Taking a stab at it

I’ve finally completed the Acupuncture Course for Physicians through The Academy of Pain Research in San Francisco! With my extensive hours of practice (especially body acupuncture), I am ready to apply all my knowledge for my members! We’ve already had some wonderful successes with it, from healing skin wounds, to treating wrist pain following a fracture, to helping with sleep, to helping with weight loss. Can I help you with your problem? I’ll take a stab at it!

Here’s what I’ve learned through the practice period: it takes commitment. There is no magic bullet, no super pill, no “single-acupuncture-treatment-and-I’m-healed.”  The more chronic and complex the problem(s), the longer it will take. But the commitment pays off, big time.

Here is the concept: we have energy pathways throughout our body that communicate with the brain. The brain is truly the engineer driving the complex train system. When there is pain, that means the energy has congested – has an obstruction over the tracks, so to speak. Until the obstruction is removed, the brain will continue to perceive the pain – even to the point that it becomes a habit. The brain is designed to learn, but not “un-learn.” It’s as if the brain gives up on that area, even after the obstruction is removed. Let’s say repetitive movements with one hand or one arm cause the muscles to cramp up. The brain perceives the blockage in the system caused by the repetitive strain on the musculature. If it goes on long enough, even when the muscles are no longer cramping up, the brain will believe there is still pain.

So, how long does it take to create a habit? Behavioral experts say it can be as little as 21 days for something simple, but more like 66 days for something more complex. This is why with longer-standing problems (the longer the obstruction has been on the tracks, so to speak) there is a higher likelihood that pain will continue to be perceived after the obstruction is removed. So is it any wonder – if acupuncture is “re-training” the brain – that in order to achieve true results it may require a couple months of treatment?

I’ve also learned that once a month is likely not often enough, and certainly once a week isn’t sufficient, at least not during the initial phase. The frequency should be at least twice-weekly treatment for 3-4 weeks, followed by a break and then another 3-4 weeks for chronic issues. I have not yet had anyone go for the 9-10 weeks that would encompass 66 days. But I have some dedicated souls who are working towards it.

The Bottom Line? Rome wasn’t built in a day.

Our body is designed to heal itself.  But in order to do so, it must have all the right tools. While duct tape and popsicle sticks came in handy for MacGyver, the body cannot effectively run on junk, much less heal itself. It needs good nutrition, sound sleep, and plenty of water – the three things in which I observe most patients to be deficient. If we are trying to heal using acupuncture, but are missing essential ingredients, all the acupuncture in the world will not be enough to get over the hurdle. This is why I recommend members add the Wellness Package to their membership. It helps get the body prepped and ready to address the needs of opening the energy system, in order to create the best environment for healing.

So – I’m ready to take a stab at it.  Are you?

It Takes Two to Trust

Our Mission at Direct Primary Care Clinics LLC is;

“To break down the barriers that currently exist in the patient-physician relationship, to restore mutual trust, and to provide excellent individualized primary health care.”

But how does one “restore mutual trust?”

First, the word “mutual” comes before “trust” in the sentence – not just because of standard English sentence structure, and not just because it is the describer of the noun. Mutual is defined by the Cambridge Dictionary as:

“(of two or more people or groups) feeling the same emotion,
or doing the same thing to or for each other.”

It can also mean holding something in common. This indicates that the trust I will have for the patient must by definition be shared by the patient with me as their physician, and most certainly vice-versa.  The patient’s trust in me must be shared by me, the physician.  This sounds very simple, since it is the basis for all relationships. But it is a rarity in today’s medical world.

Let’s start with the example of a medical problem, such as hypertension (high blood pressure). The patient often does not know they have hypertension, until their blood pressure is taken.  They may not even realize that their recent daily headaches, or the reoccurrence of nagging chest pressure, may both be signs of high blood pressure. But when discovered, it is – or rather, should be – a concern for the patient. It should also be a concern for the physician, and not simply because it falls in their area of expertise. It should create a MUTUAL concern. Now, within their relationship, the patient and physician have a mutual concern. The patient then should trust that the physician has the knowledge and means to help the patient with the problem. The physician should trust that they have the knowledge and motivation to help the patient with the medical concern. But that is not enough to truly constitute trust.

