Practicing Adult Primary Care Requires Time

In September of 1979, the American Board of Internal Medicine awarded me “Board Certification in Internal Medicine” after I completed their training and testing requirements. In 2002, I took the board certification exam in the newly created specialty of Geriatrics and passed it. I answer to the titles of “Doctor,” “ Geriatrician,” “physician”. However, CMS and private health insurers instead lump me, and other medical doctors, into the broad category of “provider”. The term “ provider” is both insulting and demeaning since what I do in general internal medicine/ geriatrics is different than what a physician’s assistant or nurse practitioner does and involves several more years of schooling as well as observed and critiqued training.

Insurers added insult to injury by stripping me of my internal medicine designation and lumping me in with family practitioners, pediatricians and obstetricians. Those are all unique specialties with their own rigorous training requirements and post training testing. They too deserve to be recognized by name for their accomplishments. But how they practice medicine and how I practice medicine are not one in the same.

I bring this up as an introduction to a research paper published in the Journal of Internal Medicine that performed time/work studies and determined that to perform the preventive care, chronic issue care, acute problem care and administrative duties, when caring for 2,500 patients, a physician would have to work 26.7 hour per days. If you provided that physician with qualified support staff, and created a care team, you could reduce the required time to 9.7 hours a day.

Ten-hour workdays are long by anyone’s standards and the article didn’t specify whether the primary care provider was limited to outpatient office work or included caring for their hospitalized patients as well. At best, this team-based approach ensures that the patient spends less time face to face with their actual physician which, in my opinion, is not a positive step.

The paper cited the example of vaccinations and immunizations being something best handled by lesser trained team members and, providing patients access to educational reading material. Once again, I have no problem with trained staff administering vaccinations but as you have seen with the corona virus pandemic and monkey pox outbreak, patients have many questions about materials injected into their body and they want to speak to a physician.

As an alternative to teams seeing patients, the authors mentioned “direct pay practices” which keep their patient load to 1000 or less, charge a monthly administrative fee and only accept cash for services rendered. I propose even smaller panels of 500 patients with insurers and CMS covering the costs of membership.

Studies sponsored by a large concierge medicine franchise program, have shown that they reduce their patients’ hospitalizations, meet preventive guidelines and ultimately save CMS and private insurers money. As an independent concierge medicine physician for 18 years, I have seen similar results limiting the number of patients I care for to 400 and giving them time, availability and advocacy with a focus on prevention.

By practicing in the concierge medicine model, you retain your patients long term and develop strong relationships with them. Also, you learn quickly that taking care of fewer people, and the relationships you establish with them,  is extremely satisfying and rewarding – something which will attract future doctors to these types of practices.

The current system does not work. Independent internists found a solution 20-years ago called concierge medicine. It’s time to give that model a try. It would save private insurers and CMS hundreds of millions of dollars per year resulting from a focus on prevention and reducing costly ER visits and hospitalizations.  For employers, it would reduce absenteeism and presenteeism, improve productivity and serve as a terrific health benefit.


More on Polio & the Breakthrough Population

In a previous blog post, I pointed out that there is a case of polio in Rockland County, NY in the orthodox Jewish population. Additionally, Public Health officials have detected polio virus in the wastewater of Rockland County, Orange County and NYC . They suspect that there must be at least 100 asymptomatic patients in that population as well. Certain facts must be clarified regarding the previous blog post.

Prior to polio vaccination, the world was dealing with the wild polio virus . It was transmitted through the fecal oral route. Paralysis and life-threatening illness occurred in 1 out of 200 patients infected. Most individuals did not even know they had it.

With funding and support from the March of Dimes, Jonas Salk, MD , invented the polio vaccine in injectable form. If you received a polio injection you could not transmit the virus to the unvaccinated.

Several years later the oral Saban vaccine was developed. You took this live attenuated virus prep orally – usually on a sugar cube. Since the natural transmission of polio was by the fecal oral route, the Saban oral vaccine produced a better level of immunity but additionally led to shedding of the virus with the potential to infect unvaccinated patients. At the time this was considered advantageous leading to more immunized patients but, as rare symptomatic cases of polio developed from the vaccine, authorities switched back to an injectable vaccine in the USA. The rest of the world did not necessarily follow suit and continued to use the less expensive live attenuated oral vaccine.

