More COVID-19 Coronavirus Thoughts

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Christian IV’s crown in Rosenborg Castle in Copenhagen, Denmark.

Social distancing is strange when it hits home. The last time we had kids and grandkids over for dinner, about a month ago, we tended to hold back giving the usual hugs. Three people were in the medical profession and two lived 5 miles away from the nursing home in Kirkland that had the big outbreak. It was like an Agatha Christie whodunnit murder mystery and we were all suspects!

At work we’ve been careful to conserve supplies for quite a while, particularly to help out for the places that really need them.

When wearing a gown I couldn’t swipe my badge to log in and out of the computer as my badge was under the gown (if over then it risked touching the patient if I was examining them). I had to pull the reader to me. Face ID doesn’t work with a mask. Last month I saw a new patient, who happened to have a cold, so we both wore masks. Neither of us really saw what the other looked like. More recently most everyone wears masks.

I often check a patient’s throat when doing a routine exam, but would skip it if not really needed to avoid having to be relatively close while they may be actively exhaling in front of me. When I do a physical exam on men, I’d think twice about telling them to turn their head and cough!

We’ve quickly changed how we practice medicine. We try to screen patients to prevent potentially sick patients from coming in. It doesn’t always work. They may have already had an appointment to follow up on their diabetes, and not mentioned that they had a cough. A phone screener may have asked if they went to South Korea or Italy or had known exposure, but that doesn’t mean they didn’t have exposure to someone sick that has yet to be diagnosed, and more recently travel history no longer matters. I documented any personal protective equipment (PPE) I used (mask, mask with eye shield, gloves, gown). That way if I later find out my patient was infected, I could look at what protection I wore. Because of equipment shortages I could not wear everything for every patient I see.

I purchased scrubs for the first time a few weeks ago. When I worked in the hospital many years ago, they provided them to us. Working in the clinic it was not considered acceptable attire for doctors. Because of the pandemic, administration authorized us to wear them. When I would get home, they would go straight to the washing machine, and I would head to the shower as a decontamination routine. We never made so much use of our LG Sidekick pedestal washer!

We’re heading towards doing telemedicine in a much bigger way. That protects our patients from being exposed coming in, and it protects health care workers, and other patients, from being exposed to sick patients. Various legal restrictions and how we are reimbursed has limited this, but now the government as temporarily removed many

restrictions and the government and private insurances are starting to pay for virtual healthcare. I was 17 minutes late the first time I did a case by phone. I was waiting for my nurse to check her in before I realized that I was supposed to call her! I also quickly realized that I needed to use my speaker phone as I could not type efficiently holding the phone with one hand. I’m now set up to do video visits from work or home, but it has been a challenge for many patients. The easiest way is to use a smart phone (iPhone or Android) and download the Epic MyChart app as we use Epic as our electronic medical record
(EMR). Then we can connect on our end using the Haiku app and have a secure video conference call. But some patients don’t have smart phones, and for those that do they often don’t understand that they need to download the app, and that there are a few steps they have to do on their end to actually connect. Some try to connect through MyChart on a browser, but that often doesn’t work. A couple of people couldn’t download the app because they didn’t remember their password for the app store. Another video app we’ve used, that is preferred by our legal department, is less intuitive and I’ve only been successful with it a few times. Occasionally we run into bandwidth issues and sound or video quality is not good. I’m not sure where the problem is, but I suspect it’s on the patient end as I’m connecting to a fast internet and Wi-Fi. When it works, though, it’s generally a good experience for patients and myself. Patients can show me a rash or swollen ankle. For both sides of a video conference, it’s helpful to have a good light source from the front. If it’s from the back one’s face is in the shadows. Try just using the rearview camera to get an idea of what you’ll look like (and what’s behind you!) beforehand. Although I think visits in person tend to be best, it’s certainly safer doing it virtually. Patients appreciate that, as well as the convenience.

