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.

Delta Variant, Breakthrough Infections & What You Need to Consider

As a primary care physician treating older adults fifty years of age and older, I am starting to be involved in the treatment of “breakthrough” COVID-19 cases in vaccinated adults. At the end of June 2021, just prior to the July 4th holiday, we were told to enjoy the summer if we were vaccinated. Many in my patient population took this to mean book flight and cruise reservations and begin travelling. Others started meeting friends to shop again, exercise together in gyms or eat lunch socially indoors.  Experts at the CDC felt it was safe to take off our masks indoors.  Then came the Delta variant – a far more transmissible virus. 

I first read about breakthrough cases in a peer reviewed medical journal discussing the widespread outbreak of COVID-19 in Israeli citizens vaccinated with the Pfizer Vaccine. The message was clear, if vaccinated, you can still get the viral infection with the Delta variant, but you won’t require hospitalization and you have a minimal chance of dying. 

With that news many of my patients continued resuming their lives and normalizing to pre-pandemic routines without masking or distancing in public areas.  Three weeks ago, our local hospital had no breakthrough cases. Two weeks ago, there were five. All the breakthrough cases in individuals 65- years of age, or older, or with symptoms, are invited to receive the monoclonal antibody treatment which shortens the course of the illness and the severity.   Treatment should be within 10 days of first developing symptoms. The cases are so numerous this week that there is a wait of days to get treated.

In discussing the breakthrough cases with my ill patients, they all feel miserable.  They are exhausted, coughing, some febrile with high fevers and severe joint and muscle aches. Some have lost their sense of taste and smell. They say the monoclonal antibodies help, but a week later most of my patients are too weak and tired to do much beyond their necessary activities of daily living. They call daily asking how much longer this will last.  My answer is, “I just do not know.”

I also do not know If their viral load was high enough to transmit the disease to the unvaccinated, the immunosuppressed vulnerable vaccinated patients or even other vaccinated individuals.  The experts are not sure either. Will these vaccinated breakthrough patients become “long haulers” with chronic symptoms stretching to months post infection?  We don’t know – it’s too soon to tell. 

I am also getting calls from patients who were out socially unmasked with close friends and relatives and have now received a phone call that their friends have the COVID-19 infection, and they were exposed.  These patients need to be tested for the disease a few days after exposure but, with the closure of all the state-run testing sites locally, you are limited to going to your pharmacy or some walk-in clinics for COVID testing. Take my advice, get the nasal PCR test sent to the lab which takes longer than the quick test but produces fewer incorrect results.

What I do know is this is a disease well worth avoiding.  Get vaccinated if you haven’t already done so.  Wear a good N95 or KN95 mask if you must go out in public to an indoor facility, and you have no idea who is vaccinated, and who isn’t, and who might be spreading the disease prior to developing clear cut symptoms.  Yes, this is retreating and taking a step backwards into a bunker mentality.  If you don’t believe me, just ask my COVID-19 breakthrough patients. They will tell you this is more than just a “bad flu.”

Blood pressure measurement, its importance in reducing vascular disease & remote patient monitoring

An article published in the prestigious journal Hypertension looked at following blood pressure over a decade and the reduction in heart attacks, strokes and deaths if you were able to keep blood pressure under control. It talked about extending your life by over four years and the preventing vascular disease from developing for at least five years.

The authors looked at multiple blood pressure trials and noted the difficulty in relying on one office visit measurement periodically. They too noticed that certain patients were always higher in the office than at home and noted the problems with home blood pressure monitors including trying to decide if they were accurate and being recorded correctly. The result was that whatever reading they obtained at your visit, when looked at over a 10-year period, influenced your survival and cardiac events.

We too have struggled with this issue in our office. We ask patients to bring in their home blood pressure equipment so we can correlate the readings they get in our office on our equipment and their equipment. Just last night a patient with no symptoms and feeling well took his blood pressure and found it elevated. Rather than contact me or his cardiologist he ran to the Emergency Room. He waited hours, had multiple tests and by that time his blood pressure lowered they referred him to his doctors without intervening at all.

