Treating Pain With Truth

collage

Then you will know the truth, and the truth will set you free.
~ John 8:32 (NIV)

…Pain free?

Confluential Truth blog posts address various issues, and many share a healthcare theme. Often the focus is on chronic pain. The following collection of Confluential Truth offers my views on how chronic pain may be effectively and safely treated, especially when the treatment involves controlled substances. Each essay is like a chapter in a mini-textbook about treating chronic pain. They are offered here hoping to provide insight into improving quality of life for pain sufferers and pain care providers.

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PROLOGUE:  The Algiatrist – To set the tone, a poem about treating pain and being “useful.”

INTRO ALGIATRIST https://jamespmurphymd.com/2013/11/22/the-algiatrist

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CHAPTER ONE:  The Dream of Pain Care – A transcript of my address to the physicians and staff of Norton Healthcare – the what, why & how. If you only have time to read one essay, this is the one.

1 wolfe https://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture

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CHAPTER TWO:  Pathway to Partnership, Part 1 (KY) – Here is how we do it in Kentucky when we do it right.2 ky path  https://jamespmurphymd.com/2015/02/13/pathway-to-partnership

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CHAPTER THREE:  Pathway to Partnership, Part 2 (IN) – Here is how we do it in Indiana when we do it right.

Screen Shot 2015-07-17 at 12.33.44 PM

https://jamespmurphymd.com/2015/03/29/pathway-to-partnership-part-ii-in

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CHAPTER FOUR:  Are We In Agreement? – Expectations, edification and enlightenment result from properly implemented patient-physician “agreements.”

agree

https://jamespmurphymd.com/2014/02/19/are-we-in-agreement

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CHAPTER FIVE:  Treating Pain Patients Like Addicts – There is ample overlap between optimal treatment for addiction and optimal treatment for chronic pain. Utilizing this knowledge can enhance the effectiveness and mitigate the risks inherent to treating chronic pain with controlled substances.5 tx like addicts https://jamespmurphymd.com/2014/11/21/treating-pain-patients-like-addicts

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CHAPTER SIX:  Basic Pain Care Certification – It’s a sad fact the number of deaths associated with drug overdose is roughly equivalent to the number of motor vehicle fatalities. Imagine how many might die on our roads if, instead of a driver’s license, all you needed to drive a car was a prescription from a doctor. Now, imagine how many less might die of drug overdose if you had earn a “license” to use controlled substances…

4.5 pain care certhttps://jamespmurphymd.com/2014/08/06/basic-pain-care-certification

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CHAPTER SEVEN:  Strength in Numbers – Successful chronic pain treatment involves: (a) medical care; (b) counseling; and (c) a support system. Find all three and you have probably found…

6 str in num https://jamespmurphymd.com/2014/07/02/strength-in-numbers

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CHAPTER EIGHT:  It’s Only Words – Over the years I have given many presentations concerning medication management for chronic pain. Often I have said that if there is only one concept I want the group to take away it’s that “addiction” and “physical dependence” are not the same thing.

8 words https://jamespmurphymd.com/2014/04/03/its-only-words

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CHAPTER NINE:  Talking Trash – We spend much time worrying about the acquisition of pain medications but too often don’t know what to do with them when we are done.

7 talk trash     https://jamespmurphymd.com/2014/07/21/talking-trash

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CHAPTER TEN:  Is There Method To This March Madness? – Too often our focus is on a specific drug, when in reality the culprit is the disease.

9 march madnesshttps://jamespmurphymd.com/2014/03/18/is-there-method-to-this-march-madness

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EPILOGUE:  Proclaim Pain Care Providers Day! – Don’t just provide great pain care… Proclaim it!

10 PCPD https://jamespmurphymd.com/2015/01/22/proclaim-pain-care-providers-day

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westminster podium

James Patrick Murphy, MD, MMM is Chair of the Board of Governors -and Immediate Past President- of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. Dr. Murphy contributes to numerous publications, has presented before national and international audiences, and consults with a wide spectrum of agencies and individuals regarding pain, addiction, and the future of healthcare in our country. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine.

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Pathway to Partnership, Part II (IN)

THE CHRONIC PAIN PATIENT’S GUIDE TO INDIANA’S REGULATIONS  Screen Shot 2015-03-29 at 2.19.10 AM

No man is an island, Entire of itself, Every man is a piece of the continent, A part of the main. – John Donne

The poet, John Donne, knew it. Every Hoosier pain patient and Hoosier pain care provider should take it to heart. No patient or provider is an island. And pain care is best when there is a partnership between the patient and provider. The Pathway to Partnership If you are treated for pain in the Hoosier State the pathway to partnership with your physician passes through Indiana’s pain regulations. Indiana’s entire southern border is Kentucky. And when it comes to patient responsibilities, Kentucky’s pain regulations have much in common with Indiana’s. Therefore, Hoosier patients can begin preparation for their Indiana chronic pain care evaluation by reading my article: Pathway to Partnership, Part I (KY) – The Chronic Pain Patient’s Guide to Kentucky’s Regulations. Screen Shot 2015-03-29 at 2.25.49 AM Available at: https://jamespmurphymd.com/2015/02/13/pathway-to-partnership Particular to Indiana is the Hoosier state’s emphasis on medication dosing limits that trigger mandatory compliance with the regulations. Calculating these dosing limits can be quite confusing and, frankly, patients are not responsible for knowing them. Prescribers are. But to be a good “partner” with your prescriber, you should at least become familiar with these dosing limits. Later in this article I will summarize. But first, in order to hold up your end of the partnership, here are ten items you can prepare:

