OK, the Fourth of July blog post is a tough one for me due to brain flooding- too many memories. West Point on my first Independence Day as a New Cadet comes to mind, but I already blogged about that last July 4th.
Independence Day: Freedom and Underwear
The pile of books I chose for preparation this year may reflect my confusion or drive for perfection or quest for truth or desire to get a comment or two about the post. Bugle Notes 1964 (the story of the Long Gray Line of West Point Graduates, updated for the entering class of 1968), Spirit Matters by Michael Lerner, The Life Application Study Bible by God, The Limits of Power by Andrew Bacevich, The Four-Fold Way by Angeles Arrien, Managing the Dream by Warren Bennis, Habits of the Heart by Robert Bellah, et al., Thinking for a Change by John C. Maxwell, Fierce Conversations by Susan Scott, Sacred Unity by Gregory Bateson, The Church Hymnal of the United Brethren Church (1935 version), The Physics of Immortality by Frank J. Tipler, The Theory of Everything by Stephen W. Hawking, The Biology of Transcendence by Joseph Chilton Pearce, The Magic of Believing by Claude M. Bristol, Achilles in Vietnam by Jonathan Shay, The Second Half of Life by Angeles Arrien, Saving America by Robert R. Carkhuff and Old World, New World by Kathleen Burk (a distant cousin of mine who I met probably for the first time a week ago at the Ankney family reunion).
Independence Day celebrates our independence from the British, which seems strange- the British as our enemy. The Burk book is "The Story of Britain and America", focusing on our relationship(s) over five centuries. She writes in the Preface: "There are a number of reasons for writing a book covering Anglo-American relations over a period of five centuries. It has never been done, not even by Churchill, and there is the attraction of doing something for the first time. .... It also makes a rather good story. And, finally, there is my strong conviction that the academy and the general reader have drifted too far apart, and that those who take the public penny have a responsibility to convey the results of their research to the public."
Jumping into the book in 1775 (pp. 148-161), I find a problem with Professor Burk's writing- it is incredibly good. I am suddenly spell-bound by her dynamic descriptions and new factoids (for me) bursting from her depth of research about "our" Revolution. The "British sentries ... confiscated (Paul) Revere's horse, forcing him to walk back to Lexington in his silver spurs and heavy riding boots." His famous ride, immortalized by the poem of Henry Wadsworth Longfellow, was completed by Dr. Samuel Prescott who joined Revere and William Dawes on the road to Concord, after he "had spent the evening in Lexington with his sweetheart". He escaped the British sentries who unsaddled Revere when he "jumped his horse over a stone wall and escaped through back roads and over fields."
"The first blood of the Revolution was shed at Lexington, not Concord, and it was shed by Minutemen." Burk notes that they were commanded by Captain John Parker and badly outnumbered by the British whose commander, Major John Pitcairn ordered the Minutemen to "Lay down your arms, you damned rebels and disperse!" Captain Parker "ordered his men to file away. But then a shot was fired-no one knows by whom- and the British in response fired a volley. Another followed, and then the soldiers charged with fixed bayonets. Eight men were killed ....and another ten wounded." And the rest is History, which keeps changing, as poets, song writers and bloggers have their way with it.
Time out, Professor Burk, for blog size considerations. Back to Dr. Synonymous. OK, back to the Burk book, it's too interesting and there's a message for bloggers and other social media fans.
"In the closing months of 1775, the legislatures of Delaware, New Jersey, New York, Pennsylvania, and South Carolina had all instructed their delegates to the Continental Congress not to vote for independence, and the Maryland legislature did the same in January 1776." Kathleen Burk, by the way, was born in America but has lived in Great Britain for decades, giving her a unique perspective on the relationship reviewed by her book. She points out that "Fundamentally, Americans took particular pride in being governed under Britain's unwritten constitution...This was not a drive for independence."