When needed, we have a patient use a 24-hour ambulatory blood pressure monitor. They wear it on their arm like a blood pressure cuff and it inflates six times per hour during daytime and four times per hour during sleep while measuring their pressure. There is a small recording device worn on their belt. After 24 hours, it is returned to our office and we print out the readings and obtain averages to help us determine just what your blood pressure really is. The equipment has a diary so the patient can note when stressful events occur and we can correlate it with the readings. The minor drawbacks to the equipment are its bulkiness, the need to keep it dry and the disturbance to sleep it causes as the cuff inflates and deflates.

To improve measurements, as well as capture other health metrics, we are introducing a remote monitoring smart wristband. We have identified a vendor who will supply you with the high-tech wrist band at no out-of-pocket expense to you. The wristband interacts with your iPhone or android phone.

The device measures and captures pulse, heart rhythm, blood pressure, blood oxygen level, and steps.  It even has built-in fall detection. The 2021 model, which will be introduced in a few months, has an EKG component to help us follow patients who get dizzy, faint or have documented heart issues. It will also capture body temperature. There is an optional blood glucose sensor monitoring device. The wristband is water resistant so you may shower with it.

Due to the Pandemic, and development of tele-health, Medicare pays for the monitoring if you wear the device a minimum of 16 days each month. Patients are asked to identify emergency contacts so that if you fall or if you have an arrhythmia, abnormal blood pressure, abnormal blood sugar, the monitoring call center contacts your emergency contact on record.

Your physician can view all the data on our computers. Certain private insurances pay for these services as well as Medicare. I will start wearing one and my wife will as well.

I will personally discuss this with each of you whom I feel will benefit from wearing the wristband as remote monitoring is proven to reduce hospital admissions and ER visits. If you have a chronic condition, disease or certain risk factors; it’s likely I will encourage you to wear the band.

Some patients have asked if the band has a panic button for you to push if you feel you need to such as after a fall. The technology senses if you fell and have not gotten up or if you are ill and calls your emergency contacts but it does not have a unique panic button to push.

We look forward to introducing this new remote high technology to improve your health, safety and peace of mind.

Caregivers & Health Care Aides are Underpaid & Underappreciated

It’s been years since I lost my mom and retired as a hands-on personal caregiver. The care I provided her was supervisory, not physical, and it was exhausting.

As a physician caring for my patients who end up in a skilled nursing facility for post hospital rehab, I have always been amazed at how under paid, under trained and overworked these well-meaning caregivers and aides truly are. It’s easy to see why burnout is common amongst them and turnover is ranges from 50% – 100 % annually with these jobs.

The devastation created by COVID-19 at senior care facilities brought this all into sharp focus. These poor employees living in multi-generational homes, and not having the luxury of working remotely, have suffered staggering losses due to this disease. With no quick accurate test for this virus available, they show up at work not knowing if they are infecting their elderly patients inadvertently or being infected and bringing it home to their loved ones. There has certainly been no organized program on a national or state level to protect the patients or the caregivers.

With lockdowns in place at these facilities, these hardworking aides are now functioning to some degree as mental health counselors as well.  But it’s the physical nature of their work that amazes me – routinely lifting and grooming men and women weighing a hundred or more pounds.

My poor little 24-pound rescue pug suffered a neurological catastrophe last weekend with an embolus to her spine leaving her paralyzed in her rear legs. I have a harness and soft belt to support her so she can walk on her front paws and squat to void and defecate. If I don’t hold her up high enough, she scrapes the skin off her knuckled rear paws and they bleed. She hates the booties I tried to protect her with.