  1. Your past medical history
  2. Your pertinent medical records
  3. An accurate medication list
  4. Any substance abuse history
  5. Your social and family history
  6. Any other medical issues
  7. Educate yourself for proper informed consent
  8. Your current level of function
  9. Your treatment goals
  10. Complete questionnaires & mental health screens

These ten items are discussed in detail in Pathway to Partnership, Part I (KY) – The Chronic Pain Patient’s Guide to Kentucky’s Regulations. Prepare as described above you will be well on your way to becoming a great partner in your care. As your partnership continues, expect to have contact with your physician on a regular basis and even randomly to:

      1. Review your progress with your treatment plan;
      2. Review the goals of your plan; and
      3. Review expectations (i.e. attending therapy, counseling, tests, etc.)

Insider Information As a partner, you are entitled to some “insider” information. Here it is… A new section of Indiana’s regulations contain a lengthy explanation of what prescribers must consider when ordering drug screens. By doing so, this section offers insight into appropriate patient behavior. The following list, summarized from the regulations, offers an insider’s look at what Indiana expects of a pain patient: In determining whether a drug monitoring test…is medically necessary, the physician shall consider” if the patient has:

      • Taken the meds as prescribed?
      • Taken more meds than allowed?
      • Given or sold meds to anyone?
      • Benefitted from the meds?
      • Taken any other drugs – legal or illegal?
      • Been honest and up front about past drug use?
      • Tried to get early refills?
      • Lost meds? Had them stolen?
      • Had an abnormal INSPECT state prescription report?
      • Failed a drug screen?
      • Been intoxicated?
      • Been acting aggressive, depressed, anxious, etc.?
      • Been diagnosed with a psychiatric condition?
      • Demanded certain specific meds?
      • Had a major illness? Pregnancy? Hospitalization?
      • Been resistant to any changes in the care plan?
      • Refused or failed to follow through with exams/tests?
      • Just not done well overall?

Bottom line: Be honest, up front and “transparent.” No one likes surprises. A good partnership is all about trust and communication. Understand what your treatment agreement says and live up to it. cs agree pic Dosing Limits Now, about those dosing limits… As I said, it can be confusing, but you should try to understand the concepts and discuss them with your prescriber. Not all pain prescriptions are subject to the Indiana regulations. Therefore, it is important to understand the dosing limits that trigger mandatory compliance. These limits are dependent upon: (1) the dose, (2) the quantity and (3) the duration. The Morphine Equivalent Dose (“MED”) is basically how strong your medication would be if it were to be substituted for morphine. This is very important to INDIANA regulatory agencies. I highly recommend you learn how to calculate your MED. Screen Shot 2015-03-29 at 10.47.08 AM Calculating the MED Step ONE: Calculate the MED for one pill Determine the dose of morphine that would be equal to one of your pills using a standard conversion table (For example: a FIVE mgm hydrocodone pill is the same as a FIVE mgm morphine pill; but a FIVE mgm oxycodone pill would be the same as a 7.5 mgm morphine pill). Indiana officials recommend this website for help with making this determination: The online opioid calculator from GlobalRPH http://www.globalrph.com/narcoticonv.htm Screen Shot 2015-03-29 at 2.30.15 AM Step TWO: Calculate your DAILY MED Once you have converted your pill to its “morphine equivalent,” simply add up the maximum number of pills your prescription allows you to take in a day and multiply this number by the morphine equivalent (MED) you determined in step one. (Number of pills per day) x MED/one pill = Daily MED For example: Since a FIVE mgm hydrocodone pill is equal to a FIVE mgm morphine pill, the daily MED of someone taking THREE of these hydrocodone pills per day would be: 5 mgm x 3 pills per day = 15 mgm MED Here are some common ORALLY prescribed opioids that compare to a MED of 15: Hydrocodone (oral) 15 mgm/day = 15 mgm of morphine (oral) Oxycodone(oral) 10 mgm/day = 15 mgm of morphine (oral) Oxymorphone (oral) 5 mgm/day = 15 mgm of morphine (oral) Codeine (oral) mgm/day = 15 mgm of morphine (oral) Hydromorphone (oral) 3.75 mgm/day = 15 mgm of morphine (oral) Tramadol (oral) 150 = 15 mgm of morphine (oral) Note: MED greater than SIXTY If you are on a treatment regimen with a morphine equivalent dose of more than SIXTY (60) MED, the physician may require you to have an evaluation by a specialist. According to the regulations, your physician must explain to you that there is an increased risk of adverse outcomes, including death, when your daily MED is greater than SIXTY. So now that you understand the MED, you are ready to look at the DOSING LIMITS that trigger compliance with the regulations. DOSE, QUANTITY & DURATION When any of the following conditions are met, your physician (and you) must comply with the Indiana pain regulations.

