DABBLE with Your Holistic Health

I like to DABBLE with holistic health.  Here's a simple outline for you.

Dream   Allow  Become  Become again  Listen  Enjoy



Dream like Goldilocks (that's a good start)

Allow like a great teacher allows their students to succeed/ fail/ learn

Become yourself with honored parts (if awakened by bears, run like Goldilocks)

Become your next (near) whole self again

Enjoy it like the (near) whole you, as your parts allow


As you imagine wholeness and fulfillment in your future, supported by personalized healthcare that aligns with your values, goals and dreams, how content might you feel as you visualize or sense your future self?

What is your dream?
If you wish to have success (as you define it), it may be more readily achieved by:
     Defining your Dream
     Having a Burning Desire to achieve it
     Believing you will reach it

Allow an honest assessment of yourself at regular intervals
     Physically
     Intellectually
     Emotionally
     Spiritually

     In your Living, Learning and Working Contexts (If you like grids, make a 4 x 3 grid giving 12 boxes to reflect on).
     Does your honest assessment yield strengths and needs conducive to actions that better align you with your values, goals and dreams?

Vioxx and Trust

Vioxx was a great medication for thousands of people with osteoarthritis.  It was great for pain relief.  Many persons, though got serious side effects.  Heart attacks and strokes.  Here's some of the initial background information:
In VIGOR, a study in 8076 patients (mean age 58; VIOXX (rofecoxib) n=4047,NAPROXEN n=4029) with a median duration of exposure of 9 months, the risk of developing a serious cardiovascular thrombotic event was significantly higher in patients treated with VIOXX (rofecoxib) 50 mg once daily (n=45) as compared to patients treated with NAPROXEN 500 mg twice daily (n=19). In VIGOR, mortality due to cardiovascular thrombotic events (7 vs 6, VIOXX (rofecoxib) vs NAPROXEN, respectively) was similar between the treatment groups. (See CLINICAL STUDIES, Special Studies, VIGOR, Other Safety Findings: Cardiovascular Safety.) In a placebo-controlled database derived from 2 studies with a total of 2142 elderly patients (mean age 75; VIOXX (rofecoxib) n=1067, placebo n=1075) with a median duration of exposure of approximately 14 months, the number of patients with serious cardiovascular thrombotic events was 21 vs 35 for patients treated with VIOXX (rofecoxib) 25 mg once daily versus placebo, respectively. In these same 2 placebo-controlled studies, mortality due to cardiovascular thrombotic events was 8 vs 3 for VIOXX (rofecoxib) versus placebo, respectively. The significance of the cardiovascular findings from these 3 studies (VIGOR and 2 placebo-controlled studies) is unknown. Prospective studies specifically designed to compare the incidence of serious CV events in patients taking VIOXX (rofecoxib) versus NSAID comparators or placebo have not been performed.

How did we miss the intensity of the medication's effects beyond the 45 of 4047 patients mentioned above?  45 of 4047 is bad enough, but it was even worse.

We physicians are gullible.  Fifty percent of major medical advances are disproven within five years. We refer to post marketing reports to understand the effects of medications on a broader population than those initially studied.

We lost some patient trust with Vioxx and similar drugs.  How do we get it back?

Chicken Pox

In "the old days", parents expected their children to catch chicken pox.  Everyone got it.  It was not considered to be a big deal.  Starting with red spots, then blisters on the trunk, it could evolve into hundreds of blisters all over the body.  It itched.  It sometimes scarred.  It took several days for the rash to get crusts and be declared, five or six days later, non-contagious (suitable for return to school, church, scout meetings, etc.).  If there were several children in a family, they could get chicken pox sequentially and result in prolonged absence from work by the care-taking parent(s).  Schools might experience a prolonged period of absenteeism as the infection went through the grades.  

The Center for Disease Control has a web page for the public about chicken pox (varicella virus) here and the chicken pox vaccination here.  A more detailed report for health care professionals is here, starting with this paragraph:  "Varicella (chickenpox) is a febrile rash illness resulting from primary infection with the varicella-zoster VIRUS (VZV). Humans are the only source of infection for this virus. Varicella is highly infectious, with secondary infection occurring in 61%-100% of susceptible household contacts.[1-5] Transmission occurs from person to person by direct contact with persons with either varicella or herpes zoster (shingles) lesions or by airborne spread from respiratory secretions or lesions of persons with chickenpox. The incubation period for varicella is 10-21 days, most commonly 14-16 days. Varicella is characterized by a pruritic, maculopapular vesicular rash that evolves into noninfectious dried crusts over a 5- to 6-day period."

So, what's your approach to chicken pox?  The initial vaccine is recommended for one year olds with a booster later per the CDC schedule.  A lot of people just want their child to get the chicken pox "naturally", which is hard to do when the majority get the vaccine, so they wait for them to get exposed.  If they don't get the chicken pox, they may decide to go ahead with the immunization, or they may decide to download a form from the Ohio Department of Health to submit to the school nurse opting out of the vaccination.  Ohio is one of thirteen states that lets parents opt out of any or all immunizations.