The canine neurologist asked that we don’t use the rear rollers you see paralyzed animals use for mobility because she wants her to walk again or at least give her a chance. Once a day I go into the pool with her and support her midsection while she paddles away with her front paws and I move the rear legs through their normal range of motion. Lifting those 24 pounds is exhausting for this 70-year old but she is making progress pushing back now against my hand in those previously flaccid limbs.

I do this out of love. I can’t imagine how difficult it would be to lug a 100+ pound person around all day while risking COVID-19 exposure, all for $15 per hour.  I tip my hat to these health aide angels who are the glue that keeps elder care together in a dreadful profit driven system.  They do it to give their loved ones a roof over their heads, food on the table and a chance at a better future.

As the U.S. population ages, we need to find a way to compensate them fairly and appropriately to show our appreciation for what they do and recognize how difficult and dangerous their essential work is.

A Perfect Storm Setting the Stage for a COVID-19 Catastrophe

The last week in June always means the recent medical school graduates have just begun their first days as real physicians working in the halls of our nation’s hospitals. With youth comes energy, altruism, enthusiasm and inexperience.

The first year was once called an internship and is now called Post Graduate Year 1. Directors of training programs and their teaching colleagues work overtime to orient, teach and supervise closely so that inexperience does not interfere with excellent patient care. Excellent programs have layer after layer of patient care review to prevent the development of judgement and experience from adversely affecting outcomes in care.

We are in the middle of a health care crisis of previously unseen proportion by old timers like me and newly minted physicians. As the coronavirus surged in the state of NY, state officials accelerated the graduation of fourth year medical students and sent them into the fray to care for COVID-19 patients on the front lines. A general call for extra help went out to the medical community nationally to bring back retired physicians but to also reassign specialty doctors to COVID-19 care even though they had little recent experience in infectious disease and respiratory care.

Some news stories talked of dentists and podiatrists being drafted to provide medical care for ailing New Yorkers. The death toll in the NY hospitals was exceptionally high and some critics believe the use of inexperienced clinicians, with minimal supervision, contributed to these extremely high death and complication rates. I believe that while that may be a factor, the real issues were lack of familiarity with a new pathogen, lack of effective medication, lack of personal protective equipment as well as a lack of sleep and rest and mental health counseling all contributing to the inexperience but valiant efforts made by NY health care personnel.

With new medical school graduates on the wards here in Florida, we now face many of the same issues our colleagues in the NY Metropolitan area faced several months ago. What they did not face months ago was a population unwilling to follow the safety measures outlined by Public Health officials, infectious disease specialists and scientists.

The financial hub of the USA, perhaps the world, closed quickly to save lives and slow the spread of disease. Our south Florida hospitals have prepared extensively for the arrival of the new medical graduates. Our best faculty members are out teaching and supervising. Despite this, they are at a disadvantage because there is no governmental leadership by example at the county, state or Federal level.

The number of Florida residents who continue to treat wearing a mask as a civil liberties issue, rather than a deadly public health issue, is astounding. The number of Floridians who do not believe that keeping a safe social distance apart prevents disease spread and fail to observe the recommended guidelines as a protest about loss of freedom is mind boggling.

 Instead of Floridians demanding a comprehensive and organized program to stop COVID-19 while meeting the financial. food, educational, safety, housing, childcare and supply needs of the populace, we have politicians telling us that the increased rate of infectivity is safe in young people. Young people give it to middle aged and old people, and they have a greater chance of getting sicker, ending up hospitalized and dying.

The daily local hospital case load is increasing. The available beds are decreasing. We have not even factored in that we are now in hurricane season which might call for evacuations and mass movements of Floridians for storm related safety.

This is the perfect storm scenario. If you are happy with it then carry on. If you are not then please call, write, text and email your elected officials at all levels of government and tell them in no uncertain terms what your needs are.

The Reality of Skilled Nursing Home Stays

The online journal Medscape published a Reuter’s article on Skilled Nursing Facilities and post hospital stays.  They discussed the often-lengthy time span between hospital discharge and the patient being seen by a physician or “an advanced care practitioner”.