      1. DOSE & DURATION >15 MED for >3 months

DAILY MED greater than FIFTEEN for DURATION of more than three consecutive months Or…

      1. QUANTITY & DURATION >60 pills for >3 months

More than SIXTY opioid pills per month for DURATION of more than THREE consecutive months Or…

      1. PATCHES > 3 months

Any opioid skin patches (e.g., fentanyl or buprenorphine), regardless of the dose or quantity, for DURATION of more than THREE consecutive months Or…

      1. Hydrocodone-Only Extended Release

Any hydrocodone-only extended release medication that is NOT in an “abuse deterrent” form, regardless of the DOSE, QUANTITY or DURATION Or…

      1. TRAMADOL (My advice) >150 mgm for >3 months

Actual language in the regulations state: “If the patient’s tramadol dose reaches a morphine equivalent dose of more than sixty (60) milligrams per day for more than three (3) consecutive months.” This tramadol dose limit seems to be overly generous when compared to other MED dosing limits. A SIXTY (60) MGM MED of tramadol is in the range of 300 to 600 mgm of tramadol. Considering that the maximum therapeutic dose for tramadol is only 400 mgm per day, one could potentially exceed the safe upper limit of tramadol and still not exceed Indiana’s dosing limit. This seems to be inconsistent with the regulation’s other opioid dosing limits. My advice: Since 150 mgm of tramadol is equivalent to a FIFTEEN (15) MED, I believe it is more consistent with the other Indiana opioid dosage limits to consider TRAMADOL greater than 150 mgm/day for more than THREE consecutive months as the dosage limit congruent with other opioid dosage limits. Reference: The online opioid calculator from GlobalRPH http://www.globalrph.com/narcoticonv.htm Wait!!! There are EXEMPTIONS !!! Regardless of the dose, quantity or duration, the Indiana pain regulations do not apply to these patients: (1) With a terminal condition (2) Residing in a licensed health facility (3) Enrolled in a licensed hospice program (4) Enrolled in a licensed palliative care program microphone 5 In summary, patients and physicians should travel the pathway to partnership together. Patients can do their part by (1) preparing for the clinical visits, (2) understanding and adhering to their treatment agreements, and (3) educating themselves about risks, side-effects, and legal aspects of their care. It is a real challenge to treat chronic pain in this day and age. Your physician needs your help. Will you leave it all up to your physician? Or will you be a good partner, heeding the words of the poet DonneAnd therefore never send to know For whom the bell tolls; It tolls for thee.  * podium thumbs up James Patrick Murphy, MD, MMM is Chair of the Board of Governors -and Immediate Past President- of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. Dr. Murphy contributes to numerous publications, has presented before national and international audiences, and consults with a wide spectrum of agencies and individuals regarding pain, addiction, and the future of healthcare in our country. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine. * References and links pertaining to this article are provided in the comments. * This unofficial summary is my personal opinion. A full, official version of the final rule should be consulted for compliance purposes at: http://www.in.gov/legislative/iac/20141105-IR-844140289FRA.xml.html The Indian State Medical Association also has a summary available at: http://www.ismanet.org/pdf/legal/IndianaPainManagementPrescribingFinalRuleSummary.pdf no harm And if you really want to explore the Indiana pain regulations in detail, there is no better source than the online guide: First Do No Harm, The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain. http://www.in.gov/bitterpill/docs/First_Do_No_Harm_V_1_0.pdf * Hey Hoosier! Who’s your partner? handshake_between_doctor_and_patient_with_the_sky_background_1341168865 * * *

White is the new look for fall

sep me cover

On July 28, 2013, the University of Louisville welcomed the Class of 2017 medical students. As an annual contribution to each new generation of emerging physicians, the Greater Louisville Medical Society purchases the students’ first white coat. As President, it was my honor to congratulate the students on behalf of the Greater Louisville Medical Society. Here are my remarks from the podium.

share in an adventure gandolf

“I’m looking for someone to share in an adventure.”

Fans of the author J.R.R. Tolkein, will recognize this as the challenge Gandalf the wizard made to the hobbit, Bilbo Baggins. This is, among other things, an adventure.

I am honored to be here on behalf your medical society – The Greater Louisville Medical Society – to congratulate you on this milestone. At close to 4000 members, we are one of the largest in country. Our mission is to: promote medicine as art and science, advocate for the wellness of our community, and protect the patient – physician relationship.

Today is a big day for you and for us. Today is a milestone along the road that will lead to a your joining our ranks. Today you are not only putting on your white coats, but you are also becoming members of the Greater Louisville Medical Society. To help you stay connected you will have access to our mobile app, where you can get alerts, educational materials, and access information about your new GLMS colleagues. As sponsors of the White Coat Ceremony, your medical society colleagues are honored to provide: your first white coat, provide, your medical society pin, membership in the Greater Louisville Medical Society, professional photographic portrait of you in your new white coat. We are your colleagues, here to support you, and we welcome you.

