Across the nation, random attempts to close Departments of Family Medicine and Family Medicine residency training programs are continuing to bubble, fade, succeed, fail and surprise those who thought more Family Physicians are needed to "bend the cost curve" of healthcare.
It's all about the money, folks. Family Physicians decrease emergency room visits, admissions and re-admissions to hospitals and over-all cost of health care. That loses money for several entities, but saves money for employers and patients (and governments, aka tax payers) .
Watch in your area to see where the cuts occur that decrease your access to Family Physicians. You may be surprised. I was.
I remember surprising moves over the years by the University of Iowa, Ohio State University, Penn State University, Duke University and numerous Community Hospitals that evicted, closed, reduced or merged Family Medicine Departments or Residency Training Programs. Rumors about the University of Minnesota were the most recent example of University versus Family Medicine.
I trained in the Family Medicine Residency of the Department of Family and Community Medicine of the Milton S. Hershey Medical Center. My training program was evicted years later and picked up by the Good Samaritan Hospital in Lebanon, PA which picked up an expanded Penn State relationship in the process.
Both flagship hospitals of the two surviving hospital networks in my area of Dayton, OH have closed their Family Medicine training centers within the last three years. Who is training the Family Physicians needed to serve the Greater Dayton area?
I'm worried about the Future of Family Medicine and access to care for Americans as we are about to add 30 million people to the ranks of "the insured". I fear that they and millions of others will find that an urgent care center or emergency room is their Family Doctor. The costs of care can only to continue to bankrupt America unless we get together about a better vision for health care.
Medicare is paying much of the costs for Family Medicine training via subsidies to training hospitals. As this money is decreased with various government policies, the hospitals may lean toward training specialists who make more money while in training such as cardiology fellows who do procedures and order lots of expensive tests routinely.
Various legislative efforts are being initiated such as H.R. 3667 to find ways to continue the training of Family Physicians and other primary care physicians. You may wish to read more about this bill and its background and sponsors by double clicking on the link below. More later.
H.R. 3667
What have you heard about reductions in training Family Physicians and other primary care physicians?
apj
Sunday, March 11, 2012
Tuesday, March 6, 2012
Fibromyalgia Update on Diagnosis and New Statin Warnings
Dr Synonymous show March 6, 2015 features comments on the latest diagnostic criteria for fibromyalgia and a discussion of the new warnings the FDA has placed on statin drugs.
We'll review patient blogs, physician blogs and Dr Synonymous blog along with some tweets and other medical trends.
Tuesday from 8-9 PM ET on Blog Talk Radio (www.blogtalkradio.com/drsynonymous). Listen in live or later to a podcast of the show.
The Dr Synonymous Show March 6, 2012 8-9 PM ET
apj
We'll review patient blogs, physician blogs and Dr Synonymous blog along with some tweets and other medical trends.
Tuesday from 8-9 PM ET on Blog Talk Radio (www.blogtalkradio.com/drsynonymous). Listen in live or later to a podcast of the show.
The Dr Synonymous Show March 6, 2012 8-9 PM ET
apj
Wednesday, February 29, 2012
Family Medicine: After Hours and Night Call
The cell phone chimes at the end of the work day. It's a call from my office (where I am still seeing my last patient, or, rarely, just finished seeing the last patient of the day). I look at the number, stop the ring and call back or answer the phone, which I already know will be our night answering system, aka our voice messaging system for after hours calls. When the machine answers and I enter a numeric code, I get a recording noting how many new messages are waiting. I press another time to hear the new message. "This is your test page", I hear from the staff member still working at the check out desk in the front of the office.
I walk to the front of the office and tell that person, "I got the test page." Every day, we have to know that our night call system is working before we leave so our patients who call after hours with problems can "leave a message for the doctor on call", as directed by our recording. Yes, folks, your Family Doctor is available 24/7 to respond to your urgent or emergency situations.