The case in Rockland County is felt to be the result of patient exposure to someone shedding the polio virus from an oral vaccination overseas. If that individual had been vaccinated against polio, they would not have contracted the disease and be shedding virus to others.

In an interesting opinion article in the NY Times, Editorial Board Member Jean Interlandi forwards the argument that lack of vaccination is not a religious issue . She has worked extensively with the orthodox community promoting public health issues and believes it is the young mothers and women who need to be educated and encouraged to vaccinate their children, not the rabbi’s who lead the community.

Ms. Interlandi may be correct but local authorities and politicians have made it far too easy for this group of individuals to ignore public health recommendations and reintroduce measles and its complications, whooping cough and now polio. Offering a carrot rather than a stick may be her best advice but, in my opinion, using both options is long overdue.

Health officials agree that if you are vaccinated you are protected against this non wild form of the virus. The solution is to vaccinate the children of Rockland and Orange County against these once eradicated diseases and allow this religious minority to worship as they please if their actions do not bring risk to the rest of the general population. At this time there are no recommendations for polio boosters in adults, immunosuppressed or the elderly populations.

On the Road Home

When I last checked in we were on our daughter’s farm in Fleischmann’s, NY. Cool morning temperatures in the low fifties were a wonderful change of pace from Florida’ s heat and humidity. This was peaceful, quiet, green and serene. It was wonderful to spend time with family and to relax in the true peace and quiet of the Catskills region.

We spent several days there before heading out on winding mountain roads to Buck Hills Falls, Pennsylvania where The Dow Jones firm developed a former Quaker property for their executives. They built individual “cottages” purchased by executives with enough room to fit at least four of my Boca Raton sized home inside each cottage. There was an inn for lesser employees to visit and vacation, but it burned to the ground and has not been rebuilt. Three golf courses, a tennis complex, equestrian stables, corrals, a children’s day camp, lawn bowling and resort size community pool provide the outdoor amenities for residents and the few lucky seasonal renters.

My brother and sister-in-law rented a home for the summer which did not permit pets inside, so we rented an AirBNB home nearby. We dined on their deck each night watching the large August full moon and a meteor shower while enjoying sweater and sweatshirt weather. Spending time with our family while helping plan our nephew’s wedding scheduled next summer, and bemoaning our beloved NY Yankees major slump, occupied our time. I wish I had planned more time with my brother, but it was time to head south.

Our adult children were adamant that we keep the driving to five or fewer hours. Our next stop was a bed and breakfast on a working farm in Fairfield, Virginia. It was “pet friendly” and five hours southwest. Their advertising “app” and email instructions were clear check in arrival was 4-7PM. The owner proprietors texted us the morning before our arrival asking when we expected to arrive. We estimated between 5-6PM. We stopped every few hours to walk the dogs and use the rest room. Major truck accidents slowed down every leg of our trip.

We arrived at 5:45PM only to learn the hosts had left for a concert and we were left an instruction letter and room key. We expected to be in a first-floor facility separate from the main inn. We were instead on the second floor of the main house accessing our accommodation by climbing a wood lumber steep exterior staircase. Carrying our luggage and a paralyzed pooch up and down the steps was great exercise and the equivalent of a cardiac stress test. The staircase was so steep that our three-year-old dog was afraid to climb or descend on it.

The property was breathtaking in the Shenandoah Valley surrounded by mountains. horses, chickens, fruit and vegetable gardens and hummingbirds. Young deer, rabbits and foxes were abundant and visible just as they had been at our stops in Maryland, Berkeley Heights, New Jersey, upstate NY and Pennsylvania.

There were no food provisions or dinners or lunch available on the property . With no one to greet us we were on our own with Waze to guide us on poorly marked northern Virginia country roads. We found Frankie’s Pizza and dined on pizza and beer on our second-floor deck one night and hoagies the next.