The Greater Louisville Medical Society has strong ties to the University of Louisville. Most of our members either graduated from the University or did post-graduate training there. I am proud to call myself a graduate of the University of Louisville Medical School Class of 1985.

Back when I was in your shoes, we did not have a white coat ceremony. Back then they wouldn’t let us wear a white coat until third year, much less actually touch a living patient. I wish we could have had a ceremony like this. That is why I invited my own family to come today. This is a special day for you and for your family and friends who have supported you. To these special people in your life, I also offer my congratulations and my gratitude.

Gratitude, yes, because you have chosen a path that is not easy and does not compensate you materially for the years spent, the sacrifices, the risks – financial, physical, emotional. But it is indeed an adventure.

As I look out upon you I see a discovery. I see a cure. I see lives saved from disaster. I see longer, better, meaningful lives. I see a suicide prevented. I see a critically ill baby saved. I see an aneurysm removed. I see a heart murmur discovered. I see a cancer detected because you followed up on the red blood cells you saw in the urinalysis report.

I also see heartache, depression, fractured lives, and failures. It is all part of the path you have chosen to follow. You may not know all the reasons why you are sitting here today. I don’t think I knew. But every day, from this day forward you will be finding answers.

The white coat itself is significant. I remember the day I finally got mine. We walked around the medical complex and even went to eat lunch in one of the hospital cafeterias. In my 3rd year of medical school Dean Ganzel was my attending on rotation through Otolaryngology. On the last day she, so graciously, took her four medical students to lunch. We ate lunch at the Kentucky Center for the Arts in our white coats. The coat meant something. It said something to the world.

9403531070_63bc08e2e1_o

I have worn many white coats since them – short, long, in between – but whenever I put on the coat it still has meaning. It speaks. So I wondered what the message would be if instead of me, my white coat could says a few words. Well, my white coat and I discussed it and now, on behalf of my white coat, I offer this:

a white coat
I symbolize
the goals you hope
to realize

a white coat
my color’s pure
to show your values
will endure

a white coat
I will glisten
if you can try
to mostly listen

a white coat
in my presence
comfort, care and
convalescence

a white coat
wear this fashion
only if
you share my passion

a white coat
for my profession
put patients first
make no concession

a white coat
answer alarm
with answers that
first do no harm

a white coat
hear the calling
wear me when
you lift the falling

a white coat
my fabric must
be nothing but
a weave of trust

a white coat
ability
tailored with
humility

a white coat
a solemn oath
a way of life
or maybe both

a white coat
I’m going to
forever be
a part of you

Dean Ganzel, colleagues, friends and families, Mom, I thank you for this day. And to the class of 2017, I congratulate you and welcome you. For those who hear this calling there is no greater professional honor than to wear that white coat and hear the words, “That’s my doctor.”

Looking out at you, it is clear that I have found someone to share in an adventure.

Gandalf_the_White_returns

… and the white look is very becoming, I must say.

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This year’s White Coat Ceremony was held on July 27, 2014 and is the subject of current GLMS President, Dr. Bruce Scott’s September eVoice.

bruce evoice

 

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Is it the singer or is it the song?

I love music.

I am not what one might call “musical.” I don’t have the pipes of a Whitney Houston (see: The Star Spangled Banner) or the soulfulness of a Bob Dylan (see: Blowing in the Wind), but I appreciate their unique virtuosity.

I am a pain care physician. Pain, like music, is a sensory and emotional experience. I don’t sing or play. I touch and treat.

Sometimes I may hit the perfect note, perform the perfect procedure, compose the perfect plan of care.

Other times, despite being well versed, my plan of care may not strike the right chord. Then creating a pleasant sensory and emotional experience depends upon the passion and conviction with which my care is conducted; my song is sung.

Is it the singer or is it the song?

Is it the caregiver or is it the care given?

Music is not only intertwined with my pain care. It is woven into every aspect of my life, including my Twitter feed.

Begging the question: Is it the tweeter or is it the tweet?

Let’s find out.

For a about a year I have been composing a Twitter message or two per day. Recently, I went back and was able to find forty tweets that were “musical” in some way. It may not be America’s top forty, but I think Casey Kasem would still have been pleased.

casey kasem b and w

There are songs from rock, country, and classical genres; from musicals, commercials, television, and the silver screen. Some are serious; some are silly. Original works, live performances, even parodies.

I now invite you to take a little journey through my musical tweets. Click on the image and the link should take you right to the performance. See if you can guess the song before you link to it. Ponder how it relates to the message. Enjoy the sensory and emotional experience. And decide for yourself…

Is it the tweeter or is it the twuuth* ?

