PMH @ Home Newsletter

PMH@Home is the newsletter that Premium Medical Home publishes quarterly. We publish here the introduction to each of the articles published

It is our effort to bring important and interesting information from the world of medical research and our medical community to our subscribers. We want to focus on information that will be useful to PMH members. We want to illustrate how medical care works through research to make progress in small and large steps. Finally, in the section called "A PMH Story" we tell how a Premium Medical Home has made a difference in the care and experience of our members.

Expertise, direct connection, a focus on convenience and optimal practice size promote not only medical care but also the comfort and confidence of PMH members. Subscribe to Premium Medical Home today and the quarterly PMH@Home newsletter will be delivered to you.

Winter 2018

PMH STORY

Premium Medical Home doctors remain active in the medical community.

Recently, I was asked to care for a hospice patient (whom I had never met) admitted to a nursing home. The resident was totally dependent upon her daughter and was in for a short respite stay. After visiting the patient and the nurses, I called the daughter.

On identifying myself to the daughter, the daughter was confused. She said, "Had there been an emergency?" I advised that there had not. She said that in the years she had been providing the care for her mother, including in and out of hospitals and nursing homes, a physician had never called her on the phone.

This is not the first, nor will it be the last, time that a family member expresses surprise and, naturally, appreciation for a doctor's personal attention to their loved one. I shared with the daughter my own personal experience serving as my father's physician. In his last months while in hospice, he had a problem and I was unsure how to proceed.

I called one of the specialists here in town and left a message on their answering service: I was just another patient's family member asking for help. Within minutes, the doctor called me back. We reviewed the issue and he stated that it sounded like I was doing the right thing. He offered to come over or see my father, or have us visit the next morning in his clinic. With the phone call, I had the information I needed and a visit was not necessary. But like the daughter of this hospice respite patient at the nursing home, like any of us when we are sick and do not know for sure what is wrong and what to do, I felt deep appreciation for this doctor who was able, willing and available to help, and willing to talk to me on the phone. We have experienced both sides of the relationship. We want our patients and families to have that support and relationship always at hand.
Robert H. Kelly, MD, FACP

WHAT IS BEST FOR PAIN?

People have been using narcotic analgesics for thousands of years. But are the narcotics any better than new drugs, such as ibuprofen and acetaminophen?

NEW BLOOD PRESSURE GUIDELINES

The American College of Cardiology and the American Heart Association issued new guidelines for the diagnosis and treatment of hypertension. For most of our patients, there will be little change. There are two groups that will notice a significant change.

DO ANTIDEPRESSANTS REDUCE DEPRESSION IN PATIENTS WITH COMPLEX CHRONIC ILLNESS?

Major depression is frequently experienced as a lack of interest in anything that would generally bring pleasure and as an unexplained sense of persistent blueness and depression. Treatment of depression is important. But randomized controlled trials of depression exclude patients with chronic and serious illnesses: cancer, heart disease, kidney disease, and others. Facing such serious illness, patients and their families commonly ask about treatment of depression symptoms.

COFFEE – STILL OUR FRIEND

In a randomized controlled trial, heart patients in Brazil were off coffee for 7 days. Then each person took five doses in 5 hours of 100 mg of caffeine as coffee. This is about the same as five 8-ounce cups of coffee. The placebo group drank coffee. Blood tests, electrocardiogram and stress tests were done. The results showed no adverse or positive effect of coffee on skipped beats, duration of exercise, heart rate, or blood pressure. People like coffee, and it appears that coffee is not dangerous, even in the face of heart failure and arrhythmia.

OSTEOPOROSIS

Long term prednisone use causes a 60% - 100% increase in fracture risk. An experiment was done with 3600 patients in Sweden who were taking prednisone. Fosamax or placebo was started 1-3 months after the initiation of prednisone. Over the 1.3 years, there was a hip fracture rate of 9/1000 in the Fosamax group versus 27/1000 in the placebo group.

PMH QUOTES

"I have come to believe that patient trust in the physician is one of the most important therapeutic elements in our armamentarium. Such trust can be built only when a lasting relationship is forged between the patient and the physician."

William Mayo, M.D.

"Many chronically ill elderly patients should be spared from spending their last hours in the grip of medical technology."

Michael Gordon, M.D., 1985.

"There is building resentment against the shackles of the present EHR; every additional click inflicts a nick on physicians’ morale."

Donna Zulman, M.D., 2016.

FALL 2017

PMH STORY
HOSPICE

By now, all older adults know that hospice is a choice they may consider for themselves or their loved ones as illness progresses and goals change.

The PMH patient was an elderly gentleman with progressive neurological disease causing paralysis. His wife had worked for years to care for him at home even as he became bedfast. The spouse took beautiful and effective care of her husband.

As he worsened, he could no longer breathe adequately. Should he transfer to the hospital for usual, aggressive care, or remain at home? The PMH doctor met with the family and the patient in the emergency room. Respiratory failure was impending. At the ER, we could quickly assess that this was nota reversible disease. The patient and his wife were asked, "Do you want to be cared for at home or do you want to be cared for in the hospital?" Both firmly expressed they wanted him to be cared for at home. A daughter, in the room, also wanted his care at the home. With this decision, hospice was offered and a referral completed.

His PMH doctor talked to the hospice team before he left, and also talked to the familyabout his condition and family goals and wishes. The family returned home but delayed starting hospice; "it didn’t feel quite right." She wanted to think about it another day or two.

Two days later, she called and said she wanted to talk to a different hospice company and the PMH doctor made that referral. The following day, the hospice referral was completed and the family had signed up with the hospice company. Thankfully, the family had the time at home that they treasured.

The patient's wife and children needed time, conversation, and the options to explore their own best choice and their own feelings and decisions. The time required to explore and understand is important and worth taking.

We believe that where there is good communication between patient, doctor and family, the decisions will be more gentle, more careful, and better for all concerned. This is why we have created PMH. We want the patients and families to have time, attention, and thought appropriate for the difficulty and magnitude of the decisions they face.
Allan R. Kelly, MD, FACP

PMH FEES

A REMINDER - Dr. Allan Kelly's new PMH fees went into effect on October 1, 2017. They are posted on our web site, PremiumMedicalHome.com and are also available by calling the office. You will be billed for the new rate on your annual PMH renewal date.
Allan R. Kelly, MD, FACP

EXERCISE, COGNITION AND FALLS IN OLDER ADULTS

Falling is a big problem for the elderly. Falling can cause injury and loss of independence,and force a move out of the home and into assisted living.

Can we reduce fall risk in those who have had a single fall? One step is to review and simplify medications. Also,we should look at the environment and reduce anything that could result in tripping, and recommend ramps, grab bars and other changes. We will often send patients to physical therapy.

Physical therapy can help and so can almost any exercise program. The exercise program need not be supervised by a physical therapist or physician. An example of this comes from Australia where persons with cognitive impairment but no dementia were randomized to receive several weeks of Tai Chi training versus no intervention. Tai Chi was provided for three weeks at an exercise center, and then the intervention group received 12 weeks of home-based encouragement and exercise, but no home visits by a physical therapist or instructor. The study looked at memory function and strength.

Individuals randomized to the Tai Chi group improved cognition and reduced falls compared to individuals randomized to usual care. Tai Chi is likely no different from other exercise programs. Commonly, intervention with exercise can improve strength, improve cognition, and reduce fall risk and injury. If you have not started an exercise program, go ahead and get it going. It can be as simple as 5 or 10 minutes of walking, Tai Chi, or other exercise of your choice.
Allan R. Kelly, MD, FACP

REDUCING NURSING HOME HOSPITALIZATIONS

Medicare wants to reduce the hospital admissions of nursing home residents. Currently, admissions are based on judgment by nurses and physicians depending on patient needs.

Researchers from the University of Minnesota studied a program to reduce hospital admissions from 85 nursing homes. Half received an intervention program developed by the research team (called "INTERACT"), and half received no intervention at all. The scope and intensity of the intervention INTERACT was remarkable: there were 12 weeks of training for the nursing home in house "champion" alone, who was responsible for implementing INTERACT. Interventions included intensive advanced care planning tools, medication reconciliation worksheets, care packs, acute change in condition file cards, reporting to CMS, hospital communication tools, hospitalization tracking tool, and quality improvement tools. This all contributed to a single "quality improvement program" that was used to "apply learning to improve care processes and education."

The results: no improvement in the hospitalization rates after this intensive intervention. Why INTERACT failed is unclear, but the authors attribute a possible cause to be "the quality of the nursing home staff and physicians." They feel that the nursing home staff failed, that they did not have enough enthusiasm for the program, and did not attend sessions reliably as they should have, (30% of meetings were missed).

In short, the authors blame the failure of this multi-million dollar trial on the nurses, doctors and administrators who were actually providing patient care. Easy for them to say!

It is likely that we will see more of this in the future. And complex administrative programs will often fail, I suspect, so long as a doctor or nurse remains committed to each individual. Trying to change this basic human responsibility is difficult. We hope that this basic human commitment remains preeminent.
Allan R. Kelly, MD, FACP

CORTICOSTEROIDS FOR IRRITATING COUGH

Patients with asthma predictably respond well to steroid therapy along with antibiotic treatment for acute bronchitis. About 15% of adults without asthma who have a lower respiratory tract infection (like bronchitis or a cold) are treated with corticosteroids. But after the acute infection, some are often left with lingering cough. The role for antibiotic treatment is negligible in reducing symptoms. Would steroids help reduce these symptoms in the person without asthma?

There were 360 persons who had been ill for 10 days or longer – average was more than three weeks. For ten days half the patients received 20mg prednisone and half with placebo. About 40% in both groups were also given antibiotics. The patients were not suspected to have acute infection, asthma or COPD when enrolled. There was no measured benefit from the prednisone therapy

Once you have had a cough for 10 or 14 days, assuming there is no fever, blood in the phlegm, or shortness of breath, this is probably a viral illness that will run its course. Treatment, whether with antibiotics or with a corticosteroid, is unlikely to be of significant benefit.
Robert H. Kelly, MD, FACP

OSTEOARTHRITIS

The National Institute of Health and Duke University studied whether intensive and complex intervention for the treatment of osteoarthritis, (a universal, degenerative condition)can make a difference

The researchers studied whether or not a planned multifaceted program of care would be superior to ordinary care. Ordinary care is people providing for their own needs at their own pace and with a doctor's participation when requested.

The experimental intervention took place over 12 months and included telephone calls, counseling, programmed interventions focused on physical activity, weight management (all subjects were overweight), and cognitive behavioral strategies for managing pain. A total of 18 telephone conferences/interviews were provided by trained clinicians. There was also intervention training for physicians of these patients – use of guidelines and recommendations for physical therapy, knee brace use, weight management programs, physical education programs, topical nonsteroidal anti-inflammatories and knee injection therapy.

In the program intervention group, there was a significant increase in use of pain medication and joint replacement surgery compared to the usual care. Also, there was no significant improvement in the intervention group.

In short, a sophisticated, expensive and intrusive program (18 phone calls from strangers to patient's homes and classroom time for the doctor) had no benefit for the individual patients compared to the physical activity and naturally selected treatments by patients and doctors collaborating together in the nonintervention group. Normal, everyday patients and doctors operating together can prudently design a treatment program which on average is superior to one designed by agencies, academic institutions and administrators.
Robert H. Kelly, MD, FACP

PMH QUOTATIONS FALL 2017

"The experience in that tiny hut [in Africa] was a reminder to stop talking, be still, and focus on the patient. The patients will tell us what's wrong with them if we listen." Ann Elise Kutzler, second year medical student, 2017.

"Listening and thinking are still what patients expect from their physicians."

Frank Sparandero, M.D., September 2017

"No disease that can be treated with diet should be treated by any other means."

Maimonides. A Physician, 1135-1204 AD

SPRING 2017

PMH STORY

Premium Medical Home is a way of running our offices and serving the public that we think is better. PMH principles are professionalism, directness, continuity of care, and enough time to give care. The fifth is affordability.

The PMH member had retired. He was careful with his money, as we all try to be, so he was surprised when he went to pick up a refill of his medications. He found that a medicine that had previously been affordable was now expensive, $300 for three months instead of $50. He called pharmacies that used his insurance and found a similar price. Knowing that his PMH doctor is committed to affordability, he called the doctor's office to ask for advice.

The staff and the doctor are aware of the financial problems and cost problems that patients face. Getting a call like this from a member is not unusual. He lived in another city, so the office called the lower cost retailers in that city and asked for a cash price. What would it cost to just buy the medication if you had no insurance at all? We found that Costco offered the product for a cash price of $30 for three months. We called the member, we sent the prescription to Costco, and the member's medical care became more affordable.

Affordability is a complex topic. At PMH we focus on affordability, like accepting insurance. We also try to be aware of what cost choices there are out there, and to pay attention to the relative benefits and risks of the drugs we prescribe. We don’t know when our members will face affordability issues, but we will help them when this arises.

Allan R. Kelly, MD, FACP

NEW ANTICOAGULANTS: XARELTO, ELIQUIS, PRADAXA vs. WARFARIN

We continue to see information on new drugs for anticoagulation. Atrial fibrillation can cause blood clots and strokes.New anticoagulants have been licensed to reduce this stroke risk. Researchers in the Journal of the AmericanCollege of Cardiology, 2016 reviewed the impact of new oral anticoagulants on all-cause mortality compared with warfarin. Looking at over 70,000 individuals who were taking one of the anticoagulants, the all-cause mortality rate during the course of the study was 8% in the new anticoagulants, and 9% in the warfarin group.

OBESITY SURGERY AND DIABETES

We continue to watch the development of treatment for the extremely obese persons with body mass indexes over 40. The Mayo Clinic has recommended gastric bypass surgery for decades for patients whose obesity problems have become unsupportable.

STEM CELLS

There is much interest in stem cell injections for degenerative joint disease. Attempts have been made to use stem cells to treat other age-related diseases. In the New England Journalof Medicine, a study looked at two patients cared for at a university in Japan. Vast efforts were made by a large team of specialists ethically using stem cells to reverse macular degeneration – the efforts failed. Other stem cell research in the eye has failed dramatically.

TESTOSTERONE AND MALE AGING

In a recent experiment, 170 men were randomized to testosterone or placebo to see the effects of testosterone replacement on coronary artery calcification or plaque. Testosterone effects on cholesterol plaque were measured by CT.

SKIPPING BREAKFAST

There has been talk about the benefit of eating breakfast when weight loss is desired: You have to eat breakfast if you want to lose weight, some said. This has been called into question with recent research.

