Good Advice and Quality Care Is Not A Negotiation!

In this era of the “Art of the Deal” many in my patient population seem to believe that dealing with science, math and physical laws of nature is a negotiation.  They seem to believe as it’s the same as if you hired a contractor to work on your home and he wants a 20% down payment when you sign the contract and you only want to pay 5%.

I’ referring particularly to the laws of transmission of respiratory viruses, droplet particles and aerosolized viral particles. We are supposed to be wearing masks or facial coverings when indoors or when we are within a few feet of each other (six feet or less). We are supposed to stay six feet or more apart.

If exposed to the coronavirus or COVID-19 you are supposed to go home, stay home and self-quarantine for 14 days. You can contact your physician and discuss the circumstances and ask for advice.

What you are not supposed to do is go home, get anxious and agitated and spend hours on the phone trying to get tested immediately. The tests are only about 70% accurate (nasopharyngeal swabs via PCR). The quick tests, with turnaround times of hours, are wrong 48% of the time.

I explain this to concerned individuals and try to soothe their fears but the negotiations begin. I am flattered by the degree of confidence and power they believe I have but just because you want me to say something contrary to what the scientific facts show, doesn’t mean it is correct or good advice.

Sometimes my patients try and make me feel like I am a priest in a Catholic Church during confession, but I have neither the training nor the connections with the good Lord. Sometimes they try and make me feel like the supreme leader who can grant them a special dispensation. I am not that powerful or good and this is Mother Nature we are dealing with and laws of science.

As an example of what I mean, let me use a personal situation as an illustration. My daughter, son-in-law and 2.5-year-old grandson live south of Miami in Dade County in an affluent community of young well-educated individuals called Palmetto Bay. They both work full-time and have been working from home due to the COVID-19 pandemic. My grandson is cared for, watched, taught, loved and instructed during the day by his loving grandmothers so the kids are free to work without incurring childcare expenses.

Both grandmas’ have master’s level early childhood teaching degrees and one is a psychologist who recently retired from the Dade County School system. Seeing my grandson grow up with his grandmothers doing what they love to do most is a joy. When COVID-19 raged in March, they closed the pre-school my grandson attended. Unexpected exposure to others resulted in both grandmothers having to avoid my children because they are both older with chronic illnesses and considered high risk for COVID-19.

The pre-school sessions resumed a few weeks ago bringing joy to my wife and grandson. My daughter’s neighbors show little or no respect for the coronavirus. When I last visited three weeks ago there was a party going on next door and four adult men in their thirties or early forties were out on the lawn without masks or social distancing puffing away on cigars while a band of young children intermingled on the lawn. We all waved hello but kept our distance.

Two days later my son-in-law left his home through a side door to take a stroller out of his SUV parked 30 yards deep in his driveway without a mask. The neighbors five-year-old, playing freely on her lawn saw him and ran over to say hello while his back was to the child. He turned around and this well-meaning child was right there in his face. He jumped back, thought nothing of it because they were outside, and he is three feet taller but realized that the close encounter was worrisome. Two hours later they received a phone call from the neighbor saying that unfortunately they had just been informed that all their friends who visited over the weekend were now ill and tested positive for COVID-19. The neighbor was concerned about the encounter between my son-in-law and her child because my daughter happens to be pregnant.

My daughter called her obstetrician who told her what I tell my patients. Your husband needs to self-distance and self-quarantine for 14 days. When my daughter said they had been in contact several times since the incident, the obstetrician repeated the original advice. They all went into self-quarantine for 14 days. The grandma nanny visits stopped. I received a frantic phone call that night after my daughter spoke to her OB and supported the advice she had been given.

Living in Dade County they tried to get tested beginning five days after exposure, but the lines were horrible, and supplies ran out while waiting several times. With no symptoms, they did not need the test. The strain of working full-time from home and caring for a toddler was an issue once the grandma’s stopped helping because they were afraid of catching the disease if the kids were exposed. They tried multiple times to negotiate another route or plan with the OB, with me and with their mothers. I finally said, “This is not a negotiation. These are the facts. These are the suggestions of the World Health Organization, the Center for Disease Control and your own doctors.“

On Day 15, the grandmas agreed to return. The neighbor’s child never tested COVID-19 positive nor did the child’s parents.

Missing your loved ones is a terrible price to pay for the unchecked virus. I feel horrible for those in quarantine who miss their loved ones dearly.

