengthen and increase our admiration for honest dealing and clean thinking, and suffer not our hatred of hypocrisy and pretence ever to diminish.... Make us to choose the harder right instead of the easier wrong, and never to be content with a half truth when the whole can be won."
"The harder right" and the "whole" truth are challenges throughout life.  The Cadet Prayer, The Corps and The Alma Mater reaffirm the meaning of the motto for West Pointers.

Country:  The United States of America.  At West Point we agreed to "To support and defend the Constitution of the United States against all enemies, foreign or domestic..." on our first day as New Cadets.  That oath meant a lot then and now.  A commitment to America was a continuous part of the West Point experience and the aftermath.

Medical Stewardship for Family Medicine

What health care model might get us beyond "Statin Sluts", Incidentalists, Inflictionists, or Bonus-Based Physicians - all of which I've written about in previous Dr. Synonymous blog posts?

I believe we're poised for an era of Medical Stewardship, appropriate use of scarce, valuable medical resources.

Medical Stewardship.
More later.

July 27, 2017 My 47th Anniversary: Leaving for Vietnam

I often reflect on my Vietnam Service.  Every July 27th I remember the day I left Dayton, Ohio for Travis AFB in California.  We flew out of Travis to Alaska to Japan to Vietnam.  I came back in late July 1971.
I frequently reflect on the 20 members of my West Point Class of 1968 who died in Vietnam as a result of injuries incurred during their service.  We now have others who are dying of cancer from toxic exposures to Agent Orange, etc. while serving in Vietnam.
War changes people on a continuing basis over a lifetime.

I flew helicopters for the 45th Engineer Group in I Corps, from the DMZ to south of Quang Ngai.
travel vietnam Quang Ngai.  I loved flying OH58A and UH 1 helicopters.

I pray for those who served and were affected by the Vietnam War (actually a "Conflict").

I'm still learning about the meaning of the Vietnam service daily.

Three Dr. Synonymous blogs each year focus on Vietnam.  Here are the last three anniversary blog posts:  departure-for-vietnam-46-years-ago.   vietnam-departure-45-years-ago       another-vietnam-personal-anniversary

Hypermobile Spectrum Disorders in Family Medicine: New Hope for Patients & Doctors

"How does it hurt that bad?" " What is the pathophysiology?" " What is my differential diagnosis?"
These are questions that occur to a family physician when evaluating a patient with problems that include excruciating pain.  With a big push to prescribe fewer to no opiates for pain, physicians are shying away from patients who hurt.  We seem to be developing an aversion to pain and suffering, a surprising paradox for a profession that was invented to prevent and/or treat pain and suffering.

The updated categorization of connective tissue disorders by our genetic friends offers hope (and confusion) to those who want to better diagnose and treat disorders that include a pain component. International Classification of EDS and HSD

The Ehlers Danlos Society does an excellent job of staying on top of and communicating about Ehlers Danlos Syndrome (EDS).  They have quickly updated to inform their members and interested others about the new definitions and diagnostic criteria for EDS and Hypermobile Spectrum Disorders (HSD).  What is HSD?

How might we assess joints for hyermobility? Assessing Joint Hypermobility

What does this mean to patients and family physicians?

More later in this series about EDS and HSD

Ehlers Danlos Syndrome in Family Medicine: Painful Surprise

Ehlers Danlos Syndrome:  Rare? Not so Rare? Not even Rare?  Pain, Pain and Pain.  It drips with clues to the possible presence of a connective tissue disorder.  When I was in medical school, the more likely term was collagen vascular disease.  Marfan's Syndrome became the poster child for this group of diseases/conditions.  Now it should be Ehlers Danlos Syndrome (EDS).

Coming in at 1 in 100 persons (per Dr. Nielson- EDS wizard at the University of Cincinnati, with whom I strongly agree), it races by hemochromatosis and others as a disease to know to provide care for patients in Family Medicine.  Every Family Physician has several patients with this diagnosis that hasn't been made.

The categorization of EDS types was reorganized in March of 2017 for better understanding.  The term Hypermobility Spectrum Disorders is added to better understand EDS and that which is beyond EDS.  It will take a while for physicians to get acquainted with the clarification.  Most family physicians are not aware of the prevalence of EDS in their daily practices, especially patients with pain syndromes.

What is Ehlers Danlos Syndrome?

From the EDS Society:  "Ehlers-Danlos syndromes are a group of connective tissue disorders that can be inherited and are varied both in how affect the body and in their genetic causes. They are generally characterized by joint hypermobility (joints that stretch further than normal), skin hyperextensibility (skin that can be stretched further than normal), and tissue fragility. (For information about the hypermobility spectrum disorders, please visit “About HSD”.)
The Ehlers-Danlos syndromes (EDS) are currently classified in a system of thirteen subtypes. Each EDS subtype has a set of clinical criteria that help guide diagnosis; a patient’s physical signs and symptoms will be matched up to the major and minor criteria to identify the subtype that is the most complete fit. There is substantial symptom overlap between the EDS subtypes and the other connective tissue disorders including hypermobility spectrum disorders, as well as a lot of variability, so a definitive diagnosis for all the EDS subtypes—except for hypermobile EDS (hEDS)—also calls for confirmation by testing to identify the responsible variant for the gene affected in each subtype."