KNEE ARTHRITIS

For decades, doctors have used intraarticular joint injections to try to relieve pain in people with chronic arthritis. However, the development of new imaging techniques and our ongoing commitment to experimental methods have led to new insights in the use of steroids for knee arthritis.

PMH QUOTATIONS

"I now see that the medical system is layered to shield the doctor from direct contact with the patient (except for the appointment time)."
Carl Norden, M.D.,2016

"I’ve learned to be intolerant of stereotypes, to recognize that every person has a unique story. When we are privileged as physicians to hear another person's story, we shouldn’t take it for granted."
Adam Hill, M.D., 2017

"This total commitment to the welfare of the patient has been undervalued in the formulation of ethical guidelines, whereas the assumption that such personalized care would be provided by the healthcare system has been over credited."
Chris Feudtner, M.D., 2001

Winter 2017

PMH STORY - THANK YOU

A big and heartfelt thank you to all of our patients and their families.

For many years, we have invited medical students to work in our offices. We want medical students to have the opportunity to work with internists who are active in their community, office, nursing home, hospital, and other facilities where our patients receive care. This is a voluntary effort on the part of the doctors. No reimbursement or payment is sought or expected, and the experience contributes to education and training of doctors for the future. Our work is endorsed by UNT Health Science Center (we are both adjunct clinical assistant professors) and by The American College of Physicians where Dr. Allan Kelly received the Texas Chapter Emerald Award for service in education.

It is your choice whether to allow the student to be part of your care. We believe that having a student involved does not distract from good care and at times has positively contributed. There will be times when a patient doesn’t want a student involved, when they don’t want to meet a new person, when they just want to work with the doctor with whom they are familiar. When a student is introduced to participate in your care, please don’t hesitate to say you would rather see the nurse or doctor. At times when you are open to working with these young people, we thank you very much. We aim to limit student participation to just two or three months out of the year.

Premium Medical Home is about running an office in a way that is good for our patients, their families, and the community. Helping young doctors and encouraging them to work in our city is good for everyone.

Allan R. Kelly, MD FACP and Robert H. Kelly, MD FACP

FALLS

When you are young, falls are embarrassing, and sometimes may be dangerous. At any age, no one wants to fall and all of us want to avoid injury.

As we age, falls are more likely to be dangerous and should be reported to your doctor. Your doctor will then likely consider what may have played a role in the fall and what measures can be taken to avoid future falls. At any age, medications should be reviewed. Strength and balance training may help.

READY FOR DISCHARGE?

When a person is admitted to the hospital, there may be uncertainty whether they are ready to go home when discharge arrives. The doctor and the nurses may all feel good about that discharge, but from time to time the patient or the family is not so sure and wonders if they are being sent home too soon. A recent report in The American Journal of Medicine looked at all discharges from hospitals in Edmonton, Alberta from October 2013 until November 2014. Patients discharged were questioned about whether or not they were ready for discharge. Twenty-three percent of patients discharged reported "being unready for discharge." Being unready for discharge was associated with disability, cognitive impairment, dementia, poor education, and multiple hospital admissions. But the risk for hospital readmission and the risk for death did not differ between the two groups over the course of the next 30 days. Specifically, only 15% of those who felt unready for discharge were readmitted, versus 18% of those who felt ready for discharge.

OVARIAN CANCER SCREENING DOES NOT WORK

Doctors recommend cancer screening in order to reduce death rates and disability from cancer. We have found that cancer screening is successful for some cancers, but not for others. One of the most important lessons of the past 20 years is the failure of ovarian cancer screening. An American study published in 2011 randomized 68,000 women between ages 55 and 74 to screen for ovarian cancer with combined blood testing and pelvic sonography. There was no difference in death rates, nor was there any difference in stage of cancer upon diagnosis. The screening failed to save lives.

METFORMIN AND COLON POLYP PREVENTION

It looks like a common medication, metformin, may reduce colon cancer risk with medical treatment. In a recent experiment, people who had had polyps removed at colonoscopy were told to come back in one year. One-half of these persons were randomly assigned to take metformin 750mg daily; the other one-half were given placebo.

NARCOTICS AND CHRONIC PAIN

In persons suffering chronic back pain, hydrocodone (an opioid narcotic) was compared with placebo to see if it was effective for chronic pain control. Pain was measured on a 100-point scale: a change in pain score of 20 points was considered significant. Nearly 50% of patients treated with hydrocodone, compared to placebo, withdrew because of side effects. Moreover, those continuing to use hydrocodone did not receive significant pain relief. Opioids, compared to placebo, reduced pain insignificantly for those patients with back pain. Other research shows that long acting opiates appear to increase the relative risk of death more than 50% compared to persons whose back pain is treated with antidepressants or medications such as gabapentin.

PMH QUOTATIONS WINTER 2017
"Clinical excellence remains the best medicine."

Burke Cunha, M.D., 2017


"I now see that the medical system is layered to shield the doctor from direct contact with the patient (except for the appointment time)."

Carl Norden, M.D., 2016


"The computer has taken over our offices. This rise of the machines…has led to more and more angst and physician burnout…we work harder, with longer hours, and more time doing meaningless, useless tasks. The physician patient relationship has been eroded almost irreparably because we so often spend too much time staring at computer screens and not enough time actually connecting with those we serve."

Hujefa Vora, M.D., 2017


Fall 2016

PMH STORY

PMH is about continuity and knowledge.

The patient was in his early 90's. The PMH doctor cared for the man and his wife for over 20 years. The wife died 15 years ago. Family always thought the PMH doctor took good care of mom, even though she died, and always had confidence in the doctor's care of their father.

A gradual downhill course eventually pointed to approaching end of life for the father. His illnesses were severe. He was comfortable and surrounded by his family in the hospital room. But it was time to confront that there was nothing else that the doctors could do to get him back on his feet and to recover his strength.

In a meeting with the family, the doctor was able to recall the patient's history dating back decades, to reflect upon the spouse's death, and to talk about the future and how to take good care of a good man, even at the end of life. The doctor had cared for the patient in the office, at the nursing home, and was sitting at the patient's bedside in the hospital. With transition to hospice, the doctor would again be by his patient's side.

The trusted and longtime physician at the patient's bedside is valuable, a good thing. Regardless of what may be happening elsewhere in hospitals and nursing homes, at PMH we are committed to this continuity of care over time. We believe continuity of care is good for the patient, the family, the doctor, and those who support the patient, even at the end of life.

Allan R. Kelly, MD FACP

ANNOUNCEMENT

Dr. Robert Kelly's Subscription Fees will be increasing as of January 1, 2017. The new fees are posted on our web site, www.PremiumMedicalHome.com and are also available by calling the office. As your PMH renewal becomes effective, you will be billed for the new 2017 fees.

BLOOD TRANSFUSIONS: IS BLOOD FROM MEN AND WOMEN DIFFERENT?

In the popular media there is all this talk about gender, malehood, femalehood, etc. Doctors have always known the truth: There is a difference.

But even we were surprised when JAMA 2016 presented data on male and female blood donors. The advent of big data has allowed for tracking outcomes in new and comprehensive ways.

ANTIBIOTIC TREATMENT: SHORTER CAN BE BETTER

We all remember the doctor's instruction when we had strep throat infections: Take the antibiotics for ten days until they were all gone. Children and young parents became accustomed to the idea of taking antibiotics for one to two weeks, even after we got better.

But times have changed. Over the past fifteen years, multiple studies have compared shorter versus longer courses of antibiotics. Dr. Brad Spellberg recently reported experiments of shorter versus longer duration therapy. For example, in community-acquired pneumonia, stopping antibiotics after five days was superior to continuing antibiotics for 7 to 10 days. Other studies included pyelonephritis (7 versus 14 days), intraabdominal infection (4 versus 10 days), sinusitis (5 versus 10 days), and cellulitis (6 versus 10 days). According to Dr. Spellberg, shorter duration beats longer duration in these clinical syndromes. I believe these new studies will lead to a change in clinical practice.

PAREGORIC, OPIUM, MORPHINE: PAST AND PRESENT

Paregoric represented an ancient tradition of care, its components in use for thousands of years. The active ingredient is a natural product from poppies, and used by people of all social statuses, all incomes, and all educations in every country since the time of Marco Polo.

Older people may remember paregoric, used for many purposes in the home. It was used for a teething child who was restless or uncomfortable with colic. It was used for people with diarrhea and stomach cramps and pain. It was available without a doctor's prescription at every drugstore. Mr. Bill Whitten, a pharmacist who built up Whitten's Pharmacy chain in Fort Worth, said he always had paregoric available over the counter. He would keep an eye on it, and if he thought that a person was buying too much, he would turn them away.

INFECTION – WARNING SIGNS

Paying attention to a worsening infection before it requires hospital care is important. One key to transition between infection that can be treated at home and infection that requires hospital care is when infection changes to a syndrome called sepsis. Sepsis is a serious problem with a mortality rate of 15-30%.

REDUCING COLON CANCER RISK

Prudently reducing the risk of colon cancer and colon polyps is important. Cancer tends to develop in a polyp, so reducing polyp formation is desirable. Though the frequency of colon cancer is relatively low for any individual, colon cancer ranks third after breast and lung cancer as a cause of death from cancer in the United States.

Americans are open to medical treatment that reduces risk. Examples are low-dose aspirin and statin drugs for those at risk for coronary disease, tobacco cessation, and bisphosphonates for osteoporosis. And now, maybe metformin for colon polyps. A recent experiment in Japan recruited persons with high risk of forming colon polyps and randomly assigned them to two groups. One group was given metformin 250 mg daily (lower than used for diabetes) and the other given placebo. Colonoscopies were performed after one year. The number and prevalence of adenomas and polyps was then measured and found to be significantly lower in the metformin group. In the metformin group, only 38% of persons had some form of polyp or adenoma on the follow-up colonoscopy, whereas nearly 60% in the placebo group. The risk of colon polyp or adenoma was reduced by almost half.

PMH QUOTATIONS FALL 2016
"The true core of good medicine is not an institution but a relationship, a relationship between two human beings. The better those two human beings know one another, the greater the potential that their relationship will prove effective and fulfilling for both."

Richard Gunderman, M.D., 2016


"He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all."

William Osler, M.D., Aequanimitas, 1904


Summer 2016

PMH STORY

The patient was in her 90's. She had been the caregiver for her husband. He passed away, and she had lived now a decade as a widow.

The patient had been part of the PMH practice since 1985, and before coming under the care of the PMH doctor, had been under the care of that doctor's father.

The patient's dementia had been inexorable, causing gradual loss of ability to care for herself, to recognize people, and to understand what they were doing. She moved from her home to assisted living, then to a nursing home, and then to hospice. She could no longer walk. She had neither children nor brothers or sisters in the area.

The doctor had cared for her at the office, the hospital, the emergency room, at the home, the assisted living facility, the nursing home, and now in hospice. Despite all these changes, her doctor did not change.

After she moved to hospice, the PMH doctor came to see her. She was in a wheelchair in a common area. He asked her how she felt and she did not answer. She seemed not to focus. He said to her, "Do you know my name?" She looked up, smiled and said, "Allan Rowan Kelly."

What does it mean to a patient with severe dementia to know the doctor who comes to her side? How important is it? In some practices, doctors do not have the opportunity to ponder this question, as they do not maintain that continuity of care from place to place and time to time. But for the PMH doctor, he felt that it was a balm for this person to recognize him, to see his familiar face, to speak a familiar name, and to smile.

As doctors, we are grateful to be able to care for those who know us and have trusted us for years. It gives meaning to our work. If we must care for strangers, so be it: It is good to care for the stranger. But it is also good to care for those we have known over time. It is important to our patients, and it is important to our doctors and nurses. We call it continuity of care, but it is a basic principle of PMH. Continuity of care is important, valuable, and helpful.

Allan R. Kelly, MD FACP

PALLIATIVE CARE By Allan R. Kelly, MD FACP

Over the past 15 years, a loss of continuity of care and other changes in medical care have led to the creation of palliative care teams in hospitals. Do they help?

The National Institutes of Health funded a large and expensive study at multiple sites in the United States, including Harvard, National Institutes of Health, and Cornell, to see if this concept worked (Carson, et al, JAMA, 2016). The study randomized 365 families whose loved ones had been in the intensive care unit for at least 7 days. Half of the group received usual care from the doctors and nurses in the ICU. The other half received usual care plus palliative care intervention, a complex effort including "…brochures…coordinators…information team…palliative care physician…nurse practitioner…social workers…chaplains…or other disciplines." This palliative care team met with the family of the sick patient in the ICU: "These important information meetings were structured according to a set of objectives and recommended topics…they were allowed some flexibility for adapting the content of the meetings to the particular needs of each family." Everyone involved had a major stake in the outcome. Massive amounts of money were spent.

BASIC LIFESUPPORT? ADVANCEDLIFE SUPPORT? IS LESSMORE? By Robert H. Kelly, MD FACP

It is often worth questioning assumptions. One assumption is that advanced life support (ALS) provided by ambulance personnel will be superior to basic life support (BLS). This question was addressed in a recent study of emergency medical care given to Medicare beneficiaries by emergency medical personnel (EMS). Sixty-five percent of the EMS crews were ALS trained. Thirty-five percent were BLS trained. Was ALS or BLS better? Did higher level training (ALS) of ambulance crews improve outcome?

ZIKA VIRUS IN TEXAS – WHAT IS THE RISK? By Jacob Underwood, MS2 and Robert H. Kelly, MD FACP

Zika virus is spread to humans through the bite of an Aedesegypti mosquito which became infected itself by biting a human with the virus in their blood – whether that human was having symptoms or not. The virus can also spread from person to person through intimate contact. In July, Utah reported a case without known mechanism of transmission. In August, Miami reported mosquito transmission in the U.S.

NOT TOO BUSY By Allan R. Kelly, MD FACP

The patient was a female physician in her late 70's. She had a perplexing syndrome of chest pain. After a stay in the hospital, there was still no specific diagnosis. She made a new patient appointment with a PMH doctor.

The PMH physician was part of the medical staff at the same hospital and so directly accessed her medical records.

PMH QUOTATIONS Summer 2016
"A good physician treats the disease; the great physician treats the patient who has the disease."

Bennett Clark, MD, 2016


"And since we’ve come to think of the hospital as serving the function of a train station – moving people down the line as fast as possible – we shouldn’t be surprised to learn that some patients’ experiences in the hospital have all the warmth of rush hour in Penn Station."

