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COVID Update

As of March 9, 2021:

The new CDC guidance says fully vaccinated people can:

  • Visit other vaccinated people indoors without masks or physical distancing.
  • Visit indoors with unvaccinated people from a single household without masks or physical distancing, if the unvaccinated people are at low risk for severe disease.
  • Skip quarantine and testing if exposed to someone who has Covid-19 but are asymptomatic, but should monitor for symptoms for 14 days.

But people who are fully vaccinated still need to take precautions in many scenarios:

  • Wear a mask and keep good physical distance around the unvaccinated who are at increased risk for severe Covid-19, or if the unvaccinated person has a household member who is at higher risk.
  • Wear masks and physically distance when visiting unvaccinated people who are from multiple households.
  • Keep physical distance in public.
  • Avoid medium- and large-sized crowds.
  • Avoid poorly ventilated public spaces.
  • Wash hands frequently.
  • Get tested for Covid-19 if you feel sick.
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There Are Three Kinds of Primary Care, Not to Be Confused With Each Other

HANS DUVEFELT, MD
 

https://acountrydoctorwrites.blog/author/acountrydoctorwrites/

Published January 24, 2021 

Primary care doctors, the way things are organized in this country, perform three kinds of services. If we don’t recognize very clearly just how fundamentally different they are, we risk becoming overwhelmed, burned out, inefficient and ineffective. And, if we think about it, should we really be the ones doing all three?

SICK CARE

Historically, people called the doctor when they were sick. That service has, at least in this country, become more or less viewed as a nuisance in primary care offices. We keep a few slots open for sick people, in part because the Patient Centered Medical Home recognition process requires us to. But our clinics may worry that those slots go unfilled and lead to lost revenue.

Instead, sick people scatter toward emergency rooms with crowding, high overhead and liability driven testing excesses or to freestanding walk-in clinics that only sometimes are integrated with the primary care office but universally staffed by providers who don’t know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced clinicians within their organizations, doing what I feel is the most challenging work in health care – sorting the very sick from the only moderately ill or even completely healthy but worried patients.

In the worst case scenarios, the walk-in clinic is freestanding, operating without any access to primary care or hospital records, starting from absolute scratch with every patient. Some of these clinics are well equipped, with laboratory and x-ray facilities and highly skilled staff. But some are set up in a room in the back of a drug store and staffed by a lone nurse practitioner with minimal equipment and no backup.

Because health care in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anybody think it would look like this?

CHRONIC DISEASE MANAGEMENT

More and more people suffer from chronic diseases like diabetes, hypertension and autoimmune conditions. This is where the bulk of primary care work is done. Much of it is straightforward and predictable: Diabetics get their glycosylated hemoglobin checked every three months, hypertensives get their blood pressure logs and blood tests reviewed at certain intervals. And, sadly, much of it is ineffective. Few people lose weight, improve their blood sugars or change their lifestyles. Our visits follow the same tired routine from one time to the next – “I’ll do better this time, Doc”.

The more our country’s chronic disease burden increases, the more clinician time and effort this kind of work will consume. And the more we need to question whether there isn’t a better way to deliver chronic disease management.

We already know that group visits can be very successful, because of the power of peer support. And even when they are limited to Zoom, they can be effective. They are certainly more efficient than speaking with patients one by one, again and again, like a broken record. Quite frankly, that is getting antiquated.

Besides through group visits, this aspect of primary care is also easily done or at least supported by technology. There are already apps for tracking blood sugar, blood pressure, exercise and sleep. I’m sure there are more applications out there already and even more in development. The feedback from all this data can easily be managed by artificial intelligence, leaving just the final decision making and personal touch for the medical provider. (More on why the personal touch is still necessary in an upcoming post.)

DISEASE PREVENTION AND SCREENING

You don’t need a dozen years of professional education to tell people to have their routine immunizations, to offer screening colonoscopies or to administer standardized questionnaires for anxiety, depression, alcohol or domestic abuse or whatever else the politicians and bureaucrats think we doctors should do.

My professional opinion is that this work is too routinized to require a medical license, but could safely be done by non-providers or even by computers with very rudimentary programming.

I also question the logic of bombarding patients with these when they come in for a sick visit with many worries and questions they hope to have time to address. In fact, I question why these things aren’t done outside the visit, through outreach via our patient portals, newsletters, phone calls, email or even printed letters.

What I do think, is that these screenings can and probably should be done under the umbrella of patients’ primary care “medical home”. But I strongly object to the misinformed assumption that this data collection is doctor work. The doctor should however be available in the loop to manage positive findings.

