My new HTC Touch Pro 2 superphone should get here this week. It will do everything. I can just aim it at my patients and they will be healed. It will also impart them and me with a glowing countenance of joy and appreciation. It will quickly inform all regulatory agencies and third parties who are glomming onto everything that happens in doctors offices that all quality, safety,confidentiality (HIPPA) and homeland security issues were perfectly handled. It will produce a perfect record of the encounter using all the right codes and special modifiers, suitable for government and payor perusal.
My superphone will also print or transfer to my patient's superphone a summary of our encounter and discount coupons for use at the mall next door or on web sites for numerous vendors. Since the record of the visit will so perfectly satisfy all the agencies, the patient and I both will accrue extra hours of special event coverage on cable TV. Last but not least, it will automatically analyze their available financial resources and suck the copay and deductibles out of their assets or those of their payor into mine, leaving a happy face in its place.
What a lifestyle I'm about to develop as a result of my HTC Touch Pro2. I obviously will have to name my phone, since it's almost human. Did I mention that I'll get NFL games on it in the fall and I can catch Doctor Anonymous, my favorite BlogTalkRadio show on it every Thursday night at nine PM? My Facebook relationships and followings will now jump into my hand. My Twitterings can be almost continuous and I'll be totally available to professional groups on LinkedIn. My email and night call pages from sick folks will resonnate through beautiful and toneful reminders.
I may have to hide it in the box from time to time to get some peace, but otherwise, I'm getting pretty excited. It may take a few weeks to get it loaded and programmed before it cures my patients, but it soon will probably be a genuine board certified family physician.
More later for you technology fans.
Monday, April 26, 2010
Family Medicine: A Human Relationship Specialty Being Crushed by the Medical Industrial Complex
Family Medicine is a relationship based specialty. The generalist nature of the family physician gives us a chance to become a systems management expert. Our patient may be a generalist or a parts oriented thinker. The confluence of our knowledge, beliefs and attitudes creates a space in which two humans may help each other. We are both humans, consumers and stewards of scarce, valuable resources. Each has an individual role of patient or physician, giving unique perspectives to their individual context. Inadequate emphasis has been given to the human, consumer and steward roles. These three factors may help to protect the patient- physician dyad from the intense pressures from time and money that are used to squeeze the quality and satisfaction from the relationship and the decisions made by the dyad. The demands of the medical industrial complex (MIC) are sucking the life out of family medicine. Can the unique aspects of the patient-physician relationship,shrouded with modern sociotechnical processes, save the day for family medicine?
Family Medicine is the specialty in breadth that combines the biological and social sciences to serve individuals, families and communities. Fewer and fewer medical students are selecting family medicine as their specialty. About eight percent of American medical school graduates now choose family medicine for their specialty training.
The American people need about thirty percent of physicians to be a primary care specialist to have an adequate primary care base as the anchor for the medical care system. Primary care pediatrics only gets about 2% of the medical students and primary care internal medicine gets 2% of medical students, since the advent of the hospitalist movement. The other often stated decision factor for specialty selection by medical students is debt versus earnings. The student graduates with about $150,000 in debt. Primary care generally pays the least of all the specialties (except psychiatry, which also has a shortage). It also is known as having a high hassle factor with paper work and forms that distract from patient care.
Emergency medicine was selected by more American medical school seniors in 2010 than family medicine. The pay is higher and the hassle factor is lower in emergency medicine. The hospitalist (an internist, pediatrician or even a family physician) may work seventeen or eighteen shifts per month and receive $30,000 to $50,000 more per year to start. The people need a lot more primary care physicians, the students aren't drawn to it. That's an expensive problem. Since the people don't have enough primary care, they go to emergency rooms and see narrow specialty physicians too often, driving up the cost of health care significantly.
What will protect and expand my specialty to serve the needs of the American people? Will it be technology? Social change? Guardian Angel? More later.
Family Medicine is the specialty in breadth that combines the biological and social sciences to serve individuals, families and communities. Fewer and fewer medical students are selecting family medicine as their specialty. About eight percent of American medical school graduates now choose family medicine for their specialty training.
The American people need about thirty percent of physicians to be a primary care specialist to have an adequate primary care base as the anchor for the medical care system. Primary care pediatrics only gets about 2% of the medical students and primary care internal medicine gets 2% of medical students, since the advent of the hospitalist movement. The other often stated decision factor for specialty selection by medical students is debt versus earnings. The student graduates with about $150,000 in debt. Primary care generally pays the least of all the specialties (except psychiatry, which also has a shortage). It also is known as having a high hassle factor with paper work and forms that distract from patient care.