AmandaFantry, MD, 2016


"Sure typing is a little bit faster, but I’ll bet a lot of doctors agree that their clinical thinking was better when their notes were scrawled long hand"

B. Ryan Brady, April, 2016


Spring 2016

PMH STORY

A woman in her late 70's was having trouble breathing. Her cardiologist referred her directly to a pulmonary specialist who prescribed three different inhalers and multiple tests. The patient tried taking the prescribed medications. She felt certain that the medications were of no help, and made her feel worse instead of better. She did not call the pulmonologist's office or staff or report the problems with her new medications. Neither did the husband or the patient receive reports or a call with results of the diagnostic studies that were done. Three weeks later, driving to the pulmonologist's office for a follow-up appointment, the patient became more short of breath and decided to go directly to the emergency room. In the emergency room, it was clear that her problems had grown much worse, and her PMH doctor was called.

The PMH doctor saw the patient in the emergency room and cared for her in the ICU over the next several days. The husband complained to the doctor about their experience with the pulmonary office.

It is not easy to complain. If you know you can tell your story to someone and not be seen as a complainer, you can tell your story in more detail and with confidence. Hearing the complaints of the patient's husband was very helpful to the PMH doctor, and was helpful to the pulmonologist and the pulmonology team to understand how they might better serve other patients.

The nature of the PMH practice allowed the patient and her husband to feel entitled to express themselves fully to their doctor. They know their doctor. Working with a doctor over time, knowing that the doctor will join you when you are sick in the hospital or the emergency room, and knowing that you can express yourself fully without judgment, can help everyone.

Allan R. Kelly, MD, FACP

THE MEDITERRANEAN DIET By Allan R. Kelly, MD, FACP

Almost a decade ago, Spanish doctors started the PREDIMED Study on the Mediterranean Diet versus a low fat diet to answer the question, "Can diet recommendations change health outcomes?" Investigators in Spain looked at 7147 persons between the ages of 55 and 80 years. Group one received a low fat diet teaching. Group two received a Mediterranean Diet teaching plus 5 ounces of free mixed nuts per week. Group three received the Mediterranean Diet instruction plus 1 liter of extra virgin olive oil (EVO) per week to be used by themselves, family, and friends.

DAYLIGHT SAVING SYNDROME By Robert H. Kelly, MD, FACP

There may well be differences of opinion, but transition to daylight saving time may not be a harmless government regulation. Not only does it require every American to take time out to reprogram clocks and watches (fortunately, our computers and iPhones can do this on their own), but it appears to have adverse health effects. A recent study (Cipila, et al) was presented at the 2016 American Academy of Neurology Annual Meeting in Vancouver, Canada.

BREAST CANCER SCREENING By Allan R. Kelly, MD, FACP

All women know that for years prudent self-care included breast cancer screening. Since the 1980's, women have been told over and over again to learn about breast self-examination, to have an annual physician examination of the breasts, and to have an annual mammogram in order to follow the guidelines of the American Cancer Society.

PMH QUOTATIONS Spring 2016
"A good physician treats the disease; the great physician treats the patient who has the disease."

William Osler, M.D.


"Almost all the current practicing physicians at Dallas Diagnostic Association have reported decreased productivity and decreased satisfaction with the practice of medicine due to burdens imposed by EHR. Dallas Diagnostic Association experienced the premature retirement of 12 physicians in large part due to the adverse impact of EHR."

Lannie Hughes, 2016 (BUP 29, 2)


"Rather than sitting at the bedside and sharing the suffering of the patient, physicians now spend their time in clinical foxholes on computers and cell phones focusing more on the disease than the person or on technology than touch. . . Just remember the doctors of old – Model them and you’ll be fine."

Paul Rousseau, M.D., 2016 (JAGS, 64, 645-6)


Winter of 2016

PMH STORY

The PMH Story section has been a place where we have written about how our model of medical care benefits subscribers. We certainly try to look at things from the patient's, not the doctor's, point of view, although the two are closely aligned. We would like to invite any subscriber to submit a brief description of what PMH means to them. What does PMH do for you that is meaningful and desirable and is not generally available in a non-PMH practice?

You may submit these anonymously. Understand that if we do have a chance to publish this, we will change names and dates (and sometimes even gender) to make sure that the patient cannot be identified as a unique individual in our practice though the story will be true and unique.

DEHYDRATION AND HYPERTENSION MEDICATIONS

Every summer we see patients who have fallen or fainted due to dehydration. Here's a heads up to stay healthier during hot weather. A recent correlation has been made between summertime and increased risk for dehydration and fainting-syncope. Fainting spells accounted for 700,000 emergency admissions last year in the USA. Problems with dehydration accounted for at least one-quarter of these. In Arizona, it is called "summer syncope syndrome." Key features include low blood pressure and blood pressure that falls when standing up. The most common symptom is light headedness.

BACON GETS NO RESPECT BY Robert H. Kelly, MD FACP

The World Health Organization recently called red meat a probable carcinogen and processed meat as a known carcinogen. Other known carcinogens include asbestos and tobacco. If a drug was a known carcinogen, the FDA would likely not approve it for sale. And yet, of course, many of us enjoy red meat and processed meat. One wonders if there is a certain degree of anxiety at the World Health Organization.

TRANSPLANTATION: BLOOD, PLASMA, STOOL By Allan R. Kelly, MD FACP

The development of transfusion and transplantation is one of the great triumphs of modern medicine. All the way from plasma for hemophiliacs, to skin for burn victims, or a whole heart, the ability to donate a healthy organ to another in need is a good thing. Doctors are now studying stool (also called fecal) transplants.

HERNIA REPAIR…WITH MOSQUITO NET By Allan R. Kelly, MD FACP

Why is American medical care more expensive than in other countries?The January 14, 2016 New England Journal of Medicine may shed some light. Lofgren and others performed a "randomized trial of low cost mesh in groin hernia repair." The authors compared two types of mesh for hernia repair. One type of mesh was produced by a prominent medical products company, Covidien. The second mesh used in this randomized and controlled experiment was a simple mosquito net produced by a plastics company in India. The Covidien mesh was polypropylene. The Indian mesh was polyethylene. The Covidien mesh cost $125.00 when purchased in Uganda. The Indian mesh was less than $1.00 for an entire mosquito net. The mosquito net was cut up into smaller pieces which were washed and sterilized.

OUT-OF-HOSPITAL OR IN-HOSPITAL BIRTHS By Allan R. Kelly, MD FACP

In our modern world there is a paradoxical interest in out-of-hospital births for pregnant women. Pregnancy and delivery are not common issues at PMH, but I thought our readers would be interested because,for some patients, out-of-hospital birth is considered highly desirable.

PMH QUOTATIONS Winter 2016
"The death of common sense is neither pretty nor fast…we are distracted by the need to fill out irrelevant information and are subsequently left with less time to get through the important parts of our visit."

N. Skolnik, M.D. and C. Notte, M.D., 2015


"As with most guidelines, these [COPD exacerbation preventing guidelines] can be a bit monotonous and hard to read if your goal is to stay awake."

Douglas Paauw, M.D., 2015


"I have witnessed the peace, the comfort, the joy, and the sense of completion when a person chooses to live unencumbered by the demands of modern medical therapy."

Larry D. Cripe, M.D., (2016/01) JAMA, 315 (3), 266.


Fall of 2015

PMH STORY by Kristina Barsten, MS-IV TCOM Class of 2016,UNT Health Science Center

As a fourth year medical student at the UNT Health Science Center in Fort Worth, I have had the opportunity to rotate through several of the hospitals and clinics in the DFW area over the past year and a half. Spending the month of August in Dr. Robert Kelly's practice, however, was the first time I experienced the model of medical care like that provided by Premium Medical Home.

The comprehensive and coordinated care provided with this model impressed me and was different from mainstream medical clinics I had seen. It allows for the primary physician, the individual most familiar with a patient's medical history and needs, to continue to direct their care while admitted to the hospital or rehab facility, with coordination of care by other providers and specialists when that is needed. During my rotation, I saw referrals to United States medical centers of excellence in cases of complex diagnoses, to ensure that appropriate treatment options were considered while a plan of therapy was developed. I had not seen this before. The quick availability of the physician to advise patients and answer medical questions is another major advantage of the model of care provided by Premium Medical Home. I have not seen this in other medical clinics. Patients have the option to communicate with their physician using the means they feel most comfortable with, whether it be email, text, phone, or in person, without being limited to the typical M-F 8-5 office hours that most practices keep.

Excellent medical care is provided in a professional manner addressing the individual needs of the patient. I am very grateful for having had the opportunity to work with Dr. Kelly and hope that my patients will be able to benefit from the same model of care in my future practice.

ARTHRITIS PAIN AND WEIGHT LOSS by Robert H. Kelly, MD FACP

We all know the importance of nutrition with regard to diabetes and heart disease. Somewhat less well-known is the role of nutrition in patients with chronic pain. A recent study looked at nutrition with regard to knee pain.

ASPIRIN HAS A ROLE by Robert H. Kelly, MD FACP

Aspirin, a derivative of willow leaf, has had a long relationship with mankind. Ancient Egyptians are said to have used willow bark (basic aspirin is in willow bark) as a remedy for aches and pains. Nearly 3,000 years ago Hippocrates recommended willow to ease the pain of childbirth and to reduce fever. Celsus, the Roman writer, also suggested willow leaf for inflammation.

WHEN TO GET THE FLU VACCINE by Allan R. Kelly, MD FACP

The flu vaccine became available in September. It is not uncommon to hear people say, "When is the best time to get the flu vaccine?" Some people have heard that it is good to wait.

THE SLIPPERY SLOPE by Allan R. Kelly, MD FACP

By now we have all read that physician-assisted suicide is legal in Washington State, Canada, and elsewhere. At PMH we consider this a dangerous stepin the wrong direction. We believe that the dying should be cared for so that they are comfortable every day with their families and those who can help them.

PMH QUOTATIONS FALL 2015

"I will keep the sick from harm and injustice. I will neither give a deadly drug to anybody who asks for it, nor will I make suggestion to this effect."


Hippocrates, a physician, 375 BC


"In every human being there is a special heaven, whole and unbroken."

Paracelsus, a physician, 1527


"All we know is still infinitely less than all that remains unknown."

William Harvey, a physician, 1640


"We need a system that rewards the physician who understands the limitations of guidelines."

George Sarosi, MD, 2015


Summer of 2015

PMH STORY by Robert H. Kelly, MD FACP

A subscriber had dementia for many years. Her husband was dedicated to her care and made all her medical decisions. Like to many of us, things such as wills and legal documents seemed not as important as being sure that a loved one's needs were met in a timely manner.

The husband died leaving the wife still confined by dementia but without her husband to speak for her. A will had been left but an advance directive or health care power of attorney had never been signed.

The PMH member, nearly 90 years old, was found to have a tumor affecting her brain. The prognosis was hopeless but neurosurgery carried a slim chance for temporary relief. There was no one there to speak for her. There were some remote relatives who were not in a position to make decisions for her.

Dr. Kelly was well-aware of the patient's previous wishes and what her husband had wanted for her. With this in mind, Dr. Kelly asked another physician to consult. Together, the two doctors completed a health directive reflecting the husband's and wife's prior wishes. An appropriate Do Not Resuscitate order and referral to Hospice were made.

Because the PMH physician was familiar with both the patient's and her husband's wishes and desires over the course of years, there was an informed and respectful referral for care which in no way hastened or accelerated the end of her life, but allowed peace and quiet that might have otherwise been out of reach. At such a time, a well-established relationship with a doctor is important.

APPENDICITIS ALTERNATIVE TO SURGERY by Allan R. Kelly, MD, FACP

In 1886 a disease called typhlitis was theorized to be a consequence of appendiceal inflammation and rupture. Over the next 20 years appendectomy was refined. By the 1920's, appendicitis was a surgical emergency treated universally with appendectomy.

CARDIAC ARREST AND BYSTANDER ASSISTANCE by Allan R. Kelly, MD, FACP

We’ve become familiar with the scenes from movies and such of trying to resuscitate someone whose heart has stopped. It is a complex process, and seems like something only doctors and nurses can do. But new research shows that simply pressing on the unconscious person's chest 60 times a minute can make a difference in survival.

CIGARETTE SMOKING AND CHANTIX by Allan R. Kelly, MD, FACP

We have seen the ads on TV for drugs curing serious illness and then comes the long list of side effects, things that might happen if you take the drug. This creates a problem for patients. The doctor may recommend a drug to help them, such as Chantix, but the implied threats in advertisements on TV can overwhelm. Many patients reject use of the drug out of hand based on these intimidating lists of problems. Use is infrequent and there are few friends with experience to share.

DEMENTIA by Robert H. Kelly, MD FACP

In a recent study in the Journal of the American Geriatric Society (August 2014) Joseph, et al show that dementia is not necessarily associated with increased risk of traffic accidents. The author studied 31,000 participants involved in a high blood pressure study. All were community living and not demented. Some had mild cognitive impairment. The results showed a surprising correlation between cognitive impairment and motor vehicle accidents: Motor vehicle accidents decreased with cognitive impairment. No specific measure of driving or accidents per mile driven was made, though those with cognitive impairment were more likely to be infrequent drivers.

SORE THROAT by Robert H. Kelly, MD FACP

Having a sore throat can be uncomfortable. There is risk of bacterial infection, like streptococcus, and antibiotics are appropriate for such disease. Less than 10% of sore throats are caused by streptococcus, so the majority of sore throats do not require antibiotic treatment and are related, principally, to viral infections. Antibiotics can kill strep, and can lessen symptoms of strep throat. But should antibiotics be used for non-streptococcal sore throat? Generally speaking, no.

PMH QUOTATIONS Summer 2015

"Medication and surgery are cornerstones of our efforts to heal patients but honesty and respect…will always be paramount to our success as physicians."


Jesse Raiten, M.D., JAMA, August 4, 2015


"When the doctor really cares about the patient everything else follows; the hard part is to align oneself to care, especially in the face of the often frenzied pace of medicine today."

Michael Khan, MD, NEJM, March 2015


"I have sacrificed my ‘physician-hood’ to document nonsense [in the electronic medical record]. This documentation we do does not benefit our patient in any way. In reality, it just ensures that we are properly reimbursed by the insurance companies."


Hujefa Vora, MD, Tarrant County Physician, July 2015


Spring of 2015

PMH STORY by Robert H. Kelly, MD FACP

Shoulder and arm pain had troubled a PMH subscriber for a couple of months. With an upcoming special event on Saturday, the problem had become a distraction. She called the office and a referral was made to a specialist for the week after the special event but the pain persisted.

