During the Pandemic: Medical Advice Is Challenged & Questioned While Patience is Thin

I, like most of the western civilized world, have had my fill of the pandemic. I see patience short both in the general population and in the medical community. The problem is that everyone seems to have lost their perspective and the value of education, experience and caring.

I received a phone call from a relatively new patient. He and his wife are recovering from breakthrough Covid-19. They are well past the point of being required to quarantine whether you use the original 14-day recommendation prior to vaccines, the revised 10-day program or the 5-day program. They still have deep, barking coughs. They do not have a fever, nor are they short of breath and they are not complaining of difficulty breathing. The cough keeps them up at night sometimes and produces clear to yellow phlegm. I advised patience, warm clear fluids, tea and honey, cough syrup and time. The patient asked for a Z-Pack (zithromycin , an antibiotic). I explained this was a viral illness not requiring an antibiotic and that the cough might be present for weeks to come. The message was poorly received.

Today as I was leaving the office the patient called back. He said that the stress of this all had stirred up his angina. He felt like he had an elephant sitting on his chest. I again asked if he was having trouble breathing and he said a bit more. He was not wheezing. He was talking comfortably on the phone. The symptoms associated with the pain did not include nausea, vomiting or massive sweating which sometimes are seen with an ongoing heart attack. The description of crushing chest pain like an elephant on the chest was sufficient to require an evaluation at a cardiac center. I suggested he sit down, take a nitroglycerin if he had one with him and call 911 immediately. He declined. He said it is probably just bronchitis and “If you don’t want to see me because of Covid issues I will just find a clinic to go to.” He told me he had heard on the news that there were no hospital beds and he didn’t want to wait for hours in an emergency room.

This patient has a history of high blood pressure, high cholesterol and had previously had a mini stroke . I explained that his complaints needed a cardiac center with heart rhythm monitoring, a quick lab to monitor cardiac enzymes and defibrillators with advanced cardiac life support trained personnel.

I called him back an hour later to see how he was feeling and what he decided to do. He was on his way to a clinic. “Must be bronchitis and if you won’t see me they will.”

As the pandemic rolls on there are no suggestions, recommendations or advice given that is not challenged and questioned. Sometimes I have to remind myself that we are on the same team, with the same goals of keeping you independent, healthy and feeling well.

I would expect with 20 plus years of schooling and training, and 40 plus years of experience and continuing education, my patients would remember we are on the same team and trust my professional experience rather than their own, or that of others, when it comes to the best interest of their health.

My interests and intent are to keep you healthy and well. However, there are medical conditions that cannot be safely seen in the office. A potential heart attack or ongoing stroke, a loss of consciousness, inability to breathe or unstoppable bleeding are a few of the conditions which require an ER not a walk-in center or physician’s office. When I suggest that a patient be seen in the emergency department I am doing so in the best interests of the patient!

I am not quite certain why when the advice is given, based on the information the patient and family provide, it is received with such skepticism?   I just know that skepticism and pushback are far greater now than they were before Covid appeared. 

Seaweed as a COVID Treatment?

A type of sea algae known as ulna, or sea lettuce, is being tested to see if it can be used as a medication to treat SARS 2 Coronavirus. In the past, other forms of seaweed and algae have been successfully used as anti-viral agents. For this reason, researchers have tested ulna against the corona virus in lab test tubes.

They first extracted ulvan, a chemical in the sea lettuce, and then placed it in test tubes with living cells and live Coronavirus. The cells exposed to ulvan did not get infected with coronavirus. The cells only exposed to the virus did become infected. The ulvan used in this experiment came from algae grown in the lab. The native algae sea lettuce is a normal part of the diet of individuals in Japan, New Zealand and Hawaii.

The researchers used two different methods to extract the ulvan from the seaweed sea lettuce. One method produced a product that showed 10 times more anti-viral effectiveness than the other. The next step is to test this product in animals and if successful in human trials. Those experiments are being developed for further study.