That seemed to change with the publication of Common Sense; Addressed to the Inhabitants of America by Thomas Paine, who arrived in Philadelphia from Britain. "He was now bankrupt, separated from his wife, and jobless, so he decided to go to America"....where he became a newspaperman. The timing of Common Sense was perfect for his readership since word that the King of England proclaimed his intentions to put a "speedy end" to the colonists desires for independence was printed in the Philadelphia newspaper on the same day of its publication. "Available for sale the following day, it sold some 120,000 copies during the following three months"... and upwards of a half million copies during the rest of the year, according to Burks extensive references.
A key element in the message of Common Sense was an upgrade to the status of "the enemy" of the colonists. The King became "The Royal Brute of Britain", shifting blame from the Parliament, which had denied the Americans representation (remember, "no taxation without representation"). This reframing of the target was a brilliant move by Paine. The other brilliance was his recommendation of a new form of government- "a republic..founded purely on popular choice, with no hereditary elements. There would be a president, more equal representation for voters,...and a constitution..." The target of the King and the goal of a new form of government turned the tide toward independence. (This is a major learning point for me from my brief introduction to Professor Burk's writing.) And the rest is History, which keeps changing as poets, song writers and bloggers have their way with it.
Message for modern day bloggers from Thomas Paine: If you want to be part of a revolution, timing and message is important. Reframing may help you to "go viral". Attacking authority figures may increase your readership. Going bankrupt, failing as a corset maker (the Paine family business in England) because of "market changes", separating from your spouse, getting a letter of reference from Ben Franklin, and coming to Philadelphia are other choices. We can read about your Revolutionary Successes in your blog. Historians may later clarify the variations on the "truths" in your blogging. And the rest will be History, unless it changes as poets, song writers and bloggers have their way with it.
Monday, July 4, 2011
Wednesday, June 29, 2011
Family Medicine: Learning from Stress in the Military- Can We Forget the Tiger?
"Stress" is a concept that we all can relate to, but each has their own set of stress definitions. How does the US Army understand Stress? Here is an excerpt from the section on "Stress and Combat Performance" from the US Army Combat Stress Control Handbook (Lyons Press 2005, pp 33-35). Does any of this sound like your life?:
"Stress is an internal process which presumably evolves because it helps the individual to function better, stay alive, and cope successfully with stressors. However, there is an optimal range of arousal (or motivation or stress) for any given task.
a. If there is too little arousal, the job is done haphazardly or not at all because the individual is easily distracted, makes errors of omission, or falls asleep. If arousal becomes too intense, the individual may be too distractible or too focused on one aspect of the task. He may have difficulty with fine motor coordination and with discriminating when and how to act. If the individual is unfamilial with his own stress reflexes and perceives them as dangerous (or incapacitating, or as a threat to self-esteem), the stress itself can become a stressor and magnify itself.
b. With extreme arousal, the individual may freeze. Alternately, he may become agitated and flee in disoriented panic. If stress persists too long, it can cause physical and mental illness. Extreme stress with hopelessness can even result in rapid death, either due to sympathetic nervous system over-stimulation (such as stroke or heart attack) or due to sympathetic nervous system shutdown (not simply exhaustion). An individual giving up can literally stop the heart from beating.
c. The original purpose of the stress reaction was to keep the person alive. The military requirement for the stress process is different. It is to keep the soldier in that range of physiological, emotional, and cognitive mobilization which best enables him to accomplish the military mission, whether that contributes to individual survival or not. This optimal range of stress differs from task to task. Tasks which require heavy but gross muscular exertion are performed best at high levels of arousal. Tasks that require fine muscle coordination and clear thinking (such as walking point on a booby-trapped jungle trail or distinguishing subtle differences between friendly and enemy targets in a night-vision gun sight) or that require inhibiting acrion (such as waiting alertly in ambush) will be disrupted unless the stress process is kept finely tuned. If the stress process allows too much or too little arousal or if arousal does not lessen when it is no longer needed, stress has become harmful."