People generally know that this pandemic has been hard on healthcare workers. What many people probably don’t realize is that in a healthcare organization a lot of others play important supporting rolls. As I serve on an informatics committee and am a Physician Builder, I’ve had a chance to see some of what’s going on. To place an order for a brand- new test, for example, some analyst had to build the functionality into our electronic medical record. There are many new workflows that were needed, including for telemedicine, and in the beginning the analysts were told we needed them yesterday.

Once a week I work with a family medicine resident to teach them geriatric medicine. I spoke with one last month that I wasn’t sure what was going to happen with her rotation since both I and my colleague were moving towards stopping seeing patients in the clinic. After she spoke with one of the faculty, they suggested she observe me doing telemedicine as I have a reputation for being good with computers. But how could I have her watch yet keep the recommended 6 feet of social distance? I did a test where I chatted with her over one of the apps and I was able to share the screen but then she went on vacation. I’m still trying to figure out a way that I can have a resident remotely do a video chat with the patient and myself. Not all the software we are using allows group video chats. Plus, I want it to be meaningful education for the residents.

I think this experience has brought increased camaraderie among doctors and others in healthcare, like serving together during war. Fortunately we have had less cases than expected in Washington so far, and we’ve not faced dire circumstances in my clinic.

Although it’s unpleasant to consider, on the plus side, this has finally got me to stop procrastinating and pushed me to get my estate plan and medical directive done.

First Thoughts on Coronavirus From a Primary Care Physician

Young girl wetting hands in fountain in Stockholm, Sweden.

The coronavirus infection COVID-19 has spread from Wuhan, China to my backyard in the Seattle area. I experienced firsthand the impact of this infection while on vacation in Hawaii over two weeks ago. The day after arriving in Honolulu, and just before traveling to Hawaii, a report came out that a Japanese tourist had been in Maui, then felt ill after arriving in Honolulu, then was diagnosed after returning to Japan. I started to see people wear masks, and friends who live there wanted to meet in a park for a picnic rather than go to a restaurant as a result.

To date 6 people in Washington State have died from COVID-19, which makes people, including healthcare workers, more nervous. We’ve already had several meetings to discuss how we will manage things. Things are still being worked out, and there are still a lot of unknowns.

As healthcare workers we are concerned about patients infecting us (and if we get sick, who will care for the patients?), or other patients. It’s a balance between asking patients not to come in if sick, and not wanting to miss other causes. It’s still flu season, and someone with a cough and fever is still more likely to have influenza then COVID-19. There are also other viruses, as well as bacterial infections that can cause pneumonia and need to be treated.

As the CDC says, the most important thing is hand washing. It’s important to not touch your face, which we tend to do often, myself included. I’ve started applying moisturizer lotion each morning as dry skin tends to itch more, which leads to touching the face more often.

I just saw a patient for hypertension and needed to start him on a medication. There are lots of choices, but for various reasons I usually start with an ACE inhibitor, such as lisinopril. That’s what I ended up prescribing, but I had second thoughts as the most common side effect is cough and I worried that people might think he had coronavirus if he developed a cough. I consider an angiotensin renin blocker, such as losartan or valsartan, but there have been frequent shortages of that class lately due to chemical contamination issues leading to recalls.

There will be lots of other things to consider as things progress. In the meantime, don’t panic, but wash your hands often. Don’t wear a mask if you’re not sick or around someone who is (it probably doesn’t help, and we need to make sure we don’t run out for those who really need it), and don’t touch your face!

TV Ad with Unintended Medical Humor

Screenshot of Infiniti QX50 rear liftgate from commercial

Recently on TV I’ve seen an Infiniti Winter Sales Event TV Commercial. About 6 seconds in the rear liftgate comes down and one can see the license plate, BPH 738. There’s no indication of what state issued it, but primary care and urology doctors would immediately recognize the first three letters as an abbreviation for benign prostatic hypertrophy (an enlarged prostate). Maybe they chose that on purpose to suggest speed, because when you gotta go, you gotta go!

New Dietary Guidelines Ignore Science

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The federal government has issued dietary guidelines every 5 years since 1980. They are the ones that came out with the food pyramid, and most recently gave limits for sugar, saturated fat, and sodium (salt). These guidelines affect many things, including what children get served for lunch at school.