We met our host and hostess the next morning at a sumptuous breakfast made with eggs, cheeses, butter, vegetables from their farm . The breakfast was luscious. Before arriving, we received strict written instructions to keep visiting pets off the deck, so we left the dogs in the room. When we finished introductions prior to being seated for breakfast, the hostess asked us to bring the dogs down.

As I carried Gigi down, she had a rare urinary accident on the wood deck outside. I offered to clean it up but instead received a stern lecture on the value of the items in each room and their concern about them being ruined by an incontinent dog . I was charged a daily pet cleaning fee in advance and signed a pet form guaranteeing responsibility for any damage as well upon arrival.

We were meticulous inside our accommodations at every stop with the older dog wearing two diapers lying on a waterproof mat placed on a waterproof doggie bed. I suggested she list her property as “pets tolerated” rather than pet friendly . It was the only negative incident over the course of the trip. This bed and breakfast is well worth relaxing at without pets or young children. The host and hostess were actually quite nice once you spent time with them, so we chose to overlook the previous days harsh lecture.

After two nights we drove south six hours to Asheville , North Carolina. The drive on I81 south then 26 east took us into Tennessee and through the mountains. I have been to Big Sur, the Pacific Coast Highway and the Amalfi Coast all wondrous and dramatic. The Tennessee mountains were far greener and more beautiful than anything I had ever seen.

Asheville reminded me of Boulder, Colorado or Venice, California with wealthy long haired seniors and street people. It was a great outdoors activity, sit outside and drink a beer from a microbrewery type of town. We were down the block from the Biltmore Estate and the Mission Hospital complex, a huge medical center I had never heard of. Patients from the south used it as a referral Center of Excellence.

With trendy stores, restaurants, pubs and activities I learned firsthand why it has become a retirement and vacation hub. I understood the allure of Asheville but it was not our cup of tea.

Our next stop on the trip south was Jekyll Island, Georgia. Beautiful natural beaches, with protected dunes and limited development made it a unique beach town. Inclement weather induced us to leave a day earlier for the six-hour drive home.

As we pulled into our residential community I was struck by how pretty and well maintained it was. Traveling up and down the east coast I saw impressive residential areas, but I still love my neighborhood.

Despite the divisiveness in the nation, most people we met were polite, civil and warm. We wore N95 masks when indoors in public places and most shopkeepers asked us if we wanted them to don a mask when we approached them. We refrained from asking them to put on a mask.

The vacation was long overdue and certainly recharged my battery. But it’s always good to be home.

Posture Makes a Difference in Pill Time to Action

Engineers at the Johns Hopkins School of Engineering have been creating models of human organs to investigate the way to make them most efficient. Recently they used an artificial human stomach to determine if our position at the time of swallowing a pill makes a difference in the time until onset of action of the medication. Most experts agree that oral medication doesn’t start to work until the material leaves the stomach and moves to the small intestine. For prime efficiency you want the pills to land in the distal portion of the stomach or antrum. You can achieve this by lying on your right side.

Their studies, published in Physics of Fluids, showed that dissolution was quicker by lying on your right side. Your left side was significantly slower. Being upright fell somewhere in between being on your right or left side. They showed that a person lying on their left side took almost 23 minutes for the material to dissolve and leave the stomach while that time was only 10 minutes on the right side. For patients with diabetic gastroparesis, or Parkinson’s disease, these positional differences may be even more significant.

As a physician prescribing medication for years, I never considered position an issue. Now when I get my headache and want quicker resolution, I will try the different positions and see if it makes a difference.

Polio is Back

One case of polio with neurological complications has been detected in Rockland County , NY. The virus is now present in the wastewater of NYC , Rockland and Orange Counties. Public health authorities believe there are 100 or more cases in that area with symptoms not yet present but the infected shedding the virus.

The disease was detected in a population of ultra-orthodox Jewish residents who do not believe in vaccinations. Statistics released today show that less than 60% of the eligible children in those two counties have been vaccinated against polio. With the disease now being found in the wastewater of NYC, Public Health authorities are considering giving boosters to children ,the immunosuppressed and the elderly. Those decisions are pending.

