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.

Quadrapill for Blood Pressure Control

At the beginning of each patient visit I make it a habit to meticulously review with each patient their list of medications, supplements, vitamins, herbs etc. I compare their list with the lists on notes sent to me from consulting specialty physicians and then I access the pharmacy prescribing data base whenever it is available.

I am always amazed by how many chemicals we put into our body for the sake of maintaining health. How patients maintain accurate medication lists and administer daily medications is something I am in awe of. In the best interest of their care, I am always looking for a way to reduce the number of medications taken and to simplify the process if possible.

Clearly researchers in Australia feel the same way. They realize that to control blood pressure, most seniors are taking low doses of 2-3 medications. In previous years we physicians prescribed one medication and pushed its dosage to the limit before adding a second medication to gain control of blood pressure. We soon realized that at the higher dosages, patients experienced adverse effects and just stopped taking their blood pressure lowering medications.

In an intriguing study, Australian researchers created a poly pill consisting of one quarter of the starting dosage of four medications. Irbesartan 37.5 mg, (angiotensin receptor blocker), amlodipine 1.25 mg (a calcium channel blocker), indapamide 0.625 mg (a thiazide diuretic) and bisoprolol 2.5 mg (a beta blocker) were put into one pill. Five hundred ninety-one patients at ten medical centers participated in the study. Their average age was 59 years with a fair mix of men and women. They were randomly selected and blinded from knowing whether they were receiving the Quadrapill or increasing dosages of one pill. If BP stayed up amlodipine was added.

At the end of three months the poly pill group had lowered their BP by 6.9mm Hg more than the single pill group. At a year the figure stools at 7.7. millimeters mercury. There were no significant adverse effects in the poly pill group. The study clearly showed that taking a pill with multiple types of blood pressure medication, at low dosage, controlled blood pressure and was convenient and tolerable. That pill is now in development and should be presented to the FDA and European Union for review in the near future. It’s release to the public will certainly make taking medication simpler and more convenient.

Walnuts Lowered LDL Cholesterol in Seniors

Emilio Ros, MD, PhD led the Walnuts and Healthy Aging Study (WAHA) looking at healthy seniors in Loma Linda, California and Barcelona, Spain. He followed 636 patients who were randomly assigned to a walnut supplemented diet or walnut free diet.

Senior Citizens who ate a diet supplemented with walnuts lowered their LDL cholesterol significantly.  The walnut supplemented group exhibited a reduction of total cholesterol of 8.5 mg/dl with an LDL cholesterol reduction of 4.3 mg/dl.  Triglycerides and HDL cholesterol were not affected. In addition to lowering cholesterol, Dr. Ros said other studies showed a positive result in lowering blood pressure. 

Christie Ballantyne MD, chief of cardiology at Baylor College of Medicine, and director of cardiovascular disease prevention at Methodist DeBakey Heart Center, said nutritional studies are difficult to complete. The number of participants is usually small and the length of the study short. This study encompassed large numbers over two years in two different locales. 

Dr. Ros commented that adults are always wondering what can they eat as a healthy snack?  Walnuts can now be added to that list.

Influenza Season 2021-2022 is Approaching

The office has ordered enough influenza vaccine for all patients including 65 and older.  Let’s start the discussion by making it very clear that you can take the influenza vaccine at the same time you take the COVID-19 vaccine or booster. Several vaccine companies are actually producing a combination vaccine of COVID-19 and influenza but that product will not be available in the USA this fall.

The next issue to examine is when does influenza A generally arrive in south Florida? In most years we see very little influenza A prior to Thanksgiving . There is a smattering of influenza B primarily in the pediatric population year-round.

The disease arrives earlier north of the Mason Dixon Line but last season due to masking, lockdowns and school closures there was very little spread of the flu. It takes about two weeks to develop immunity after you receive the vaccine so if you are planning on traveling in October and November it pays to research when influenza arrives in the area you are traveling to and get vaccinated two weeks in advance of the trip.

In South Florida the influenza season peaks the last week in January and first weeks in February most years. Think Super Bowl weekend as the most infectious time.