After reading this article I wonder if there is any less COVID infection in the population that regularly consumes this sea lettuce and, if infected, are the clinical symptoms and presentations milder?

Disappointment in Decision-Making Regarding COVID-19

I received an email from the Chief Medical Officer at my main local hospital informing me that elective surgical and diagnostic procedures had been cancelled due to understaffing because of COVID-19 infections. He mentioned 136 employees testing positive yesterday and 36 nurses not reporting to work this morning for the day shift due to COVID. Nearby Holy Cross Medical Center has stopped delivering babies due to a shortage of staff.

I subscribe to numerous physician run newsletters that discuss expert opinions on many specialty topics. The physician writers are all at the stage of life where they and their children are young and they are grappling with in-person schooling and infection. They write about hosting large holiday gatherings and now learning that multiple attendees are ill and positive with COVID-19.

While there have been few hospitalizations so far in this young professional vaccinated group, they worry about infecting their young unvaccinated children and elderly parents with chronic illnesses. These are leaders in the health care public policy and influence pedaling industry today and their lack of discipline and ability to delay gratification has put us all in the unenviable position of having to face an absence of available medical services due to further spread of COVID-19

I have no more success with my own highly educated children who do not work in health care. My eldest child hosted a holiday gathering in Venice, California to celebrate their Christmas Canal Boat Parade and multiple attendees reported being sick four days later. She then boarded a plane to New Mexico with friends.  Upon their return, two of the three travelers are home with COVID-19

We are in a major surge of infection with a highly transmissible virus. Texas Children’s Hospital is full of children too young to be vaccinated and struggling to breathe and survive. Locally, Jack Nicklaus Children’s Hospital and Joe DiMaggio Children’s Hospital are facing similar problems.

I urge you to stay home. Wear a mask if you go out in public which is a N95 or KN95 mask or triple layer cloth surgical mask. Avoid eating out at restaurants even outside. Stay out of gyms. Stay out of country club dining rooms and card rooms. “The Board” can make those places clean but they can not make them safe from a respiratory virus with twice the transmissibility of smallpox and measles. The economy will suffer but can recover with intelligent leadership. Sadly, businesses will suffer too but they can recover. Lost children and seniors cannot be replaced.

Omicron is the Grinch That Stole Christmas

The Center for Disease Control (CDC) is reporting that up to 90% of the infections with COVID-19 Sars 2 Coronavirus are the new Omicron strain. It replicates itself 70 times faster than the Delta strain and contact with an infected person within 12 feet for one or more seconds can result in infection. For those who have been vaccinated against COVID-19 with the Moderna or Pfizer Vaccine, and received a third shot or booster, the expectation is that if they become infected with Omicron, they will either have no symptoms or a mild case. By definition “mild COVID” means your respiratory system is not compromised enough to require hospitalization. Despite this, most of the current deaths in countries which are having a COVID surge are in people older than 65 years of age.

In the past, when patients in this area became infected with COVID-19, we arranged for them to go to the local hospitals to receive an infusion of a monoclonal antibody solution made either by Regeneron or by Eli Lilly. The infusion prevented the infection from becoming severe enough to progress to a severe state requiring inpatient hospital respiratory care. These monoclonal antibodies do not work against Omicron. For this reason, the FDA and CDC have removed the Emergency Use Authorization and ended the administration of these drugs nationwide.

There is a third monoclonal antibody made by Glaxo and Var called Sotrovimab which effectively throttles Omicron, but it is in limited supply. As of today, the State of Florida has received 1050 dosages. Production has been accelerated and hopefully the drug will be available in mid to late January for infusion. There are two new antiviral pills which should work as well. The Pfizer product received FDA approval today and, with production acceleration, some should be available by mid-January. Until these drugs are locally available the medical community has no medications to offer patients who contract the COVID-19 Delta or Omicron variant to limit the severity of the disease.