 

* twuuth (definition)

  • noun\ˈtwüth\ the twuuth : the truth in a tweet

 

#40

1 25 oct 13

25 October 2013  How the Ghost Stole Pain Care. Dramatic reading by Phil Ward and music composed by Megan McIver

https://twitter.com/jamespmurphymd/status/393876826809843712/photo/1

http://vimeo.com/77715467

 

#39

2 21 dec 13

21 December 2013  A Winter’s Solstice

https://twitter.com/jamespmurphymd/status/414443104792354816?refsrc=email

https://www.youtube.com/watch?v=kh_sckAUkgE&list=PLe1seBFJFklgHIqjjUUUhxZmL_rchZau9

 

#38

3 10 jan 2014

10 January 2014  Act Naturally

https://twitter.com/jamespmurphymd/status/421697528891854848/photo/1

https://www.youtube.com/watch?v=c-07qmTUi9A

 

#37

4 12 jan 2014

12 January 2014 Les Miserables

https://twitter.com/jamespmurphymd/status/422410734950043648/photo/1

https://www.youtube.com/watch?v=HPIos2mXbUE

 

#36

5 26 jan 14

26 January 2014 I’m Only Sleeping

https://twitter.com/jamespmurphymd/status/427318581399789569/photo/1

https://www.youtube.com/watch?v=8KAsr-hix9s

 

#35

6 10 feb 14

10 February 2014 The Gold and Beyond

https://twitter.com/jamespmurphymd/status/433042987648417792?refsrc=email

https://www.youtube.com/watch?v=2hBB4DPw-h4

 

#34

7 12 feb 14

12 February 2014 ABC

https://twitter.com/jamespmurphymd/status/433632926316515329/photo/1

https://www.youtube.com/watch?v=I8GvDLDYhNM

 

#33

8 12 feb 14

12 February 2014 Hearing Winter

https://twitter.com/jamespmurphymd/status/433655563193286656/photo/1

https://www.youtube.com/watch?v=VaXGGPVNnxU

 

#32

9 17 feb 14

17 February 2014 The Way We Were

https://twitter.com/jamespmurphymd/status/435621354222526464/photo/1

https://www.youtube.com/watch?v=6VhNaXV8K4U

 

#31

10 17 feb 14

17 February 2014 Peace of Mind

https://twitter.com/jamespmurphymd/status/435639476686045184/photo/1

https://www.youtube.com/watch?v=Q5ZL8qvEmR0

 

#30

11 21 feb 14

21 February 2014 Doctor Pat

https://twitter.com/jamespmurphymd/status/437033465536462849/photo/1

https://www.youtube.com/watch?v=6vuUpSnPXz0

 

#29

12 22 feb 14

22 February 2014 Honesty

https://twitter.com/jamespmurphymd/status/437388430465462273/photo/1

https://www.youtube.com/watch?v=R4gOIt-M02A

 

#28

13 2 mar 14

2 March 2014 My Bologna

https://twitter.com/jamespmurphymd/status/440310294867234816/photo/1

https://www.youtube.com/watch?v=rmPRHJd3uHI

 

#27

14 5 mar 14

5 March 2014 Oklahoma

https://twitter.com/jamespmurphymd/status/441273659001286657/photo/1

https://www.youtube.com/watch?v=ZbrnXl2gO_k

 

#26

15 14 mar 14

14 March 2014 Hair

https://twitter.com/jamespmurphymd/status/444682878396293120?refsrc=email

https://www.youtube.com/watch?v=7Qf2R-1saDQ

 

#25

16 29 mar 14

29 March 2014 Stupid

 

https://twitter.com/jamespmurphymd/status/449943660134555649?refsrc=email

https://www.youtube.com/watch?v=ers0YPoMxbk

 

#24

17 4 apr 14

4 April 2014 Words

https://twitter.com/jamespmurphymd/status/452173873299980291?refsrc=email

https://www.youtube.com/watch?v=sr-WW5abcwQ

 

#23

18 7 apr 14

7 April 2014 Oops

https://twitter.com/jamespmurphymd/status/453267038077984768?refsrc=email

http://vimeo.com/54035300

 

#22

19 9 apr 14

9 April 2014 Call On Me

https://twitter.com/jamespmurphymd/status/453922140312440833?refsrc=email

https://www.youtube.com/watch?v=Wh86uSsux1M&feature=kp

 

#21

20 17 apr 14

17 April 2014 Lights Went Out

https://twitter.com/jamespmurphymd/status/456764575258402816?refsrc=email

https://www.youtube.com/watch?v=uSSJwKixbKU

 

#20

21 19 apr 14

19 April 2014 Little Wonders

https://twitter.com/jamespmurphymd/status/457546932161110016?refsrc=email

https://www.youtube.com/watch?v=tWU8_uUJJu0

 

#19

22 28 apr 14

28 April 2014 Undun

https://twitter.com/jamespmurphymd/status/460961322163642368?refsrc=email

https://www.youtube.com/watch?v=QzSLxYLuJhI

 

#18

23 15 may 14

15 May 2014 I’m Sorry 

https://twitter.com/jamespmurphymd/status/467135943741157378?refsrc=email

https://www.youtube.com/watch?v=4a_vhiBxi90

 

#17

24 5 june 14

5 June 2014 Let It Go

https://twitter.com/jamespmurphymd/status/474655637620535296?refsrc=email

https://www.youtube.com/watch?v=EtAG3e3JLNI

 

#16

royals

5 June 2014 We Will Never Be Doctors

https://www.youtube.com/watch?v=mxyNzqQNa50

 

#15

25 7 june 14

7 June 2014 Daniel Boone 

https://twitter.com/jamespmurphymd/status/475246656968200192?refsrc=email

https://www.youtube.com/watch?v=VLMCO-JZqWs

 