For the first time ever, the Department of Health and Human Services and the Department of Agriculture, under the direction of the Trump administration, is limiting the scope of the committee. They gave them a list of 80 questions, and said they are not to consider anything outside that list. Those questions do not include health risks such as too much salt, red meat, and processed foods.

The nature of science is that with ongoing research things change. Most of you can probably recall getting conflicting diet recommendations over the years. We were told to avoid fats, as we subsequently got collectively heavier, then ketogenic diets said the opposite. Alcohol can decrease heart disease, then studies showed it can increase breast cancer. That’s why it’s important to periodically review the literature and adjust recommendations if warranted.

Why would the Trump administration want to limit the committee? For one thing, they have generally been anti-science in many areas, such as global warming. For another, as they say, follow the money. Thirteen out of 20 of the committee members have food industry ties. This compares with two of 12 members in 2015. You can read more details in a Washington Post article.

Health care costs have been going up at a rate higher than inflation for many years. Although there are many reasons for this, part of it is because people are getting more obese. This leads to such health issues as diabetes, hypertension, heart disease, and arthritis. The new rules effectively says that corporate interests trump human health. So that corporations can profit more, we will pay the price in our health, and in our future medical bills.

The statute (Public Law 101-445, 7 U.S.C. 5341 et seq.) that required the guidelines specifically says that the Dietary Guidelines be based on the preponderance of current scientific and medical knowledge. As that wouldn’t be the case, unless the restrictions are removed, I expect that from 2020 to 2025 I’ll be advising my patients to follow the 2015 guidelines.

Aspirin – Questioning Established Wisdom

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Bayer began selling aspirin (acetylsalicylic acid) in 1899, and the similar salicylic acid, derived from willow bark and other sources, has been used medicinally for thousands of years.  Since the 1960’s it has often been used for heart attacks and strokes. Studies showed that in patients who have had heart attacks, daily aspirin prevents another one. This is know as secondary prevention.

Doctors have assumed that it would also be good to prevent the first heart attack in patients at higher risk. This is know as primary prevention. The problem is that’s much harder to prove.  Even patients at higher risk might never have one, or maybe not for many years, so a research study can take many thousands of patients followed for many years, thus costing many millions of dollars, to tell if there is a benefit. Rare side effects can take many years to figure out. There have been studies done over the years, with inconclusive and sometimes with inconsistent results.

According to a trio of recent articles (Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly, Effect of Aspirin on All-Cause Mortality in the Healthy Elderly, and Effect of Aspirin on Disability-free Survival in the Healthy Elderly), aspirin use may cause more harm than benefit for primary prevention. They looked at patients >= 70-year-old (>= 65-year-old for blacks/hispanics in the US). A low proportion of participants regularly took low-dose aspirin before entering the trial, which did not directly address whether healthy older persons who have been using aspirin for primary prevention should continue or discontinue its use. Now 2019 guidelines from the American College of Cardiology and the American Heart Association recommend low dose aspirin for primary prevention only in limited patient populations at higher risk.

When it comes to medical treatments, it’s pretty much always a question of balancing benefit versus risk and cost. For aspirin, cost is pretty much not an issue. Although studies may look at thousands of patients, people are not homogenous, and any particular study may not apply to a particular patient. The guidelines listed above state that aspirin might be considered for primary prevention in adults age 40 to 70 at higher heart risk but who do not have a higher bleeding risk. They do not recommend it for routine use for those over 70-years-old. Note that it still may be warranted in some because of higher risk, and it’s still recommended for most older patient if they have known heart disease.

