Family Medicine: The Myth

I've noticed after about 177,000 patient encounters many similarities and differences.  One of my main responsibilities as a Family Physician, it seems, is to make sure that each patient knows that they matter- sort of a human validation and often a role validation (father, mother, patient, guardian, etc.).

AND, that I know that I matter, too.  I value human centering as a skill/strategy of importance, as differentiated from patient centering which seems over-rated and potentially hazardous to the health of ourselves and our colleagues.

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After Kurt Stange introduced us to Ken Wilber via his series in the Annals of FM, I dug into A Brief History of Everything and Integral Spirituality, finding many beneficial validations and launching points.

Extrapolating from Wilber's points about the role of religion, I can resonate to one aspect of the "priestly role" of the Family Physician as "carrying forth the myth that can't be proven" (or measured?).  People have faith that something will happen (or is happening and will continue to happen when they see or reflect upon their Family Physician and the meaning of the relationship).  What is the myth?  Well, you believe it, but maybe you don't know what it is.  It is not measurable in a coding sort of  way.

Could we have a measurable energy that when combined with our context and the patient's context, delivers wholeness? (the unmeasurable and unbillable quest of many).  I like this concept.  The human energy field of patient and physician engaged in dyadic sharing and mutual interdependence may be measurable as technology evolves (probably with a cell phone).

Their (patients) fear of short term or long term loss, or fear that we won't connect to their reality and further mis-align them with their potential for whatever, combined with our fear that their problem might exceed our skills or our coding skills or our employer's mandates for our scope of practice and time allotment may suddenly (or over time) melt into a mutually beneficial human dance of meaning, enhancing organ and system and spiritual unction for both. Can the creative tension of the dyadic dance show merit of a financial sort to someone who might pay?

I love what I get to do.  I love being a Family Physician.  I'm blessed to get a close look at the human condition in the context of meaningful relationships that enable humans to better align with their values, goals and dreams. Yes, My values, goals and dreams are included in the outcomes of doing Family Medicine.

Just a few thoughts.

Onward.

Peace
More later about The Myth and The Magic.  apj

Review of The Direct Primary Care Ohio "Unsummit" on The Dr Synonymous Show May 20

The Dr Synonymous Show on Blog Talk Radio May 20, 2014 will review this meeting. Direct Primary Care Ohio "Unsummit" II  Tune in live Tuesday 9:30-10:30 PM ET or listen 24/7 to the recording.

The DPC "solution" moved ahead via information shared and relationships established or advanced at the Direct Primary Care Ohio "Unsummit" held in Beavercreek, Ohio on May 17.  The Center for Innovation in Family and Community Health (CIFCH) sponsored the Unsummit, with help from the Family Medicine Education Consortium, Inc. (FMEC).  Special thanks to Shayla Rammel of the FMEC staff.

"If a practice is "all in", they should remember WHY they are "all in".  Traditional overhead of 65-70 % versus DPC overhead of 30%.  Having a satisfying practice which allows adequate time to establish meaningful patient-physician relationships delivers better opportunities for mutually agreed to "quality" outcomes.  Having "quality relationships" that deliver deeper, outcome sensitive goals affords more opportunities to re-define Family Medicine as a human centered specialty.  Human centering allows alignment with patient AND physician values, goals and dreams.  Understanding of, and commitment to, the human condition allows hope for human wholeness, a commitment to an interconnected, imperfect existence of wholehearted appreciation." - A. P. Jonas, MD See more at: http://drsynonymous.blogspot.com/#sthash.Nquo0clJ.dpuf

The Direct Primary Care

Ohio “Unsummit” II – May 17, 2014

Morning Session

8:30 - 8:45 a.m.                   Welcome, Introductions, and Disclaimer(s)

                                                Pat Jonas, MD - President CIFCH

8:45 - 9:00 a.m.                   Direct Primary Care: Why Now, Why Here?