Emergency medicine was selected by more American medical school seniors in 2010 than family medicine. The pay is higher and the hassle factor is lower in emergency medicine. The hospitalist (an internist, pediatrician or even a family physician) may work seventeen or eighteen shifts per month and receive $30,000 to $50,000 more per year to start. The people need a lot more primary care physicians, the students aren't drawn to it. That's an expensive problem. Since the people don't have enough primary care, they go to emergency rooms and see narrow specialty physicians too often, driving up the cost of health care significantly.
What will protect and expand my specialty to serve the needs of the American people? Will it be technology? Social change? Guardian Angel? More later.
Wednesday, April 21, 2010
Monday in Family Medicine
"Oh Monday morning, you gave me the warning of what was to be..." Mommas and the Poppas 1960's.
First patient "Diabetes and lab review"
BP 100/68, P 56. frequently lightheaded, cardiologist just added amlodipine to metoprolol and isosorbide but letter from her doesn't clarify why. Hmm. If it was me, I would stop the amlodipine. Do we wait until she sees the cardiologist, call the cardiologist (time is a big problem with dr to dr connection), ask the patient to call the nurse at cardiologist office to clarify w/ cardiologist if she can stop the amlodipine to get higher BP (generally not a cardiology concept)? Some control confusion since cardiologist seems to relate to her BP, but I'd rather manage that and the lipids myself, and I'm already managing the diabetes (patient is with my input-and she has great "numbers"). Not usually a problem, but this patient had a cardiologist in another hospital system before she became a patient of mine. I've never met her cardiologist. Etc.
2. Three call in notes from patients: "Not feeling well, would like us to order a blood test." Hmm. A diabetic who doesn't test glucose isn't feeling well, wants a blood test instead of appointment. I scribble response: What is blood glucose? schedule two visits- one for sickness at which we'll determine what blood tests are needed for the sickness and/or for the chronic disease management and prevention that we'll relate to at second visit.
Next note: "Forgot to get three meds refilled at recent visit" which was scheduled as an acute illness, but pt added desire to deal with three chronic diseases while he was here. Please write the prescriptions for him and mail to him. Hmm. Another person with diabetes and Htn, drinks six beers daily, recently decided to start checking glucose. Finally went to see oft recommended dietitian. Is his goal to avoid the cajoling and hugs from the doctor that might realign his health with his stated health goals? Don't have time to write rx now, recommend visit in one/two weeks to f/u diabetes and what wasn't covered by dietitian.
Next note: Pt with MRSA infected crush injury of a finger, "can't get car running, should pt continue antibiotic?" Hmm. Dangerous car that could lead to disastrous infection. Quickly review last visit date and recommend pt continue medication and follow up tomorrow to review and re-evaluate.
Now, I get to see the second patient (or is this my fifth patient of the day? Might I now be a bit behind schedule?)
Time for "California Dreaming"?
First patient "Diabetes and lab review"
BP 100/68, P 56. frequently lightheaded, cardiologist just added amlodipine to metoprolol and isosorbide but letter from her doesn't clarify why. Hmm. If it was me, I would stop the amlodipine. Do we wait until she sees the cardiologist, call the cardiologist (time is a big problem with dr to dr connection), ask the patient to call the nurse at cardiologist office to clarify w/ cardiologist if she can stop the amlodipine to get higher BP (generally not a cardiology concept)? Some control confusion since cardiologist seems to relate to her BP, but I'd rather manage that and the lipids myself, and I'm already managing the diabetes (patient is with my input-and she has great "numbers"). Not usually a problem, but this patient had a cardiologist in another hospital system before she became a patient of mine. I've never met her cardiologist. Etc.
2. Three call in notes from patients: "Not feeling well, would like us to order a blood test." Hmm. A diabetic who doesn't test glucose isn't feeling well, wants a blood test instead of appointment. I scribble response: What is blood glucose? schedule two visits- one for sickness at which we'll determine what blood tests are needed for the sickness and/or for the chronic disease management and prevention that we'll relate to at second visit.
Next note: "Forgot to get three meds refilled at recent visit" which was scheduled as an acute illness, but pt added desire to deal with three chronic diseases while he was here. Please write the prescriptions for him and mail to him. Hmm. Another person with diabetes and Htn, drinks six beers daily, recently decided to start checking glucose. Finally went to see oft recommended dietitian. Is his goal to avoid the cajoling and hugs from the doctor that might realign his health with his stated health goals? Don't have time to write rx now, recommend visit in one/two weeks to f/u diabetes and what wasn't covered by dietitian.