On Friday afternoon, she called for more help. There had not been a visit in many months. Obviously having severe pain, some evaluation was in order. A request was made to meet Dr. Kelly in the Emergency Room the next day. The subscriber did not want to do this because of the amount of trouble sometimes associated with an Emergency Room visit. Dr. Kelly recommended instead that they just meet at the Emergency Room waiting area and then make a decision on whether or not checking into the Emergency Room for further evaluation would be needed.

The new Marion Emergency Care Center at Harris Hospital downtown makes a great place to visit and make a decision about needs. At 8:30, Dr. Kelly met the subscriber and a proper evaluation and examination was done. The problem did not seem to be dangerous at all, and a decision was made to plan x-rays at a later time and begin treatment for what was likely an inflammatory musculoskeletal condition. She did not "check in" to the Emergency Room, saving hours of time and great expense.

Premium Medical Home makes such visits possible. As a PMH patient you are able to see the same physician at the hospital, who will also then see you at his office, the same physician with whom you have spoken on the telephone, whether it is a weekend or a weekday. Because there are fewer patients in Premium Medical Home, there is more time to try to understand the patient's needs and circumstances and try to match the visit or treatment more carefully with these matters of convenience and comfort.

SURGICAL VERSUS NONSURGICAL TREATMENT OF A SHOULDER FRACTURE by Allan R. Kelly, MD FACP

As we get older, fractures become more common and often require surgery. Generally, we are going to leave the decision to have surgery to the orthopedic surgeon. A recent study in the Journal of the American Medical Association (March 2015) by authors from Europe, compared shoulder (humerus) fracture outcomes at six months, 12 months, and 24 months after treatment. These were serious fractures of the proximal humerus with displacement (separation) of the bone fragments. Patients were randomized to non-surgical treatment (sling immobilization) or surgery (fracture fixation or shoulder replacement).

STATINS by Robert H. Kelly, MD FACP

CMedical treatment of disease is meant to promote better health, reduce need for medical care, and allow fuller enjoyment of life. Medical treatment should not promote harmful or high-risk behavior. Statins are used to reduce the problem of disease and death caused by hardening of the arteries. Most importantly, statin drugs, in the appropriate population, significantly reduce the risk of heart attack, stroke, and premature death.

CLOSTRIDIUM DIFFICILE by Robert H. Kelly, MD FACP

C. difficile is a difficult problem in medical care today. C. diff infection can cause diarrhea, severe illness, and even death. Diagnosis is based on testing for the presence of C. difficile organisms in a stool specimen. There are novel treatment ideas out there. A previous PMH@Home article mentioned doing a stool transplant to treat C. difficile. Another idea is to improve identification and diagnosis of disease.

SMART WALKING by Robert H. Kelly, MD FACP

An article in JAMA (Accuracy of Smart Phone Applications, 2/10/2015, Vol. 313, #6, pg. 625), looked at the accuracy of some of the devices used to measure activities or steps. The devices were compared against a standard 500 and 1500 step trial. A treadmill was used set at 3 miles per hour and 10 different devices were worn. Step count from the devices was measured after each trial.

PEANUT ALLERGIES by Allan R. Kelly, MD FACP

Peanut allergies are a problem in the pediatric age group, but I thought PMH members would be interested in a report from the New England Journal of Medicine on how to prevent peanut allergy from developing.

PMH QUOTATIONS Spring 2015

"They who are accustomed to daily labor, although even weak or old, endure labor more easily than the robust or young who are unaccustomed to it."


Hippocrates


"I tell all my patients that frequent exercise is just as important as their medication in controlling their cardiovascular disease."

Joseph S. Alpert, MD


"At day's end, after we have stripped away the science, medicine consists of one person helping another, and the visceral desire to assuage another's hurt, to provide hope even when we have lost it ourselves."


Samir K. Shah, MD


Winter of 2015

PMH STORY by Allan R. Kelly, MD FACP

Premium Medical Home has many components, including direct communication by telephone and cell phone between the doctor, the patient, and the patient's family. A recent example of the value of direct communication involved an elderly lady whose husband could no longer care for her at home. He spent some time choosing an excellent assisted living facility. He chose one that was close to his home and that offered much of what he wanted. He moved his wife to the facility on a Wednesday. All seemed well, but five days later on Monday, the husband called the doctor with bad news. The facility could no longer care for his wife, and he would have to take her home the next day. He was told her needs were beyond the capacity of the facility because of behaviors the facility could not handle. The PMH doctor asked who had told him that his wife would have to leave and then set up a conference call between the husband, the facility charge nurse, and the physician. In this 3-way conference call, the specific concerns of the charge nurse were explored and discussed. The problem was amenable to medical treatment, and the doctor made recommendations for changes in medication and behavioral modifications. The nurse, the husband, and the doctor agreed on a plan of care over the next several days, and the facility agreed to keep the wife in their facility. Psychiatric consultation was also arranged.

The next day, the charge nurse reported that the behaviors had improved.

Later, the doctor's office received a thank you note from the husband saying he had given up hope that his wife could stay in the facility and was surprised by the quick conference call. He further added that the nurses at the facility much appreciated the prompt assistance.

A doctor's schedule can often be busy or hectic, but less so in a PMH office. PMH emphasizes the comfort and convenience of patients and their families. Comfort and convenience are not trivial, and enhance the experience of patients and families in their medical care.

SLEEP AND WAKEFULNESS by Robert H. Kelly, MD FACP

A recent report showed that of nearly 1000 patients referred to the Mayo Clinic for insomnia, 91% were found to be suffering from obstructive sleep apnea, not from simple insomnia. In such cases, treatment with standard sleeping pills would worsen the sleep apnea problem, the disease which was driving the patient's insomnia: why is this so?

IMPROVING PRIMARY CARE by Allan R. Kelly, MD FACP

Continuous improvement is an important goal. We want to do a better job. One of the great interests in medicine today is to improve the outpatient care of patients with serious chronic illnesses. A recent study looked at how to improve care for high risk and chronically ill children. The study called the process "enhanced medical home." I have reviewed many studies of how organizations can improve care: the results have been so-so. Some added more healthcare practitioners, nutritionists, social workers and consultants. But this study proposed "comprehensive care." The goal was to have the clinic open 40 hours per week and staffed by a physician and nurses. Another big element was: "All patients had the cell phone number to directly reach one of the primary care clinicians at all hours." There were direct conferences with ER doctors about emergency care. These are the same types of interventions that we emphasize in Premium Medical Home.

AMERICAN HEART ASSOCIATION, STATIN USE, AND EXERCISE by Allan R. Kelly, MD FACP

In 2013, the American Heart Association changed guidelines for the use of statins, doubling the number of Americans falling into the "treatment recommended" group.

HAND WASHING by Robert H. Kelly, MD FACP

There are at least two key elements to hand washing: the cleansing agent and the method of drying. The most important disease control for the doctor to do in the clinic, and for patients to do in their everyday lives, is to keep their hands washed at appropriate intervals. This is true for all of us prior to mealtime and after being in the restroom or public places. With adequate hand washing, significant reductions in infectious disease have been reported in hospitals, schools, and elsewhere.

PMH QUOTATIONS Winter 2015

"Most important of all, your patients may not see [things] the same way that you [physicians] do. We [patients] are the experts on what we value."


J. McDonagh, JAMA Internal Medicine, 2014; 174 (12): 1889.


"Walking is man's best medicine."

Hippocrates


"The best preventive approach in frail older adults may sometimes involve doing less rather than more."


M. Clarfield, JAGS 2010; 58: 2019.


Fall of 2014

PMH STORY by Allan R. Kelly, MD, FACP

The patient was an elderly gentleman whose daughter was his caregiver. He lived in a rural area, and most of his care had been provided by rural doctors. He was hospitalized, and the PMH doctor was asked to visit. During the consultation, staying in touch via a few cell calls, the patient's illness and needs were tracked.

Soon thereafter the patient was discharged home. The patient's daughter requested that the PMH doctor continue to care for her father at home, despite the distance. The PMH doctor asked the daughter what value she saw in this extra cost. She said that after decades of trying to coordinate her father's care, she had never before had the personal cell phone number of a physician. She found it so unusual, so helpful, that even though she might not be able to bring her father to see the PMH doctor on a regular basis, just knowing that she could consult by telephone when needed was valuable to her.

We hope that all doctors will embrace the idea of direct, open, and convenient communication between themselves and their patients. As our motto says, it's "like having a doctor in the family.", a doctor you can call when you need to, when there are questions, and when there is illness. A direct relationship can promote better outcomes for patients and their families.

Of course, there will always be limits. Doctors need to sleep and have time to do their work. But it is not a burden to offer the same direct communication to our subscribers as we would to family, neighbors, or old friends. This is part of the PMH subscription, a premium valuable to patients and families.

ANXIETY, EXERCISE, AND YOGA by Allan R. Kelly, MD, FACP

Researchers reported on the effect of exercise on anxiety. Participants in the study were randomized into three groups. One group would only stand, another would walk, and the third would jog gently or walk quickly on a treadmill for ten minutes.

NUTS, CORN, AND POPCORN IN DIVERTICULOSIS by Robert H. Kelly, MD, FACP

Diverticula, or the little pouches that form along the wall of the colon, measuring from a few millimeters to 2.0 centimeters in size, are part of aging. Rarely seen before the age of 40, by the age of 70 they are common. They are a normal part of the colon after the age of 60, a condition called diverticulosis.

EXERCISING FOR HEALTH by Allan R. Kelly, MD, FACP & Robert H. Kelly, MD, FACP

Exercise improves health. Recent reports continue to confirm that sedentary adults over the age of 50 have a fourfold increased risk of death over the course of study compared with adults who pursue moderate physical activity.

FOOTBALL SEASON by Robert H. Kelly, MD, FACP

Data were published several years ago looking at NFL football players’ cardiovascular risk factors. Compared to the normal population of average risk individuals, men 25-37 years of age, there were some striking differences that suggested football players were an unhealthy lot: body mass index was higher, waist size higher, and blood pressure higher.

PMH QUOTATIONS Fall 2014

"The fact is that in order to have the privilege of doing this job, we may have to miss dinner once in a while to take care of someone who got sick. . ."


Victoria Johnson, MD, NEJM 2013; 369:2279


". . . the relief and comfort given to an aged patient often effect the prolongation of life if only by restoring the willingness to live."

Alfred Worcester, MD, JAMA 2014; 312:1159


Summer of 2014

PREMIUM MEDICAL HOME STORY by Allan R. Kelly, MD FACP

Mr. Doe had excellent health most of his life, but had recently been having abdominal symptoms. Workup showed an unusual malignancy.

We made arrangements for consultation in Fort Worth. The patient was satisfied with the oncologic consultant, and we began a plan of treatment. But the patient was uncertain whether or not more should be done. The oncologist was a new doctor for Mr. Doe who didn’t know entirely how to "read" the doctor's manner.

This led to repeat telephone consultation with his PMH doctor. The patient was trying to develop insight into the consultant's style. The PMH doctor had known this consultant for decades, understood these issues, reassured the patient, and went over the details. Though helpful, the patient wanted more. Fifteen years earlier, for a malignancy that had been cured, he had ended up going to M.D. Anderson hospital. He wondered if he should go back.

The patient was getting ready to go on vacation, was anxious, and faced a potentially life-threatening illness with important decisions to be made. After hanging up from Mr. Doe, Dr. Kelly called M.D. Anderson and found the names of two doctors there who treated this specific malignancy. One of the doctors kindly and promptly called back. Dr. Kelly was able to review what M.D. Anderson could do for Mr. Doe. The M.D. Anderson doctor offered to see Mr. Doe at a time of convenience.

Dr. Kelly called back Mr. Doe. Dr. Kelly outlined what he had learned about what M.D. Anderson had to offer. Mr. Doe listened carefully, considering his options. He said that he would think about it some more, that he appreciated Dr. Kelly's work, and it sounded to him like he would probably decide simply to stay right here in Fort Worth and work with his new oncologist.

When patients face severe issues, such as cancer, there are going to be a lot of questions. Many of those questions should be answered and should be resolved by the oncologist. But there will be issues of personality, manner, and judgment calls where an open, friendly, and professional relationship with a physician can make a big difference. But also, does the primary care doctor have time to search out answers and options for his patient? In many practices, driven by volume, short appointments, and insulation of the physician from telephone contact with patients, there may not be enough time. In the PMH practice, it is our commitment to make that time available to you at times of stress such as an important diagnosis, injury, or hospitalization.

THE IPHONE PANCREAS by Allan R. Kelly, MD, FACP

Diabetes is a major cause of illness and expense in the United States. Its complications include amputation, end-stage renal disease, stroke, and blindness. Diabetes for centuries was treated with dietary modification, weight loss, and calorie restriction. Since 1928, the development of insulin and the ability to easily measure blood glucose have transformed the lives of diabetics for the better.

OSTEOARTHRITIS PHYSICAL THERAPY by Robert H. Kelly, MD, FACP

A series of recent publications have examined the safety of "hypnotic" drugs, drugs like Ambien, Xanax and Ativan. This class of drugs is derived from Valium. They have been helpful in medical practice. Ativan, for example, has been used to treat anxiety, seizures, sleep disorder, and psychosis.

OBESITY by Robert H. Kelly, MD, FACP

Nutrition is good but too much food, eating more than we should, can cause obesity. Obesity leads to diseases such as sleep apnea and liver dysfunction, and it makes other diseases worse, like hypertension and diabetes mellitus. Obesity increases weakness, sickness, and risk.

ADVERSE EFFECTS OF MARIJUANA USE by Robert H. Kelly, MD, FACP

Though Colorado has made marijuana purchase and possession legal, there is debate about whether or not marijuana is harmful. It's a safe bet that it is: medicines which adversely affect judgement and health, create dependency and habituation, and do not improve health are bad and should not be used.

PMH QUOTATIONS Summer 2014

"Above all, physician do no harm must be first and foremost, just in front of humility."


Peter Weiss, MD, FACOG, UCLA School of Medicine, 2014


"For a generally healthy 85-year-old, the physical exam could reasonably be limited to blood pressure measurement and assessment of the body mass index."

Michael Rothberg, MD


"The opportunity for doing wrong by careless talk to sick people and their families seems almost limitless."
Sol Pepper, Doing Right, p.26

Spring of 2014

PREMIUM MEDICAL HOME STORY by Robert H. Kelly, MD, FACP

The patient received a note from his pharmacy supplier that a critical brand name medication would no longer be covered. Early in the course of his illness, he had been unable to tolerate the generic version of the medication. The brand name was well tolerated and for 10 years had helped prevent serious illness. In addition, recent gastrointestinal complications had increased the risk of medication side effects. The patient came by the office to address concerns about changing medications.

