Exploring Cuba – Part 1

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If you travel because you like to see different cultures and experience things you usually don’t, Cuba is a good place to go. For Americans Cuba has been kind of like forbidden fruit. I thought it was a good time to go as it recently became easier, and I wanted to see the country before it gets changed too much by hordes of tourists.

Although they do have beautiful beaches, as an American you can’t currently legally go there just to stay at a beach resort. You have to declare which category you are traveling under, and tourism is not one of them. Most people choose the people-to-people category. When I went last month with my wife and daughter, I chose the journalism category, as I have a blog and photography site, but in practice, I think it’s rare that anyone actually checks. That could change with the incoming administration, though. In this article I’ll get into some of the details of the trip, for those interested in going.

We flew from Seatac to Miami airport and stayed at the Miami International Airport Hotel, conveniently in the terminal, saving time to catch the early morning flight to Havana on Delta Airlines. We obtained our visa when we checked in, paying $25 for each one. That’s part of the reason they tell you to check in 3 hours early.

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Although you will see plenty of places that accept credit cards, including MasterCard and Visa, they do not accept American credit or debit cards. Thus you have to carry cash. There are two currencies, the Cuban Convertible Peso (CUC), which is about equal to a US dollar, and the Cuban Peso (CUP), mainly used by locals, and about 24 CUP equals 1 CUC. The official rate is used everywhere, except for the black market. You will pay about 3% to change you money to CUC and 3% to change it back, but if it’s US dollars they tack on an extra 10% as punishment for our embargo. I converted my dollars to Canadian dollars first, saving about 7% (saving 10% not converting from US currency, but paying 3% for converting it to Canadian). When I left Cuba I converted the relatively little CUC I had left to Euro, as I plan to go there later in the year.  You can convert money at the airport and at banks, but the later often had lines out the door. Major hotels often will convert money, but some require that you stay there. Most places did not give a receipt.

Except for one night, we only stayed at places we booked through Airbnb. One place was basically a guest suite connected to a beautiful large house with friendly hosts, and a very nice breakfast for an additional 5 CUC per person. Another place was really a hotel that they were using Airbnb for bookings. One was from an older couple that owned a few apartments and rented out a couple of them. Having to deal with just cash was a little nerve wracking. I carried a fairly large sum in a money belt most of the trip. I never worried about being robbed, but it was uncomfortable in the heat. Even more concerning was worrying about the possibility that I might run out of money. The first couple of days was more expensive than I anticipated and I contacted a cousin that by coincidence was arriving in Havana a week later than us. She brought me some money as a loan. I never ended up needing it, but it did provide peace of mind.  A big advantage of Airbnb is that you pay that in advance, so you do not need to bring money for your lodging. At a couple of the places they incidentally did offer to exchange dollars to CUC at better than the official rate, though probably not quite as good as if you exchanged using Euro or Canadian dollars. I didn’t use them, and you have to be careful, but I would have over standing in line at a bank. I advise you to convert a little more than what you think you will need for your entire trip, and carry emergency money in your native currency that you would only change if needed.

For the three of us, I rightfully worried about getting around with lots of luggage. We limited ourselves to one carry on luggage without any full check in size luggage. Particularly as I was bringing some medical supplies (more on that later), and anything you might need but can’t count on being able to buy there, space was at a premium. One thing I did was to buy two pairs of quick drying ExOfficio underwear, and Sea to Summit Lite Line clothesline to hang it up on.

It just so happened that we arrived in Havana the day Fidel Castro was buried in Santiago de Cuba. Raúl Castro declared a 9 day mourning period after Fidel died, banning public music and sales of alcohol. It was not followed completely, but it was certainly more subdued when we first arrived. They have 9 or so TV channels, and during the mourning period they played revolutionary type programming, such as black and white videos (or dramas?) of soldiers fighting in the jungle. As one Cuban told me, it was interesting, but not for 9 days.

We went on our own, not part of a tour, though I worked with a Cuban tourist guide someone introduced me to before the trip. She made suggestions to the itinerary I made, and helped me hire a car and driver for 6 days. One of the travel changes I made at her suggestion was to cancel a fight to Baracoa on the other end of the island. I hadn’t realized that it had been badly damaged by Hurricane Matthew. In addition, the only airline that flies there, Cubana de Aviación, is notorious for bad service. When I made the flight reservations I had to enter all our contact and passport information. To my chagrin the email confirmation included all of the details! I emailed them about my concerns about identity theft, but they never responded.