Larry Bauer, MSW, MEd –CEO, FMEC

9:00 – 9:15 a.m.                  Health Insurance in Ohio and Beyond   

Randy Gifford - Insurance Agent

9:15 – 9:30 a.m.                  Neighborly Family Medicine         

                                             Pat Jonas, MD - President CIFCH

9:30 – 9:45 a.m.                  Human Centering in Primary Care 

Steve Deal - Systems Engineer

9:45 – 10:00 a.m.               Academic to Private Practice Hybrid  

Phil Whitecar, MD – Independent FP, Beavercreek

10:00 – 10:25 a.m.            Town Hall: Q & A

                                                All Speakers

Nuts & Bolts Session

10:30 – 10:40 a.m.             Welcome, Introductions, and Disclaimer(s)

                                                Pat Jonas, MD - President CIFCH

10:40 – 11:00 a.m.             Vision for Family Medicine

Larry Bauer, MSW, MEd – CEO, FMEC

11:05 – 11:30 a.m.             DPC Pioneer in North Carolina (via video)   

Brian Forrest, MD – Access Healthcare; Board Chair NCAFP

11:30 a.m. – Noon              The Affordable Care Act

                                                Randy Gifford - Insurance Agent

                                            

Noon – 12:59 p.m. Lunch 

1:00 – 1:35 p.m.                  Transition to Hybrid: Challenges and Pitfalls  

Pat Jonas, MD - President CIFCH

1:35 – 2:00 p.m.                 Human Centered Design in Family Medicine

                                                Steve Deal - Systems Engineer

2:00 – 2:15 p.m.                  Break

2:15 - 2:45 p.m.                  DPC Multi-Site Tour via WWW

Pat Jonas, MD - President CIFCH

 2:45 – 3:15 p.m.                  Town Hall: Q & A

                                                All Speakers

Direct Primary Care: Transition to Hybrid- Challenges and Pitfalls IV

Balance between Traditional and DPC enroute to Hybrid may be elusive.  One strategy is to go "all in" and take no new patients other than DPC which allows focus on the marketing and office protocols for new patients.

Allowing a continuation of new patients in the Traditional track is easier for office staff.  "So and so wants her sister's family to be patients here, too.  They have insurance and don't want the DPC track.  Can we take them?  They're really nice people."

If a practice is "all in", they should remember WHY they are "all in".  Traditional overhead of 65-70 % versus DPC overhead of 30%.  Having a satisfying practice which allows adequate time to establish meaningful patient-physician relationships delivers better opportunities for mutually agreed to "quality" outcomes.  Having "quality relationships" that deliver deeper, outcome sensitive goals affords more opportunities to re-define Family Medicine as a human centered specialty.  Human centering allows alignment with patient AND physician values, goals and dreams.  Understanding of, and commitment to, the human condition allows hope for human wholeness, a commitment to an interconnected, imperfect existence of wholehearted appreciation.

Another strategy is to allow the dysfunctions to bubble up via empowered staff who undermine the Hybrid goal of practice owners.  The dysfunction of most significance may come from physicians.  Passionate people may intend well, but harm the practice financially if their passion is secret.  Meetings dripping with honesty, self revelation, passion, intensity, wisdom, humor and human vision become important.  Follow-up meetings with similar openness become important for clarification.  Physicians should understand that a gradual commitment to Hybrid may result in changing relationships, even splitting of partnerships or "split the question" types of new practice agreements or business relationships.  Remember the creative juices that must flow when physicians go through practice transformations.

Another strategy is to start a new DPC practice parallel to the Traditional one.  This allows co-existence of Traditional and DPC which may merge later into "full" Hybrid.  It also may allow a gradual splitting of a partnership via the "DPC fanatic" going "all in" on DPC new patients only while the more reluctant for DPC physician continues as Traditional only with continuing new patients in the traditional track.  The cross coverage may become challenging to afford an opportunity for the Traditional physician to be paid by the DPC fanatic for seeing their patients when DPC fanatic is not available.