(In my EMR the doctor has to sign off even normal screening tests in a most cumbersome work flow as part of an office visit. Why not have a standing order and an automated process to only flag the provider for scores above a certain value?)

Prevention and screening services to 331,000,000 citizens, one by one and face to face, for innumerable diseases and risk factors is not the best use of our 209,000 primary care physicians. At least not if we want to be fiscally responsible. It is definitely not a good idea if we want doctors to also have time to treat the sick. And it is a very questionable strategy if we don’t want them to burn out and leave the profession as soon as they can afford to.

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CRAZY AMERICA: Health Insurance Covers Testing When You Are Well But Not When You Are Sick

By Hans Duvefelt MD

Published October 25, 2020

Insurance is the wrong word for what we have here. Our private health insurance system’s prioritization of sometimes frivolous screenings but non-coverage for common illnesses and emergencies is a travesty and an insult to typical American middle class families.

State Medicaid insurance for the underemployed has minimal copays of just a few dollars for doctor visits and medications. From my vantage point as a physician, it is the best insurance a patient can have. They cover almost everything and it is clear to me how to apply for exceptions or follow their step care requirements. I cannot say that about most other insurers.

Most employed people have the kind of commercial health “insurance” that covers an annual physical and certain screening tests at no cost, but requires people to pay the first several thousand dollars of actual sick care expenses out of pocket. This is, in my opinion, insane. It causes delays and omissions in diagnosis and treatment.

A shining example of this bizarre arrangement is the screening colonoscopy. It is free as long as it is normal. If a patient has a polyp removed, which if unchecked could turn cancerous, future health care costs for treating colon cancer are eliminated. But the patient gets billed for the early cure.

The pandemic we live under has demonstrated the thin financial margins many Americans live with. A couple of months of missed paychecks and suburban families are lining up at food pantries.

The high deductibles and the high and often undisclosed cost of health care tests and procedures can be more than enough to destabilize an average American family’s economy. Under such circumstances people hesitate seeking care for new symptoms, even if they seem serious.

Historically, the word insurance is derived from the Old French ensurer, meaning “make safe”. The word assure is an even older word, long used specifically for providing a guarantee against loss in exchange for money. American health insurance has drifted into higher and higher deductibles and people now feel less and less safe for having health insurance.

I have many patients who, because of the cost, hesitate getting the lab work to monitor their chronic conditions and to ensure that their medications aren’t causing adverse effects. At the same time, I have patients who are perfectly healthy and take advantage of the “free” physical and random blood tests year after year. But if you feel fine and your weight and lifestyle never change, chances are your blood count, chemistries or lipid profile won’t change much from year to year either.

In fact, annual screening blood tests and even routine “complete physicals” have little or no proven value, depending on exactly who you listen to, including the US Public Health Service Taskforce on Prevention. However, an annual review and conversation around specific health screenings, immunizations and disease prevention, such as the no-touch Medicare “Wellness Visit” has been shown to improve compliance with preventive care guidelines (often called quality).

The whole concept of health insurance is confusing because it is so different from other types of insurance.

My car insurance only pays for accidents. They don’t pay for my state inspection, scheduled maintenance or normal wear and tear, and certainly not for mechanical failures. A brand new or certified used car, on the other hand, may be covered by a “bumper-to-bumper” warranty for a few years, but never for its entire useful life.

There is complete disagreement about how health care should be paid for. Socialized medicine and insurance medicine are two very different models. Americans seem to intuitively, emotionally, want to think of commercial health insurance as something a lot closer to free health care or a car warranty than it actually is. Commercial health insurance is a for profit enterprise that happens to be in the health care field. Their ultimate reason for existing is to make money. They do that by paying out as little as possible and keeping as much as possible of our premiums without looking unacceptably greedy.

I left Sweden with the insight that its socialized healthcare system had many inefficiencies and much bureaucracy. I live in America with the insight that a government bureaucracy, like our Medicaid, is easier to understand and navigate than a hodgepodge of federal, state and commercial payers. And it saddens me to see the insecurity of my fellow Americans who risk getting bankrupted by health care expenses and inadequate sick time benefits or disability income protections – many of them, just like health care, provided by for profit insurance companies.

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Causes of Death, 7-25-20

From the CDC, 2018:

In 2018, the latest year for which final data is available, the top 10 leading causes of death among all ages in the United States were:

  1. Heart disease (655,381)
  2. Cancer (599,274)
  3. Unintentional injury (167,127)
  4. Chronic lower respiratory disease (159,486)
  5. Stroke (147,810)
  6. Alzheimer’s disease (122,019)
  7. Diabetes (84,946)
  8. Flu and pneumonia (59,120)
  9. Nephritis (51,386)
  10. Suicide (48,344)

In the first seven months of 2020, COVID-19 has killed 150,000 people in the US. That beats stroke, the 5th leading cause of death. But the year isn’t over yet. It could end up being the 3rd leading COD in the US in 2020. That is, if its death rate doesn’t rise or fall over the rest of the year.