When a patient leaves a message, the system automatically pages our doctor on call immediately, who receives a call on their cell phone just like the test page, giving them the opportunity to listen to the message immediately or when they finish their current task. The doctor on call listens to the patient's message and phone number and returns the call. Our machine records the patient's phone number, also, so we can listen to the recorded number via voice recording of the system immediately at the end of the patient's recorded message. This is useful if the patient recording wasn't clear, due to the patient's illness (hoarseness, weakness, crying baby, barking dog, etc.). Also, it's helpful for people who forget to leave their phone number or hang up without leaving a number. Usually the person who hangs up without leaving a message actually had a need that the physician can respond to but the patient had second thoughts about bothering the physician. I almost always call the hang ups, knowing it's always been a patient of ours who is calling. Wrong numbers must be hearing the recording and hang up before the paging system is activated.
What do people call about? Someone is sick, miserable, having a reaction to medication, having no response to medication for intense symptoms, pain, acute stress reaction, clarifying whether to go to an emergency room (or urgent care). If we advise going to an emergency room, we call the emergency room to let them know about our patient and whether we wish to be called back once a diagnosis and treatment plan is established. We help the patient, the ER staff and ourselves by calling since we know our schedule for follow up possibilities and we know our patient and their family. We may apprise the ER staff- usually I speak with a physician- about the past medical and personal history of the patient to provide the physician with a better starting point for understanding our patient and their situation.
I want them to sense that my patient is a unique and interesting person with a doctor who cares. ("Please love my patient, you wonderful ER doc, you won't regret it. I will make your work easier by willingly seeing the patient in follow up at which time I will edify the work done in the ER and the people who did it.") We also let them know who will be admitting the patient should the need arise (we have most people admitted to a hospitalist group that we know fairly well, since we stopped admitting about two years ago. This is worthy of another post since a new hospital just opened right next door to our office. I love going to hospitals and caring for my own patients and want to start admitting again, BUT there are considerations about increasing complexity in all of our endeavors that may preclude admitting my own patients. More later on this subject.).
We also let the ER doctor know whether the patient has already seen a sub-specialist in an area of concern for the current episode (if they may be having a heart problem and they have a cardiologist, we want the ER to relate to the same cardiologist and not accidentally consult another cardiology group- continuity is important). I also let them know that if the patient is admitted, I want to speak with the admitting physician so I can give more background about my patient. This type of personal communication helps everyone, increases "quality" and decreases the potential for disasters.
Sick babies are especially important to us at night. Parents can be very stressed with a sick child, so we are committed to hearing their story and connecting to the stress as well as the sickness. The first child (what I call the "training child") generates more stress than later ones, so we add comments of validation and reassurance when speaking with parents about the "training child". A friendly comment to "call back if you aren't comfortable with how the child is doing or your pulse rate is over 100." The parent, who is also our patient -one of the beautiful aspects of Family Medicine- often feels better knowing that it's ok to call back (Yes, we're in this together).
As a Family Physician, I (or my cross coverage-someone from my own practice) am available 24/7. I get surprised when I see an ad on TV or a billboard promoting Ask a Nurse type night call companies and think, "Why ask a nurse when you can ask your own personal Family Physician?" There must be physician groups with less availability at night than ours, or less curiosity or more stress. I could see a patient use of Nurse on- call companies for when the patient doesn't get along with the doctor on cross-coverage call or doesn't agree with their advice. The nurse may be very comforting for them.
This post was inspired by the calls I received in the last 12 hours while I've been on call. We're very close to the Ohio flu season, so night call will get even more interesting. What have your experiences been with after hours and night call medical interactions?
I walk to the front of the office and tell that person, "I got the test page." Every day, we have to know that our night call system is working before we leave so our patients who call after hours with problems can "leave a message for the doctor on call", as directed by our recording. Yes, folks, your Family Doctor is available 24/7 to respond to your urgent or emergency situations.