Prior to the patient's arrival at the office, Dr. Kelly had received information about the denial of medication coverage. A form had been completed requesting pre-authorization for the questioned medication. In the meantime, thought was given to whether or not a change in dose or change in medication would be acceptable.

Dr. Kelly called a neurology specialist. The specialist answered the call and said that he would be happy to see the patient in 15 minutes. A quick consultation was completed. The specialist thought it best not to change the medication or dose. We communicated these conclusions to the insurance company, and the needed medication was then authorized.

In the course of an hour, a serious question had been addressed, pre-authorization completed, and consultation done to confirm the course of treatment. This level of coordination is accomplished on a daily basis in many medical offices, but because of often crowded schedules, communication may be delayed. In large offices, different providers are tasked with different elements of the care, contributing to fragmentation of care and possible delay. In the Premium Medical Home, however, more often the physician and the patient will directly address and resolve these questions, promoting more rapid and less complicated resolution.

This is one of the benefits of a Premium Medical Home, providing not only for prompt medical care and recommendations, but also for the patient's convenience and comfort.

DO PHYSICIAN EXTENDERS IMPROVE MEDICAL CARE? by Allan R. Kelly, MD, FACP

A report in the February 2014 Journal of the American Medical Association addressed whether adding more money and using physician extenders can improve medical care. The study, done in Pennsylvania between 2008 and 2011, looked at practices run by doctors based on their own judgment versus practices participating in a government designed program. The interventions in the latter group included bureaucratic creations like "breakthrough series learning collaborative," "monthly quality indicator reports," "practice coaches," NCQAPPC-PCMH recognition with level one recognition required, and performance improvement efforts. More definitively, the Pennsylvania experiment offered doctors money, a bonus of up to $95,000 to each physician who hired a physician extender such as a nurse practitioner or physician's assistant.

AMBIEN, XANAX, ATIVAN… by Allan R. Kelly, MD, FACP

A series of recent publications have examined the safety of "hypnotic" drugs, drugs like Ambien, Xanax and Ativan. This class of drugs is derived from Valium. They have been helpful in medical practice. Ativan, for example, has been used to treat anxiety, seizures, sleep disorder, and psychosis.

MARION EMERGENCY CARE CENTER by Robert H. Kelly, MD, FACP

Harris Hospital has opened the new Marion Emergency Care Center and an attached Senior Health Center. Until the opening of the Marion Emergency Room, Harris's ER was plagued by crowding, hallway examinations, and long delays. These have been eliminated with the new Marion ER. The whole hospital seems to have refocused on the comfort and dignity of sick patients and their families while continuing to provide medical care.

COLON CANCER SCREENING by Robert H. Kelly, MD, FACP

The American Cancer Society recommends colon cancer screening after age 50. Cancer screening is commonly done either with fecal occult blood testing or colonoscopy. The American Cancer Society prefers colonoscopy because it is a more thorough exam. But despite being better, this recommendation causes some harm: recommending colonoscopy and neglecting the option of the stool test kit reduces the overall level of screening.

PMH QUOTATIONS Spring 2014

"The needs of the patient come first."


Mayo Clinic


"Where the art of medicine is loved, there is also a love of humanity."

Hippocrates


"That which is used develops. That which is not used wastes away."
Hippocrates

Winter of 2014

PREMIUM MEDICAL HOME STORY by Robert H. Kelly, MD, FACP

The patient, a doctor, had been well, but suddenly became ill on a Sunday afternoon. There was no recent travel, and others in her family were well. She suffered marked nausea and repetitive vomiting: nothing would stay down.

When she called, she reported to her doctor that she had tried a dose of nausea medicine: even that would not stay down. She felt as bad as she had ever felt in her life. She told her PMH doctor she was going to the emergency room.

After hearing the story, her PMH doctor asked a few questions. There was no sign of fever or bleeding. She had never been sick like this before. Options were discussed. Recommendations were made to rest and to take a second dose of the anti-vomiting medication, try some clear liquids, call back after half an hour and delay going to the ER.

At the time of her call back, she was resting in bed. She had taken the extra dose of medication and had kept down some sips of clear liquids. She felt better and decided not to go to the emergency room after all. The evening was spent in the peace and quiet of her own home, not at the ER. Her body was able to recover somewhat more naturally, with the help of the medication.

The next morning she reported recovery and decided to go on to work. This was, in short, an episode of food-borne illness with nausea and vomiting which resolved.

An experienced doctor who picks up the phone can give a person, even a fellow health care provider, confidence and prudent advice she can follow. Too often telephone calls to a doctor's office after hours are handled differently: the answering service, the waiting, the nurse who triages the call and the customary, "If you are suddenly ill, go to the emergency room" are routines that have to be followed. At PMH we think it is better when a knowledgeable, committed physician answers the phone. Familiar with the member's history, her health, and the tools available, the doctor can make a more defined, personal set of recommendations.

Sometimes patients are sick and have to go to the ER or hospital. But in many cases, knowledge and experience quickly accessed can save a trip to the hospital or emergency room. This is one of the benefits of the Premium Medical Home model.

NUTS AND HEALTH by Robert H. Kelly, MD, FACP

"You are what you eat", our grandmothers told us. Diet is important. Nut consumption has been of interest to doctors and patients. Are nuts good for your health? This question was addressed in the 2013 New England Journal of Medicine study of 100,000 men and women in the Nurses’ Health Study from 1986 to 2010. That was 3,000,000 years at risk that were assessed! The recent study showed that nut intake correlated with survival. Pooled analysis for death showed a 7% risk reduction for those who ate nuts less than once a week on average, compared to those who did not eat nuts; 11% risk reduction for those eating nuts at least once a week; 20% reduction for those eating nuts 7 or more times per week. Eating nuts at least once per week appeared to reduce overall mortality, and specifically mortality related to cancer, heart disease and respiratory disease.

AROMATHERAPY by Robert H. Kelly, MD, FACP

Falls in the elderly can lead to severe injury, increased risk of death and loss of independence. Efforts at reducing falls have attracted attention for some time in geriatric care, especially in hospitals and nursing homes, where the elderly are at high risk of falling.

TAKE YOUR MEDICINE by Allan R. Kelly, MD, FACP

One of the critical jobs a physician faces is to identify disease and propose treatment that will alleviate suffering and promote health. Oftentimes, medications are an important part of this effort.

SHINGLES VACCINE by Allan R. Kelly, MD, FACP

The shingles vaccine, Zostavax, has markedly reduced the incidence of painful shingles. This is a boon to adults. The vaccine was originally released for the over 60 population, and then later approved for over 50. At a December meeting of the American Advisory Committee on Immunization Practices, the CDC addressed the relative benefits of vaccinating at 50 or at 60.

PMH QUOTATIONS Winter 2014

"The health of my patient will be my first consideration."


Declaration of Geneva, JAMA, November 27, 2013; Vol. 310, No. 20: p. 2191


"I don't know what your destiny will be . . . but I know one thing: the only ones among you who will be really happy are those who have sought and found how to serve."

Albert Schweitzer


"The only real change, it seems, is that every year, fewer of us practice medicine and more of us talk about it."
James H. King, MD, Annals of Internal Medicine, January 7, 2014; Vol.160, No.1: p. 68

FALL 2013

PMH STORY by Allan R. Kelly MD FACP

The elderly patient had not been seen for some time in the doctor's office. He had three children. There had been no complaints from the patient, nor had the doctor received any calls from the family.

A call came in from the patient's daughter who lived far away. She asked the doctor to call her back.

When time allowed, the doctor called. At first the daughter's concerns seemed minor. She talked about her father's weight gain and then his poor spirits after the death of the mother a year ago. But with time the daughter talked about other concerns. She recalled her father's tremor and a fall months ago which had not been reported to the doctor. The patient and doctor visited the next day. With special attention to the fall, adjustments were made in medication and arrangements made for physical therapy to address imbalance and fall risk.

Allowing time for conversations like this results in better understanding. There is no way to predict what we will learn from a conversation. A doctor needs time to allow families to bring their concerns forward. In a practice driven by volume and billing codes, such time is hard to come by. In a practice where families communicate indirectly with the doctor through office staff, there is less opportunity for direct dialog.

In Premium Medical Home, we are committed to making time for family members to talk to the doctor. The doctor will, of course, respect the patient's privacy. The relationship is direct: the patient or family talk directly to the physician when they feel the need. The number of patients is limited so that there is time to talk. This is a part of Premium Medical Home.

STATIN DRUGS MAY PREVENT DEMENTIA by Robert H. Kelly, MD, FACP

The FDA, in the last year, warned that statin drugs might be associated with memory problems. Are statin drugs bad for our brains? We don't see such evidence.

For example, a recent study published in the Journal of the American Geriatric Society (2013, Volume 61) showed using statin drugs before Alzheimer's disease develops may reduce the risks of developing Alzheimer's.

SORE THROAT, COUGH, AND BRONCHITIS - WHAT TO DO? by Allan R. Kelly, MD, FACP

Most of us have had wintertime illnesses characterized by stuffiness, drainage, sore throat, and cough. For example, see the PMH Story in this newsletter. The majority of these illnesses will resolve spontaneously and antibiotics usually make no difference

There are things we can do. Websites can be informative (e.g., MayoClinic.com). For adults, over-the-counter medications can be helpful. Tylenol, zinc lozenges, and vitamin C have all been shown to be useful for some patients. Even the old home remedy of a teaspoon of honey reduces nighttime cough and discomfort. Prescription medicines also may slightly reduce symptoms.

FRAILTY by Robert H. Kelly, MD, FACP

As we age, our health changes. And there is a pattern - some are healthier and others are not. A syndrome of chronic poor health in the elderly is called frailty.

Frailty is a syndrome, a collection of symptoms and signs of illness of uncertain cause. The key elements of frailty are: loss of function in an activity of daily living, decreased strength or energy, unintended weight loss, and increased vulnerability, infection, and illness.

SHOULD I MEASURE MY OWN BLOOD PRESSURE? by Allan R. Kelly, MD, FACP

When high blood pressure is identified and treated, there is a substantial immediate and long-term reduction in the risk of stroke. Office measurement and treatment are the bedrock for the evaluation and management of hypertension.

Blood pressure can be easily measured in our homes. Blood pressure monitoring equipment is available in pharmacies and health clubs. Does self-monitoring of blood pressure further reduce the risk of stroke or heart attack compared to simple office measurement?

HEPATITIS C by Allan R. Kelly, MD, FACP

Hepatitis C is an uncommon but dangerous infection. Those who have had transfusions are at greater risk. It can result in problems including cirrhosis, liver cancer and death.

Hepatitis C spread throughout the world after the Second World War.

PMH FEES

New PMH fees will go into effect on January 1, 2014. The new fees are posted on our web site,www.PremiumMedicalHome.comand are also available by calling the office. As your PMH renewal becomes effective, you will be billed for the new 2014 fees.

PMH QUOTATIONS FALL 2013
"Our dean asked the medical students how many of them had been advised by at least one physician not to go into medicine; 80% of the students raised a hand."
- Lawrence Hergott, MD ; "The View From Fiesole"JAMA, July 10, 2013; Page 147
"I have the distinct feeling that the patient in America is becoming invisible. She is unseen and unheard. . . I generally insist that we go to the bedside, but that is often the place where the team is no longer at ease. I realize what has happened: the patient in the bed is merely an icon for the real patient, who exists on the computer."
- Abraham Verghese, MD; JAMA, July 17, 2013; Page 265
"To prevent disease, to relieve suffering, and to heal the sick - this is our work."
- William Osler, MD

Summer of 2013

PMH STORY by Robert Kelly MD FACP

The patient was at home. Her husband had died some years ago. Her family lived out of state.

She noticed a strange feeling in her chest. Heart attack was far from her mind – there was no prior problem with heart disease. Simple remedies like yawning and deep breathing did not resolve the sense of oppression across the chest. She called her Premium Medical Home doctor's office at approximately 9:00 a.m. and was immediately speaking with the PMH nurse so well known to her. Within minutes, her PMH doctor had reviewed her chart and her problem, and recommendations were given to go to the hospital for care. The doctor called and alerted the hospital staff to the patient's needs.

A cardiologist, whom the patient had not previously met, was waiting when the ambulance arrived. By noon, cardiac catheterization and intervention was done. The problem was identified, a solution provided, and she was soon recovering in the intensive care unit.

Lying on a bed in the ICU, surrounded by strangers, there was a certain feeling of anxiety and anonymity. At 2:00 p.m., the patient's PMH physician came to see her. On his arrival, the patient exclaimed, "Oh, Dr. Kelly, I can’t tell you how good it is to see you." Discharge was made several days later, with a continued healthful life at home.

This is a Premium Medical Home story, not because of a favorable medical outcome, an outcome which would have likely been achieved with prudent care. What is different is that, in the midst of this illness, in the midst of all the new people, and in the midst of the intensive care unit, members of a Premium Medical Home can count on seeing the physician whom they have learned to trust and whose manner and methods they have become accustomed to. They are seen by a physician who knows them and their family, who knows what has been important to them over the months or years prior to their acute illness and who knows the consultants and the hospital staff. This was why the patient was so happy to see her doctor. This is another reason we created Premium Medical Home.

A DOCTOR'S OFFICE VISIT IS NOT ALWAYS NECESSARY by Robert H. Kelly MD FACP

Recent issues in the abortion debate may unexpectedly shed light on efficiency that could improve medical care. The doctor's office is not always the best place to get the medical care we need. Certainly, many treatments are now available without prescription, such as over the counter medications, even the Plan B contraceptive that can be sold to any girl regardless of age. It seems reasonable to ask, if regulators believe a 12 year-old girl has adequate judgment to buy Plan B, why should not a 42 year-old mother of three have the ability to buy antibiotics for her children? This issue of patient directed care deserves attention in less controversial areas.

PHOTOGRAPHS by Allan R. Kelly MD FACP

A helpful communication is taking and sending photos by cell phone. Recently a middle-aged woman noticed a spot on her finger and wondered whether it was the sort of thing that she should check with the doctor. She had hurt it, it was tender, and she thought it was infected. She called my office late in the afternoon. She asked whether or not she should go to the emergency room.

SHELF LIFE: BETTER THAN YOU MIGHT THINK by Robert H. Kelly, MD FACP

The question often arises: how long after the expiration date can the medication still be safely used? From the safety perspective, the answer may be that there is little safety concern, but from a potency or effectiveness perspective some medications do lose their effectiveness. A study was done last year that looked at medications that were held in a federal program of strategic reserve. These medications had expired between 28 and 40 years before testing. Capsules or tablets from each medication were tested looking for the presence and concentration of the active ingredients.