From The Economist, May 2020: Covid-19 has become one of the biggest killers of 2020 worldwide. This year its global toll exceeds that of lung cancer or malaria.

(Curious to see what this graph looks like today.)

From the World Health Organization: Every year, 10 million people fall ill with tuberculosis (TB). Despite being a preventable and curable disease, 1.5 million people die from TB each year – making it the world’s top infectious killer. But from the data below, from 2000 to 2018, both the incidence and the death rate are going down, worldwide.

The slope of the COVID-19 curve is markedly different from the slope of the TB curve (blue line graph on the right). Are masks, social distancing, and economic suicide helping to decrease the spread? Would hospitalizations and deaths be even greater if we weren’t doing this? It’s hard to know because we don’t have a year of Coronavirus without social distancing for comparison.

But could other infectious diseases serve as a bellwether? Is social distancing decreasing the spread of other contagious illnesses, like colds and flu? Norovirus? STDs? Mono? 5th disease? If it is, it would be reasonable to assume that social distancing is curtailing the spread of Coronavirus, too. And that fewer people are dying.

For now, we have to hope that our sacrifices will be worthwhile in time.  Without these sacrifices, thousands of people more would be dead. All we know for sure is that if we didn’t have the novel Coronavirus, 650,000 people (worldwide) would still be with us.

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Dear President Trump

Dear President Trump,
I have an idea that may be helpful. Instead of handing out billions of dollars in cash to millions of people, we should put that money into a system that allows healthy people to go back to work (and back to spending money, too). If we could test everyone in the country for Coronavirus every week, we could get the economy going again. We should put billions of dollars into massive testing and a system which would allow people to show that they tested negative and when. Such as an app that shows you were negative last Monday. You show this app to go to work, go to school, go out to eat, go on a trip, etc. That would be more effective at getting the economy going again, than a cash handout.
Another option besides mass testing might be putting billions of dollars into ramping up vaccine development. But that might still take too much time since there is a lot of trial and error involved. It might get the economy going faster if we could do mass testing and get the 90% of us who are healthy back to work and spending.
If you have a million dollars and you want the most bang for your buck, you could give a million people one dollar each. Or you could build a school, a hospital, or a factory. Which is better for the economy?

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Has This Ever Happened to You?


“If I’m sick, I need to be seen today, not three weeks from Thursday!”
And “My new doctor’s first available appointment isn’t for three months!” 

Hello, I’m Laurie Thomas, your hometown family doctor. Whether you’re a new patient or have been seeing me for a long time, I will try to see you today if you’re sick. Otherwise, I can usually see you for routine appointments within a week.

“The doctor spends 5 minutes with me, then he’s out the door!”

How much time would you like to spend? It’s up to you.

I can never get through to my doctor on the phone!” “My doctor’s office never returns my calls!”

You can reach me easily by phone, 24/7. My office phone number, 400-8223, is my cell phone. If I don’t answer, I’m with a patient or on the phone with a patient. Leave a voicemail. I’ll call you back.

“The doctor spent the entire appointment typing on the computer. Never even looked at me.”

I don’t have computerized medical records.

“I had a cat scan last year, but I never heard the results. It must be OK, because I would’ve heard by now if there was a problem. Right?”

This is one of the scariest things I hear from patients. Always call for test results. Keep calling until you get them. Never assume a test was normal  just because you haven’t heard anything. If you don’t get results in a reasonable time, assume they are lost. Yes, it can happen. And sometimes bad news gets lost.

“My insurance changed, and my doctor is not on my new plan. I have to find a new doctor.” “The doctor I’ve had for years stopped taking my insurance. I have to find a new one. Again.”

Since I don’t deal with insurance, my patients will never be forced to find a new doctor.

“My doctor doesn’t really listen to me.”

Doctors who take insurance have to keep their appointments short and see a lot of people every day. No wonder they don’t listen. They don’t have time. Most of the art of medicine is in the art of listening. Since I don’t take insurance, I have the time to listen.

Think about what you are looking for in a doctor. My goal is to deliver modern medicine with old fashioned care. If you are looking for more personal healthcare, ask yourself if Dr Laurie Thomas may be right for you!

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An Old Cherokee Tale of Two Wolves

One evening a Cherokee Indian told his grandson about a struggle inside all people. He said, ‘My son, there is a battle is between two ‘wolves’ inside each of us.