Per Genetics Home Reference Definition

What are the types of Ehlers Danlos Syndrome?

Chart of Types of EDS with detailed definitions.

"Thank You" Used to Mean Quality

This is a response I wrote to a Blogger Friend who was lamenting about her mother being ignored out of getting a referral which she needed in a part of the healthcare system out west.

When I read your Mom’s story, I know it’s totally true. And sad. I mourn for my profession which sold out to Wall Street, dressed as harmless hospital administrators and pharmaceutical representatives and faceless insurance companies with phony quality initiatives and empty terms that somehow appealed to good boy and girl scouts like physicians. 

Now, we have “Value” based care and drop down bonus-based EHR’s that prevent us from seeing the patient, who doesn’t get a drop down bonus of their own. The mutant brain of the physician, who amassed impressive SAT and/or ACT scores is dulled by the mechanistic drivel of the pile of prescription rejections at the start of every year and the ensuing Prior Authorization forms to get the patient out of tier 4 and back to tier 2 on their pharmaceutical co-pay. There’s little room in the physician’s brain for the challenge and fun of developing a complex differential diagnosis that get’s your mother aligned with the best opportunity for achieving her remaining dreams. They used to have fun and get great satisfaction our of the patient’s “Thank You, Doctor.” That was the bonus. That assured the quality. That relationship kept the thieves away. I mourn for my profession and the patients it has abandoned.

The NP’s and PA’s are used in places to keep physicians practicing at the “Top of their license”, meaning they don’t get to enjoy and deliver relationship-based care. The PA’s and NP’s have their own limitations in education and sometimes of licensure, depending on state laws, some of which you already mentioned.
(p.s., I don’t use an EHR, but own two. I have fun every day. Patients say “Thank You, Doctor.” I get to discuss personal (even complex nutrigenomic) strategies daily with patients, if indicated, with time to listen to their story- the most important part of the visit- and their values, goals and dreams. I am a fossil. Endangered fossil. I expect to drop all relationships with insurance companies at the end of this year to expand my Direct Family Medicine practice which enables patients to tell their story, unencumbered with the next massive wave of phony quality initiatives which will result in a 6 to 9% penalty ($) for Medicare patients and already is 12% with one commercial carrier.)
Oops, this is long enough to be a blog post- so I’ll post it on my blog, too.
Peace to you and yours.

Patient Centered Care and Other Lies

"Eating fat is bad for you.  Cholesterol is bad for you.  Drink low fat milk."

These are basically medical lies.  Your brain is mostly made of fat and cholesterol, by the way.
Wheat and sugars are the root of most obesity.

"Value driven, patient centered care will solve most of the problems in healthcare."

Translation:  These terms will sound good to people while we continue to maximize shareholder value for the pharmaceutical, insurance and hospital industry, aka the Medical- Industrial Complex (MIC).
We will maximize the use of the Electronic Health Record (EHR) to inflict maximal "quality sounding" billables on an unsuspecting public.
We will take advantage of the intense desire of physicians to pay off their medical school debts to induce them into specialties that can be used to maximize MIC profits.
We will use electronic prescribing to maximize the medications taken per capita by eliminating patient choice about filling prescriptions.
We will inflict guidelines on patients as if they are facts or legal standards of care and not let them know their actual probabilities, eliminating their ability to choose which medical risks they wish to take.
Metrics will drive bonuses and more inflicted care on patients.  Drop down menus will remind physicians of value based bonuses that they receive if they inflict a medication or procedure on the patient.
We will call it patient centered care.  (It is actually profit centered care)
It will look good.
It will be filled with more lies.

What do you think?

How Dangerous are Herbs, including Marijuana?

Herbal Medicine's Hidden Risks Pose Threat to Health
The title of this article highlighted on February 27, 2017 as Top News by this daily email, MDLinx, to thousands of physicians aligns with the party line about herbals and most health foods from the medical profession. The same people who are ignoring the risks of "Taxable" Marijuana by allowing members of our profession to "recommend" so-called "Medical" Marijuana (MM) still condemn herbal medicine. Marijuana is an herb. We physicians should soundly refuse to recommend the MM because of its risks, but read The German Commission E Report which scientifically analyzes other herbal medicines. It then identifies risks and benefits of the herbal medicines in medical and civilian terms, suitable for decision making about their use. No marijuana isn't included in their analysis.  It has too many cannabinoids to qualify as medical or understandable as a medicine.  As chemicals are extracted from cannabis, they are being individually studied for potential benefits and harms in FDA approved research processes.  Since the FDA still lists marijuana as a schedule I drug (same Schedule as heroin), it is illegal for a physician to prescribe it.  Asking physicians to "recommend" it, as many state legislatures have done, is dishonoring of the medical profession and demonstrating a poor understanding of a still worthy profession, if medical ethical standards are reaffirmed for the protection of society.