Since I’m into defining for you, let’s see how the Cambridge Dictionary defines Trust:

  • to have confidence in something, or to believe in someone, or
  • to hope and expect something is true.

In our above scenario, the patient should have confidence in the physician and believe the physician is working in their best interests. The patient HOPES and EXPECTS something from the physician. In Mutual Trust, the physician also has confidence – in the patient. The physician HOPES and EXPECTS something from the patient in return. I believe it boils down to this: the patient and physician will be on the same page regarding their hypertension, or whatever the real-world medical problem may be.

It is my belief that this mutual trust is absolutely essential to provide the “excellent individualized primary health care” we commit to in our DPC Clinics Mission.  If the trust is one-sided – either on the side of the patient, or the physician – and not mutual trust, the delivery of excellent care is impeded. If the patient has full trust and confidence in their physician, but the physician is suspicious of the patient and is confident in only their own medical ability, the physician does not – CANNOT – deliver truly excellent care. If the patient is suspicious of the physician and does not have confidence in the physician’s ability or motivation (even when the physician believes in the patient and their integrity), the delivery of care could well be “dead on arrival.” What is the saying? “You can lead a horse to water, but you can’t make it drink.”

This relationship-essential atmosphere of mutual trust has been assaulted by a number of outside sources, which I may touch on in a separate rambling. The concept of restoring this precious thing – mutual trust – is part of our Mission. The relationship has been broken, and building it back together like Humpty Dumpty is exacting and can be tiring. It takes effort, and must be done one person, one interaction at a time. Because it is time-consuming, it cannot be realistically accomplished in 10-15 minute intervals with 40 people a day. When you take into account time for administrative grunt work, not to mention the time required for personal relationship-building, you begin to see that time is the primary obstruction standing in the way of restored mutual trust. This is also why Direct Primary Care (DPC) is the best model for rebuilding that relationship – because we have adjusted our time around building relationships, instead of adjusting our relationship-building to fit the time.

By keeping our patient panel – the number of patients for whom we care – purposefully low, we can spend more time with each individual, provide better communication tools for our patients, and work on restoring mutual trust. Our Mission Statement posted in the DPC waiting room. It’s the first thing you see when you walk through the door and – hopefully – it will be the first thing you notice during your interactions with our DPC Clinics team.

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Deer Me!

HALvsdeer

It was bound to happen sooner or later, with the abundant amount of deer roaming loose in the Ozarks.  These gals and guys don’t bother to look both ways when crossing a street, I’ve noted, and when you drive a quiet hybrid car, they must tend to think that the headlights are a large lightning bug approaching.

I was driving home one evening, just me and the little dog in her seatbelt-strapped-in carrier, minding my own business, on a winding wooded country road.  We were only going about 40-45 miles per hour, since we’d just turned left at a near 90-degree turn and were gathering up a little speed to head up a hill.  Out of Nowhere – which apparently is my name for the wooded area just at the bottom of the hill on the driver’s side heading home – out of my peripheral vision came barreling toward me the largest un-antlered deer I’ve ever seen. It may have been a small elk for all I know.  At any rate, no time to stop, I realized it was going to hit me. I instinctively swerved as I stomped on the brake pedal, and braced myself as the deer slammed into me.  “I am going into the ditch,” was my thought, and so I held on, steering the car so that the passenger side wheels would not go into the ravine part of the ditch.  I did not want to roll the car. Slowed to a crawl now, I drove forward for a few feet, thinking I might be able to drive out of the ditch, but as I heard the undercarriage of HAL (my Prius) being scraped and smelled a hot car I thought best to stop.  (Yes, I named my Prius after the computer on 2001: A Space Odyssey. http://www.imdb.com/title/tt0062622/ )

I sat for a moment, reasoning; I can’t drive this car out of this ditch, the ravine is too deep, and I can’t back up because there are large rocks in the ditch that have already scraped the undercarriage.  I looked at the space between my driver’s side door and the road.  I could probably open the door about 5 inches, and I’m no slender girl.  So I unbuckled myself, and my little dog’s carrier, put her in the back seat and crawled over to get out on the passenger side. I looked back down the road and, sure enough, there lay the deer – in the opposite lane of traffic, lying right across it like he/she was taking a nap and hogging the entire lane to him/herself. Along came a fella in a pickup truck who pulled over and got out to make sure I was okay.  I assured him I was fine, but I wasn’t so sure about either my car (I didn’t want to confuse him by referring to HAL) or the poor deer.  He looked back down the road and then offered to go move the deer.  I agreed that would be helpful for others who may be traversing the road that evening.