We know that in those 65 years of age or older the protective effects begin to fade at 90 days. For this reason, we advise our senior citizen patients to take the influenza vaccine between Halloween and Thanksgiving. For patients over 65 who already took their flu shot at their pharmacy, we recommend a booster shot in late December or early January. For younger patients, the immunity lasts much longer and, if they choose to take the shot earlier, they should be protected for most of the flu season.

THE VACCINE IS ALREADY IN OUR OFFICE. We will officially start vaccinating in October. Seniors 65 and older will receive a version of the senior high dose quadrivalent vaccine. Younger patients will receive the traditional influenza vaccine. The vaccination will be recorded on Florida Shots – the official vaccination recording site of the State of Florida.

There is Nothing Mild About “Mild COVID-19”

Medical experts divide COVID-19 infections into the categories of “mild,” “moderate to severe” and “severe”. To be defined as “mild” you must have COVID-19 but have no respiratory symptoms that necessitate the use of supplemental oxygen or hospitalization. I currently have “mild” COVID-19 and I am recovering. I am observing the appropriate quarantine procedures and let me make this clear, there is nothing mild about mild Covid-19.

I became aware something was wrong a bit over a week ago. I developed a mild irritating bronchial cough with a stuffy nose. Since I have inhaled allergies for years, I wasn’t quite sure if it was a bad allergy day or something else. As I did my exercise routine everything was a bit stiffer and harder to loosen up and a bit more tiresome but nothing dramatic. My wife made our favorite dish for dinner but I just wasn’t very hungry. I ate a minimal amount. The next morning I woke up much sorer than usual. I attributed this to getting older and pushed through my workout and daily routine. By day’s end, I noticed my nose was running occasionally. I slept sparingly that night being unable to find a comfortable position with my hip hurting out of proportion to any injury.

On Monday my aches and pains were severe. By evening I was flushed and febrile. The aches and pains that occurred in my joints and muscles required some Tylenol to take off the edge. That night the chills and shakes started, the frontal headache worsened, the muscle and joint pains exacerbated and the fatigue was overwhelming. I was exhausted but I could not sleep. I vowed to get tested the next morning. I sat upright in a chair – unable to get comfortable most of the night.

When my wife woke up, we drove over to the test site and 30-minutes later I had my notification of a positive COVID antigen test. By the next day the PCR nasal swab confirmed it. The aches and pains and difficulty of initiating and completing simple movements, like walking to the toilet, were exhausting and accompanied by drenching sweats. The simple task of walking my small dogs to the front lawn to relieve themselves felt like the end of a long hard work-out.

Later in the day I was infused with monoclonal antibodies to decrease the chances of mild COVID progressing to moderate or severe COVID. The time after the infusion was probably the most painful and uncomfortable period I have gone through in years. I was wearing a sweatsuit mid-day in Florida with temperatures that felt like the 100 degree range, sipping tea and honey and still feeling cold and hot at the same time. The aches and pains actually got worse for a few hours.

After several hours, the symptoms began to subside – likely from the RegenCov monoclonal antibodies As my symptoms diminished my sense of smell and taste disappeared and have not yet returned. Wearing a mask in my own home to protect my wife and pets from COVID is clearly a necessity but an inconvenience. Isolating to a portion of the house for quarantine is also an inconvenience but a necessity.

I did not anticipate the loss of concentration which was present for several days and made doing clinical work from home with telehealth difficult. My patience was non-existent so expressing sympathy and empathy for anything or anyone was a challenge. I have lost ten pounds in a week due to no appetite, no taste or smell.

There is nothing mild about mild COVID. It is worse than a “bad flu” and, possibly the designation as “mild” is too non-descriptive to make the unvaccinated and even the vaccinated, who are looking to rejoin life with no restrictions, understand that this disease is a beast and best avoided.

Blood Test Biomarkers for Alzheimer’s Disease

Adam Boxer, MD, PhD of the University of California San Francisco and associates published in Lancet Neurology a study which discussed their identifying two chemical biomarkers that distinguish normal patients from those with Alzheimer’s disease or other types of dementia. The two blood markers, phosphorylated tau 217 (p-tau217) and phosphorylated tau 181(p-tau181) showed “exquisite sensitivity and specificity” for discriminating Alzheimer disease from normal and other entities.