Next note: Pt with MRSA infected crush injury of a finger, "can't get car running, should pt continue antibiotic?" Hmm. Dangerous car that could lead to disastrous infection. Quickly review last visit date and recommend pt continue medication and follow up tomorrow to review and re-evaluate.
Now, I get to see the second patient (or is this my fifth patient of the day? Might I now be a bit behind schedule?)
Time for "California Dreaming"?
Monday, April 19, 2010
Clinical Decision Making: Heart, Mind and Brain
"As a man thinketh, in his heart, so is he."... The Bible
As a family physician, I see many people with a wide variety of symptoms, often undifferentiated with regard to a specific or obvious diagnosis. In these circumstances, I establish a differential diagnosis (list of possible diagnoses that might cause the main complaints) and seek to clarify, in partnership with my patient, what direction to pursue for diagnostic and/ or therapeutic strategies. If the symptoms and physical findings don't align with specific diagnoses, I further clarify with the patient what the symptoms prevent them from being, doing or having. It's also helpful to clarify the patient's misalignment with life goals and dreams as a result of the symptoms. I might ask, "When is the last time you were yourself?" As the misalignment is clarified, we review ways the patient might realign with their life direction.
Often, people are blocked from taking the ideal path to realignment with themselves by a limiting belief. "I always get bronchitis when I get an upper respiratory infection." "What's the use in following the diet and exercise plan, I know that eventually I'll have my legs cut off like my grandpa now that I have diabetes." "If I disagree with my mother about the need for her to get a home care nurse, she'll give me the 'look' and I'll freeze up again." "If I don't go to the ER when I get the chest pain, it might finally be the heart instead of the gastroesophageal reflux." "My friend took Chantix to quit smoking and got a serious depression. I don't want any part of that stuff." Many other limiting beliefs derail people's desire to be whole, challenging the family physician to be a "belief change agent".
The limiting belief is usually in the brain, so I may remind my patient that the brain is a simple filing system that can be changed by the mind which may be more creative and flexible. "You can imagineer your way to a new belief with your mind. Imagine a future in which you see, feel or hear a different reality for yourself."
"See yourself at your daughter's wedding." "Feel the sand between your toes at the beach." "Smell the breeze at the beach." "Hear the music of your church choir." "Feel the strength in your legs as you walk your dog on a spring day in your neighborhood."
Some patients can allow their heart to overcome their brain's limitations via the Quick Coherence Technique developed by Heartmath (at Heartmath.com). This entails getting a heart focus and "breathing" through the heart area and appreciating through the heart area. After establishing Coherence (geeks may wish to buy their software and ear sensor to demonstrate through analysis of heart rate variability a balance between sympathetic and parasympathetic nervous systems), the patient can inquire of their heart center as to what to do to change the limiting belief or what alternative action to pursue. This is a hard science way to clarify what may previously have been seen as a holistic or religious approach to problem solving or "integration" of mind, brain and heart.
Through Heart or mind or brain or a combination of two or three of them, family physicians may help patients to change limiting beliefs that impair the patient's ability to align with their ideal health strategies. Positive belief alignment may lead to better health alignment and better life alignment. Medical outcomes such as Hgb A1C, BP, Lipids, etc. may be more achievable as the patient learns to overcome limiting beliefs.
As a family physician, I see many people with a wide variety of symptoms, often undifferentiated with regard to a specific or obvious diagnosis. In these circumstances, I establish a differential diagnosis (list of possible diagnoses that might cause the main complaints) and seek to clarify, in partnership with my patient, what direction to pursue for diagnostic and/ or therapeutic strategies. If the symptoms and physical findings don't align with specific diagnoses, I further clarify with the patient what the symptoms prevent them from being, doing or having. It's also helpful to clarify the patient's misalignment with life goals and dreams as a result of the symptoms. I might ask, "When is the last time you were yourself?" As the misalignment is clarified, we review ways the patient might realign with their life direction.
Often, people are blocked from taking the ideal path to realignment with themselves by a limiting belief. "I always get bronchitis when I get an upper respiratory infection." "What's the use in following the diet and exercise plan, I know that eventually I'll have my legs cut off like my grandpa now that I have diabetes." "If I disagree with my mother about the need for her to get a home care nurse, she'll give me the 'look' and I'll freeze up again." "If I don't go to the ER when I get the chest pain, it might finally be the heart instead of the gastroesophageal reflux." "My friend took Chantix to quit smoking and got a serious depression. I don't want any part of that stuff." Many other limiting beliefs derail people's desire to be whole, challenging the family physician to be a "belief change agent".