My Good Samaritan walked down to the deer and was standing near it, to judge – I suppose – how he was going to move this large animal.  Then, surprising both of us, it suddenly sprang up and ran back into the wooded area from whence it came.

The next day my right trapezius started to ache, like I’d lifted something heavy.  By the time I got to the office I considered either seeing if I could get a same-day massage from Infinite Touch Integrative Therapies (https://www.facebook.com/InfiniteTouchLLC/?fref=ts) or get trigger point injections into the shoulder.  But then Rebekah Anglin walked into our office.

 

Rebekah is the Wellness Coach who works out of our office on Thursdays and Fridays.  Her business is multi-faceted, but among other things, Rebekah uses essential oils and does auriculotherapy.  Now, I don’t know the physiology of essential oils, nor homeopathy, nor of acupuncture, reflexology or auriculotherapy.  But I know that if I can avoid leaving the office during a busy scheduled day, and I don’t have to have a needle shoved into my muscles, I am all for trying it.

First she concocted a muscle rub using a couple different essential oils mixed with carrier oil and it was rubbed into the aching muscle.  After about 15-20 minutes, I didn’t really notice the muscle as much.  A couple hours later I lay down on her table and she touched my ears.  Weird, but so cool.  There was one spot on the ear that – as soon as she touched it – I felt a lightning bolt go into my right shoulder.  There was another place that when she touched both ears, I felt an aching in my neck. Then, using a cotton-tipped applicator, she applied essential oil(s?) to those areas.  After asking my feet a couple of questions (don’t ask!), I got off the table and resumed work.  I felt terrific, until about 4:00 that afternoon when the aching in the shoulder resumed.  I took the oil combination she’d given me and rubbed more of it on the spot.  That night, before bed, I rubbed some more on, just for good measure, though I could longer feel the aching.

The next morning, it was as if the accident had never happened.

Now, I’m not about to stop taking Edarbi, which I take for my hypertension.  But if I have any further problems with this right shoulder, I’m making an appointment with Rebekah Anglin.  You can too, simply by calling her at (573)836-1197 or emailing: rebekah.a02@gmail.com.  She not only can work miracles (in my opinion) with essential oils and auriculotherapy, she can help you manage what ails you using nutrition.

I’m betting that deer could use her services!

Why I Am Firing My Family Medicine Board

I am firing my family medicine board, the American Board of Family Medicine, through which I have held certification for a long time.

First of all, some clarification: board certification is not required for state licensing. Once upon a time it was little more than a nice fancy title one could put after their name: “Diplomate, Board of Specialty Medicine.” It was a status symbol at one time, much like being named in “Who’s Who in America.”

Physician licensure is maintained by the State, and has nothing to do with board certification. All physicians must must renew their licenses yearly and attest that we have achieved a required amount of continuing medical education. Board certification is generally more related to what kind of original medical education a physician received: were they taught to research and study on their own, or just spoon-fed facts and taught to regurgitate them and take multiple choice exams? Can a physician think on their feet and outside the box?

The problem with many board certifications is that someone along the way decided they are schemes to remove physicians from their money.

Over the years, medicine boards have moved from a one-time passage of board exams to requiring reexamination every few years, and these exams are very costly. Many boards have implemented “maintenance of certification” programs with annual fees. Board exams have been made increasingly difficult in order to sell expensive Board Exam Review Courses prior to the exams themselves, and revenue from the study guides goes directly to the boards. Legislation has also been passed making it difficult, and potentially illegal, for physicians who have recently passed the exams to pass useful information to other physicians about to take them. And there is no recourse for addressing grievances.

In short, the board certification process has, in my opinion, become completely untenable. At least for the American Board of Family Medicine.

Back when my employer expected board certification, and when the insurance companies they billed required the same, I spent the money and was reimbursed at least a portion of it. But when I walked away from hospital employment and opened my own practice, I began working for patients. This forces me to look at those dollars quite differently. Is it truly a good investment for my patients to spend their money for my board examinations, or the costly yearly maintenance of certification programs? Sure, I get continuing medical education credit, but how much of what I am learning (i.e., to pass a multiple-choice exam) can be put into practice and actually benefit my patients?