These biomarkers are currently only being used for research purposes and are not available to be used by doctors and patients through commercial labs yet. The researchers believe a commercially available lab test will be developed within the next few years

Walking Helps Stave Off Dementia

A paper presented at the Alzheimer’s Association 2021 International Conference by Natan Feter, PhD of Pelotas, Brazil suggested that even low levels of exercise as you age reduces your chances of developing Alzheimer’s type dementia. Their study looked at the English Longitudinal Study of Aging that included 8,270 individuals 50 years or older between the years 2002-2019. Fifty-six percent were female with a mean age of participants of 64 years. Over the 17-year course of the study, 8% of the participants developed dementia. T

They found the risk of dementia increased by 7.8% for each year increase in age. The risk of developing dementia was reduced by individuals who were physically active – more so for moderate to vigorous exercisers than for low level exercisers. Eighty-year old’s who were vigorous exercisers turned out to have a lower risk of dementia than inactive 50 -69-year-olds.

The message from the study was simple if you exercise even one time a week you reduce your risk of developing dementia. Walking certainly counts favorably. A reviewer simply said that regular walking is good for the heart and what is good for the heart is good for the head.

Why Have Guidelines, Rules & Regulations If No One Adheres to Them & There are NO Consequences?

I live and practice internal medicine and geriatrics in South Florida. We have a substantial elderly population living both independently and in senior facilities. The Sars2 Coronavirus Pandemic has been devastating to this patient population. There are many who became ill and passed away under the loneliest circumstances of in-hospital isolation. There are those who became ill and recovered but have lingering long-term effects. There are those who have avoided infection but are just beaten down by the daily monotony of staying safe, avoiding crowded public places and subsequently forsaking the company of friends and family.

The vaccine rollout in Florida was Helter Skelter and disorganized. It was every man and woman for themselves trying to obtain an appointment to be vaccinated. For the most, part the senior community managed to get the shots.

We were all grateful and buoyed as the summer of 2021 began by the news that we could venture out without masks and start resuming our pre-pandemic lives. The Delta variant and the recent surge in infectious cases, hospitalizations and now mortality put a quick and moribund end to that for most. The disparity between the message coming out of Washington and the CDC and the message delivered by our Governor and State Legislature has made decision making for individuals far more difficult than it should be. The latest conundrum is about the need for booster COVID vaccines or not.

The State of Israel, which exclusively used the Pfizer Vaccine, announced a third shot for those over 50 beginning a few weeks ago. Germany announced it would start such a program in September.

The CDC hinted at a booster program but until a NY Times article appeared on the evening of August 16th there was no official news on the subject beyond the recommendation that immunosuppressed individuals, especially organ transplant patients and cancer patients, under therapy get a third shot. Days before this announcement my patients had begun calling me, texting me, emailing me to tell me that their friends had walked into a Walgreens Pharmacy or Publix Pharmacy, showed them their Medicare ID card and their vaccine card and had been administered a third COVID vaccine shot with no questions asked. This was substantiated by multiple other patients including one couple spending the summer in the mountains of North Carolina.

Is there one set of rules for large chain pharmacies and another set for the rest of the world? What is the point of data and evidence-based recommendations if anyone can just do what they want when they want to?

At this point I will wait to hear the CDC’s recommendations on when to take a third shot and the data they used to explain why. I am thrilled that Pfizer has shown that a third shot is safe with few adverse effects. I am also buoyed by a research paper that showed that those groups who spaced their second shot at longer than the three- or four-week recommendations had a more robust immunologic response.

When my friends call me and ask me to join them on a trip to Publix or Walgreens to get the third shot now, I will hear my late mother’s voice in my brain asking that irritating question, “If all your friends decided to jump off the Empire State Building would you jump too?”

Coffee Consumption, Brain Volume & Dementia – Moderation is the Key

Researchers at the Australian Center for Precision Health at the University of South Australia reported on a study looking at coffee consumption and its effects on the brain. The study investigator, Elina Hypponen, PhD found that drinking coffee in moderation had no ill effect on the brain but drinking six or more cups a day produced adverse effects.

The researchers looked at the United Kingdom Biobank which had information on 500,000 participants ranging in age from 37-73 representing 22 study sites in a four-year period between March 2006 and October 2010. From the 500,000 Biobank patients they looked, at 398,646 coffee drinkers. These participants had undergone health questioning, physical exams and lab evaluation of blood, urine and saliva. MRIs of the brain, heart and body were done on 100,000.