When a patient leaves a message, the system automatically pages our doctor on call immediately, who receives a call on their cell phone just like the test page, giving them the opportunity to listen to the message immediately or when they finish their current task. The doctor on call listens to the patient's message and phone number and returns the call. Our machine records the patient's phone number, also, so we can listen to the recorded number via voice recording of the system immediately at the end of the patient's recorded message. This is useful if the patient recording wasn't clear, due to the patient's illness (hoarseness, weakness, crying baby, barking dog, etc.). Also, it's helpful for people who forget to leave their phone number or hang up without leaving a number. Usually the person who hangs up without leaving a message actually had a need that the physician can respond to but the patient had second thoughts about bothering the physician. I almost always call the hang ups, knowing it's always been a patient of ours who is calling. Wrong numbers must be hearing the recording and hang up before the paging system is activated.
What do people call about? Someone is sick, miserable, having a reaction to medication, having no response to medication for intense symptoms, pain, acute stress reaction, clarifying whether to go to an emergency room (or urgent care). If we advise going to an emergency room, we call the emergency room to let them know about our patient and whether we wish to be called back once a diagnosis and treatment plan is established. We help the patient, the ER staff and ourselves by calling since we know our schedule for follow up possibilities and we know our patient and their family. We may apprise the ER staff- usually I speak with a physician- about the past medical and personal history of the patient to provide the physician with a better starting point for understanding our patient and their situation.
I want them to sense that my patient is a unique and interesting person with a doctor who cares. ("Please love my patient, you wonderful ER doc, you won't regret it. I will make your work easier by willingly seeing the patient in follow up at which time I will edify the work done in the ER and the people who did it.") We also let them know who will be admitting the patient should the need arise (we have most people admitted to a hospitalist group that we know fairly well, since we stopped admitting about two years ago. This is worthy of another post since a new hospital just opened right next door to our office. I love going to hospitals and caring for my own patients and want to start admitting again, BUT there are considerations about increasing complexity in all of our endeavors that may preclude admitting my own patients. More later on this subject.).
We also let the ER doctor know whether the patient has already seen a sub-specialist in an area of concern for the current episode (if they may be having a heart problem and they have a cardiologist, we want the ER to relate to the same cardiologist and not accidentally consult another cardiology group- continuity is important). I also let them know that if the patient is admitted, I want to speak with the admitting physician so I can give more background about my patient. This type of personal communication helps everyone, increases "quality" and decreases the potential for disasters.
Sick babies are especially important to us at night. Parents can be very stressed with a sick child, so we are committed to hearing their story and connecting to the stress as well as the sickness. The first child (what I call the "training child") generates more stress than later ones, so we add comments of validation and reassurance when speaking with parents about the "training child". A friendly comment to "call back if you aren't comfortable with how the child is doing or your pulse rate is over 100." The parent, who is also our patient -one of the beautiful aspects of Family Medicine- often feels better knowing that it's ok to call back (Yes, we're in this together).
As a Family Physician, I (or my cross coverage-someone from my own practice) am available 24/7. I get surprised when I see an ad on TV or a billboard promoting Ask a Nurse type night call companies and think, "Why ask a nurse when you can ask your own personal Family Physician?" There must be physician groups with less availability at night than ours, or less curiosity or more stress. I could see a patient use of Nurse on- call companies for when the patient doesn't get along with the doctor on cross-coverage call or doesn't agree with their advice. The nurse may be very comforting for them.
This post was inspired by the calls I received in the last 12 hours while I've been on call. We're very close to the Ohio flu season, so night call will get even more interesting. What have your experiences been with after hours and night call medical interactions?
Sunday, February 26, 2012
Blog Milestone and Reflection at 25,000 Views
OK, I'll congratulate myself a bit in this post. My Dr. Synonymous blog has reached 25,000 views. Thank you, readers. I have to look back on the blog and reflect a bit. Why did I blog? What did I write about? What did people look at? What generated reader response? What mattered?