Older, more infirm and cognitively impaired patients tend to be seen later than other patients. Apparently the later you are seen, the more likely it is that you will be sent back to the acute care hospital and be readmitted.  The study was conducted by Kira Ryskina of the Perlman School of Medicine at the University of Pennsylvania in Philadelphia. The researchers looked at Medicare claims from nearly 2.4 million patients discharged from acute care hospitals. Her data indicated that when patients were seen by doctors at the facility soon after discharge they tended to recover more often not requiring acute readmission to the hospital for the same problem.

The author went on to say that most families confronted with a family member requiring post hospital rehabilitation at a skilled nursing home do not know what to expect from a skilled nursing facility (SNF).  The truth is, most doctors who practice in the inpatient setting or in surgical and medical specialties have no idea what to expect. They have never gone into one, unless it is for their own recovering family member, and they have never cared for a patient on a daily basis in one.

My first month as a private physician in 1979, my employer took me to the local facilities to meet the administrators, charge nurses and social workers at the facilities. The medical director was a young internist who had no private outpatient office or practices just a nursing home practice at five institutions he called on.  I was told that the law required me to see new patients within 24 hours of arrival, examine them and write a note and review all orders and either approve or change them.  I was surprised that facilities were staffed with only one registered nurse per 40 patients. The RN was required to pass the medications each shift, with most patients being on multiple medications so that most RNs had little time per shift to do much else but pass the medications.

When a patient had a complication or problem the nursing staff called the family member and the doctor. The volume of calls was so immense that the young facility medical director could not find any physicians who would agree to cross-cover with him on the weekends so he could get some time off.  In most cases, even if I decided the phone call related medical problem could be dealt with at the facility, the family decided otherwise and wanted their loved one transported to the ER. Those of us who cared for patients at these SNF’s joked that the protocol for caring for a problem was to call 911 and copy the chart for transfer.

It used to disturb me that EMS services were being diverted to these facilities for non-critical issues taking them away from true emergencies, and delaying response times, but they seemed to like it.  The more trips they were called on, the more evidence they could present for a larger share of the city or county budget.

At some SNFs there was always an EMS bus or ambulance sitting in the parking lot outside.  The patients were insured by Medicare guaranteeing bill payment so the receiving Emergency Department and staff were happy as well.

We were required to see the patient monthly and write a note. I saw sicker and less stable patients more often than monthly.  Progress in rehabilitation was discussed at mid-day care planning conferences that the physicians were rarely made aware of.  My goal for discharge was when the patient could safely transfer from the bed to a walker or wheel chair, get to the bathroom and on and off the toilet safely and; get in and out of a car. If the family could convert their home into a “skilled nursing facility” the patient could go home as well.  Often the patient was sent home by the facility “magically cured” when their insurance benefits ran out.

Most of the work at the facilities is performed by lower paid aides. In my area of practice most of the aides are men and women of color from the Caribbean who have little in common with the mostly Caucasian elderly population they care for. The work is hard and the pay low with the employee turnover rate extraordinarily high annually at most institutions. The patients are elderly, chronically ill, often with impaired cognition, hearing, and vision. Their family’s vision of what should be done is vastly different from what can be accomplished.  I believe most of the staff are caring and well-meaning just under staffed and under trained.  Administrations concerns about liability from medical malpractice, elder abuse and other issues is well founded based on the plethora of ads on prime time TV, newspapers and the sides of travelling public buses touting law firms seeking elder care cases.

It is now harder and harder to actually see patients at these facilities even if you wish to.  While community- based physicians with local hospital privileges were once welcomed and encouraged to attend to their patients at the facility, now the facilities require doctors to go through a lengthy credentialing process – as if you were applying for hospital staff privileges.   When you actually show up and care for your patients you rarely see a physician colleague. Most of the care is assessed and provided by nurse practitioners and physician assistants working for physicians who rarely, if ever, venture into the facilities. They may supervise the care plan on paper but rarely lay eyes or hands on the patient.