The split, two practice strategy makes it easier on the DPC side to accept all patients who enroll, without consideration for dual charging of government paid patients that plagues the Hybrid practices.  In the DPC only practice, it functions like a "pure" DPC practice with no insurance relationships honored or considered. The logistics of operating parallel practices cold get complex on issues like practice identity, answering the phone, stationery, professional business cards, etc.  Competition between the two models may generate a friendly or pathologic co-existence.

Yes, it's confusing.  If it wasn't complex, it wouldn't be so much fun.  More later.

Direct Primary Care: Challenges and Pitfalls III

OK, We have a phone "schpiel" to present to potential new Direct Primary Care patients who call.  It takes about three weeks or five separate new patient calls for an individual staff member to get "calibrated" in our front office to the DPC patients.

Remember that we are a "niche" practice - "Families Only!"  I believe in Family Medicine!  I love it!  It works!  Families are amazing!  They know something about each other and their culture/identity.  It fits nicely into Family Medicine practice.

How does that translate into medical practice?  Perfectly.  How many people understand that?  Few.  The founders of the specialty stumbled onto "The Family" but didn't really understand the potential.  (I spoke with G. Gayle Stephens at length about this).  I digress because the "Families Only" approach has made my experience in Family Medicine so enjoyable and meaningful.  I hope that others try it and learn one of the secrets of the specialty.

Direct Family Medicine (DFM) is what I practice in a Direct Primary Care business environment.  Each new patient has to be "vetted" to clarify if we can continue, once they show up for their first.  As I mentioned before, I have a contract with government health plans such as Medicare and Medicaid that preclude me treating patients in different financial ways. No one can make a separate financial arrangement with me about those patients.  The "Pure DPC" physicians don't have to worry about this.  Many patients on these plans see DPC physicians and pay them their fees to get the personalized care and extra time.

We have a one page summary of Direct Family Medicine that we review with each patient- twice if possible because they are too busy with forms, etc. to grasp the details on the phone and at the initial visit.  Relationship-based, Continuous, Comprehensive care of the individual patient and their family who resides  in their home is the base/ anchor for my practice.  We offer care for prevention as well as acute illness/ injury, as well as chronic disease.  Physicals are part of the prevention strategy.  We use the MilCom patient history forms to organize the initial information about each patient, providing discussion starter information and a place to scribble notes.  (EMR aspects of this later).

After the initial visit, persons with multiple problems or chronic diseases are usually scheduled for one or more follow-up visits to "peel the onion" of chronic disease and hear their story.  The time available in DFM is generally more than in traditional practice.  They also are more likely to align with the prevention and health strategies than the traditional practice patient.  In the traditional part of my practice, it's more difficult to have people come in three weeks in a row to get through their whole story and sort out the diseases and medications and their impact on individual and family life, goals and dreams.  This is not a superficial undertaking.  Burrowing with someone into their living room their life and their DNA to clarify and develop differential diagnoses using the biopsychosocial model helps me to form the patient physician relationship and develop direction and mutually agreed to outcome goals.

If it was easy, it wouldn't be so much fun.

More later.

Direct Primary Care: Not for Everyone

If you are FED UP, CONFUSED or CURIOUS with the health care dilemma, Direct Primary Care (DPC) may be for you.  Pay for your Family Physician yourself.  And, generally, save money.  If you're not FED UP, CONFUSED or CURIOUS Direct Primary Care is probably not for you.  It's not for everyone.  Don't worry, either, only two practices in the Dayton area offer DPC, so you may not be able to try it.

In DPC, patients generally pay an enrollment fee, and a membership fee monthly (In Ohio, this has to be at the end of the month).  Other fees may arise for labs or imaging services and more complex procedures like office surgeries.  Each practice seems to vary from its neighbor somewhat.  It's up to them to provide the patient with a list of services provided.

Direct Primary Care IS NOT INSURANCE!  It is health care.  And it's not for everyone.