However, I cannot give you a “Get Out of Jail Free” card like they have in Monopoly. I cannot tell you that if you are recovering from a lymphoproliferative cancer it is safe to pass through an airport, take a commercial airliner and visit your kids or folks if it really isn’t. I cannot safely tell you after arriving it is fine to not self-quarantine for 14 days before seeing high risk relatives. I cannot tell you the same-day quick COVID-19 test they are performing at the local private walk-in center or your community board is providing is fully accurate when in fact science shows it is not.

I will discuss with you the facts and if asked for an opinion give you an honest opinion based on science and data. I will not negotiate however so please don’t ask me to anymore! As a famous detective said on a famous black and white TV show , “Just the facts.“ is what I will tell you because it is best for you even if it is not what you want to hear.

Life’s New Reality with Coronavirus aka COVID-19

We are bombarded daily with news about the spreading infections with CoronaVirus or Covid-19. With television, the Internet and other news mediums; the quantity, quality and accuracy of information can be overwhelming.

This single stranded RNA virus has managed to invade most of our populated continents and is now moving into communities. There is more we do not know about this pathogen than we do know.

Public health officials which include the Trump Administration, the CDC, the NIH and local health departments have been extremely tight-lipped on the clinical course of the hundreds of US citizens evacuated from infected areas and quarantined for 14 days.

We do not know if there are any telltale historical or clinical markers to tip us off as to whether the patient in front of us with a cough and low grade fever might have a run of the mill seasonal viral infection or Covid-19.

And, it is still unclear,

  • How long the virus stays alive on a surface and remains infective.
  • How long the incubation period is and how long in advance of demonstrating signs of infection asymptomatic patients can transmit the disease.
  • What role, if any, children, who seem to be less vulnerable to the disease, play in the transmission of the disease as asymptomatic carriers?
  • How a relatively healthy nonsmoking adult in their 30’s to 50’s will do if they catch the disease?

The recommendations on testing from the administration and CDC have been unrealistic based on the lack of availability of the testing labs and kits in affected states. This will improve with time, but will it improve to the level of the “quick, never get out of your car, drive-through testing” being done in South Korea? That story, covered by CNN, was both enlightening and disheartening. Enlightening by illustrating how government can institute a plan quickly and efficiently.   Disheartening realizing that with all our wealth and expertise in the United States we are not doing something similar.

The recommendations about prevention are commonsense. Do I really need to log onto the CDC website to learn that I need to wash my hands, avoid touching my face and stay home if ill?

The selfishness and entitlement of the American public make even asking these minimal changes in our pattern to be a major inconvenience and intrusion into our privacy. I see the Ultra Rock Festival in Miami and the Calle Ocho street festival have been cancelled smartly to prevent infection. At the same time restaurants are jammed, servers and food preparation individuals without sick leave and health insurance still show up at work ill, to serve and prepare food, and many chronological adults balk at giving up their restaurants, bars, clubs and shows to prevent the spread of disease.

Posters suggesting we stay six feet away from others are plastered on buses and train platforms of mass transit systems where if you can stay 6 microns away from another transit passenger it’s as if you are travelling in the First Class section.

If we are all fortunate, Covid-19 will ultimately be an annoyance in the low risk population. We will develop fast and effective ways to detect it and then, with knowledge of how it spreads, we will be able to provide advice on how to protect others.

I am just not sure today’s American public has the will, the determination or the sense of community, altruism and sacrifice of lifestyle needed to prevent a major health and economic crisis.

INFORMATIONAL RESOURCES:

Making Sense of the Corona Virus Outbreak in China

The news media has been extensively covering the outbreak of a new virus that causes upper respiratory symptoms. What is known is that it probably originated in bats in a cave and passed through animals and is now infectious to human beings.

The first cases were reported as originating in a fish market in Wuhan, China that illegally sold exotic animals as well. Sources have reported on this new illness for months with much of the information being suppressed by the Chinese government.

Wuhan, China is home to a first-class, state-of-the art virology research lab. That lab’s main researcher has been urging infectious disease experts to evaluate these corona viruses for years while receiving little reward for her efforts. She reports that the previous epidemic of SARS is caused by a corona virus as well.