These facilities serve a vital role in the post-acute hospital care of patients. According to this study and article, Medicare spent $60 billion dollars in 2015 on this care. When a hospitalized patient has a frail spouse or no spouse at home, with no local nuclear family able to provide home care, the SNF is the only real option.

I suggest families visit the potential choices first. Speak to patients and their families about the care and services.  Review online state inspection and violations records. Ask about the transition from the hospital to the SNF. Who will be responsible for caring for them at the facility?  Meet them and talk to them. Make sure you are on the same page. If you can find a facility that has an onsite physician team with a geriatrician as the chief medical provider.  It may be the best option.

For these transitions to work and save money by stopping the revolving door form hospital to SNF to emergency room for every medical question, the SNF’s need some form of sovereign immunity from frivolous lawsuits if their services and care meet the legally required standards. The recent post- hurricane heat-related tragedy at a Hollywood, Florida nursing home underscores the need for vigilant inspection and regulation of this industry. The good homes need to be identified and need to be given the support and latitude required to care for this ever increasing portion of our American society.

Why the Medicare System Can Not Stay Solvent

My spry 90 year old patient decided she had a urinary tract infection two weeks ago. She had difficulty urinating and the constant urge to void with no fever, no chills, no back pain, no bloody urine. She was advised to come in for an appointment the same morning but this didn’t suit her. The alternative choice was to see her urologist who made time available that same day. She decided this was not convenient either. I called her and took a history and attempted to negotiate a visit but she declined strongly. She chose to void into a sterile container she had at home, put it into the refrigerator for storage and start to take some ampicillin that had been prescribed for her last urinary tract infection weeks before. One day into the ampicillin therapy she had her full time aide drop the urine off at the office for a culture and analysis (It came back negative for an infection several days later). That night she could not void. She called the urologist and the covering doctor suggested she drink more water. She complied even after she developed nausea and vomiting which continued into the early morning hours. Her aide called 911 and EMS brought her to the emergency department.

This frail elderly woman has not been eating well for months. As her total protein drops and her activity diminishes decreasing her leg muscle tone, her lower extremity peripheral edema or swelling increases. Her veins drain less efficiently than in the past contributing to the swelling. She suffers from a chemical electrolyte regulatory abnormality with chronic low serum sodium. Vomiting electrolyte rich material and replacing it with electrolyte free water further diluted and lowered her serum sodium. Upon arrival in the Emergency Department, the ED physician noticed the swelling in her legs and reflex ordered a Congestive Heart Failure (CHF) lab panel. The government (CMS) has made such a big deal about recognizing CHF that physicians and hospitals are afraid to not recognize it and not treat it. If you don’t treat it there are financial penalties for the docs and the institutions. The CHF panel consists of expensive and sensitive heart muscle enzymes that elevate in a heart attack, a lipid profile and a BNP which elevates in CHF. The problem is that the heart enzymes and BNP elevate in a host of chronic conditions seen in the elderly unrelated to heart failure.

I was called into the hospital to evaluate and admit the patient in the middle of the night. A Foley Catheter was now inserted into her bladder and draining fluid. Steps had been taken to slowly correct her sodium abnormality. A urine culture was sent with the initial catheterized urine and the evaluation of her heart based on “indeterminate” heart enzymes was completed. She did not have a heart attack. She was not in heart failure. Her serum sodium rebounded slowly with a treatment called fluid restriction. Three days later she was voiding without the catheter, ambulating with her walker and aides assistance and ready to go home under the care of her aide and two daughters. She was scheduled to see me in 72 hours with the urologist to follow.