Personally, I'm pleased to have the opportunity to write, which I enjoy. I'm on the back (screened in but not heated) porch writing now, watching our dog run around and explore the yard and the critters, including the tractor that just went through the field just to the west of us, beyond the treeline. The birds at the feeder are twelve or so feet in front of me, pecking at the suet and cracking the sunflower seeds. Finches, cardinals (Ohio's state bird), chickadees, tit mouses, woodpeckers, blue jays, grackles, and others show up from time to time which reminds me of life and nature. The air is pure outside (if you don't mind the prolonged mold and early pollen levels which actually are good for business in Family Medicine- I tell many patients, as I've written in this blog, "Mucous is the state bird in Ohio"- of course you know it isn't since I noted above that it's the cardinal.) and I love the tones from the chime set six feet to the right of me that rings in the light and chilly breeze today.
Overall, the writings relate to Family Medicine and issues related thereto. Patients are the most important aspect of the whys and wherefores of Family Medicine, so I comment a lot about patient situations and physician responses. The history of Family Medicine gets several posts as does the ongoing training of Family Physicians. I reveal some aspects about physician thinking, diagnosing and treating and comment often about how patients may connect to the physician process of working and caring.
The situation of healthcare bankrupting America shamelessly gets attention in the Dr. Synonymous blog along with lamentations about the gradual disappearance of Family Medicine for financial considerations, even when the major lifeline for the entire health care system seems to be Family Medicine (says the Family Physician, humbly). Some posts note how we might learn a lot from others such as Dr. Marcus Welby and Dog the Bounty Hunter, while others reflect on the "Founders of Family Medicine". The Patient Centered Medical Home (PCMH) gets a few words for being a good idea while the Human Centered Health Home (HCHH) gets numerous posts as an upgrade to the PCMH.
The Medical Industrial Complex is not favored in my writings, since I see it as so misaligned with the needs of the citizenry. Yet, I'm part of it. The paradox hasn't received enough of my writing in this blog, yet.
Several posts refer to days of the week to give a glimpse of what may be happening in a Family Physician's office in a particular time frame, such as Friday morning or Monday morning or Saturday morning in Family Medicine. Specific processes such as House calls, end of life care, relationship to nurses and nurse practitioners are singled out for the readers. Special people such as unit secretaries in hospitals, hospice nurses, patients and families also get extra focus. My most viewed post at present "Corporatizing Hospice- More Heart Needed" laments an over-emphasis on corporate thinking to the detriment of patient care. Many echo a plea to save Family Medicine because it is needed as a Medical Specialty that helps people and saves money.
As a Vietnam Veteran and graduate of West Point, several of the posts are my thoughts about those experiences relating to the military, war, West Point and the West Point Alumni Glee Club (one of my current top 5 most viewed posts). Patriotic themes float through my comments about The Wall (Vietnam Veterans Memorial), Memorial Day, Independence Day (also one of my top five most viewed posts). The anniversary of my going to and returning from Vietnam seem to get posts as does the anniversary of the "Peace" in Vietnam. Those 20 members of the West Point class of 1968 who died in the struggle in Vietnam are constant reminders about war and peace, life and death, and truth and lies.
Human relationships and human processes seem to be at the heart of my posts. As a Family Physician for over thirty years, I've been impressed by the human spirit. I've tried to write about it. I will continue
Thanks to the people who've helped with my learning about how to blog and how to write and especially to those who read my posts. Your views and your comments have kept me sensitive to the needs of readers and patients and Family Physicians. More reflections at 50,000 views. Peace. apj
Personally, I'm pleased to have the opportunity to write, which I enjoy. I'm on the back (screened in but not heated) porch writing now, watching our dog run around and explore the yard and the critters, including the tractor that just went through the field just to the west of us, beyond the treeline. The birds at the feeder are twelve or so feet in front of me, pecking at the suet and cracking the sunflower seeds. Finches, cardinals (Ohio's state bird), chickadees, tit mouses, woodpeckers, blue jays, grackles, and others show up from time to time which reminds me of life and nature. The air is pure outside (if you don't mind the prolonged mold and early pollen levels which actually are good for business in Family Medicine- I tell many patients, as I've written in this blog, "Mucous is the state bird in Ohio"- of course you know it isn't since I noted above that it's the cardinal.) and I love the tones from the chime set six feet to the right of me that rings in the light and chilly breeze today.