One of the other things our guide did was to make many restaurant reservations for us, which was surprisingly often necessary.  When it comes to restaurants, there are two kinds: state owned, and private. The latter were only allowed less than 3 years ago. They are generally more expensive, but better quality. We ate at a few of the state owned places. Although the buildings were often beautiful, the food quality was often lacking, serving such things as canned green beans.  In Havana, restaurants we particularly liked included La Guarida, San Cristóbal Paladar, Doña Eutimia, El Cocinero, Atelier, and Paladar Vistamar. In Cienfuegos Las Mamparas was quite cheap and pretty good food. In the Viñales Valley Finca Agroecologica El Paraiso was amazing.

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When people think of Cuba, they think about old cars. There are many American cars from the 1950’s, quite a few Russian Lada cars, plenty of Chinese and other cars. Cars are very expensive (it can be the same as a house there), and most everyone with a car is also a mechanic. You have to be to keep the cars running. Our driver said that a particular 7 person Hyundai van was popular for giving group tours, and a used one, if you could get it, cost 140,000 CUC!

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It was common to see people on horseback or in horse drawn carriages, particularly outside of Havana. I even saw two using the inside passing lane on the highway!

After a couple of days in Havana, we drove to Cienfuegos, stopping at the Giron Museum (Museo Giron) by the Bay of Pigs, and the Cueva de los Peces (Cave of Fishes). We passed by areas where the farmers spread their rice on the the edge of the road to dry, then would sweep it up at the end of the day, then repeat it for about 6 days to totally dry the rice.

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Cienfuegos is a nice port city that has a French influence. Outside the usual tourist things there, we toured a cemetery, where a couple of boys rode up on a donkey. We visited a botanical garden. We also took a day trip to El Nicho waterfalls, and another to Trinidad.

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Trinidad, also a UNESCO World Heritage site, is a charming cobblestone paved town. It’s reportedly often the hottest part of Cuba, and even in December it was pretty warm.

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We left Cienfuegos to drive to Santa Clara where we saw the town and the Che Guevera Monument. From there we drove to quiet but lovely town of Remedios to spend the night.

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Next it was on to the Santa Maria Cayo (key). The road there reminded me of driving to the Florida Keys. We spent 1/2 a day at the Lasterrazas resort. As I said earlier, technically you can’t go to Cuba just to take a beach vacation as a US citizen. It was just a small fraction of our trip not only for that reason, but because that wasn’t what I wanted out of a trip to Cuba, though I know many others could spend their whole time there.

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We then drove back to Havana, where we stayed the rest of the trip, except for a day trip the following day to the town of Pinar Del Río, where we toured a cigar factory,  then on to the Viñales Valley where we gorged ourselves over lunch at the amazing Finca Agroecologica El Paraiso.  We saw a couple of sites, including the tacky Mural de la Prehistoria.

Our driver said the Pinar Del Rio province, where they grow a lot of tobacco, is called the Valley of the Fools. He told the story of Pedro Perez. Before a race he was invited to answer a question for a prize. The announcer said, “OK Pedro, how much is 2 plus 2?”  “6,” he replied. The crowd roared, “Give him another chance. Give him another chance.”  The announcer said, “Ok Pedro, I’ll give you another chance. How much is 2 plus 2?”  Pedro scratched his head and thought about it and said, “5.” Again the crowd yelled, “Give him another chance. Give him another chance.” The announcer said, “This is your last chance, so think carefully, Pedro. I asked you how much is 2 plus 2. First you said 6, then you said 5, so what is your answer?” “4,” said Pedro. The crowd shouted, “Give him another chance. Give him another chance.”

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Back in Havana we took a trip to the outskirts to see Hemingway’s estate. Our taxi driver gave us a tour, though you will get a lot more information if you take an official tour (I listened in on some of them).

As a communist economy, mixed with a little capitalism, there are some strange things when it comes to prices. Taxi drivers often make more than doctors. Natural gas in Havana is cheap. Our driver said the prior month it cost him 25 cents. Because that’s the same price as a box of matches, some people leave their stoves on all the time.