One is Evil. It is anger, envy, jealousy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego.

The other is Good. It is joy, peace, love, hope, serenity, humility, kindness, benevolence, empathy, generosity, truth, compassion and faith.’

The grandson thought about it for a minute and then asked his grandfather: ‘Which wolf wins?’

The old Cherokee simply replied, ‘The one you feed.’

 

Nurture your compassion. Starve your anger and self-pity. Keep the Good Wolf strong. —Dr T

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Help for nighttime leg cramps

Nighttime leg cramps cause pain and sudden muscle tightness in the legs, feet, or both. The cramps can wake you up from sleep. They can last for many minutes or just a few seconds.

Nighttime leg cramps are common in both adults and children. But as people get older, they are more likely to get them. About half of people older than 50 get nighttime leg cramps.

What causes nighttime leg cramps? — Most nighttime leg cramps do not have a cause that doctors can find. When doctors do find causes, the causes can include:

  • Having a leg or foot structure that is different from normal – For example, having flat feet or a knee that bends in the wrong direction
  • Sitting in an awkward position or sitting too long in one position
  • Standing or walking a lot on concrete floors
  • Changes in your body’s fluid balance – This can happen if you:
  • Take medicines called diuretics (also called “water pills”)
  • Are on dialysis (a kind of treatment for kidney disease)
  • Sweat too much
  • Exercising
  • Having certain conditions – For example, Parkinson disease, diabetes, or low thyroid
  • Being pregnant – Some pregnant women do not have enough of the mineral magnesium in their blood. This can cause leg cramps.
  • Taking certain medicines

Is there anything I can do on my own to feel better? — Yes. Things you can try include:

  • Riding a stationary bike for a few minutes before bed – If you normally get little exercise, this might help.
  • Doing stretching exercises (picture 1)
  • Wearing shoes with firm support, especially at the back of your foot around your heel
  • Keeping bed covers loose at the foot of your bed and NOT tucked in
  • Drinking plenty of water, especially if you take diuretics. (Do this only if your doctor or nurse has not told you to limit the amount of water you drink.)
  • Limiting the amount of alcohol and caffeine you drink
  • Staying cool when you exercise, and NOT exercising in very hot weather or hot rooms

If you get a cramp, slowly stretch the cramped muscle. To prevent more cramps, you can try:

  • Walking around or jiggling your leg or foot
  • Lying down with your legs and feet up
  • Taking a hot shower with water spraying on the cramp for 5 minutes, or taking a warm bath
  • Rubbing the cramp with ice wrapped in a towel

Should I see a doctor or nurse? — See a doctor or nurse if:

  • You wake up several times a night with leg cramps
  • Your cramps keep you from getting enough sleep
  • Your cramps are very painful
  • You have cramps in other parts of your body, such as your upper back or belly

Are there tests I should have? — Probably not. Your doctor or nurse will talk with you about your symptoms and do an exam to find out what could be causing your nighttime leg cramps. Depending on your symptoms and exam, you might also need some blood tests.

How are nighttime leg cramps treated? — Treatment is different for everyone. Most people have to try a few different things before they find a treatment that helps them.

Treatment options include:

  • Mineral and vitamin supplementation, including vitamin B complex (three times daily, containing 30 mg of vitamin B6) or vitamin E (800 international units before bed), before using prescription medications. Vitamin B complex (containing fursultiamine 50 mg, hydroxocobalamin 250 micrograms, pyridoxal phosphate 30 mg, and riboflavin 5 mg) showed benefit in one randomized trial [40]; and vitamin E was beneficial in some small studies but not others [35,41].

Iron may be helpful in patients who have iron-deficient anemia; and magnesium supplementation may be of benefit in patients with pregnancy-related cramps [19,42]. However, a systematic review of randomized trials comparing magnesium supplementation with placebo identified four trials involving 322 patients with idiopathic (primarily nocturnal) leg cramps; meta-analysis of the trials found no evidence of significant benefit in the frequency or severity of cramping with magnesium therapy [42]. Three trials involving a total of 202 women with pregnancy-associated leg cramps were identified in the systematic review; only one found benefit.

  • If vitamin and mineral supplements are ineffective, you can try diphenhydramine (Benadryl), 12.5 to 50 mg nightly, at bedtime.

How to stretch the backs of your legs

Stand facing the wall, feet together, about 2 feet from the wall. With your heels firmly on the floor and your shoulders, hips, and knees lined up straight, lean forward into the wall. This should stretch the backs of your legs. Hold this position for 10 to 30 seconds. Repeat 5 times each session, at least twice a day.

Leg stretch