REFLUX MEDICINES AND FRACTURES by Allan R. Kelly MD FACP

The longer medicines are on the market the more we learn about their benefits and their risks. Learning about the risks of medicines can clarify how best to use them safely. Newly reported problems with proton pump inhibitors (PPI's) have come to light after twenty years of experience. Examples of PPI's are Nexium, Prilosec, omeprazole, Protonix, and Prevacid, among others. They often relieve symptoms of reflux and protect from complications such as ulcers, perforation and bleeding. They do a great job. It appears that prolonged use of PPI's increases the risk of fracture. This is important as fractures are associated with serious health problems, surgery and functional loss.

DEMENTIA: MEMORY OR BEHAVIOR? by Allan R. Kelly MD FACP

We all know that smoking causes suffering from stroke, heart attack, and cancers. There are other risks worth being aware of, as we counsel family and friends who smoke.Tobacco use correlates with psychiatric illness, complicates its treatment and contributes to early mortality and morbidity in those with mental illness. This is a perspective that many may be unaware of.

PMH QUOTATIONS SUMMER 2013
""Once with his patient, he must, in word and thought, attend to nothing but his patient's case and what concerns it."
" - Oath of the Hindu Physician, circa 1500 B.C.
"Under the present system of supervision it is unlikely that many of the successful surgical innovations we have witnessed would have been achieved "
- Allen B. Weisse, M.D.; Proceedings; Baylor University Medical Center; July 2013, Volume 26, No. 3, Page 310
"". . . the importance that professionals ascribe to patients' deep experience and such enduring moral practices of caring, as the laying on of hands, the expression of kindness, the enactment of decency, and the commitment to presence – being there for those who need them. This is the embodied wisdom medical students need to learn and we all must remember."
- Arthur Kleinan, M.D.; New England Journal of Medicine; April 2013

SPRING 2013

PMH STORY by Robert R. Kelly, MD FACP

Around 2 PM one weekday afternoon, a long time patient e-mailed Dr. Kelly with concerns about depression and anxiety. An hour or so later, looking at e-mails while between patient appointments, Dr. Kelly noted the message. The chart was pulled for Dr. Kelly, who sent the patient a quick e-mail that discussed some principal treatment options to consider, including a change in medication, visits, consultation, and further testing. Within minutes, an opportunity arose to call the subscriber on the phone; discuss symptoms; review the e-mail notes; and establish reasonably that there was no suicidal risk. Options were discussed.Based on the patient's preferences, a referral was made to a counselor. The Premium Medical Home nurse called the subscriber back that afternoon with contact information for the counseling.

Though happy to visit with the subscriber at an office visit, the needs, in this case, were well met by a consideration of the patient's symptoms; review and modification of treatment; and referral to an appropriate source for psychological counseling.

Subscribers can avoid long waits for a return call when they are in a Premium Medical Home. They do not need to first talk to a nurse or a nurse practitioner. There is no need or expectation that they visit at the office to receive information about options or alternatives, as some of the most important care given to patients occurs on the phone and when they are at home.

Your Premium Medical Home subscription recognizes this fact and creates avenues for you to contact your doctor directly for advice, counsel, treatment, and referral where needed. This leads to more efficient care and better satisfaction.

HOSPITAL ACQUIRED INFECTIONS: NOT ALL SOAPS ARE THE SAME by Dr. Allan R. Kelly, MD FACP

Everyone knows that antibiotics can have side effects, and one of the side effects can be diarrhea. Many have heard about Clostridium difficile or C. diff. A disease that is a complication of antibiotic therapy, C. diff can be dangerous, and even a cause of death. The treatment is only partially successful: many patients relapse, some die, and many may face months or years of recurrent illness.

FALLING by Dr. Allan R. Kelly, MD FACP

Falls are embarrassing and can be dangerous. It is important for doctors, patients, and families to work together to reduce falls. After age 70, the most common causes of accidental death are injuries sustained in a fall. Most falls do not result in injury, and it is estimated that people over age 85 will have two to three falls per year.

QUALITY OF CARE by Dr. Robert Kelly, MD FACP

One pernicious element of centrally planned medical and surgical care is an assumption that normal people are not capable of making judgments about what is best for themselves. Can a federal agency better identify what is best? The problem with this assumption was recently demonstrated in a study of weight loss surgery, also called bariatric surgery. The best approach to weight loss in the obese is life style change.

BLOOD PRESSURE by Dr. Robert Kelly, MD FACP

For blood pressure, the doctor should treat the person, not the number. In the younger elderly, those below 80 years of age, treatment of hypertension helps reduce the problem of heart failure, dementia, and stroke. New research on high blood pressure in those older than 80 is yielding surprising conclusions. A recent report from the Netherlands published in The Journal of the American Geriatric Society explores high blood pressure in the over 85 group.

PMH QUOTATIONS
"What is allegedly true and useful today may be shown to be worthless tomorrow."
- Joseph Alpert, MD, The American Journal of Medicine, February 2013
"We medical people really have no idea what we put patients through."
- Edward Viner, MD: The Physician as Patient, 1985
"May there never arise in me the notion that I know enough, but give me the strength and leisure and zeal to enlarge my knowledge. Our work is great and the mind of man presses forward forever."
- Maimonides, physician (1135 – 1204)

Winter of 2013

PMH STORY by Robert H. Kelly, MD FACP

The patient woke up Friday morning with poor appetite, weakness, diarrhea and vomiting. He spoke on the telephone with his PMH doctor, who suspected a GI virus and prescribed medicines to help with the nausea. In a follow-up phone call the patient was not improved. The doctor recommended admission to the hospital for testing, IV fluids and better symptom control.

The doctor called the hospital and reserved a room for the patient. Initial orders for care were given. The PMH nurse called the patient back with room number and explanation of the admission process. An ambulance was called for transportation.

The paramedics took him to the hospital. The Emergency room was crowded, full of influenza cases and Friday Emergencies. The patient reported that patients were lined up two deep in the hallway, and some family had prepared pallets on the floor to sit or rest.

The paramedics told the ER desk clerk that the patient had been directly admitted to the hospital by Dr. Kelly, and was not to be seen in the ER. The clerk confirmed the bed assignment and the patient went upstairs for continued care. The stay in the emergency room was less than five minutes.

Upon leaving the ER, the paramedic told the patient, "You must have some kind of doctor." His partner added, "Yeah, most of the time when people tell us that admission was arranged by the doctor, no one in the ER knows anything about it so they stay in the ER."

Sometimes emergency room care is necessary and cannot be prudently bypassed. Sometimes the patient's needs are better met in a regular hospital room, not in the Emergency Room. When that is the case, it is good to have a doctor that you can call directly and who will arrange direct admission to the hospital without an unneeded visit to the ER. This is one value of a PMH subscription.

LABORATORY TESTS: TO FAST OR NOT TO FAST by Allan R Kelly MD FACP

In the 20th century, the diagnoses of diabetes and cholesterol abnormalities were based upon fasting blood work. Fasting blood work dates back to the 1930's and 1940's when treatment for diabetes with insulin first became available. A fasting oral glucose tolerance test was the gold standard. Subsequently, fasting was thought to be the appropriate time to test other metabolic parameters. Our patients who were born prior to 1960 are accustomed to the idea that blood work should be taken prior to the first meal of the day.

URINARY TRACT INFECTIONS: OVER-TREATMENT CAUSES PROBLEMS By Allan R. Kelly, MD FACP

Urinary tract infections are a common problem in both the healthy and the frail populations. Traditionally, a urinary tract infection is diagnosed when people have bladder symptoms and laboratory testing shows inflammation of urine, as well as a positive culture. Many are familiar with this scenario in ourselves and our family. We know that a few days of antibiotics will generally take care of the problem.

FLU VACCINATION by Allan R. Kelly, MD FACP

We have all gotten used to the idea that the flu vaccine is good. Most medical organizations recommend routine annual flu vaccine for certain groups. However, past recommendations have generally not included the healthy adult between the ages of 20 and 50.

GERIATRIC ISSUES by Robert H. Kelly, MD FACP

Aspirin keeps attracting attention, some of it negative, some positive. For example, in persons suffering adult ‘wet’ macular degeneration, aspirin use may increase bleeding complications. If you have adult "wet" macular degeneration, ask your eye doctor if aspirin should be stopped or continued. On the positive side, in persons with heart disease or who have suffered stroke, the benefit of aspirin is well proven.

SLEEPING, VITAMINS AND FRESH AIR by Robert H. Kelly, MD FAC

Sleeping pills for insomnia are coming under increasing scrutiny and regulation. Each person deserves careful consideration of the causes and possible treatments for sleep disorder. There is some information that may be generally useful.

PMH QUOTATIONS WINTER 2013
"I hope physicians will avoid words like health care provider and consumer. We are physicians and we care for patients. Let the cost accountants provide and consume."
- Sol Papper, Doing Right: Everyday Medical Ethics, 1983, p. 66
"[Patient] Autonomy is not threatened by hearing the thoughtful opinion of experts about what they claim is the best course of action."
- Arthur Caplan, Mayo Clinic Proceedings, November 2012, p.1041

Fall of 2012

PMH STORY by Allan Kelly MD FACP

A PMH subscriber had a visitor. His family was hosting a teacher from China. Unfortunately, on the day prior to leaving Fort Worth, there was an accident. The host family's automobile was hit by another car. The car was drivable, and no one complained of injury. Initially, the teacher felt fine. On the way home, he said perhaps he should see a doctor.

Due to leave the next day, there was little time to make an appointment. The obvious alternative was to go to the emergency room, with expected long delays and high bills.

The subscriber called Dr. Kelly. After talking, Dr. Kelly offered to come to the subscriber's home and assist with evaluating and giving recommendations for care.

The visitor, now a patient, was seen and examined. The history was relatively benign, suggesting a whiplash like discomfort in the neck. Physical exam was normal. The medical options were straightforward and outlined to the patient. Symptomatic care was provided. Then the patient said he would need a certificate to give to his physicians in China.

Inquiring into more details, it was determined that a certificate could be quickly provided in longhand writing to satisfy the young man's needs. He returned to China the next day, "certificate" in hand!

The total time involved in this service was less than an hour, as opposed to the many hours that would have been required for an emergency room visit. The availability of medical evaluation and treatment access, which respects the individual's schedule, needs, and pocketbook, is one of the features and benefits of a PMH subscription.

PROVIDING CARE: THE WORK NO ONE SEES by Allan R. Kelly MD FACP

Though the United States continues to have good medical care for its citizens, there are issues that we need to address to improve quality of care and service. We hear people complain about short doctor visits and impersonal care. On the other hand, people are generally confident that the doctor is doing a good job.

RETHINKING THE ASSOCIATION OF HIGH BLOOD PRESSURE AND MORTALITY IN ELDERLY ADULTS by Allan R. Kelly MD FACP

Identifying and treating hypertension is a cornerstone of care for many adults. Over the past 20 years, mortality rates from cardiovascular disease have declined in part because of the power of antihypertensive therapy.

But later in life, the meaning of hypertension becomes more complicatd.

GERIATRIC CARE by Robert H. Kelly MD FACP

Geriatric medicine involves the treatment and care of adult patients with chronic illnesses and functional decline. Fifty percent of older adults have three or more chronic medical problems such as diabetes, arthritis, heart disease, and malignancy. Illness and treatment, combined with advancing years, are associated with decline in a person's function. It is the balance of medications, illness and function that concerns the geriatrician.

ORGANIC FOODS by Robert H. Kelly MD FACP

Some interesting findings about organic food have been reported recently. Research published regarding organic food came in the September 2012 Annals of Internal Medicine. Some of the key findings were:

1. Pesticide levels in urine were lower in children on diets with organic food, although in both regular food and organic food, pesticide levels were well below limits of toxicity.

PRAVACHOL, STATINS, AND MEMORY IMPAIRMENT by Robert H. Kelly MD FACP

Statin drugs are effective at preventing recurrent myocardial infarction. Regular use of statins by those with cholesterol elevation leads to reduced death rates.

Earlier this year the FDA warned about reported memory impairment in statin users: "Cognitive brain related impairment, such as memory loss, forgetfulness, and confusion, has been reported by some statin drug users." The FDA's concern began when several persons taking statin medication wrote the agency about problems with memory that occurred during their treatment.

PMH QUOTATIONS Fall 2012
"In this work against sickness we begin not with genetic or cellular interactions, but with human ones.
" - Atul Gawande, M.D., BUMCP, Volume 25, No. 1, January 2012, Pg. 60
"We miss more by not seeing than we do by not knowing."
- William Osler, M.D. 1926

Summer of 2012

PMH STORY by Allan Kelly, MD FACP and Robert Kelly MD FACP

Our father, Gordon Kelly, started a practice in Fort Worth in 1953. Over the next 40 years, he served the citizens of our community, the hospitals, and his colleagues in caring for the sick and providing good advice to the healthy.

Gordon's practice was devoted to private and one-on-one care of the individual. This represents an ancient and honorable tradition dating back to the days of Hippocrates. Over time, this basic relationship between a physician and a patient, a unique and personal relationship, has been the basis of medical and surgical care into the modern era.

Up to this point, it has not been demonstrated that there is something better than this traditional relationship. We hope that the development of medical teams, managed care, and diffusion of responsibility will be helpful and beneficial to our fellow citizens and our colleagues, but the benefit is uncertain.

Gordon died on June 29, 2012. His career is the basis of Premium Medical Home. His practice of medicine illustrates the ancient, honorable, and enduring human relationship between the sick and their physician. This is a tradition we treasure and promote at PMH.

CANCER SCREENING AND CONTROVERSIES by Allan R. Kelly MD FACP and Robert H. Kelly MD FACP

There are controversies in the areas of cancer screening. Two controversies emphasize reducing the frequency and intensity of cancer screening in otherwise healthy and vigorous people.

First, the annual visit for women for cervical cancer screening is changing. Years ago the American Cancer Society and the United States Preventative Services Task Force (USPSTF) recommended reducing pap smears to every three years. The recommendations changed as of 2012 to as little as every five years for women over 30.

RETHINKING THE ASSOCIATION OF HIGH BLOOD PRESSURE AND MORTALITY IN ELDERLY ADULTS by Allan R. Kelly MD FACP

Identifying and treating hypertension is a cornerstone of care for many adults. Over the past 20 years, mortality rates from cardiovascular disease have declined in part because of the power of antihypertensive therapy.

But later in life, the meaning of hypertension becomes more complicatd.

CONTINUITY OF CARE IS GOOD by Allan R. Kelly MD FACP

Patients like having the same doctor for a long time, a doctor who knows their medical history well. But does this actually improve outcomes; does it improve efficiency, cost, or morbidity?