At this point, researchers from the World Health Organization (WHO) and the US Center for Disease Control (CDC) are attempting to obtain enough information to evaluate how much of a threat this new illness represents. We do not yet publicly know the exact incubation period. We do not know the length of time an individual is a contagious carrier prior to symptoms developing. Some have claimed you are contagious for about two weeks before symptoms appear. This is not consistent with a Vietnamese visitor to Wuhan who returned home ill and his family in Vietnam were all ill with the new coronavirus within three days. We do not know how aggressive this disease is yet.

Are the fatalities from it primarily in the infirm, very young and very old or does the disease strike down the fittest and healthiest as well? Are the deaths in China due to the lack of availability of modern health care, respiratory treatments and medications?

More information should be forthcoming soon. An evacuation of 200 Americans from Wuhan this week, to a military base in Riverside, California, for a voluntary quarantine should provide valuable data. These frightened but responsible individuals will be monitored and treated and studied.

Of interest to me was an article in the NY Times weekend edition by a “medical historian” who outlined the lack of success in containing infectious diseases we have had when no medications or treatments for these diseases existed. As I read it, I kept thinking that while the quarantines were certainly not 100% effective, what data exists to predict the infection severity and mortality that would have occurred if the quarantines had not been put in place?

As a doctor who regularly sees individuals with acute upper respiratory illness, I am comfortable with the CDC’s initial recommendations of avoiding travel to China, hand washing, wearing a mask and taking a travel history on your patients presenting with upper respiratory tract symptoms.

For those of you looking for more information on the new Corona Virus I suggest accessing the online infectious disease newsletter produced by the University of Minnesota School of Medicine called CIDRAP at http://www.CIDRAP.com. They cover this illness, Ebola, SARS, MERS (Middle Eastern Respiratory Syndrome) Bird Flu, food poisoning outbreaks due to infectious agents and other infectious diseases worldwide. If you read that newsletter you will be informed, and frightened, by the reality of what is out there.

Flu Shot Campaign Begins

As school bells ring out announcing a new school year and pigskins fly through the air announcing the arrival of a new football season, the Center for Disease Control and Prevention (“CDC”) begins its annual influenza vaccine campaign.  “Flu” or influenza is a viral illness associated with fever, severe muscle aches, general malaise and respiratory symptoms.  Most healthy children and adults can run a fever for 5 – 7 days and fight off the infection over a 10 day to three week period.  There is clearly a long period of malaise and debilitation in many that lasts for weeks after the acute febrile illness resolves.

The illness is especially severe and often lethal in the elderly, in infants, in patients with asthma and chronic lung disease and in those patients who have a weakened immune system due to disease or cancer treatments. Diabetics and heart patients are particularly vulnerable to the lethal effects of unchecked influenza.

The CDC recommends vaccinating all Americans over six years old against influenza.  Adults can receive an injection, or a nasal application.  The 2012 – 2013 vaccine has been updated from the 2011 – 2012 version based on samplings of current influenza viruses spreading around the world.   It takes about two weeks to develop antibodies and immunity to influenza after you receive the vaccination.  If you received the vaccine last season or had the flu last season you are still advised to receive the 2012 – 2013 vaccine this year because immunity fades with time.  Flu vaccine should have arrived in most physician offices and community health centers and pharmacies by mid- August.  The CDC advises taking the shot as soon as it is available.

The vaccines used are not live viruses so one cannot catch the flu from the vaccine. Side effects usually include warmth and tenderness at the injection site and rarely general malaise and low grade fever a day or so later.  The benefits of receiving the vaccine far outweigh these minor and rare ill effects which can be treated with an ice pack to the injection site and some acetaminophen.  Please call your doctor to set up an appointment for a flu vaccine.

For those individuals who catch the flu we still have several antiviral agents available to treat the illness. These agents should decrease the intensity or severity and duration of the flu. We try to use these medicines as infrequently as possible because the flu can develop resistance to them over time.

Prevention of disease is an ever increasing component of our everyday language. Vaccination against an infectious disease such as flu or influenza is clearly one of the more effective preventive strategies physicians have available to offer patients.  While you are making arrangements to receive your flu shot inquire about several other effective adult vaccines including Pneumovax to prevent bacterial pneumonia, Zostavax to prevent shingles and post herpetic neuralgia and Tdap to prevent whooping cough or pertussis and tetanus.