My advice to my patients and loved ones is to reintroduce distancing and masking. Wear a good N95 mask when you will be around others – especially indoors. If you must be indoors with others, make sure the windows and doors are open and the ventilation is excellent. If there is an air filtration system with HEPA Merv 13 level filters and ultraviolet light that adds protection. Distancing with the aggressive Omicron variant will require 12 feet not six feet.

This is a heartbreaking restrictive change in scheduling and behavior we are asking for at a time of the year when families and friends travel to gather to celebrate. Younger and leaner healthier individuals who are vaccinated will survive this. The real questions are who they will transmit this infection to unknowingly, who is too young to be vaccinated or too old to have a robust immune system?

Our office staff will be reassessing the risk to patients and staff daily. With the local testing positivity rate >10% in Palm Beach County, our contacts will be by phone and telehealth. When the Pfizer anti-viral pill Paxlovid is available, and or Sotrovimab for infusion, we will return to regular in-office patient visits.

I apologize for the inconvenience. Stay safe and call if you have questions.

COVID-19 & Public Health Departments

I received an email from the Florida Department of Public Health saying a Federal Judge from Missouri had struck down the necessity for health care workers to be vaccinated against COVID or risk losing their jobs. The suit was brought by several states and, while Florida was not part of this particular lawsuit, was part of other lawsuits which are ongoing.  My immediate thought is that the Florida Department of Public Health should have more important things to do such as providing public health! 

I contrast this with a story told to me by a reliable source – a 66-year-old New Yorker. He lives in the Upper West Side of Manhattan with his 63-year-old wife and spends winters at a home on the West Coast of Florida. 

They packed up their car and, for the first time, hired a professional driver to transport it plus some belongings down to their Florida winter home . They were scheduled to board a flight to Sarasota on December 2nd until the husband received a text message from the NY City Department of Health.  The message said that using cell phone location tracking data they have discovered that the husband was within six feet of an individual who tested positive for COVID-19.  They provided contact information and requested he call the number to receive precautionary recommendations.

When he called, they advised that if he was vaccinated and had no symptoms of COVID he should be tested in four to seven days but remain masked and quarantined until then. The husband stays home most days, except for a daily morning bicycle ride along the Hudson River down to Battery Park where he rents out a gym for a private 90-minute workout with a vaccinated masked trainer who is the only other individual in the facility.  He then bikes home along the Hudson River stopping at a food truck on sunny days to purchase a cup of coffee which he drinks alone on a bench overlooking the river. He and his wife mask, maintain safe distances from others and avoid indoor facilities.

The couple decided to follow the advice of the Health Department. They separated within their home staying masked indoors. They rescheduled their flights for the following week. They have appointments to have nasal PCR tests on day 7 after exposure.

Wouldn’t it be lovely if we had a public health department in Florida that actually practiced public health along with citizens who respected the health of others by following recommendations to prevent transmission of the disease?

Alcohol & Gastrointestinal Cancer

For many years now we have been taught that adult consumption of alcohol in moderation is an acceptable life practice. We have been told that women can safely drink one alcoholic beverage per day, if not pregnant, while men can drink two per day. Of course, driving a car or handling machinery while under the influence is not acceptable. We were also taught that our alcoholic beverages were highly caloric and that they, in fact, were considered “empty” calories providing little if any nutritional benefit.

Unfortunately, the purchase and consumption of alcoholic beverages during the COVID-19 Pandemic has markedly increased as a result of isolation, stress and quarantine.  We have also seen individuals binge drink large quantities of alcohol and even seen individuals become toxic with alcohol poisoning. Moderation and being responsible are always stressed with regard to alcohol consumption.

A study in JAMA Network Open may make us reconsider those ideas. This study looked at the adult South Korean population from 2009- 2017 who did not have a gastrointestinal cancer diagnosed. They followed almost 12,000 adults aged 40 or older with 40% agreeing they drank alcohol. Participants were divided into mild, moderate and heavy drinkers based on the volume of alcohol consumed. They were then followed and compared to the non-drinking portion of the group for the development of GI cancers.