I underlined the one phrase about "whether that contributes to individual survival or not". In the military, sometimes mission accomplishment results in loss of life. In the REHEARSAL for D Day in 1944, there were about 800 deaths. This is way beyond what is supposed to happen in our work places, but many times our bodies are reacting as if a tiger is about to attack us. Our body then gets an intense stress reaction. Once we know we can respond successfully to tiger attacks with learning and maturity, we don't need as many tigers. Can't we get away from the tigers? Can't we find ways to reduce the pressure on each other and become more human-centered? Isn't it time?
In Family Medicine, we have opportunities to help people to identify their stressors and upgrade their coping skills. We know how to help people to clear up their view of their personal tigers and balance their stress without having a heart attack. Stress can be helpful, as noted by the US Army, but also dangerous. We don't have to be soldiers and experience combat to develop a variety of responses to stress. Human to human, not tiger to tiger, we can move ahead with more balanced stress responses.
What do you think?
"Stress is an internal process which presumably evolves because it helps the individual to function better, stay alive, and cope successfully with stressors. However, there is an optimal range of arousal (or motivation or stress) for any given task.
a. If there is too little arousal, the job is done haphazardly or not at all because the individual is easily distracted, makes errors of omission, or falls asleep. If arousal becomes too intense, the individual may be too distractible or too focused on one aspect of the task. He may have difficulty with fine motor coordination and with discriminating when and how to act. If the individual is unfamilial with his own stress reflexes and perceives them as dangerous (or incapacitating, or as a threat to self-esteem), the stress itself can become a stressor and magnify itself.
b. With extreme arousal, the individual may freeze. Alternately, he may become agitated and flee in disoriented panic. If stress persists too long, it can cause physical and mental illness. Extreme stress with hopelessness can even result in rapid death, either due to sympathetic nervous system over-stimulation (such as stroke or heart attack) or due to sympathetic nervous system shutdown (not simply exhaustion). An individual giving up can literally stop the heart from beating.
c. The original purpose of the stress reaction was to keep the person alive. The military requirement for the stress process is different. It is to keep the soldier in that range of physiological, emotional, and cognitive mobilization which best enables him to accomplish the military mission, whether that contributes to individual survival or not. This optimal range of stress differs from task to task. Tasks which require heavy but gross muscular exertion are performed best at high levels of arousal. Tasks that require fine muscle coordination and clear thinking (such as walking point on a booby-trapped jungle trail or distinguishing subtle differences between friendly and enemy targets in a night-vision gun sight) or that require inhibiting acrion (such as waiting alertly in ambush) will be disrupted unless the stress process is kept finely tuned. If the stress process allows too much or too little arousal or if arousal does not lessen when it is no longer needed, stress has become harmful."
I underlined the one phrase about "whether that contributes to individual survival or not". In the military, sometimes mission accomplishment results in loss of life. In the REHEARSAL for D Day in 1944, there were about 800 deaths. This is way beyond what is supposed to happen in our work places, but many times our bodies are reacting as if a tiger is about to attack us. Our body then gets an intense stress reaction. Once we know we can respond successfully to tiger attacks with learning and maturity, we don't need as many tigers. Can't we get away from the tigers? Can't we find ways to reduce the pressure on each other and become more human-centered? Isn't it time?
In Family Medicine, we have opportunities to help people to identify their stressors and upgrade their coping skills. We know how to help people to clear up their view of their personal tigers and balance their stress without having a heart attack. Stress can be helpful, as noted by the US Army, but also dangerous. We don't have to be soldiers and experience combat to develop a variety of responses to stress. Human to human, not tiger to tiger, we can move ahead with more balanced stress responses.
What do you think?
Tuesday, June 21, 2011
Human Centered Health Home: Reflecting on Patient Values, Goals and Dreams
During the last major process of the patient-physician engagement in the Human Centered Health Home (HCHH)- Reflecting, a primary aspect involves patient goals. The patient relates with the physician to remain in line, or re-align with, personal values, goals and dreams. Various aspects of these elements may be clarified over time in the context of the patient-physician relationship During each engagement, either party may seek to clarify how health or health problems may relate to long and/or short term life goals. While reflecting near the end of the encounter, long and short term values, goals and dreams of either or both parties may be reviewed to facilitate better short and/or long term decision making. Past posts have given specific examples and future posts will give more examples of how to do this.