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Dogs run wild in many places. They were never threatening and most seemed well fed. Although some people have them as pets, many are on their own.

The Cuban people are often critical of their government, when asked in private, though proud of some of their achievements, such as medical care and literacy. To thumb their nose at communism, many cars have Apple stickers on them. Kids may sing America from West Side Story in front of the neighborhood commander.

Cuba has a vibrant music scene. We enjoyed some of it, but missed a lot because we couldn’t stay up late enough.

There is no longer a limit on importing cigars or rum for personal use. At the airport I decided to buy two more bottles of rum, one dark, and one white, plus some honey, at the duty free shop. When we arrived at Atlanta we had to pick up our luggage then turn it back in to go to Seatac before going back through security. One of the workers there said clear bottles were not a problem going through the x-rays in security, but he recommended taking out dark bottles and putting it in our luggage. I showed the duty free bag and he said to put the dark rum and honey in my bag but the clear bottle could go in my carry on. I didn’t have room to check all of it in, and I questioned whether it was really ok to open the duty free bag. He said it was no problem at that point and to trust him. I shouldn’t have. When I made it to security they saw the clear bottle and said it couldn’t go through since the duty free bag had been opened. I was told I could go back to check it in (but my suitcase was long since gone) or throw it away. I didn’t ask if I could just drink it on the spot!

You can see more of my photos here. In my next post I’ll discuss some health and medical issues regarding Cuba.

 

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Presidential Politics and Influenza Vaccinations

Recently a patient of mine expressed frustration with the presidential campaign, saying the other side wouldn’t listen to facts and just believed what they wanted to believe.

Knowing that she had repeatedly refused to get a flu shot, I asked her in that case if she’d like to get one, given that scientific studies have shown that the benefit outweighs the risk for most people. Although she hesitated, I unfortunately could not convince her.

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ICD-10 Keeps Getting More Painful

As I previously discussed,  a year ago we transitioned from the disease classification ICD-9 to ICD-10. That has been painful, but they keep making tweaks that require more work.

I guess the powers that be decided that more than 155,000 diagnoses were not enough when they recently changed many diabetes diagnoses (a day or two ago, at least, my organization implemented the latest edition). Now it’s no longer sufficient to say that someone has Type 2 Diabetes Mellitus with Diabetic Neuropathy [E11.40], for example, but I now have to specify in addition whether it’s with or without long term insulin use, or if it’s unspecified. That means all my carefully constructed Problem Lists on my patients no longer work. Every diabetic medication I reorder will have to be changed as they are associated with a diagnosis.

Across all my patients I’d estimate that’s close to 1000 changes I will need to make. Assuming it takes me 30 seconds each time (I’m probably a lot faster than most of my colleagues) that’s over 8 hours, so a full work day. Multiply that across all the primary care doctors and that’s a lot of time – about 1000 people working years! We have a shortage of primary care physicians and I think there are many better ways to spend our time.

I typed “type 2 diabetes mellitus” into my electronic medical record. I eventually scrolled to the bottom to see a message that there were 3158 diagnoses loaded, but that the results had been limited due to it being a common phrase! Many of these were synonyms, and one can save favorites, but I think it’s ludicrous that we have so many codes for just one disease. Those who promulgated moving to ICD-10 claimed the higher specificity would lead to all kind of advantages by being more precise, but in reality physicians can’t spend all day just to pick a diagnoses and they are going to pick something close that will satisfy the billing system. For many diagnoses you can’t even get precise agreement. There are various codes for uncontrolled diabetes, for example, but if you ask different doctors what that means, you’ll get different answers.

Patients with diabetes have to suffer from complications of their disease, increased medical costs, and being stuck more often for blood or injections. It’s too bad their physicians have to suffer more as well.

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Remote Globe Puppy

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The New York times just ran a story about how Mongolia uses a system for their mail where each address consists of three words. A clever British start-up company What3Words divided a map of the world into 57 trillion pieces, each 9 square meters (about 10 x 10 feet), and assigned a 3 word combination to each one.

I checked the address of my office, and it’s crowned.tamed.raced. Given that each address takes up such a small area, I honed in on the map to where the actual rooms in my building are. Here are some of the address I came up with: remote.globe.puppy, patio.thin.ropes, living.quit.exit, castle.lofts.roses, famous.learns.cheek, and minds.agent.former.