As it turns out, I believe my patients—my employers—receive very little tangible result from my effort in maintaining that board certification. I can obtain just as much education and updates on treatment from far less expensive forums.

So, there you are: that’s why I am firing my family medicine board. The expense does not provide sufficient benefit for my patients. It is a bad investment. The return simply is not there.

I did get certification through the National Board of Physicians and Surgeons https://nbpas.org/. I did this mostly to support this board in hopes that it will be become recognized where board certification is required (primarily through hospitals and insurance programs, which I don’t play with anyway).

I just want everyone to understand that since I now work solely for my members—not a hospital system, not any insurance companies, not any governmental bodies—I have to consider every payment and every obligation, weighing whether it is worthwhile and beneficial for my “employers.” And I’m willing to bet not one of them cares at all whether I have that ongoing American Board of Family Medicine certification or not.

But they DO care whether I would end up having to increase my fees in order to continue to dance to that music.

So, you will no longer see the words “Diplomate, American Board of Family Medicine” below my name on my business cards. I will be taking down the framed paper that states I have re-certified through 2016. And I won’t have to increase membership fees.

I hope that you all, as my employers, agree with my decision

Change

“Change is the law of life. And those who look only to the past or present are certain to miss the future.” ~ John F. Kennedy

No one really likes change. Some may claim they want or welcome change, but there is something within them that wants to cling to the present, or the past. How many times have you thought to yourself, “But we’ve always done it this way!” Don’t worry; it’s natural to resist change. But understand this: change IS the law of life. Everything changes; hopefully it is in small, easily-digestible bite-size pieces, because we accommodate more change when it is slow and barely noticeable.

Think of the (usually) slow transition of the seasons, or the budding and then flowering of fruit trees. Eventually that bump at the base of the flower becomes a pear, or an apple. If one day there were bare branches and the next day full ripened fruit, how magical it would appear to us, though the same end is accomplished through the gradual process of growth.

I sense we are on the cusp of some big changes—in our neighborhoods, our state, our country, and in our world. I’ve told more than one of you “It’s going to be a long, hot summer,” and I mean more than just the weather. When so many different things are teetering on the edge, change is inevitable. Whether for better or for worse is anyone’s guess, and subject to their own perspective.

The Affordable Care Act started a wave of change in the medical world that continues to have an impact on patients and physicians and medical care workers daily. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2013 will change how physicians are paid, especially with the recently disclosed 952-page rules on payment. The very physician organizations that heralded that bill as the “Doc Fix” are now complaining that this will bankrupt the vast majority of independent physicians and are “demanding” the rules be changed. That will not happen any more than will Congress repeal or replace the ACA. These changes will impact American medicine for years, if not generations, to come. Locally, here at the Lake of the Ozarks, a major hospital chain has pulled out and left their clinic (and its patients) stranded. Sure, patients can travel 30 minutes or more to go to one of their other clinics, but they will NOT be able to “keep their doctor” as the hospital system has stranded him as well. He will now be an independent physician, but if he intends to bill Medicare, the rules of MACRA will actually punish him for being independent! How long can one tread water?

Meanwhile, we soldier along here at Direct Primary Care Clinics, serving our members regardless of their insurance coverage, or lack thereof. I anticipate a day that Medicare will not cover the medications I write for Medicare patients, and when that day comes I am sure we will find a way around that roadblock too. Because that is what change does—it forces one to either conform or to find creative alternatives.

Here’s to creative alternatives!

 

 

 

 

Precious Privacy

What a human tendency it is to deny that we have anything “to hide!”  Does this mere sentence cause your self-defensive hairs to rise? It should, because we all have something precious to “hide,” something we take for granted that is the envy of millions around the world.

We all have our privacy to hide.

It concerns me that that with every new, sweeping loss of our privacy no one seems to bat an eye. Oh we might complain a little, or make jokes about it; but, we don’t seem to notice that little by little our precious privacy is being eroded. We have been trained to point to the attacks of 9/11/2001 and declare that if there had been better surveillance, it would not have happened.  “We can’t let it happen again,” is exclaimed.