The physician has already shared their perspective with the patient using a process such as "get, give, merge and go." (see explanation here) The patient now has the satisfaction of having a mutually agreeable perspective relative to their chief concern since they participated competently with the physician. The physician is relating to the content of their clinical note for recording recommendations and agreed to decisions already discussed. They may be using the format of the eventual final note to guide their comments and give the engagement another reportable element.
There may be a lot of probabilistic commentary during this section, as the physician comments on the probabilities that the patient will achieve their goal(s) using various diagnostic, therapeutic and educational strategies. The patient may clarify their goal(s) as this discussion progresses. The driving value of most concern to the patient may be mentioned, clarified and recorded in the note as having influenced the decision process to be able to remind the participants of that value and its importance. Reflecting on patient (and physician) values in recorded media (the medical record) enriches the human alignment potential for both parties.
These values may be physical, intellectual, emotional and/or spiritual relating to any aspect of the biopsychosocial model, from the biosphere to the subatomic level. The physician must remain mindful of patient safety and costs throughout this element of the engagement. They may also be reflecting on their own biopsychosocial values and their own humanity during the discussion and while assuming various roles throughout the relationship with the patient. The vast array of considerations is dependent on respectful, honest communication by both parties and timely recording of key components of the discussion and decisions.
This synthesis of phenomena is usually concurrent with record keeping, including the filling out of forms that relate to elements of the shared decisions (lab slips, prescriptions, encounter forms, physical therapy orders, etc.) which usually are the purview of the physician, but may change via use of the Electronic Medical Record (EMR) and the Personal Health Record (PHR). The distraction potential during this content rich reflecting period is high, with patients often comforted enough by the process to suddenly bring up more problems for their family physician to consider, instead of celebrating the progress made as the physician might desire.
The mutual respect of the dyad may need a refreshing nudge at this time to stay focused on the main purpose of the encounter and the ongoing nature of the relationship. Shifting back to roles of "human to human" may be one useful strategy that enables conclusion of the "clinical" engagement and a moment to honor their shared humanity. This process is very complex and requires training and trial and error to achieve comfort and confidence. Humans can do it as they remember to honor their shared humanity. An over emphasis on patient or physician roles could mire the engagement in sludge, resulting in dissatisfaction for both.
Remember to GO HUMAN in the Human Centered Health Home.
The physician has already shared their perspective with the patient using a process such as "get, give, merge and go." (see explanation here) The patient now has the satisfaction of having a mutually agreeable perspective relative to their chief concern since they participated competently with the physician. The physician is relating to the content of their clinical note for recording recommendations and agreed to decisions already discussed. They may be using the format of the eventual final note to guide their comments and give the engagement another reportable element.
There may be a lot of probabilistic commentary during this section, as the physician comments on the probabilities that the patient will achieve their goal(s) using various diagnostic, therapeutic and educational strategies. The patient may clarify their goal(s) as this discussion progresses. The driving value of most concern to the patient may be mentioned, clarified and recorded in the note as having influenced the decision process to be able to remind the participants of that value and its importance. Reflecting on patient (and physician) values in recorded media (the medical record) enriches the human alignment potential for both parties.
These values may be physical, intellectual, emotional and/or spiritual relating to any aspect of the biopsychosocial model, from the biosphere to the subatomic level. The physician must remain mindful of patient safety and costs throughout this element of the engagement. They may also be reflecting on their own biopsychosocial values and their own humanity during the discussion and while assuming various roles throughout the relationship with the patient. The vast array of considerations is dependent on respectful, honest communication by both parties and timely recording of key components of the discussion and decisions.
This synthesis of phenomena is usually concurrent with record keeping, including the filling out of forms that relate to elements of the shared decisions (lab slips, prescriptions, encounter forms, physical therapy orders, etc.) which usually are the purview of the physician, but may change via use of the Electronic Medical Record (EMR) and the Personal Health Record (PHR). The distraction potential during this content rich reflecting period is high, with patients often comforted enough by the process to suddenly bring up more problems for their family physician to consider, instead of celebrating the progress made as the physician might desire.