Overall, the writings relate to Family Medicine and issues related thereto. Patients are the most important aspect of the whys and wherefores of Family Medicine, so I comment a lot about patient situations and physician responses. The history of Family Medicine gets several posts as does the ongoing training of Family Physicians. I reveal some aspects about physician thinking, diagnosing and treating and comment often about how patients may connect to the physician process of working and caring.
The situation of healthcare bankrupting America shamelessly gets attention in the Dr. Synonymous blog along with lamentations about the gradual disappearance of Family Medicine for financial considerations, even when the major lifeline for the entire health care system seems to be Family Medicine (says the Family Physician, humbly). Some posts note how we might learn a lot from others such as Dr. Marcus Welby and Dog the Bounty Hunter, while others reflect on the "Founders of Family Medicine". The Patient Centered Medical Home (PCMH) gets a few words for being a good idea while the Human Centered Health Home (HCHH) gets numerous posts as an upgrade to the PCMH.
The Medical Industrial Complex is not favored in my writings, since I see it as so misaligned with the needs of the citizenry. Yet, I'm part of it. The paradox hasn't received enough of my writing in this blog, yet.
Several posts refer to days of the week to give a glimpse of what may be happening in a Family Physician's office in a particular time frame, such as Friday morning or Monday morning or Saturday morning in Family Medicine. Specific processes such as House calls, end of life care, relationship to nurses and nurse practitioners are singled out for the readers. Special people such as unit secretaries in hospitals, hospice nurses, patients and families also get extra focus. My most viewed post at present "Corporatizing Hospice- More Heart Needed" laments an over-emphasis on corporate thinking to the detriment of patient care. Many echo a plea to save Family Medicine because it is needed as a Medical Specialty that helps people and saves money.
As a Vietnam Veteran and graduate of West Point, several of the posts are my thoughts about those experiences relating to the military, war, West Point and the West Point Alumni Glee Club (one of my current top 5 most viewed posts). Patriotic themes float through my comments about The Wall (Vietnam Veterans Memorial), Memorial Day, Independence Day (also one of my top five most viewed posts). The anniversary of my going to and returning from Vietnam seem to get posts as does the anniversary of the "Peace" in Vietnam. Those 20 members of the West Point class of 1968 who died in the struggle in Vietnam are constant reminders about war and peace, life and death, and truth and lies.
Human relationships and human processes seem to be at the heart of my posts. As a Family Physician for over thirty years, I've been impressed by the human spirit. I've tried to write about it. I will continue
Thanks to the people who've helped with my learning about how to blog and how to write and especially to those who read my posts. Your views and your comments have kept me sensitive to the needs of readers and patients and Family Physicians. More reflections at 50,000 views. Peace. apj
Sunday, February 19, 2012
Family Medicine: Marcus Welby, MD - Caring, Angry and Committed
I'm viewing the first season of Marcus Welby, MD on DVD to reflect on how the early TV doctors practiced (acted). I was surprised to see how angry Dr Welby was on numerous occasions (in sunny California, even). He was totally committed to his patients and to his community reputation of "Doctor", but the amount of anger surprised me.
For some background, in case you don't remember of weren't alive then, in the 1960's and 1970's, patients saw their personal physician, and usually paid for the doctor's services on the way out of the office. Insurance was only used for hospitalization, not for office or outpatient services. Diagnostic support such as CT scans or MRI's were just being invented in the late 1970's. Dr. Welby and his young associate, Dr. Steve Kiley, had to do it all from cradle to grave, sometimes with the help of their local hospital- where they admitted their own patients, delivered their babies, removed their tonsils and maintained professional relationships with other physicians.