The study found that the frequency of drinking is more of a risk factor for developing GI cancers than the actual volume consumed. In fact, among mild drinkers, those who had an alcoholic drink 3-4 nights a week had a greater chance of developing a GI cancer than those who drank heavily but less frequently.

In life nothing comes without a price. The question I raised and have not received an answer to is “Just how high is this risk?” Is the risk of developing a GI cancer with a cocktail with dinner equivalent to the risk of being killed in an auto accident on a major highway? Is a cocktail with dinner riskier than smoking a pack of cigarettes per day, or sky diving?

Until someone can present the data in a manner that I understand the true risk, it’s difficult to develop a health recommendation. Were these results an outlier unique to the Korean population? When I know based on evidence, I will let you know. Until then “cheers.”

Should I Measure My COVID Antibodies?

On a daily basis I get asked by patients to please add an antibody test to their necessary blood work monitoring chronic conditions and medications to see if they have immunity against COVID-19. Some want the information just to feel comfortable that they have responded to their vaccine administration. Some have had COVID-19 and want to see if their immunity is sufficient to avoid taking a COVID-19 vaccine or booster shot? Some who have not been vaccinated and have been ill recently but not tested just want to know if the illness was COVID-19.

The topic was just reviewed in the online journal MedPage Today. First of all, the test you order to determine if you developed immunity based on receiving the vaccine is different than the test you order to measure antibodies arising from a previous infection. Nathan Landau, PhD, a virologist with the NYU Grossman School of Medicine believes we do not yet have the data to determine if antibodies we develop from infection or vaccination are appropriate to provide immunity. “The real answer is we just don’t know. It takes time to gather that data, to know what titers people have and what their chance of getting infected is.”

To determine the level of antibody that is needed to prevent infection scientists must first perform neutralization assays or tests. These are not performed in the commercial labs that do antibody tests for COVID-19. The neutralization assay is the Gold Standard . The test is performed by taking the blood of an infected individual, isolating the blood serum and then diluting it into different strengths. The different strengths are then mixed with the live Sars2 Coronavirus in a set amount. They then observe if the virus is killed off.

 In order to kill the virus you must have neutralizing antibodies. The commercial labs only measure the total antibody not specifying how much of that is actually successful in neutralizing the live virus. The neutralization assay looks to see what dilution of the antibody kills off 50% of the virus.

For example a dilution of 1:100 means 1 milliliter of serum was mixed with 99 milliliter of saline. At this point we do not know what dilution is necessary to prevent infection. This data is known for diseases such as measles, German measles and different strains of hepatitis.

There has just not been enough time yet to make this determination but the research is ongoing and conclusions should be released soon. What is known is that the mRNA vaccines produce more immunity than the non mRNA vaccines. They also know that the antibody produced from a vaccine is superior to the immunity from infection against new variants and reinfection. The commercial tests are expensive, time consuming and use reagents affected by supply chain problems.

Omicron the new COVID Variant & the Pandemic

Last week my office staff and I met to discuss loosening some of our COVID-19 precautions due to the low positivity rate in the area and the vaccination status of the local population. We all enjoyed the return to normal this Thanksgiving inviting family to celebrate with us for the first time in two years. My children, their spouses and kids all flew home for a joyful few days. Then came news of a new variant out of South Africa, Omicron.

It is too soon for scientists to know very much other than structurally there are multiple mutations on the P-spike. It is felt that this makes the virus more transmissible than previous versions including the Delta strain.

We don’t yet know if the Omicron variant will produce more severe illness. It is too soon to know the incubation period and most significant period of disease transmission. We do not know if the COVID-19 vaccines will work against Omicron or if it will dodge our immune response. Nor do we know if it will bypass the immune response of those previously infected? I expect it will take at least three weeks to get some of the answers but probably three months to have a better idea.