#14

26 10 jun 14

10 June 2014 Turn It Off

https://twitter.com/jamespmurphymd/status/476212528289038336?refsrc=email

https://www.youtube.com/watch?v=JjCfE1n6nW4&list=PLf470HqOWw3d8Oj5uAXPV19yJ7E7aGDwX&index=163

 

#13

27 13 jun 14

27 June 2014 Don’t Stop Me Now

https://twitter.com/jamespmurphymd/status/477316980274237440?refsrc=email

http://vimeo.com/30126989

 

#12

28 14 jun 14

 14 June 2014 It’s a Grand Old Flag

https://twitter.com/jamespmurphymd/status/477902903290515457/photo/1

http://fan.tcm.com/_James-Cagney-You39re-a-Grand-Old-Flag/video/1146300/66470.html?createPassive=true

 

#11

29 15 jun 14

15 June 2014 In the Living Years 

https://twitter.com/jamespmurphymd/status/478362296126013440?refsrc=email

https://www.youtube.com/watch?v=bWiwde4z9Qk

 

#10

30 16 jun 14

16 June 2014 Pressure

https://twitter.com/jamespmurphymd/status/478599157926473728?refsrc=email

https://www.youtube.com/watch?v=SJCTgtDU-74

 

#9

31 21 jun 14

21 June 2014 Sunrise

https://twitter.com/jamespmurphymd/status/480542585535352832?refsrc=email

http://vimeo.com/88197078

 

#8

32 27 jun 14

27 June 2014 Listen

https://twitter.com/jamespmurphymd/status/482653910616666112?refsrc=email

https://www.youtube.com/watch?v=K5aRRq9mquo

 

#7

33 29 jun 14

29 June 2014 Rumor Has It 

https://twitter.com/jamespmurphymd/status/483451855125479424/photo/1

http://vimeo.com/41795630

 

#6

34 the letter

1 July 2014 The Letter

https://twitter.com/jamespmurphymd/status/484055472618500096

https://www.youtube.com/watch?v=Vrv9slgO7Ic

 

#5

35 all together now

2 July 2014 All Together Now

https://twitter.com/jamespmurphymd/status/484446529210445824

https://www.youtube.com/watch?v=xFpW8g83g6E

 

#4

36 dialogue

4 July 2014 Dialogue

https://twitter.com/jamespmurphymd/status/484941146976567296

https://www.youtube.com/watch?v=YTL53bmYqzM

 

#3

37 danger zone

4 July 2014 Danger Zone

https://twitter.com/jamespmurphymd/status/484955780253106177

https://www.youtube.com/watch?v=58QOBqAWNzE

 

#2

38 if you want it

6 July 2014 If You Want It Here It Is 

https://twitter.com/jamespmurphymd/status/485956691708477442

https://www.youtube.com/watch?v=KWbTZuEWjnc

 

And the #1 musical tweet in the land is…

39 stipe tweet

7 July 2014 Everybody Hurts 

https://twitter.com/jamespmurphymd/status/486224816618213376

https://www.youtube.com/watch?v=ijZRCIrTgQc

 

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keep you feet on the ground

 

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*

 

Giving them the business

Screen Shot 2014-06-22 at 11.21.32 PM

On May 22, 2014 the University of Louisville Residents’ Business seminar was the last group I would address as President of the Greater Louisville Medical Society. It went something like this…

hello 2 screen

I didn’t have a course like this when I was a resident.

I wish I had.

Somewhere between respiratory acidosis and cardiac preload, learning to read a spreadsheet could have been worked in.

But it wasn’t.

You’re very fortunate that your university is enlightened and generous enough to offer this course for you.

Today, with healthcare taking up about 20% of our nation’s GDP, there are many non-medical types grasping for our nation’s healthcare steering wheel.

Soon you will be finishing your residencies.

You’ll board the healthcare industry train.

You can either be a passenger or a driver.

It’s your choice.

As I prepared for today’s seminar, I thought about what I would say to myself if I could time travel back fifteen years to when I was sitting where you are now, finishing my residency.

3 balls screen

I would tell myself that there are three balls I will have to juggle.

The first ball is your “clinical” ball. Thus far, keeping this ball in the air has been the primary focus of medical school and residency training. Patients’ needs must be met. Your patients must be well.

The second ball is your “family” ball. You’re not on this journey alone. Your loved ones and close friends depend upon you as much as you depend upon them. Lose their support and the stress of being a physician can be overwhelming. Your family must be well.

The third ball is your “self” ball. Do not neglect your own health, outside interests, passions, talents, or loves. Your self must be well.

juggle screen

The best way to keep these balls in the air is by juggling them yourself. Don’t delegate that job. Even though most of you will be employed, avoid dependence by becoming as comfortable in boardrooms as you are in operating rooms. You must not ignore the business of medicine.

*

open letter screen

(A letter arrives. It is from the future. It reads…)

Dear 2014 Me,

I’m writing you from the year 2025. Physicians are no longer considered necessary. They just get in the way. Healthcare is a mess. It’s all based on metrics. Everything is quantified and graded. There is no creativity. No innovation. No flexibility. No passion. No compassion. But at least we get to go home when the whistle blows at three p.m.