I would say that as a geriatrician, living.quit.exit is a pretty good description of what I do, but from a marketing perspective, I’d have to go with remote.globe.puppy.

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Let’s be Clear on ClariSpray

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Bayer, the maker of Claritin, has a new product, ClariSpray. This is a good product, but with a confusing name. It has nothing to do with Claritin, other than they are both used for allergies (allergic rhinitis).

It’s actually fluticasone nasal spray, the same ingredient as Flonase, a prescription product, but now available over-the-counter.

Their website does takes pains to explain this, but there are some things things they don’t mention. They don’t say how it compares with Flonase or Nasacort. Although there are slight differences, and some people may prefer one over the other, they are basically similar, and just a matter of personal preference. Bayer’s website also doesn’t tell you that you shouldn’t take ClariSpray if you are taking Flonase or Nasocort, or one of the other nasal steroid sprays only available by prescription.

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Healthy Snacks

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I was pleasantly surprised to see this sign at the edge of the produce department. Good job, Fred Meyer!!

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The Medical Paperwork Reduction Act

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Painting in the Mauritshuis Museum

Today, in a rare moment of bipartisanship, Congress passed the Medical Paperwork Reduction Act. It states that administrative requirements will be decreased to the minimum required for good medical care and billing. The Department of Labor estimated that this will reduce the average physicians paperwork by 1.7 hours a day, and that for primary care physicians, it will be closer to 3 hours a day. That in turn is expected to significantly decrease the primary care physician shortage, as they will be able to see more patients a day, and lessen unnecessary emergency room visits. Doctors’ morale is expected to improve with improved job satisfaction, leading to less early retirement, decreased physician suicide, and a lower divorce rate. Despite an increase in administrators and clerical staff seeking unemployment benefits, the Congressional Budget Office estimates a net benefit to the economy of 17.2 billion in the first year. “This is a special day. I never dreamed of seeing this,” said AMA spokesman Jonathan Dreckle, “not in a million years.”

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Trump the Bureaucracy

About 6 weeks ago I referred a patient of mine with a knee problem to an orthopedic surgeon in my group. He ended up seeing someone else in the same group about 3 1/2 weeks later, and the doctor prescribed a knee brace.

A few days ago my patient said his insurance company wanted me to do a new referral, because I had referred him to a different physician than the one he ended up seeing. Even worse, he still did not have the brace because they required his primary care physician (that’s me) to write them a letter saying the brace was necessary.

I did write a letter saying that I’m not qualified to say whether or not the brace is necessary, and that if they wouldn’t approve it, then their medical director should contact the orthopedic surgeon to explain why not.

Physicians have far better things to do with their time than waste it on unnecessary paperwork. If we could only channel our collective anger and frustration with the system, as Donald Trump has been doing in the realm of politics, maybe we could spend more of our time treating patients, rather than placating the government and insurance companies.

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Gluteus Maximus

I ordered atorvastatin (generic Lipitor) for one of my patients with high cholesterol and Medicare Part D coverage. It was denied. We then appealed it (prior authorization). A fax from Maximus Federal Services said their decision was, “UNFAVORABLE.” They said the patient had not tried and failed one of the preferred generic statins (lovastatin or simvastatin). They did note that we could appeal to an Administrative Law Judge.

In fact the person had tried simvastatin, which I had noted on the prior authorization. However the cost savings is minor. According to Goodrx, a 90 day supply of atorvastatin is as low as $19.25 around where I work.  For the equivalent dose of simvastatin it’s $10.06.

Yes, it’s almost half the price, but it’s still a pretty small amount, especially in my patient who had already had a heart attack, and the difference will only get smaller as Lipitor has not been generic for all that long. Contrast that with the staff time wasted dealing with this on both ends. Dealing with this is a pain in the Gluteus Maximus!

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Disabled Parking and Needless Paperwork

Date and Place SignedIn Washington State, if you want a disabled parking permit you need your doctor to fill out a form. Effective 7/1/15, a new law also requires a written prescription to help combat forgery. Physicians already have to deal with far too much paperwork. Their latest form ridiculously asks us to write down the place signed. As the photo above shows, I made up a stamp that has the latitude and longitude of my office. They want to know where I signed it? They got it!

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