Participants reported coffee intake in cups per day. They compared drinkers of 1-2 cups per day with others who consumed 3-4 cups per day, 5-6 cups per day and more than 6 cups per day. Brain imaging was done at entry into the data bank and 4-6 years later.

There turned out to be an inverse linear relationship between daily coffee consumption and non-white matter brain volume. They concluded that drinking six or more cups of coffee per day is associated with smaller brain volume and a 53% increased risk for dementia compared to light coffee consumption of 1-2 cups per day.

The study was published online on MDedge Internal Medicine and Nutritional Neuroscience. After reading this work, it once again becomes clear that consuming coffee in moderation seems to produce no ill effect on the brain.

Sleep, Foods and Melatonin

Marie-Pierre St-Onge is an associate professor of nutritional medicine at Columbia University Irving Medical Center. She is the director of their Sleep Center of Excellence at Columbia and has spent years studying the relationships between the foods we eat and our sleep satisfaction. She believes eating a diet rich in plants, fibers and unsaturated fat such as nuts, olive oil, fish and avocados promotes sound sleep while a diet high in sugar, saturated fat and processed carbohydrates can be disruptive. She also believes pairing foods rich in tryptophan with complex carbohydrates helps the tryptophan cross the blood brain barrier and stimulate the pineal gland to make and secrete melatonin. She cites the Mediterranean Diet as a perfect balance of tryptophan producing foods and complex carbohydrates to stimulate more satisfying sleep.

When one eats a diet rich in saturated fats, simple carbohydrates such as white bread, pasta, bagels and pastries they tend to fall asleep faster but wake up often and don’t always move into those sleep patterns that produce a rested state. She believes this is due to wide fluctuations in blood glucose levels and insulin responses not seen with a diet rich in plants, high fiber, unsaturated fats and complex carbohydrates.

The converse is additionally true so if you are sleep deprived you tend to crave unhealthy diets rich in sugars, unsaturated fats and highly processed foods. In men short sleep promotes an increased appetite and greater activation in the brain reward centers for foods such as pepperoni pizza, doughnuts and candy. When these subjects were fed a healthy diet with carrots, yogurt, oatmeal and fruit and had five nights of excellent sleep their brain reward center reverted to normal response when exposed to junk foods. Sleep deprived women do not develop a need for more food they just produce a lesser amount of a chemical which tells them they are full.

Apparently, tryptophan rich foods eaten without complex carbohydrates do not cross the blood brain barrier to help produce melatonin. What exactly is melatonin and what is its role in this process. Melatonin is a hormone that regulates sleep timing. The pineal gland starts secreting it after dark and it tells your body it’s time for sleep by lowering alertness and reducing your core body temperature. It works together with your body’s natural rhythms to tell you it’s time to go to sleep.

You can purchase melatonin over the counter. Be sure the product you buy is certified by USP labs or a similar service to make sure that what you see on the label is what you are taking when you ingest it. If you are taking it to overcome a circadian rhythm issue such as jetlag Dr. Bhanu Kolla, an associate professor of psychiatry and psychology and consultant at the Center for Sleep Medicine at the Mayo Clinic, suggests using a low dose such as 0.5 mg two to three hours prior to sleep. For people with insomnia, she suggests 5 mg thirty minutes before sleep and suggests additional sleep ritual actions such as:

1. Turn off computers, tablets and electronic devices two hours before bedtime

2. Do not watch the news within two hours of bedtime

3. Avoid alcohol and caffeine at night

4. Cool the room down to 67 degrees Fahrenheit

5. Get as much sunlight as you can during the day to regulate your internal clock

6. Maintain a regular sleep schedule trying to go to bed the same time and perform the same rituals before getting into bed and once you are under the covers.

7 Most sleep experts will tell you that the bedroom is for sleeping and intimacy and nothing else. If despite a healthy diet, a great sleep ritual and use of melatonin you cannot get a restful night’s sleep then it is time to see a physician who specializes in sleep disorders. Experts suggest you give the melatonin, improved diet and sleep rituals two or three weeks to work before seeking additional help.