The limiting belief is usually in the brain, so I may remind my patient that the brain is a simple filing system that can be changed by the mind which may be more creative and flexible. "You can imagineer your way to a new belief with your mind. Imagine a future in which you see, feel or hear a different reality for yourself."
"See yourself at your daughter's wedding." "Feel the sand between your toes at the beach." "Smell the breeze at the beach." "Hear the music of your church choir." "Feel the strength in your legs as you walk your dog on a spring day in your neighborhood."
Some patients can allow their heart to overcome their brain's limitations via the Quick Coherence Technique developed by Heartmath (at Heartmath.com). This entails getting a heart focus and "breathing" through the heart area and appreciating through the heart area. After establishing Coherence (geeks may wish to buy their software and ear sensor to demonstrate through analysis of heart rate variability a balance between sympathetic and parasympathetic nervous systems), the patient can inquire of their heart center as to what to do to change the limiting belief or what alternative action to pursue. This is a hard science way to clarify what may previously have been seen as a holistic or religious approach to problem solving or "integration" of mind, brain and heart.
Through Heart or mind or brain or a combination of two or three of them, family physicians may help patients to change limiting beliefs that impair the patient's ability to align with their ideal health strategies. Positive belief alignment may lead to better health alignment and better life alignment. Medical outcomes such as Hgb A1C, BP, Lipids, etc. may be more achievable as the patient learns to overcome limiting beliefs.
Friday, April 16, 2010
Allergy and Infection: The Yellow Victory
I practice in the Dayton, Ohio area, the fourth worst allergy city in America. I'm hoping we can move up to number one if we work on it. Maybe plant a few thousand more trees or start a ragweed farm. August 15th is "Ragweed Day", March 15th is "Tree Day" and April 1st (no fooling) is "Grass Day". From Ragweed Day til the first frost, allergy medications and tissues are popular items in all the stores. When the first frost arrives, the "sinus sufferers" facial pain stops and the asthmatics start their winter wheezing (like a tag team). I often tell patients, "Mucous is the state bird in Ohio", to apprise them of the ubiquitous nature of Ohio Mucous. Patients may have a need to dry it and block it or flow it and blow it, depending on the location and the nature of the mucous. My medical advice depends on their innate ability to store or process mucous. The normal adult head makes about two liters of mucous daily (correct- it would fill a two liter soft drink bottle).
My patients often are unlucky enough to get an upper respiratory infection in their excess allergic mucous. This adds a few hundred more mililiters of mucous to the 2 liters. Then it might feel like it's coming through their face, unless they flow it and blow it, or have huge sinuses in which to store the excess mucous. When they see the yellow mucous from the infection, many believe that they need an antibiotic to treat the infection. The associated body aches combined with the facial pain add to the pressure to get an antibiotic from their family physician. When they ask, "don't I need antibiotic since I have yellow snot" (Ohioans seem comfortable with this word)?, I tend to respond, "No, actually it's cause for celebration since you're experiencing "The Yellow Victory". That means that your body is killing the infection and you don't have leukemia. Congratulations!"
Helpful therapeutic strategies include saline nasal spray and gargle, loratadine or cetirizine for the allergies and guiafenescen to flow the mucous. To stop the mucous, pseudoephedrine is a great drier-upper of mucous.
To celebrate the yellow "victory", start with mucous and add infection. If your face doesn't start hurting, move to Dayton, Ohio. We'll celebrate the Yellow Victory with you .
My patients often are unlucky enough to get an upper respiratory infection in their excess allergic mucous. This adds a few hundred more mililiters of mucous to the 2 liters. Then it might feel like it's coming through their face, unless they flow it and blow it, or have huge sinuses in which to store the excess mucous. When they see the yellow mucous from the infection, many believe that they need an antibiotic to treat the infection. The associated body aches combined with the facial pain add to the pressure to get an antibiotic from their family physician. When they ask, "don't I need antibiotic since I have yellow snot" (Ohioans seem comfortable with this word)?, I tend to respond, "No, actually it's cause for celebration since you're experiencing "The Yellow Victory". That means that your body is killing the infection and you don't have leukemia. Congratulations!"
Helpful therapeutic strategies include saline nasal spray and gargle, loratadine or cetirizine for the allergies and guiafenescen to flow the mucous. To stop the mucous, pseudoephedrine is a great drier-upper of mucous.
To celebrate the yellow "victory", start with mucous and add infection. If your face doesn't start hurting, move to Dayton, Ohio. We'll celebrate the Yellow Victory with you .
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