The decisions about chicken pox are simple and complex.  We study a lot about infectious diseases, the immune system, immunizations and human behavior to help people with decisions about vaccine preventable diseases. Chicken pox is a good example.

What do you think?

Patient Enrollment in Direct Family Medicine aka, Direct Primary Care- Family Medicine Style

When figuring our charges for Direct Family Medicine (using the Direct Primary Care business model), we consider the context in which we relate to our patients.  Family Medicine is a relationship based specialty defined by the American Academy of Family Physicians (AAFP) as :  "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. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity." (1984) (2010 COD)

The specialty has been cut apart by the current nit picking approach to physician reimbursement that distracts both patient and physician.  The relative value units used to determine billing codes is a key element of the distraction.  The DPC business model, generally anchored by a monthly payment after an enrollment fee, frees patient and physician from many distractions related to the RVU's and the Electronic Medical Record. The focus of clinical encounters is dependent on the relationship of patient and physician instead of physician and reimbursement rules, EMR and employer.  The patient doesn't have to be concerned about their insurance company preventing them from acting on the plan agreed to with the physician.

OK, you may be sensing less clutter in the office visit.  In fact, the office visit doesn't have to be the center of the activity.  Without the focus on  RVU's and traditional coding and billing, the office may be omitted from being the venue where we solve many problems.  Many follow-up visits may be accomplished online, or on the phone or via home visits.  With fewer patients, more time and less office "lock", more home visits may fit in.

The enrollment fee allows the physician to have some front money to prepare for patients and to offset the Ohio end of the month mandate for the monthly membership charge.  They cannot prepay or we would be seen as an insurance company and arrested for not following the Ohio rules.  Each state has the potential for making similar unusual rules that may stifle this business model.

What if patients enroll and never pay the monthly fee at the end of the month?  Or only pay for one month and never show up again or pay again?  We require a three month initial enrollment to get the relationship established and to guard against doctor shoppers or people who may not appreciate the value of Family Medicine and the patient- physician relationship.  If the patient drops out after the initial enrollment, we figure that they gave it a good try and it just didn't work out.  If they re- enroll, they are charged the enrollment fee again and signed up for a minimum of three months.  They are allowed to drop out and re-enroll twice unless there are unusual circumstances (such as, they moved and came back).

Another twist for our practice, Neighborly Family Medicine, is that we take "Families Only" as patients. That means the whole household has to enroll as patients or we con't take any or them (I've done this for 34 years- it works well).  It also means they'll be paying enrollment fees for multiple persons.

To make this process smoother, we have a member management platform company that allows online enrollment for Neighborly Family Medicine.  Patients can read about Direct Family Medicine and our philosophy of care and various practice policies on the site at www.Hint.com and apply with their information and credit card number.  Yes they apply and we review their information to clarify that they actually qualify for our Direct Family Medicine path.  It detracts slightly from the beauty of this process when we have to review their information before accepting them.

We're a hybrid practice with about 2500 "traditional" patients from all sorts of insurances and government plans that preclude us offering this path to them so we have our original Family Health Connections, Inc. practice that houses them (but with the same tax ID number as Neighborly Family Medicine).  Insurance rules and contracts combined with our current confusion about Direct Primary Care type payment strategies make it challenging to do something that enhances healthcare and the patient- physician relationship.

So, there you have a bit of information about one DPC hybrid practice: Family Health Connections, Inc. and Neighborly Family Medicine and our enrollment process.

What do you think?

Direct Primary Care = Direct Family Medicine, Direct Pediatrics & Direct Internal Medicine

Direct Primary Care is a business model for medical practice that is gathering momentum with a boost from the American Academy of Family Physicians (AAFP) through the "Health is Primary" Campaign. See it here Find definitions of Direct Primary Care at www.dpcare.org

My practice, Neighborly Family Medicine in Beavercreek, OH, uses the DPC business model to practice Direct Family Medicine (DFM).  Notice that I'm differentiating the business model from the specialty practice.  The semantics are important, but take a while to understand.  Direct Family Medicine helps me to understand what I'm offering to patients.  I assume that a pediatrician would deliver Direct Pediatrics, while an internist would offer Direct Internal Medicine.  A Med- Peds physician would do Direct Med-Peds. Clarifying how the DPC business model is applied can be very helpful for patients and doctors.  The term Direct Primary Care comes up short of adequate clarification when patients seek care.  I love doing Direct Family Medicine (and saying it, too).

Direct Internal Medicine and Direct Pediatrics are needed.  The physicians in those specialties deserve to have the fun and freedom of using DPC to support their specialty.  We need a lot more internists and pediatricians in a DPC business model.  Join the movement, Folks.  We need you.  There are not enough Family Physicians to meet the care needs for America at the primary care level.  Let's team up and shift the cost curve together.

Patients:  Introduce DPC to your pediatricians and internists.  They'll love Direct Pediatrics and Direct Internal Medicine.