Yours truly,

2025 Me

*

letter 1 screen

This does not have to be our default future. We can do better. But only if we have physicians willing to lead. And physician leaders now must understand the business of medicine, or else medicine will be nothing more than a business. We must be in boardrooms and wrestle back control of the steering wheel.

*

letter 2 screen

(Another letter from the future arrives…)

Dear 2014 Me,

I’m writing you from the year 2025. Physicians are the essential driving force in medicine. Metrics are used to add structure to the art of medicine, not to govern or discipline. The patient-physician relationship is secure and flourishing. Creativity, innovation, and compassion fuel our passions. I don’t know what you told those residents back in 2014, but it must have worked. Thank them for me and for all of us.

 Yours truly,

2025 Me

*

Someone here must have listened. Someone decided to fill the vacuum created by the lack of physician business leadership. Someone stepped up and took firm grasp of the steering wheel guiding our nation’s healthcare. Someone refused to accept our default future.

Who was it?

hands 2

*

*

 

Continuity of Care

TourtheTower

On June 1, 2014 at Louisville’s historic and newly renovated Water Tower, the Greater Louisville Medical Society held its annual Presidents’ Celebration.

crowd at watertower

As outgoing president I had the honor of introducing Dr. Bruce Scott – my esteemed colleague and childhood friend – as our new President. I also thanked some of the many great folks who worked so hard to make this the most satisfying year of my professional life.

pat and bruce screen

Before I handed over the President’s gavel to Bruce and assumed my new role as Chair of the GLMS Board of Governors, I had this to say…

pat podium

A year ago, as your newly elected President, the last words I said on that stage were:

The Greater Louisville Medical Society is our organization, our tribe, our road to a place where medicine is both science and art, where our community enjoys wellness, and the sacred bond between our patients and us is secure. And my goal this year is to see us united.

murphy speech at pres celeb

It’s one year later, and our profession is under attack as never before. Physician burnout is an epidemic. This is why, more than ever, we must be united.

Back in the day, physicians were a more homogenous group. There were fewer specialists. We shared common values and common goals.

Now government, employers, specialties, patients, and family pull us in many directions. There is an ever-increasing burden for maintenance of board certifications and licensure. Each separate payer and practice facility requires its own credentialing. Medical liability risks keep mounting. The insatiable quest for quantifying quality with data points and benchmarks threatens to crush our creativity and mandate cookbook-style care. Rival non-physician tribes continuously grab pieces of what used to be our acknowledged scope of practice.

How do we respond? All too often by retreating to presumed “safe houses” provided by the one, two, three or more specialty societies each of us believes offers the most protection of our turf.

Got to survive, you know.

The irony is that these refuges are not safe at all. They are static. Stationary. It makes us benign targets for attack by all who would prefer a leaderless mechanized conveyor belt of universal one-size-fits-none healthcare. This sanctimonious deconstruction of our profession is done in homage and servitude to the inscrutable holy trinity of cost-effectiveness, quality, and value.

Survive?

Why not thrive!

Regardless of where your professional journey has led, you and I and our colleagues remain connected at our roots. We still share common values and must share common goals. We are physicians by education, oath, and calling.

And more…

We love our profession.

We love humanity.

And we love each other.

That is why we get up every day, put on our white coats, and go out to save the world.

Because it must be saved.

And we know…

We are the ones who must do it.

United.

gavel trophy

Art Imitates Life Imitates Art

celebration invite screen

On May 19, 2013 the Greater Louisville Medical Society held its annual Presidents’ Celebration at the Kentucky Country Day School Performing Arts Center in Louisville, Kentucky. On that day I was honored by inauguration as president of the medical society. Early in my address to those in attendance I was abruptly interrupted by a “heckler” in the audience. Here is a transcript of that encounter…

 

fraud title pose

 

Fraud

 

A play in one act by James Patrick Murphy, M.D.

gettng the gavel

Characters:

Doctor Murphy (DOCTOR) – A physician who has just been given the gavel and installed as the next president of his medical society.

Patient (PATIENT) – A female audience member.

Voices in unison (VOICES) – A group of people off stage who are never seen, but say the last line in unison.

*

The lights come up to reveal DOCTOR on the stage, addressing the audience. DOCTOR’s first line is somewhere in the middle of his acceptance speech.

doctor address  crowd 1

                                                  DOCTOR

I know there are actually some of my patients out here too. And I won’t ask anybody to raise their hand, because I understand the confidentiality but thank you…

(DOCTOR is interrupted by a voice from the darkened audience)

 

                                                  PATIENT

Thank YOU Doctor Murphy.

(Audience applauds)

silvie full in audience 2

 

                                                  DOCTOR

(Peering out into the audience, sheepishly)

Who was that?

 

                                                  PATIENT

(Raising hand)

Me.

 

                                                  DOCTOR

Do I…?

audience silvie 2

                                                  PATIENT

Yeah, you may not remember me, but I sure remember you. Thank you.

(DOCTOR is smiling, but is clearly rattled by this interruption)

 

                                                  DOCTOR

Thank you. Uh… Just a second. Can I talk to you?