The travel restrictions imposed by world leaders are too little and probably too late. Banning foreign nationals from entering your country while permitting citizens to return assumes the virus recognizes national flags and only infects foreign nationals. This decision is an outrage. Returning citizens need to be tested frequently while being quarantined for about 14-days. That is the type of travel restriction required. It is highly probable the new strain is already in the USA.

We need mass testing to start again so we can identify infection quickly and we need the lab capability to identify the infecting viral strain. In the meantime, while we learn about what we are dealing with, we need to once again wear masks, keep our social distance and avoid crowded indoor venues.

My practice will continue to screen patients over the phone and at the door. We will limit entry into our office and require masks to be worn. We will stagger patient visit times so that patients coming and going are not in close proximity. If necessary, we will return to telehealth visits only.

On the bright side, we are much more prepared for a new surge than before. More individuals are vaccinated and boosted. The COVID treatment pills work via a mechanism that is independent from the genetic mutations on the P-spike protein. Vaccine manufacturers have already begun preparing a vaccine against the Omicron strain that will take three months to reach the market. It is disheartening to face this crisis again, but we will, and hope the knowledge we need to acquire is learned quickly.

Blood Pressure Control Becoming Trickier & More Personalized

In the era of the COVID-19 Pandemic it’s difficult to find published research which does not deal with the Sars2-Coronavirus. There have been several articles recently about blood pressure that have been of interest. One study previously mentioned discussed the development of a polypill. This pill contained small amounts of four different classes of blood pressure medicine. The researchers noted that in the past physicians were taught to try one pill and keep increasing the dosage until the blood pressure was controlled. The unfortunate part was that as the dosage of the one pill was increased the appearance of adverse side effects took place and patients simply stopped taking their medicines.

The polypill controlled blood pressure better than a single pill and produced fewer adverse effects than a single pill at higher dosages. A separate study reviewed this week looked at the same question. Should we just keep increasing the dosage of a single medication until blood pressure is controlled or should we add a second medication that works by a different mechanism. This study agreed with the polypill study finding that adding a second pill at a lower dosage lowered blood pressure more than a single pill and compliance was better as well due to fewer adverse effects.

A recent publication in the Journal of the American College of Cardiology, published by Tara Chang MD, MS of Stanford University School of Medicine in California, added to the confusion by suggesting that there should be different blood pressure goals for prevention of different diseases. Individuals with heart attacks may do better with a higher diastolic blood pressure than individuals trying to prevent a stroke. Ideally BP would be kept at the 110-120 mm HG to protect the brain, but this range might be too low to protect against another heart attack. For those individuals with both coronary artery disease and cerebrovascular disease the decision on how low to go needs to be discussed with your primary care doctor and cardiologist.

This is clearly an evolving science with more data to come. Hopefully with more data and study it will be less confusing for patients and clinicians as well.

Concierge Medicine and the Pandemic

Twenty years ago I practiced internal medicine and geriatrics locally in a traditional medical practice. I cared for 2700 patients seen in 15-minute visits with an annual checkup being given a full 30 minutes. The majority of my patients were over 55 years old and many had already been patients for 10-20 years. The practice office revenue was enhanced by having an in house laboratory, chest x-ray machine, pulmonary function lab and flexible sigmoidoscopy colon cancer surveillance program. If patients needed more time, we allotted more time or, more likely, we just fell behind leaving patients stranded in the waiting room wondering when they would be seen. I had a robust hospital practice made easier by the fact that the hospital was a short walk across the street and most of my hospitalized patients came from being required to cover the emergency room periodically for patients requiring admission but not having a physician.

Much changed quickly in the early 1990’s as we approached the millennium. Insurers managed care programs kidnapped our younger patients by approaching employers and guaranteeing cost savings on health insurance by demanding we provide care at a 25% discount. In addition, mandatory ER call became a nightmare because insurers would only compensate contracted physicians to care for their hospital inpatients.