I called her the next day and she was doing fine. The next morning when I called she was constipated so we instituted a program which using over the counter medications corrected the problem. At 3 PM the next day she called my office and left a message that she wanted to speak to me. My nurse asked her if she was sick and she just repeated the need to talk to me. I called her when I finished with patients and she told me, “I am dying. I am very sick. I feel like I have to pee and I cannot. I have called 911 and I am on my way to the hospital.” When I tried to determine what the definition of “very sick” meant she couldn’t elaborate. She was not febrile. She had no chest discomfort or shortness of breath, she just couldn’t void. I called the ED and spoke to the head nurse and physician and reviewed her recent clinical course and findings. One hour later they called me to tell me she was in urinary retention and her bladder was overloaded. They placed a Foley Catheter in her bladder and ¾ of a liter of urine emptied relieving her discomfort and very sick feeling. The problem was that the ED physician saw her leg edema and sent off the CHF Lab Protocol again. This was a different ED physician than the week before. This time the Troponin I cardiac enzyme marker was in a higher in determinant range. “Steve,” he said, “her EKG is abnormal. I think she is evolving a myocardial infarction and needs to be readmitted.” I reminded him that we had completed this exercise last week with her long time cardiologist and her heart was fine. He told me he didn’t care. The risk medical legally was too high to send her home. The costs and hospital stay now start again.

This patient had daily 24 hour care by an experienced aide. Both her college educated adult children were with her. She had my office phone and cell phone as well as access to the very flexible urologist. She still chose to do it her way relying on EMS and Emergency Departments due to fear, anxiety and having no financial skin in the game. The urologist wondered why she didn’t just call him and he would have reinserted the catheter in his office. I wondered why she just didn’t call earlier so we could see her before my staff left for the evening. It didn’t matter if we were capitated, being paid for quality metrics or if the fee for service system was abolished. This strong willed independent complicated ancient senior citizen was determined to do it her way. The system runs on algorithms and protocols and generates information routinely that requires a common sense interpretation based on the clinical setting and issues. The risk of medical malpractice despite government funding this care plus the risk of government sanctions based on chronic disease protocols makes intelligent and compassionate care which is affordable almost impossible.

MRI Use in the Detection of Prostate Cancer

As men live longer the likelihood of them developing prostate cancer increases. Some experts estimate that if we biopsied the prostate of every male 80 years old or older, we probably would find prostate cancer present in almost all of them.

The PSA test has been shown to be less valuable than previously thought when discovered because it does not distinguish between an elevated level due to normal prostatic enlargement, infection or the presence of cancer.  When it is elevated due to cancer it cannot predict which tumors are aggressive and require aggressive treatment and which tumors are non-aggressive or indolent and can just be watched.  For this reason, CMS or Medicare and the United States Preventive Task Force are opposed to PSA use as a screening test.

To deal with these issues, Robert K. Nam MD, MSc, chairperson of genitourinary oncology and professor of surgery at Sunnybrook-Health Sciences Centre in Toronto, Canada has published a small preliminary study in the Journal of Urology on the use of MRI (magnetic resonance imaging) to predict the presence of and the aggressive status of prostate cancer disease.

They recruited men who knew they would be undergoing a PSA test, a MRI of the prostate and a prostate biopsy. Their preliminary results show that the MRI was a better predictor of the presence of prostate cancer than the PSA.  It was also felt to identify how aggressive the disease was which influenced treatment options offered. It was additionally felt to be very accurate in identifying when no prostate cancer was present.

Small numbers of patients were entered in this pilot study. A larger randomized controlled study is now in the planning stages to further clarify these initial findings.  At the same time in our community some of the urologists are now ordering MRI scans to elucidate what is causing an elevated PSA in individuals who have a non-diagnostic digital rectal exam and an elevating PSA.

Antibiotic Associated Colitis Increases Risk

At least a half dozen times per week patient’s call with symptoms of a viral upper respiratory tract infection or present to the office for a visit with symptoms and signs of a cold.  These illnesses are caused by small viral particles which do not respond to antibiotic treatment.   Your body’s defense system attacks these viral particles and over a period of hours to days defeats them.   Despite years of ongoing public health announcements and handouts by doctors and nurses and attempts at patient education you find yourself negotiating with strong willed patients who want a “Z Pack” or some other antibiotic which they do not need.  “I know my body,” they argue.  “My northern or previous physician knew to always give me an antibiotic, why won’t you?”