(PATIENT gets up from audience and meets DOCTOR at the corner of the stage. After brief hushed conversation, DOCTOR invites PATIENT up onto the stage)

 

                                                  DOCTOR

(To audience)

This is kind of unusual, but she’s going to say something that really fits into what I’m going to say later on. This is kind of amazing.

first patient 3

                                                  PATIENT

(To audience, holding a microphone)

Well, I was Doctor Murphy’s first patient, ever. I was only eight years old. And he was on his… (Turns to address DOCTOR) You were on your first clinical rounds, your rotation in med school. And you came every morning and looked in on me and checked my pulse and my temperature and my lungs and got me ready for my open-heart surgery. (To audience) I had open-heart surgery. I was so little and so scared.

going to be okay 4

(To DOCTOR) And you just let me know that everything was going to be OK, that I was going to do great. And I did! And I swore I would never forget you. And I haven’t.

 

                                                  DOCTOR

Well, thank you so much. That’s great. (To audience) Isn’t that great? I remember that. Thank you.

(DOCTOR reaches to take the microphone from PATIENT, but at the last moment PATIENT pulls away and continues speaking into the microphone)

microphone 5

                                                  PATIENT

Thank you and I didn’t…I…I…You rotated away after that.

 

                                                  DOCTOR

Yeah, I know. I rotated in medical school.

that's OK navy 7

                                         

                                                  PATIENT

But that’s OK. You don’t have to explain anything, because I understood. I know how those things go. I trusted you and I was grateful for all that you did for me.

dont have to explain 6

                                                  DOCTOR

Thank you.

(DOCTOR attempts to applaud, but is cut off by PATIENT)

 

                                                  PATIENT

(Backing away a little more)

Oh and I remember I saw you at that clinic in the navy hospital in San Diego. Yeah, I was so nervous and you had some really bad news to give me, but you set me up with a specialist. But then after that I never saw you. You left the hospital after that.

 

                                                  DOCTOR

Well, I was in the navy. I had to go out on the ship.

 

                                                  PATIENT

(Backing away a little more)

Yeah, I understand. You don’t have to say anything. You don’t have to explain. I completely understand. I was grateful for all that you did for me. I trusted you.

(Backing away)

And then I remember you were my anesthesiologist before my surgery. I was waiting for my surgery. And you were a little bit under the gun, because the OR was ready and the surgeon was ready and standing by. And right before we were going to leave to go in I asked if I could pray with my pastor. And you stopped everything and let that happen.

pray 8

                                                  DOCTOR

Yeah, I remember that. And I hope you don’t think that you were inconveniencing me at that time.

 

                                                  PATIENT

(Backing even farther away)

Oh no no no. You don’t have to say anything. I understand. I trusted you. And I was grateful for all that you did for me.

And then I had to have all those pain medications because I had five back surgeries. And the insurance company had some doctor I’d never seen before look at my records and not at me. And you did write a letter after they said that the insurance shouldn’t have to pay for my medications. You wrote a letter but they still denied my medicine.

wrote me a letter 9

                                                  DOCTOR

I know. I was going to call, but, you know, the preauthorization takes so much time. And I’m so busy. And I have to see a lot of patients. I have to pay my bills.

 

                                                  PATIENT

(Backing still farther away)

Yeah, I understand. You don’t have to say anything. I trusted you. I was grateful for all that you did for me.

start all over 10

And then I got that letter. I got that letter that started off, “Dear Valued Customer.” And then went on to say that I was going to have to get another doctor because you were not in my plan. You’d been cut out of my plan. Or because you’d started working for this big health care corporation and they didn’t accept my insurance. So I had to go find someone else and start all over.

 

explaining 10.5

                                                  DOCTOR

Well you know there are so many regulations now. There’s so much. There’s laws. And there’s the EMR. I have to document so much stuff. I can’t do it on my own. I have an employer now. I’m part of a corporation. I have corporate policies. (PATIENT is now exiting the stage) You know, I want to be your doctor. I want to be the leader of the health care team.

not okay 11

 

                                                  PATIENT

(No longer on stage, now only a voice on the PA system)

I don’t think that’s OK. I really don’t like your explanation. I’m not sure I trust you anymore. I am not grateful to you. I’m not a person anymore.

 

                                                  VOICES

(Off stage)

I am a population.

population 12

 

                                                     END

 

sad at end

 

*

Postscript: Silvie Zamora played the role of PATIENT. Silvie is an incredibly talented actress and dear friend. She and her equally talented husband, Phil Ward (also a lifelong dear friend), were vital to this little one-act’s artistic value and true message.

 phil and silvie

When you watch the video, keep in mind this was never rehearsed on stage. Silvie is the queen of improvisation!

Initially, the audience was not aware that this was a ruse. From my vantage point on stage it was fun to sense each individual gradually becoming aware that they were taking part in a group theatrical event.

“FRAUD” was written to be a wake up call for all physicians.

And, by the way, the events depicted in the play actually happened.
…and this just scratches the surface.

thumbs up

*

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Here’s the link to the “Fraud” video:

http://vimeo.com/67679697

 

 

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