United States Preventive Care Can Be Better, Center for Disease Control Says

Ralph Coates, PhD of the Center for Disease Control (CDC) described in the June 15, 2012 issue of Morbidity and Mortality Weekly Report that by looking back at a U.S. study done between 2007-2010 called “Use of Selected Clinical Preventive Services among Adults,” health providers need to do a more comprehensive job of offering preventive services.

According to the report, only 47% of patients with documented heart and vascular disease were given a recommendation to use aspirin for prevention. They additionally found that only 44% had their blood pressure under control. When looking at cholesterol and lipid control only 33% of the men and 26% of the women were tested with a blood lipid test in the last five years.  Of those patients who did measure their lipid levels, only 32% of the men and women surveyed had their lipids under control. Among diabetics, 13% had poor sugar control with a HgbA1C > 9 (goal is 6-8).

The data indicate that at 37% of the visits, patients weren’t asked about their smoking or tobacco status.  When patients were asked, and answered that they were smoking, only 21% were given smoking cessation counseling and only 7.6 % were prescribed medications or a way to stop smoking.

Screening for cancer needs improvement as well. Twenty percent of women between the ages of 50-74 had not had a mammogram in over two years.  In the same age group, a third of the patients were not current on screening for colon and rectal cancer.

The data was collected prior to the passage of the controversial Affordable Care Act. When the data was analyzed and divided according to socioeconomic status, education level, and health insurance status; it was clear that the poorest and least educated had the fewest screenings. It is hoped that with passage of the new health care law, and new insight by health insurers that it is cheaper to prevent a disease than treat it, these numbers will improve.

There are several other factors that need to be looked at as well. Data is now being collected from electronic medical health records.

I ask my patients about tobacco status on every patient visit.  When I note that the patient is smoking in their electronic health record, there are three or four ways to document counseling has been offered. Only one of them triggers the audit data for the government to review. Our software instructors were unaware of that when they taught us to use the system.  How much of this study is the result of data collection error is unknown.  “Health care providers” – not just physicians, are now delivering health care.

Access to physicians and a shortage of primary care physicians exacerbate the problem. It takes time to extract this information, record it, and counsel the patient. Because PCPs are underpaid, they will continue to see patients in high volumes to cover their expenses, causing the use of comprehensive preventative questioning to remain low.

I Lost 52 Pounds And Feel Fantastic!

Patients have noticed my recent 52 pound weight loss but, for the most part, have been reluctant to approach me to discuss it. I’m sure many have wondered if this was a planned weight loss or the result of a serious illness.

Let me bring clarity to any concerns. My weight loss was planned as part of a lifestyle improvement program and, as a result of my commitment, I now feel great!

Like many Americans, I had accumulated extra pounds due to poor food choices, large portions and poor health habits. Finally, I decided to get healthy BEFORE I became ill and my doctor insisted on it.  I established certain criteria in choosing a weight loss program. It had to be safe, effective and rapid. I did not want medications or injections to be involved. Any program I was to consider had to have a proven safety record with no patients becoming ill.  There needed to be a sane transition program and maintenance program to teach me how to prevent regaining the weight rapidly and how to move on and live a healthy future life.

After much research I found the Take Shape for Life Program (www.tsfl.com).  Clinical studies by Johns Hopkins, the National Institutes of Health (NIH) and other organizations have proven the effectiveness of this program.  It has been recommended by over 20,000 doctors.

Take Shape For Life provides a network of ongoing behavioral support, education and other tools while using the nutritionally-sound Medifast meal replacements.

TSFL participants eat six small meals per day – all of which are low in fat and sugar but rich in protein and nutrients.  The five daily small Medifast meal replacements are supplied by TSFL and are eaten every two to three hours along with one lean and green meal that you prepare yourself.  These small frequent meals keep you from becoming hungry and getting cravings. As part of the program you have access to a free health coach / guide / cheerleader who assists with recipes, lifestyle tips and helps order product. The low average monthly cost to participate in the TSFL program is about $315.

I started the program in mid January and reached my goal weight in just four months. I am now working on transitioning to the maintenance program. My lovely wife is also participating in the TSFL program and has over 40 pounds to date.

I suggest those of you who are struggling to lose weight discuss it with me.  The program is perfect for diabetics, hypertensives, individuals with heart disease and individuals with gluten sensitive enteropathy.

Please contact me with any questions you may have, to request information or, to begin your journey to achieving optimal health by enrolling in Take Shape For Life.