Family Physicians: Blog On!

Hi Folks,
I've smoldered into hypoblogemia.  Blogging less is getting into my blood.

A cup of coffee from one of my top five coffee cups early Sunday morning listening to gospel bluegrass on the radio has me ready to write.  Reading started it- The Bible 1 Timothy 2:1-4, A Synopsis of Bible Doctrine in the back of my Ryrie Study Bible, Psalms (there was a bookmark and underlinings on Psalm 33).

The Wright Way by Mark Eppler, Incomplete Nature by Terence W. Deacon, Synaptic Self by Joseph LeDoux each get a few pages of attention from me.  Entropy, thermodynamics, morphodynamics, complexity, absence, reductionism, order, organization, and mind are words on the pages that wake up some areas of my memory and some brain filing cabinets, as well as stimulating some of my senses.

And so to blog.  As Samuel Johnson might be writing is he was still alive.

Is it all about the money?  Or Beauty and Truth?  Or Sin and Salvation?  (It's Sunday and I'll be in church-United Methodist- in a couple hours.  Yes, Sin and Salvation is more a Baptist focus than Methodist.  And taking notes.  Like, who else is taking notes in church?  Bloggers?)

"Blog on, blog on with hope in your heart and you'll never blog alone", the song may be changed.

People are different.  Unique.  One of a kind.
The Human Condition.  Blogworthy.
Family Medicine.  Also Blogworthy.

Feel Good Nutrigenomics by Amy Yasko, PhD, NHD, HHP, FAAIM is a useful introduction to a way of helping people through nutrition and genomics.  Pharmacogenomics was to be the great hope for the next era of medicine.  It hasn't panned out.  Nutritional strategies for bypassing genomic flaws are delivering that hope for many.  Nutrigenomics, Epigenetics and Methylation are key words in this book.  It has changed how I practice medicine for the last two years (before I had the book- the internet holds much of Dr. Yasko's work and videos on YouTube have hours of her lectures)

Zinc.  In Nutrient Power by William J.  Walsh, PhD, he points out that 93% of persons at their clinic with psychiatric diagnoses had a moderate to severe zinc deficiency.

Zinc is the "Chemical of the Month" in my practice.  Not so fast.  Many persons with zinc deficiency need it replaced slowly to not stimulate toxic levels of other chemicals.  Fifty mg. daily was used for many in Dr. Walsh's clinical experience.

Direct Primary Care.  Is it the great hope for a return to quality in health care?  Will it get bogged down by self-inflicted regulation?  See my previous blog posts about DPC for more background on what it is and why it's important.

I intend to shift most or all of my practice time to Direct Primary Care in January 2018. It's a model that eliminates administrative hassles from insurance companies and the government.

Nutrigenomics in the practice will soon include specific tests to hone in on individual needs and responses to therapy.  The DPC model allows the time to personalize better for each patient and their family.

Blog On!

Family Medicine: Clock Management

OK, Family Docs, what percentage of the time during your usual office clinical encounter is used to directly relate to the patient?  What should it be according to your dream of the best physician you can be??  What should it be according to your employer if you have one (or two or whatever)?

Direct Primary Care Ohio UnSummit V Feb 18, 2017 Columbus

Direct Primary fans in and around Ohio will be pleased to hear more about the next UnSummit coming up in February on the OU Heritage Medical Campus in (West of) Dublin, Ohio- a Columbus suburb.

Speakers will review the two major training models/schools which are in Kansas and North Carolina.  They will speak about DPC for medical students and residents, and DPC for early career physicians.  We'll discuss mid-career and late career DPC start-ups and transitions.
Ohio DPC physicians will introduce their perspectives from several areas of the state.  Pearls and Pitfalls are always fun, and sometimes worrisome, to discuss, but we'll do it anyway.

New this year will be "Medical Marijuana" in Ohio and DPC.  Also new will be discussion about what to do as a side job or moonlighting if necessary to fund your DPC path.

Favorites that will be presented in update fashion are "DPC for Geezers", "DPC National Online Tour", "My DPC Practice" (panels of physicians).  DPC networking in and around Ohio.  Legislative update.  "Why we don't/do need to regulate and control DPC".  A Townhall session will close out the day.

No CME credit is available for this meaningful day.  More later, like how to register (for a mere $150, less for students and residents) will be in next weeks blog post.

Follow the Facebook page of main sponsor The Center for Innovation in Family and Community Health for continuing commentary about this opportunity.  Facebook Page CIFCH
Flyer and Registration Form DPC Ohio UnSummit V