The mutual respect of the dyad may need a refreshing nudge at this time to stay focused on the main purpose of the encounter and the ongoing nature of the relationship. Shifting back to roles of "human to human" may be one useful strategy that enables conclusion of the "clinical" engagement and a moment to honor their shared humanity. This process is very complex and requires training and trial and error to achieve comfort and confidence. Humans can do it as they remember to honor their shared humanity. An over emphasis on patient or physician roles could mire the engagement in sludge, resulting in dissatisfaction for both.
Remember to GO HUMAN in the Human Centered Health Home.
Wednesday, June 15, 2011
Family Medicine: Can Willie Nelson Write Us a Song?
"The last thing I needed the first thing this morning was to have you walk out on me," sings Willie Nelson. I reflect on those words from time to time as I feel a sense of betrayal from one aspect of the health care system or another. Many other Family Physicians (FP's) feel some of the emptiness as they reflect on the "rock and hard place" forming the bookends for their potential demise.
Their patients are vulnerable to misleading health care marketing about the "scan of the month" or the "ultra-center of excellence" for one of their parts at the hospital. The money they need for survival is controlled by parties not aligned with their patients needs, maybe even their employer. If the employed FP's are pushed to see 24-28 patients every day, many patients are sent on for scans, tests or subspecialist evaluation who otherwise would be served by their Family Physician. This increases the overall cost of care and the profit for the healthcare system. Do employers understand that their local hospital is a "frenemy"?
How about it, Willie, would you write a song for Family Doctors and Family Medicine? What would the title be? "My Heroes Have Always Been Family Doctors" "Family Doctors Flying too close to the Ground" "We Tried, We Cared, We Faded" "Unsustainable" "I'm Using My Last Tongue Blade" "Stethoscope for Sale" "We Love You More When We Get Your Copay" "Don't Drop Your Copay on the Ground" "Too Much Debt to Fight" "We Didn't See it Coming" "Would the Last Patient Please Turn Out the Lights?"
What titles can you think of for Willie to write for Family Medicine?
Their patients are vulnerable to misleading health care marketing about the "scan of the month" or the "ultra-center of excellence" for one of their parts at the hospital. The money they need for survival is controlled by parties not aligned with their patients needs, maybe even their employer. If the employed FP's are pushed to see 24-28 patients every day, many patients are sent on for scans, tests or subspecialist evaluation who otherwise would be served by their Family Physician. This increases the overall cost of care and the profit for the healthcare system. Do employers understand that their local hospital is a "frenemy"?
How about it, Willie, would you write a song for Family Doctors and Family Medicine? What would the title be? "My Heroes Have Always Been Family Doctors" "Family Doctors Flying too close to the Ground" "We Tried, We Cared, We Faded" "Unsustainable" "I'm Using My Last Tongue Blade" "Stethoscope for Sale" "We Love You More When We Get Your Copay" "Don't Drop Your Copay on the Ground" "Too Much Debt to Fight" "We Didn't See it Coming" "Would the Last Patient Please Turn Out the Lights?"
What titles can you think of for Willie to write for Family Medicine?
Tuesday, June 7, 2011
The Human Centered Health Home: Reflecting on the Patient Encounter
After Respecting, Protecting, Connecting, Detecting,and Correcting, the last element of the encounter between patients and physicians in the Human Centered Health Home is Reflecting. This usually occurs at the end of the office clinical encounter or just after it's over. Reflecting also includes completing the record of the encounter and the information needed to satisfactorally bill for services rendered.
Using the standard S-O-A-P format for recording the note helps immensely with this step. The note may be written in the room as the patient tells their story and the physician expands and clarifies via mental models, some of which are mentioned in the earlier HCHH writings (see previous posts). As the physician explores and narrows the possibilities, the note is developed, the assessment determined and the plan is shared. The P- Plan includes the diagnostic aspects, therapeutic elements and patient education including the timing of the follow-up for the current situation and continuous care/ prevention.