I remember polio. My friend’s older siblings died from polio. My best friend’s older sister wore a brace on her leg and used a crutch to walk. My maternal grandmother’s best friend caught polio while pregnant. She survived it but we sat with her thirty something daughter born with no legs on the beach daily in the summers. We had crude elementary school level jokes about the disease. “Johnny i see you brought your father’s iron lung to school today for show and tell. What did he have to say about it?” Johnny answered, “ Uggggh”.

I remember the excitement when we received a notice from P.S. 253 that the NYC Public Health Department was going to vaccinate all elementary school children against polio. We lined up in the gym excited to be vaccinated with a shot in the arm. There was no discussion of long-term adverse effects of the vaccine. There was no talk about how effective the shot would be.

When my brother and I became ill that winter with fever and viral illness no one contemplated whether this was a breakthrough case of polio with no neurological consequences or death due to vaccination. We did not have the technology available to determine that anyway. We just knew we would not end up paralyzed, on an iron lung for life or die from polio.

As an adult I have spent years defending the right of religious groups to practice their religion in the privacy of their homes and communities. Isn’t that what America is supposed to be all about?

Growing up in a beachside residential community on the tip of Coney Island called Sea Gate, I witnessed this same community rent and purchase dilapidated multi dwelling structures and use them as summer retreats at the beach . I defended their rights to their privacy despite the fact that if I went out to wash and clean the car after sundown on Friday evening I would be verbally abused or even have objects thrown at me for disturbing their view of the Sabbath.

I still support their right to worship as they please, but not at the expense of violating reasonable public health vaccination recommendations which puts the general population at risk. Their community now has a voting bloc and financial strength to prevent the local enforcement of vaccination mandates. If G-D didn’t want humans to develop medications against dreaded diseases, then it would not have happened.

It’s long since overdue for public officials and health officials in NY City and State to charge these individuals with child abuse, throw them and any leaders who support them in jail and make it clear that if they want their rights to live and pray in peace in the community, they need to start thinking about more than just themselves.

Driving Up the East Coast on Vacation

The Pandemic resulted in me not taking a vacation for three years. A quick trip by plane to NJ in June for a high school graduation was cancelled when COVID infected the graduate’s immediate family. The party was pushed back to August but a paucity of dog sitters to watch my disabled failing pug while we were gone complicated trip plans. I consulted our vet who just suggested we take the pups with us in the car . My three adult daughters thought my wife and I were crazy for planning this vacation but here seven days later on a wooden deck on a mountain top in Upstate NY enjoying the shade, low humidity and cool breezes.

It’s great to leave Florida by car. No flight cancellations. No lost luggage. My wife and I split the driving and stop every few hours to walk the dogs and use a clean rest room ourselves. We listen to my wife’s radio choices while she drives and vice versa.

I belly laughed up the coast because she loves comedy greats on Spotify. I laughed to comic routines by Jack Carter, Jan Murray, Hennie Youngman, Robert Klein , Robin Williams, Redd Fox and other greats I had not heard in decades. We stay in dog friendly highly recommended chain hotels which are clean, serve a breakfast and have helpful friendly staff.

At stops in Beaufort , South Carolina, Richmond , Virginia and Rockville, Maryland there is no such thing as a corona virus pandemic. We were the only ones wearing masks, eating outdoors exclusively and avoiding crowds indoors. Until we arrived here high in the Catskill Mountains the weather was Florida-like, hot and humid.

On the road I stopped to see my niece, her husband and infant little girl . My niece is a pediatric hematologist, he’s an anesthesiologist and Aria is just a beautiful captivating 18-month-old. I learned how these young docs feel about medicine and how they try and balance both professional and personal responsibilities while my niece learns that being a mom really is the toughest job in the world. I was able to see their new home and the life they are building . It was a rewarding uplifting experience to see those you love happy, healthy and living their dream.

I also got to break bread with my business associate and friend who for fifteen years has directed practice advertising, website improvement, newsletters and blogs. We usually see each other a few times each year but communications have been by phone and Facetime since the pandemic began. Getting together face to face just reaffirmed why I like and respect this gentleman.

We are currently in a farmhouse in Upstate NY, which my daughter and son in law are renovating. It’s breezy, cool, serene and plush outdoors. We are planning our return trip south with overnight stops every five hours.

See you all soon.