The Mayo Clinic has used hospitalists for its inpatients for some time. A recent study, published in April 2012 by Chandra et al., looked at continuity of care among hospitalists and how it affected length of stay, healthcare costs and other outcomes. In one group, the same doctor remained in charge for the patient's hospital stay. In the other group, the attending changed with every shift.

TELE-MONITORING OR PERSONAL COMMUNICATION? by Allan R. Kelly MD FACP

The scientific method involves creating hypotheses and then doing experiments to test the hypotheses. An example of this simply involves the question of how we take care of people as they get older and suffer complex illness. A study in the Archives of Internal Medicine looked at patients over the age of 60 who are at high risk for re-hospitalization because of chronic medical illness. Does increased screening or monitoring improve health?

NOT ALL SYMPTOMS ARE WARNINGS OF DISEASE by Robert H. Kelly MD FACP

Some symptoms are common in healthy people. Hunger, thirst, sleepiness are universal experiences. Symptoms found in more than 30% include nausea, muscle pains and aches, and anger. Fifteen percent of normal persons report difficulty sleeping, headache and head pains, tiredness or lack of energy, nervousness, feeling of tension, worry and dizziness.

SMOKING by Robert H. Kelly MD FACP

We all know that smoking causes suffering from stroke, heart attack, and cancers. There are other risks worth being aware of, as we counsel family and friends who smoke.

Tobacco use correlates with psychiatric illness, complicates its treatment and contributes to early mortality and morbidity in those with mental illness. This is a perspective that many may be unaware of.

PMH QUOTATIONS SUMMER 2012
"The physician must have two special objects in view with regard to disease, mainly, to do good or to do no harm
" - Hippocrates Epidemics
"I love technology, but I think we are discovering that the physician-patient relationship is timeless. It cannot be abandoned . . "
- Andrew Verghese, MD, New England Journal of Medicine, May 17, 2012
"On a lot of patients, we cannot make the correct diagnosis. Some we diagnose, we cannot cure. But there is never a time in the practice of medicine that you can’t be kind to a sick man."
- Tate Miller, MD; BUMC Proceedings, Volume 25, No. 3, July 2012, Page 256

Spring of 2012

PMH STORY by Robert H. Kelly MD FACP

The call was not ordinary. A grandmother was requesting help for a visiting, out-of-town family member: her 10-year-old granddaughter. She had traveled here from out of state to join a family vacation. Unfortunately, she had become ill with fever and sore throat. The grandmother was worried, both about her and about others on the trip. Dr. Kelly offered referral to a pediatrician, but she said that she would like his help, so the grandmother and the granddaughter came to the office.

The child was not particularly ill. Dr. Kelly spoke with her mother on the phone and requested a release for treatment. This was provided via e-mail. She could be treated in the office or the child could be referred to a Pediatrician's office. Well aware of her options, she requested that Dr. Kelly proceed and take care of her daughter.

A culture was obtained and treatment initiated. The culture came back: there was no Streptococcus or other pathogen. This was likely a viral illness. As there was no fever by this time, the child posed little risk to others, and the vacation went along as planned.

The grandmother called at around 9 o’clock. The patient was seen at around 10:30 and was out of the office before 11:30. As a Premium Medical Home subscriber she was able to get direct and immediate access to her physician for her family member.

This is one of the advantages of a Premium Medical Home. When a family member or a visitor from out of town needs medical help, a host always has options. Emergency rooms are open 24/7. Urgent care clinics are available. Some family medical offices have walk-in clinics. As a Premium Medical Home subscriber, you have an option: call your physician directly for help, even when the patient would be new to the doctor's practice.

BREAST CANCER SCREENING: IT’S COMPLICATED by Allan R. Kelly MD FACP

A recent study from Norway looked at the question of mammography and the over-diagnosis of breast cancer. There has long been interest in whether annual mammography poses any risk to patients.In the past, there was study and recognition of the effect of x-rays on women with annual mammography. The risk of x-ray was straightforward and the dose has been greatly reduced. More challenging is the concept of "over-diagnosis" of invasive breast cancer.

NEXIUM, PRILOSEC, AND THEIR RELATIVES by Allan R. Kelly MD FACP

As medications come into widespread use, we learn more about their risks and benefits. This does not mean a medication becomes more dangerous, but that we know better how to use it, what to look for, and we learn about rare side effects or complications.

STATIN DRUGS: WARNINGS AND REASSURANCE by Allan R. Kelly MD FACP

Statin drugs like Lipitor, Simvastatin, and Crestor are known to reduce the risk of heart attack and stroke in many groups of patients. These drugs save lives.

When initially introduced, the risk of liver disease from statins was highlighted and there was an FDA warning that all patients on statin drugs should have liver testing done. This year the FDA has removed that warning.

MEDICARE WELLNESS VISIT by Robert H. Kelly MD FACP

Beginning in 2011, Medicare has directed doctors to offer an Annual Wellness Visit (AWV) to its beneficiaries. This concept of an annual check-up applies to all health conscious persons. In the past, such a visit was often referred to as an annual physical, but that name does not well describe the goals of an Annual Wellness Visit.

NEW FEES

Two years ago we launched Premium Medical Home to expand communication and enhance the relationship between you and your doctor. In order to maintain this high level of service and communication, we are adjusting the annual subscription to Premium Medical Home. The new rates will become effective July 1, 2012 and will be reflected on your statement as you reach your anniversary date for renewal.

PMH QUOTATIONS SPRING 2012
"While the convenience of electronic storage and retrieval of medical tests is undeniable, I am concerned about the likelihood of having to pay attention to the laptop to the detriment of the patient. The foundation of medical care starts with the patient-doctor interaction. That something so fundamental be disrupted by EMR's may be one of the reasons for their slow adoption .
" - Corey Krueger, MD, FACP, 2012
"The glory in medicine is that it is constantly moving forward and there is always more to learn."
- William Mayo, MD

Winter of 2012 Volume 3, Issue 1

PMH STORY by Robert H. Kelly MD FACP

I walked into my first medical care class. For two years, I had been studying medical science. Now it was time to learn about medical care: the clinical rotations. Surgery, Medicine, Pediatrics, all the sub-specialties: I had been waiting for this day.

A respected physician was at the front of the lecture room. There were 200 eager and intelligent medical students sitting in rapt attention. This was their first clinical lecture.

The gray-haired and thoughtful physician stood before us. He began his talk, and he said that he was there to tell us what the most important job was for a physician. We students leaned further forward. Newspapers were put down. Pens stopped clicking. Conversations were hushed. Four hundred eyes and 400 ears were tuned in to what the esteemed professor was about to say.

Many of us thought that he would say that cardiopulmonary resuscitation was the most important job that we would have, bringing those who had nearly slipped from our world back into life. Others thought that perhaps it would be the delivery, not only of a single birth, but perhaps twins or triplets. Others reasonably believed that the key issue would be the public health services of vaccination and prevention. Maybe research: the discovery of the next polio vaccination. Saving life. Preventing death. We all waited, knowing that our dreams of greatness would be confirmed by what our teacher was about to say.

"The first and most important job of a physician is to identify who is sick and who is well." He let that thought sink in. The room remained silent. Clearly this could not be our most important job. It had to be something bigger. The doctor went on to explain.

Doctors are needed to identify those who are sick and who are well. If they fail to identify those who are well, then people who are not sick will be treated, subjected to examinations and procedures that are not necessary, that are associated with cost and risk. At the same time, to fail to identify those who are sick leaves those suffering without the treatment that could give them comfort. In the world today, a common belief is that our problems are caused by some illness; there is disease that accounts for what is wrong. However, that is not always the case. Often, a person is well, and the problems they experience do not arise from disease, but arise from living, the normal function of the body, and the challenges that we all face.

At the very start of helping another person as a physician, the first job, the job this professor told me about 31 years ago, is to identify who is sick and who is well. Assistance, care, treatments, advice, and counseling can follow.

CANCER SCREENING GUIDELINES by Allan R. Kelly MD FACP

The American Cancer Society is a helpful source of information about cancer and cancer screening. In our offices we use the American Cancer Society (ACS) Screening Guidelines or the United States Preventive Services Task Force (USPSTF) to help give our patients good advice. Though The American Cancer Society is reliable, it is not above criticism.

NARCOTICS OVERDOSE AND DEATH by Allan R. Kelly MD FACP

The Center for Disease Control in JAMA, December 14, 2011, reported on troubling increases in death rates from prescription pain medications.

Over the past 10 years, the sale of prescription narcotics has increased 400%.This is an extraordinary increase. But the increase is not consistent. For example, non-Hispanic whites and American Indians are three times more likely to have narcotic prescriptions than Hispanics and Blacks.

CARDIOVASCULAR DISEASE by Robert H. Kelly MD FACP

For the last 40 years, knowledge of risk factors for lifetime risk of cardiovascular disease has been accumulating. This work was first studied in a town in Massachusetts, Framingham, where the earliest evidence of risk factors was identified. There is now a Framingham Risk Calculator, for example, which uses standard risk factors to calculate the risk of heart attack and stroke.

LOWER BACK PAIN AND YOGA by Robert H. Kelly MD FACP

Back pain is common. The best approach to a strained back or common backache is to continue with usual activities and try to resume a program of non-strenuous walking. Back exercises and simple over-the-counter remedies are useful adjuncts. Extensive evaluations or dangerous treatments are usually not helpful and, if research is correct, are counterproductive.

PMH QUOTATIONS WINTER 2012
The number of medical students who choose to train for a career in primary care internal medicine has been falling for decades and has now reached a critical point. If the trend is not reversed, many patients in the US will be left without access to a primary care internist "
- Joseph S. Alpert, M.D. , Editor in Chief American Journal of Medicine, 2011
"The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal."
- Francis Peabody, M.D.(1881–1927) The Care of the Patient

Fall of 2011 Volume 2, Issue 4

PMH STORY by Allan R. Kelly MD FACP

An elderly patient suffered aortic stenosis, a type of heart disease which can lead to poor heart function. Ten years earlier he had coronary artery bypass grafting on two occasions without complications and the aortic valve did not warrant repair. As the patient entered his 80's, the aortic stenosis became more of a problem: he would need surgical treatment or suffer heart failure and premature death. But in the setting of two prior heart surgeries in an 80 year old, the feasibility of aortic valve replacement seemed virtually impossible.

The patient's cardiologist referred him to a surgeon in Dallas doing a research study of percutaneous aortic valve replacement. The PMH internal medicine doctor was not part of this referral. The patient and his family asked the PMH doctor to review the protocols, talk to the doctors in Dallas and Tarrant County and share his opinions about the options. The patient benefited by talking about his problem with his PMH physician.

The PMH doctor also discussed the case with the surgeon in Dallas and made sure the surgeon had all the information he needed for enrolling the patient in the research study.

The implantation of the experimental valve went well, relieving the patient of his heart failure symptoms and resolving the problems of heart weakness. Upon leaving the hospital, the surgeon commented to the family, "Your primary doctor really cared."

Your PMH doctor is available to help you with difficult questions. Your private doctor, though no substitute for skilled sub-specialists and surgeons, is likely to have information and insight to help understand options. This direct availability and counseling is not described in CPT codes. We believe that this type of availability helps define a Premium Medical Home experience, like having a doctor in the family.

EXERCISE PROTECTS AGAINST COGNITIVE DECLINE by Allan R. Kelly MD FACP

Memory problems are common. But when do memory problems become an illness: Dementia or Alzheimer's disease? There are other reasons why memory may seem impaired………

EXERCISE PROTECTS AGAINST COGNITIVE DECLINE by Allan R. Kelly MD FACP

As reported elsewhere in PMH@ Home, cognitive decline is a common problem. We all know that memory changes as we get older, and many of us find it increasingly handy to keep a list in our pockets to help us remember………..

COUGH: OFTEN MORE BARK THAN BITE by Robert H. Kelly MD FACP

Cough is a common symptom. An acute cough is one described as lasting one to two weeks; subacute cough lasting three to eight weeks; and chronic cough more than eight weeks…………

OVARIAN CANCER SCREENING by Allan R. Kelly MD FACP

Ovarian cancer is an uncommon but often lethal form of cancer. While we have reasonable screening for cervical, colon, and breast cancers, the benefits of screening for ovarian cancer is unproven. In fact, the United States Prevention Services Task Force recommends against screening for ovarian cancer.

Medical Quotes:
"Reducing medicine to economics makes a mockery of the bond between the healer and the sick."
- Pamela and Jerome Groopman MD
"When we ourselves are ill, we want someone to care about us as people, not as paying customers, and individualize our treatment according to our values. "
- Pamela and Jerome Goodman MD

Summer of 2011 Volume 2, Issue 3

PMH STORY by Allan R. Kelly MD FACP

A Premium Medical Home subscriber was traveling to visit family. While in New York City on Saturday morning, she noticed pain and discomfort in the hip. Shortly thereafter, she noticed a rash and was uncertain of the cause, but it was both painful and visible. She called her Premium Medical Home doctor for advice.

Talking with the patient, the diagnosis was not immediately clear. The doctor knew that an examination of the rash would probably settle the diagnosis. He asked the patient to use her cell phone to take a picture of the rash and send it to him.

The picture was duly sent within two to three minutes. The photo demonstrated a rash consistent with shingles.

The doctor called the subscriber back and reviewed her symptoms and medical history again. The doctor asked her to look out the window of her hotel and see if she saw a pharmacy. There was one right across the street. The doctor called the pharmacy and ordered medication for shingles.

On returning to Fort Worth two days later, the patient had a consultation with a dermatologist, who confirmed the diagnosis that was made over the weekend. Medications were continued. Early treatment reduces the pain and suffering of shingles in mature patients. This patient got treatment quickly and conveniently.

Premium Medical Home encourages patients and doctors to work together in a way that is comfortable and convenient. We believe that this focus is not only valuable itself, but improves medical care, improves outcomes, and improves satisfaction. The patient would have received the same treatment, perhaps, in an emergency room or urgent care clinic. But ready availability of her doctor allowed for more comfortable, convenient, and timely evaluation. Such options are a benefit of your PMH subscription.

This is why we have changed our practice to the Premium Medical Home model. We believe that by focusing on the Premium Medical Home model, we can find better ways to help our patients.

ELECTRONIC HEALTH RECORDS by Allan Kelly MD FACP

There is a lot of interest in using electronic health records. Recent legislation from Washington awards doctors incentives of up to $55,000 over three to four years if they will convert their offices from paper records to an electronic record.......