The answer is quite simple. They do not work to shorten the course, intensity or duration of your illness. They do in fact put you at risk of developing complications of antibiotic use. When your infection requires the use of antibiotics to restore health, it is worth taking these risks. When you do not need the medication it definitely is not. This was confirmed by an article and research presented by E Erik Dubberke, MD of Washington University School of Medicine in Saint Louis, Missouri commenting on Medicare Data about the death rate associated with antibiotic related colitis infections due to Clostridia Difficile.  Bacteria normally reside in our large intestine and promote health and digestion.  When we prescribe an antibiotic it kills off the healthy and beneficial bacteria as well as the infection related bacteria. This destruction of healthy bacteria creates an environment conducive to “opportunistic “bacteria normally suppressed by the normal flora to invade and take over your gut. The resulting fever, cramping, diarrhea with blood occurs as the intestine become inflamed with colitis. One of the common opportunistic pathogens is Clostridia Difficile.

Dr. Dubberke looked at Medicare data and compared 175,000 patients older than 65 years of age and diagnosed with Clostridia difficile infection and compared them to 1.45 million control patients. He found that those with clostridia difficile infection had a 44% increased risk of death. When comparing admissions to nursing homes for treatment there was an 89% increased risk due to antibiotic related colitis care.

Antibiotics are wonderful when appropriate. They will always carry a risk of a side effect, adverse reaction or complication which is a risk worth taking in the correct setting.  It is clearly not worth the risk when your doctor tells you that it will not work.

How Much of Yourself Can You Give to Others?

I have been practicing general internal medicine for over 35 years in the same community. I have many patients who started with me in 1979 and are now in their late eighties to early nineties.  Predictably and sadly they are failing.  Not a week goes by without one or two of them moving from general medical care to palliative care, very often with the involvement of Hospice for end of life care.   Medicare may now compensate for discussion of end of life issues but anyone practicing general internal medicine or family practice has been discussing end of life issues appropriately for years with no compensation. It just comes with the territory.

Most of us still practicing primary care thrive on being able to improve our patient’s quality of life and our major compensation can be hearing about their interactions and social engagements with family and friends.  It is an accomplishment to see you’re 90 year old with multisystem disease for years, dance at her great grandchild’s wedding.  No one who cares for patients longitudinally for years is that dispassionate that they do not give up a piece of their heart and soul each time they lose a patient or have one take a turn for the worse.   When I lose a patient, if time permits, I will attend the funeral or family grieving gathering during the mourning period.  Everyone gets a personal hand written letter. Completion of the circle of life and then moving on is part of the process.

I think physicians’ families take the brunt of this caring and I am sure mine does. As much as you want to have time and patience and sympathy and empathy for your loved ones, the work truly drains your tank and reserve. When you answer the questions of the elderly and their families over and over, often the same questions, it drains you.  Unfortunately, I believe my elderly failing mother is cheated the most by this process. Last weekend when making my weekly visit she was complaining again about the same things, asking the same questions that have repeatedly and compassionately been addressed by my brother and I. My wife interjected that I sounded angry and annoyed. I was. I told her that unfortunately all the compassion and understanding in me had been drained already today and I needed time to recharge.

I saw the widow of a patient who expired last month in his nineties. I had offered to make home visits and they were declined several times by the patient and his spouse. His last week of life he asked to receive Hospice care and they assumed his care.  I called the surviving spouse and wrote what I considered a personal letter of condolence.  His wife told me she was disappointed in me for not coming up to see him one last time. I apologized for not meeting their needs but wondered inwardly, how much can I give and still have something left for myself and my loved ones?