My very profitable chest x-ray machine became an albatross because that $28 x-ray reimbursement was now accompanied by a fee to dispose of the developing fluid by only a certified chemical disposal firm even though the EPA said there was not enough silver in the waste to require that you do anything other than dump it down the sink. The lab closed too. Congress enacted strict testing and over site rules which made the cost of doing business too expensive and not profitable. That flexible sigmoidoscopy went the way of the Model-T Ford when the medical community enlarged to accommodate board certified gastroenterologists certified to look at the entire colon under anesthesia not just the distal colon and sigmoid.

We tried to overcome increased costs and lost revenue by seeing more patients per day. We banded together as physician owned groups owning imaging centers and common labs but the Center for Medicare Services (CMS), which runs Medicare, and private insurers plus Congressional rules on conflict of interest thwarted those ideas. We attended seminars on becoming a member of an HMO and taking full risk for a patient’s health care and cost.

The message was clear, you could make a great deal of money if you put barriers in front of patients limiting access to care and especially in patient hospital care. The ethics of that model did not sit well with many. So, we started earlier, shortened each visit and worked later and harder. As time wore on, and our loyal patients aged, we realized that we needed to spend MORE TIME with them more frequently.  Not less time!

Spending less time with patients was the primary impetus which prompted my exploration of concierge medicine when I realized I was better off emotionally, ethically and morally caring well for fewer patients. Financially, seeing a smaller panel of patients who paid a membership fee generated similar income to maintaining a large panel of patients in a capitated system or fee for service seeing more people with shorter visits.

I discuss this now because I often wonder how I would be able to care for my large panel of patients today in the midst of this COVID-19 Pandemic.

For the most part I have been able to give my patients the time and availability they need to stay safe from Coronavirus and still keep up with the prevention and surveillance testing they need periodically. The 24/7 phone, email and text message access has allowed me to stay in touch with patients – something that would have been near impossible to do in a practice with 2700 adult patients.

I applaud my colleagues who continued in the traditional practice primary care setting despite the fact that most sold their practices to local hospital systems or large investment groups who placed administrators in the care decision-making process dictating time and number of daily visits, referral patterns and products used in the care of the patients.

As an independent physician, I have been able to continue to provide services and referrals that are the best in the area using doctors and equipment I would see as a patient and proudly refer my parents, my wife and children, beloved friends and family members. I am able to guide patients based on evidence and quality of measures not only what is most cost effective. I have no contract with a health system that requires me to see a certain number of patients per day, per week, per month or face a drop in salary or dismissal. I am proud and fulfilled at the end of the day because I can look in the mirror and know that I tried my best for the patients.

I additionally have the ability to say “no” to a potential new patient that I believe would not benefit from being in my practice for numerous reasons. Providing time to meet potential new patients gives both the patient and physician an opportunity to assess whether developing a professional relationship would be a good fit for both.

During the pandemic these meetings have become tele-health virtual meetings which are far more impersonal and less educational for both the potential patient and the doctor. It is still far better than having an administrator schedule a new patient, with no questions asked, on your schedule with the only criteria being can they pay the price?

Sadly, this horrible SARS 2 Coronavirus pandemic has made concierge internal medicine and family medicine more attractive than less. Having your physician available to discuss prevention, vaccines, testing methods and locations and treatments, if infected, is much easier in these membership practices than in a traditional practice where your phone calls are routed through an automated attendant phone system, reviewed by a non-physician provider and handled usually by a nurse practitioner or physician assistant with only the most serious and complicated situations reaching the physician’s desk.

I predict that more and more patients will seek concierge care in the next few years because patients are getting tired of fighting the bureaucracy and struggling to get the attention of their health care providers when they think they need it.  But don’t blame the providers.  It’s the dysfunctional, inefficient and profit driven corporate system that has created this situation.