PREVENTING DIABETES by Robert Kelly MD FACP

Pre-diabetes is common. It predicts a high probability that in the person's future, diabetes mellitus will develop.In the last 20 years there have been significant changes in the average American's diet and activity. One measure of this was that in about 1990 only one of the 50 states had…..

SMOKERS SUFFER by Allan Kelly MD FACP

We all know that smoking is bad for our health, but did you know that current smokers suffer poorer outcomes of other illnesses, even when those illnesses are unrelated to smoking? A smoker may philosophically accept the fact that ……

CHANGES IN DIET/LIFESTYLE AND LONG TERM WEIGHT GAIN by Robert Kelly MD FACP

A recent study from the National Institutes of Health (this is not an article on wasteful government research!) looked at food habits associated with weight change. Four items were each associated with significant weight gain…….

Medical Quotes:
"Although scientific knowledge is available to all, there is a vast difference between the best and worst of doctors, that difference representing the art of medicine."
- D. J. Weatherall, M.D., 2011
"While medicine is a science, in many particulars it cannot be exact, so baffling are the varying conditions of human life. " -
Charles Mayo, 1909

Spring of 2011 Volume 2, Issue 2

PMH STORY by Robert Kelly MD FACP

"My direct access to you and your attention to the details of my care is worth a million." A gentleman's pain had begun unexpectedly. There were questions whether or not the pain was caused by a disease which would require surgical intervention. He had undergone cervical spine surgery in the past for a painful condition and had done well, so the possibility of another surgery was considered.

After seeing the patient in the office he was admitted directly to the hospital. Over two days, he was seen by subspecialty caregivers to assess why this pain in the lower back was occurring. Unfortunately, an emergency at home prompted him to have to leave the hospital unexpectedly before definitive care.

At home, after addressing his emergency, pain, nausea and vomiting persisted. He called his PMH doctor and reported that the pain was not improving and he was having recalcitrant nausea and vomiting. He was again directly admitted to Harris Hospital for further care.

In the hospital, a team from neurosurgery, urology, and palliative medicine, including an anesthesiologist, saw the patient. After five days in the hospital with attention to pain relief he showed no need for surgical intervention, and the pain began to abate. He was able to eat, and the nausea and vomiting resolved.

The patient was pleased by the way, at each step, he had been able to reach his doctor and describe his complaints. This led to prompt effective intervention. His quote appears above.

Subscribing to Premium Medical Home and being a patient in a Premium Medical Home benefits subscribers and patients. It allows direct access. It provides attention to interdisciplinary care and the attention, when appropriate, of a subspecialty team coordinated by a trained expert physician who knows the patient well. This is a great value to patients and family.

DO STERIOIDS HELP JOINT PROBLEMS by Allan Kelly MD FACP

Common joint and tendon problems can improve with exercise and weight loss. Pain relief can be achieved with drugs like Tylenol, and elastic supports can be helpful at the wrist and the ankle and the elbow. Other interventions are less certain......

THE RISK OF BLOOD CLOTS FROM LONG FLIGHTS by Robert Kelly MD FACP

The risk of blood clots goes up after a long airplane ride, The absolute risk is low, less than 1%. In an average group of 400 passengers on a flight lasting for 12 hours, it is probable that one person may have an episode of blood clot from the flight.....

FATIGUE by Allan Kelly, MD FACP

Fatigue is a common symptom for patients making a doctor appointment. Fatigue is something that we all experience: It can be a part of our daily life, even in people who are healthy and strong. Fatigue is also a common manifestation of illness. Infection, malignancy, metabolic diseases, diabetes, and others will, in the natural history of the illness, cause fatigue........

NEW CANCER STATISTICS by Robert Kelly MD FACP

The March issue of CA, a cancer journal for physicians, included a review of cancer incidence. Worldwide, approximately one third of cancer deaths were potentially avoidable through reducing major risk factor, including tobacco use, unhealthy diet, physical inactivity, infection, unsafe sex and alchol use.........

Medical Quotes:
"Medicine, at its fundamental, is still about suffering, healing, and comforting; it is about individuals; it is about relationships and trust; it is about stories…… Concern of coding, billing, documenting, administration, computers, surveys, rules, regulations, and politics have increasingly occupied my mind and space like an intracranial tumor."
- Michael Monroe, JAMA, Volume 305, No. 12, Page 1176 to 1177

Winter of 2011 Volume 2, Issue 1

VACCINATIONS AGAINST CANCER by Allan R. Kelly MD FACP

Vaccinations have been a great gift to mankind. Some were called miracles. The development of the first vaccination for smallpox saved hundreds of millions of lives. The benefits can hardly be exaggerated, and now we see that the disease smallpox is effectively eradicated.

FULL BODY AIRPORT SCANNERS by Allan R. Kelly MD FACP

Are full body airport scanner safe? The Transportation Security Administration (TSA) uses backscatter x-ray to screen travelers. We know that many of our Premium Medical Home members will be going through airport security, and we want to let you know what we know about the new back scanner machines.

NUTRITIONAL SUPPLEMENTS: Less May Be More by Robert H. Kelly MD FACP

Nutritional supplements continue to receive a lot of attention. Shelves of stores are loaded with different supplements. Within a single class, such as vitamin D, there multiple different preparations, origins, strengths, and promised benefits.

PREVENTIVE CARE: Prostate Cancer Screening by Robert H. Kelly MD FACP

The United States Preventive Services Task Force (USPSTF), a national organization that looks at clinical effectiveness of screening and prevention methods, examined the records of nearly 400,000 asymptomatic men 45 to 80 years old. Screening with digital rectal examination and PSA was done.

Medical Quotes:
"All patients are interesting, but not all doctors are interested."
- Herb Fred, M.D., Houston, Texas
"First I will define what I consider medicine to be. In general terms, it is to do away with the suffering of the sick, to lessen the violence of their diseases …"
- Hippocrates

Fall of 2010 Volume 1, Issue 3

PMH STORY by Robert H. Kelly MD FACP

A Premium Medical Home member's adult daughter became ill with fever, swollen legs and red skin. The daughter had called her doctor's answering service, but her doctor was not on call. The on call doctor did not return the daughter's phone call. The daughter was concerned and so were the parents. She was not covered by a health insurance policy.

The Premium Medical Home member called and told Dr. Kelly about their daughter's health concerns. Dr. Kelly offered to see the patient at 7:00 the next morning in the emergency room, but the family was understandably cost conscious and realized these costs could be avoided by meeting in the office. Because the Premium Medical Home office had reduced the size of the practice to a more optimal level, there was time Friday for the member's daughter to come to the office for a prompt evaluation.

Dr. Kelly saw the patient and recognized the severity of the condition: the family was right to be concerned. Urgent testing and out-patient x-ray led to the diagnosis. Treatment was effective and the patient learned how this problem might be avoided in the future.

As a Premium Medical Home member, members can call Dr. Kelly regarding an out of town guest or family member who needs medical care. Sometimes healthy younger people lack a physician relationship. Though there is no guarantee that Dr. Kelly will be able to see the out of town guest or family member, as a member, you can count on rapid enhanced access to an expert physician, who will consider the needs and recommend action for the problem you face. This is a real benefit, both to the Premium Medical Home member and also to the member's friend, guest, or family.

Often Dr. Kelly will be able to visit and temporarily serve as that guest's doctor. This allows a timely expert opinion in an environment preferred by the guest or family member. This is often all that's needed and is more convenient and economical than going to the emergency room.

If an out of town guest is with you and needs medical attention, or if a family member without access to a physician has trouble, then as a Premium Medical Home member you know you can call for help. We will visit on the phone and, if prudent and agreeable, then meet with the guest or family member so that their medical needs are met.

INFLUENZA: Time To Get Vaccinated by Allan R. Kelly MD FACP

"The 2009-2010 flu season is over and what an exciting one it was. For the first time in thirty years a serious pandemic H1N1 influenza virus appeared in the United States. It caused much confusion and we feared the worse......"

VITAMIN D, AN IMPORTANT PART OF HEALTH by Robert H. Kelly MD FACP

"Vitamin D is in the news. One recent journal article was titled "Vitamin D: Super Drug". Claims range from preventing multiple sclerosis, cancer, colon polyps, and dementia to strengthening bones and reducing aches & pains......."

NOCTURIA (NIGHTTIME TRIPS TO THE BATHROOM) IMPROVES WITH LIFESTYLE CHANGE by Allan R. Kelly MD FACP

"Waking up at night to go to the bathroom is a common adult experience. This problem is called nocturia. For many adults nighttime voiding increases as time goes by. Nocturia can be a sign of illness, such as prostatism or more serious illness, such as infection or cancer......"

Medical Quotes:
The patient should be managed the way the doctor or a member of his family would wish to be treated if he were the patient in the bed at that time."
- Robert F. Loeb, MD
"There are individuals – doctors and nurses, for example – whose very existence is a constant reminder of our frailties; and considering the notoriously irritating character of such people, I often wonder that the world deals so gently with them."
- Osler, MD

Summer of 2010 Volume 1, Issue 2

A PMH STORY – DIRECT CONTACT YIELDS DIRECT RESULTS by Robert Kelly MD FACP

An elderly woman was discharged from the hospital after a difficult illness and transferred to a long-term care facility or nursing center. She and her husband were early subscribers to the Premium Medical Home.

It was not a long term care facility that Dr. Kelly visits so she was assigned to the care of the facility medical director. The patient and her husband preferred this facility because it was more convenient for him to visits.

After she was discharged from the hospital in the afternoon, her husband accompanied her to the nursing center. When he left he saw the security system at the front door. He did not understand how it worked, but saw it would be locked in the evening. When he left for home that evening, her medicines had not yet arrived. Arriving home, finishing supper, he tried to call the facility to see if she had been given her evening medicines.

After calling many times, he realized no one was answering the phone. Alarmed, he called Dr. Kelly on his cell phone. The call was directly answered. Dr. Kelly listened to the story and recognized that the phone number the husband was dialing was not the best number to reach the nurses’ station. In a 3-way conversation, Dr. Kelly called an alternate number and got the nurse on the phone. The husband's intuition was correct – the needed medicines had not arrived and delivery was not certain.

The nurse provided the simple code for the front door lock so that the husband could come and go as he wished. Speaking with Dr. Kelly, she also agreed that if the husband were to bring the medicines from home, the nurse would see that they were promptly given to the resident and avoid any further delay or anxiety. This was a great relief to the husband and a great comfort to the wife because of her painful symptoms.

Such is the usefulness of direct contact with your PMH doctor. Knowledge and understanding about how long-term care facilities, hospitals, and other parts of healthcare systems operate was immediately available to the subscriber. This kind of enhanced access solved this problem and also relieved alarm, worry, and uncertainty. In a standard medical office, a phone call expressing concern about an inability to complete a phone call to a nursing home or getting a combination to a security door would generally not be met with direct help and intervention. At a Premium Medical Home, we are available to help with the medical needs that are important to you.

FITNESS AS PREVENTION-A SCIENTIFIC FACT by Robert Kelly MD FACP

On Sunday morning a young man wakes up and discovers a rash. What should he do? Rashes can be serious – the patient needs to see a doctor soon, but the doctor's office is closed on the weekend. The young man started a new and vital medication two weeks ago, and this could be an allergic reaction.

PREVENTION OF HEART ATTACH, STROKE AND DEATH IN DIABETICS by Allan Kelly MD FACP

"Diabetics and all adults are at risk for vascular complications. Hopefully, your doctor can help you to prevent and delay such problems….."

CANCER DEATHS DECREASING by Allan Kelly MD FACP

"Recent reports from the American Cancer Society indicate decreasing rates of cancer over the past ten years. Overall, cancer diagnoses have been declining approximately 1% per year over the 8 years and deaths have declined 1.6% per year over the past six years…"

Medical Quotes:
"It's a poor government that does not realize that the prolonged life, health and happiness of its people are its greatest asset." –
Charles Horace Mayo

Spring of 2010 Volume 1, Issue 1

PMH STORY by Allan R. Kelly MD FACP

On Sunday morning a young man wakes up and discovers a rash. What should he do? Rashes can be serious – the patient needs to see a doctor soon, but the doctor's office is closed on the weekend. The young man started a new and vital medication two weeks ago, and this could be an allergic reaction.

As a PMH Subscriber, the young man has access to his doctor 24/7, so he is able to get in touch with his doctor immediately via cell phone, even on Sunday morning. In this case, the doctor is on his way to the hospital to make rounds when he receives the call. He meets the young man at the hospital, allowing him to bypass the ER. The doctor quickly assesses the problem, determines that the rash is a reaction to the new medication, recommends care, and schedules a follow-up visit, all within an hour.

For a patient who is not a PMH Subscriber, emergency care necessitates visiting the emergency room or an urgent care clinic. These options are time-consuming, expensive, and require the patient to be treated by an unfamiliar doctor who has no prior knowledge of the patient's medical history, conditions, or medications.

For PMH Subscribers, enhanced communications options enabled the young man to see his primary care doctor without delay, eliminating hurdles and expenses. As the patient's primary care provider, the PMH doctor is familiar with the patient and can recall critical medical information from prior visits. And importantly, the follow-up visit will be with the same doctor who examined and treated the patient on Sunday.

We believe that such availability and responsiveness improves care while simultaneously reducing costs. In this scenario, the patient had a better experience at a lower cost, and he can be confident in the doctor's ongoing attention and care. We call this a Premium Medical Home experience.

RISK ASSOCIATED WITH CT SCAN FREQUENCY by Allan Kelly MD FACP

"Healthcare topics are receiving significant coverage in the media, and one issue that has received considerable public attention concerns testing and screening procedures. Medical institutions are changing their recommendations for frequency of screenings like mammography, and physicians have to balance these recommendations with what is appropriate for their patients……."

DISCUSSION ABOUT A FORT WORTH MEDICAL SCHOOL by Robert Kelly MD FACP

"The four most common cancers in the United States are cervical/prostate cancer, gastrointestinal cancer, lung cancer and breast cancer. The most common cause of cancer death is lung cancer, followed by cancer of the colon….."

CAUSES OF CANCER IN THE UNITED STATES by Robert Kelly MD FACP

"The four most common cancers in the United States are cervical/prostate cancer, gastrointestinal cancer, lung cancer and breast cancer. The most common cause of cancer death is lung cancer, followed by cancer of the colon….."

Medical Quotes:
"The practice of medicine is predominantly a humanistic act. Physicians must care about their patients, and they must constantly improve their scientific knowledge about disease. To care and not know is dangerous. To know and not care is even worse. Caring and knowing must be combined to succeed in doctoring." –
– J. Willis Hurst, MD