In such an era, the "presence" of the physician was a major aspect of treatment. The doctor was committed to your well-being as long as you honored their profession and followed doctor's orders. Just as now, many individuals disagreed with Dr. Welby (even Dr Kiley disagreed at one point or another during most of the shows in the season one DVD that I viewed). "Therapeutic Presence" was important in the world of Welby and Kiley. At times, they had little to offer medically, so the patient-physician relationship was very important as a therapeutic element.
Dr. Welby at times was very possessive of his patients, even demanding and angry when others interfered in their relationship. Anger was a visitor every week from the TV doctor who had just experienced a long run as the fatherly lead in "Father Knows Best", which used the same house front as "Marcus Welby, MD". Dr. Welby compensated with 24/7 willingness to be there for his patients- in their home, in the hospital or at the local "trailer park"- and with the motherly support as office assistant and sometime lunch preparer of Elena Verdugo who played Consuelo Lopez.
Everyone seemed to love Consuelo and most were forgiving of the youthful, geeky bluntness of Dr Kiley who lived in the house with Dr. Welby that doubled as their doctor's office. Only Marcus Welby, MD had to get the full brunt of various angry patients or their relatives. Still, he persisted, and confronted and hugged and argued. He pleaded for an autistic boy to be treated by a research center and basically berated the Medical Director who politely apologized for society's failure to take care of all. He lived in the home of that boy empathizing with his parents about the possible need to institutionalize the boy out of concern for the safety of the new baby in the home. Never fear, Welby taught the boy to feed the horse and colt, suddenly seeing the boy connect with animals and humans at the midnight hour (end of show) as a reward for the good doctor's extra care.
I can't wait to get season two to watch the maturing of the characters and the script. What do you remember about the "Marcus Welby, MD" show?
For some background, in case you don't remember of weren't alive then, in the 1960's and 1970's, patients saw their personal physician, and usually paid for the doctor's services on the way out of the office. Insurance was only used for hospitalization, not for office or outpatient services. Diagnostic support such as CT scans or MRI's were just being invented in the late 1970's. Dr. Welby and his young associate, Dr. Steve Kiley, had to do it all from cradle to grave, sometimes with the help of their local hospital- where they admitted their own patients, delivered their babies, removed their tonsils and maintained professional relationships with other physicians.
In such an era, the "presence" of the physician was a major aspect of treatment. The doctor was committed to your well-being as long as you honored their profession and followed doctor's orders. Just as now, many individuals disagreed with Dr. Welby (even Dr Kiley disagreed at one point or another during most of the shows in the season one DVD that I viewed). "Therapeutic Presence" was important in the world of Welby and Kiley. At times, they had little to offer medically, so the patient-physician relationship was very important as a therapeutic element.
Dr. Welby at times was very possessive of his patients, even demanding and angry when others interfered in their relationship. Anger was a visitor every week from the TV doctor who had just experienced a long run as the fatherly lead in "Father Knows Best", which used the same house front as "Marcus Welby, MD". Dr. Welby compensated with 24/7 willingness to be there for his patients- in their home, in the hospital or at the local "trailer park"- and with the motherly support as office assistant and sometime lunch preparer of Elena Verdugo who played Consuelo Lopez.
Everyone seemed to love Consuelo and most were forgiving of the youthful, geeky bluntness of Dr Kiley who lived in the house with Dr. Welby that doubled as their doctor's office. Only Marcus Welby, MD had to get the full brunt of various angry patients or their relatives. Still, he persisted, and confronted and hugged and argued. He pleaded for an autistic boy to be treated by a research center and basically berated the Medical Director who politely apologized for society's failure to take care of all. He lived in the home of that boy empathizing with his parents about the possible need to institutionalize the boy out of concern for the safety of the new baby in the home. Never fear, Welby taught the boy to feed the horse and colt, suddenly seeing the boy connect with animals and humans at the midnight hour (end of show) as a reward for the good doctor's extra care.
I can't wait to get season two to watch the maturing of the characters and the script. What do you remember about the "Marcus Welby, MD" show?
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