“In the name of National Security” has become a mantra. Please, do me a favor: find someone who lived in the Soviet Union or Cuba and ask them about National Security.

It concerns me that when we see a vehicle pulled over we make assumptions. They must have been speeding, we think.  When I talk to patients who share their stories of being pulled over and having their medications with them, I cringe.  Then, I print off a copy of KrisAnne Hall’s Fourth Amendment handout http://krisannehall.com/wp-content/uploads/2014/07/fourth-amendment-facts.pdf, which explains the right to privacy guaranteed by the Fourth Amendment.

There are no local, state or federal laws that may supersede the Fourth Amendment! If they do so, they are illegal. A search warrant is required—period.  It will not be difficult to get a search warrant if there is probable cause.  But, I will leave the technical legalities to another day.

My biggest concern is the general lackadaisical attitude toward the privacy of medical records. First, to whom do your medical records belong? By right they should belong to you.

But, I encourage you to try to get a copy of your full records. Go ahead. It will probably cost you, and you’ll have no guarantee what you get includes ALL your records. By requesting a COPY of your records, you are not purging your records, either. You may be told that you have access to your records electronically, but the keeper of the records is careful to control what part of your records you may access. However, your insurance company is not so bridled; they may have full access, and do not require your written permission! Why? Because, you signed a paper signing away all your rights to privacy when it comes to your medical records! Your insurance company, the federal government, other physicians and their office personnel—basically, anyone with whom the record-keeper does business—have access to your records, as long as they sign a business associate contract.

The Health Insurance Portability and Accountability Act (HIPAA) http://www.gpo.gov/fdsys/pkg/PLAW-104publ191/html/PLAW-104publ191.htm really has nothing to do with your privacy, though that is all anyone (including “healthcare providers”) thinks it maintains. The Department of Health and Human Services  (HHS) wants you to think that’s what HIPPA is all about as well. But realize, any law that allows the department of HHS to access your records without your knowledge is not a law about maintaining your privacy.

Did you know that you do NOT have to sign that you have received the privacy policy of the “healthcare” facility you utilize? Did you know you don’t have to answer any questions you don’t want to answer?  Did you know that HIPAA was the first step in a long line of “laws” designed to create an “interoperable nationwide health information infrastructure?”  (These are official words, not mine.)

Is there anything in that phrase—interoperable nationwide health information infrastructure—that sounds at all reassuring, that it is your privacy they are concerned about preserving? Am I the only one who immediately thinks of George Orwell’s 1984 when I merely read that phrase?

My friends, do you have any notion of what unholy behemoth we have unleashed? It doesn’t eat your soul, but it devours your medical privacy. Plus, with the re-definition of the practice of medicine to “healthcare,” your medical privacy extends to everything you ingest, breathe, wear and to which you expose yourself.  Then, because it is realized that in order to control your health, we have to control your personal habits—there you have the development of an interoperable nationwide health information infrastructure!

Yes, I can hear at least one “friend” cry, “The sky is falling!”

Oh yes my “friend”—it is.

If by sky you mean your freedom, and by falling you mean death.

I just utilized a “healthcare provider” last week.  It is someone with whom I have a real friendship, and this provider likes to have certain things in her medical records; so, I answered some things honestly.  However, there was a lot I wouldn’t answer. It is not pertinent to the issue with which I was seeking care.  I was honest and reported that I do not smoke, unless I am on fire, and that my source of caffeine use is coffee.  The amount? All of it, which is an exaggeration, but it told her what she needed to know.

And no, I did not sign the HIPAA release.

Privacy—an inherent right recognized by our Constitution—has been taken for granted for far too long.  We should never feel we have to give up some of our privacy in exchange for some security.  I am not willing to sacrifice my privacy on the altar of “security”, not for your security, nor for mine. Don’t fall for the “I have nothing to hide” trap. You have something not only to hide, but also to hoard and protect with your life: your right to privacy.

The right of the people to be secure in their persons, houses, papers and effects, against unreasonable searches and seizures, shall not be violated, and no warrants shall issue, but upon probable cause, supported by oath or affirmation, and particularly describing the place to be searched, and the person or things to be seized. Fourth Amendment, U.S. Constitution.

~JPowell MD