There may be a lot of probabilistic commentary during this section, as the physician comments on the probabilities that the patient will achieve their goal(s) using various diagnostic, therapeutic and educational strategies. The patient may clarify their goal(s) as this discussion progresses. The physician may say, "With our findings here, there is a very high probability that you have a kidney stone passing from your kidney through your ureter toward your bladder."
"With the CT scan of the abdomen which bills at $2300, there is a 30-50% higher chance you'll know the exact size of your kidney stone (primarily if it's smaller than 4mm, which usually passes spontaneously) than with the renal ultrasound which bills at $550 and accurately shows stone size if 4mm or greater (the size that has a higher chance of not passing spontaneously). The CT scan involves radiation exposure similar to about 500 chest x-rays and has a 1-2% chance of causing cancer 20 or so years later. The ultrasound has no radiation and no cancer risk. Overall it will show stones that may not pass, but less likely to show the size of stones that will pass spontaneously. Generally, neither imaging study is necessary unless the stone, diagnosed clinically with the history, physical examination and urinalysis, is painful for too long. What questions do you have about those options?"
The physician helps the patient to frame the situation and explore the options, sometimes shifting into teacher, learner, consumer coach and values clarifier. Information resources in person or online may be very useful in this segment of the clinical encounter, as contingencies are developed and explored, before final decisions are made. Sometimes there is further clarification about financial burdens of various medications and testing strategies before working decisions are agreed to.
Reflecting also includes context considerations for the physician. Am I comfortable with this type of patient and this symptom complex? What is enjoyable about this patient? How does this type patient and problem inform the physicians career about likes and dislikes in family medicine. As the physician reflects on the encounter, what did he/she learn?
Reflecting may include a vast array of considerations which will be expanded further in future posts.
Using the standard S-O-A-P format for recording the note helps immensely with this step. The note may be written in the room as the patient tells their story and the physician expands and clarifies via mental models, some of which are mentioned in the earlier HCHH writings (see previous posts). As the physician explores and narrows the possibilities, the note is developed, the assessment determined and the plan is shared. The P- Plan includes the diagnostic aspects, therapeutic elements and patient education including the timing of the follow-up for the current situation and continuous care/ prevention.
There may be a lot of probabilistic commentary during this section, as the physician comments on the probabilities that the patient will achieve their goal(s) using various diagnostic, therapeutic and educational strategies. The patient may clarify their goal(s) as this discussion progresses. The physician may say, "With our findings here, there is a very high probability that you have a kidney stone passing from your kidney through your ureter toward your bladder."
"With the CT scan of the abdomen which bills at $2300, there is a 30-50% higher chance you'll know the exact size of your kidney stone (primarily if it's smaller than 4mm, which usually passes spontaneously) than with the renal ultrasound which bills at $550 and accurately shows stone size if 4mm or greater (the size that has a higher chance of not passing spontaneously). The CT scan involves radiation exposure similar to about 500 chest x-rays and has a 1-2% chance of causing cancer 20 or so years later. The ultrasound has no radiation and no cancer risk. Overall it will show stones that may not pass, but less likely to show the size of stones that will pass spontaneously. Generally, neither imaging study is necessary unless the stone, diagnosed clinically with the history, physical examination and urinalysis, is painful for too long. What questions do you have about those options?"
The physician helps the patient to frame the situation and explore the options, sometimes shifting into teacher, learner, consumer coach and values clarifier. Information resources in person or online may be very useful in this segment of the clinical encounter, as contingencies are developed and explored, before final decisions are made. Sometimes there is further clarification about financial burdens of various medications and testing strategies before working decisions are agreed to.
Reflecting also includes context considerations for the physician. Am I comfortable with this type of patient and this symptom complex? What is enjoyable about this patient? How does this type patient and problem inform the physicians career about likes and dislikes in family medicine. As the physician reflects on the encounter, what did he/she learn?
Reflecting may include a vast array of considerations which will be expanded further in future posts.
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