I think these new recommendations will eventually lead to less patients taking aspirin to prevent a first heart attack. This will lead to less bleeding, but it may increase other problems For example, aspirin may decrease the risk of colon and other cancers. It may help prevent deep venous thrombosis (DVT) blood clots in the legs, which could lead to a more serious pulmonary embolism (PE), so long distance air travelers may be at higher risk of a clot if they stop taking their aspirin. They could just take it before a trip, but will they remember? The FDA just added a block box warning for Uloric (febuxostat), a medicine used for gout, because of recently appreciated increased risk of cardiovascular disease. Surely there will be patients on that medication on aspirin for primary prevention who will stop aspirin, as a result of reading in the media that they should, but will then go on to have a heart attack because either they didn’t discuss it with their physician, or they did but their doctor didn’t know or appreciate the increased heart attack risk with Uloric. That medicine, by the way, should also be judged on benefits versus risks and alternatives, and is still appropriate for some patients, though not as many people as the drug reps would have had doctors believe. They’ve stopped promoting it as it’s almost generic, but that’s another story.

Medical Pricing Transparency via Non-Transparent Rule

copyright 2015 Daniel Ginsberg PhotographyHidden in a 700-page draft regulation to improve patient’s access to their electronic medical records is a proposal to require doctors, hospitals, and other healthcare providers to publicly reveal the prices they have negotiated with insurers. This rule, tied to the 21st Century Cures Act, would set the stage for eventually making prices publicly available. Although price transparency may be a good way to help lower medical costs, it’s ironic that there is a lack of transparency when it comes to the proposed rule. I challenge you to read the Title, Summary, or Actions section and realize that it includes such a major change (hint – in the PDF document it’s on page 7513 of the Federal Register under Price Information).

On the face of it, making prices readily available sounds like a no-brainer, but I think it’s more complicated than that, and there may be unforeseen consequences. The rule is long and complex, and I don’t have the few days it would probably take me to really understand it, but let me play devil’s advocate. Some of the comments posted say that medicine is the only industry that hides the cost. To a certain extent that’s true, but this rule could go beyond just saying the price consumers pay. If you go to a restaurant they won’t reveal how much they paid for the the ingredients. If you book through a 3rd party website, they don’t tell you how much, if any, they pay them for the referral. When you buy a car the dealer usually doesn’t tell you if the automobile manufacturer is giving them a rebate. From the point of view of a business, the consumer shouldn’t get to know their internal costs as that’s secret competitive information.

What mitigates that argument is that the price of healthcare has gotten out of control. Despite being better educated about the matter than most, when it comes to getting healthcare for their own family I suspect most physicians struggle to understand their bills just like everyone else.

When it comes to pay, doctors are a commodity. For a given surgical procedure or office visit of a certain complexity, they are paid the same amount as mandated by Medicare or Medicaid, as negotiated with insurance companies, or their list price for the unfortunate cash patient. Just like any profession, some doctors are better than others. If you want to hire a top lawyer or an A list actor, you have to pay top dollar.  But that’s not so with much of healthcare. The price doesn’t necessarily reflect the quality of the care.

Hospital systems mitigate that somewhat. They can negotiate higher prices with insurance companies and with large employers by demonstrating that they provide higher quality care and/or lower cost care, or because patient perceive them as providing superior care and they demand that that can get care from them. What will happen if the rule goes into affect and patients can easily compare prices? I don’t know, but potentially they might choose the lowest cost without regard to quality. That could lead to systems competing on price, cutting corners to do so, and ultimately lowering quality.

The lowest price might actually not be the path to cost savings. Imagine two surgeons. One of them charges $5,000 for a knee replacement, and operates on 60% of the patients seen for knee arthritis, treating the rest successfully with injections and physical therapy, which on average costs $1,000. The other charges $7,000, and operates on 50% of the patients seen and treats the rest successfully with the same conservative measures. Besides the physician fee, the hospital system charges $10,000 for the surgery. In this example, treating 100 patients would cost $940,000 for the first surgeon, and $900,000 for second. So even though the second surgeon charges 40% more than the first, on average the doctor ends up being cheaper when it comes to managing knee arthritis.

I’m inclined to support more transparency in healthcare pricing, but I don’t know how much of an impact it will have, and there may be unintended consequences.

Don’t expect to see published prices anytime soon. Even if the proposal goes forward, following a public comment period that ends May 3, it’s likely to be tied up in legal challenges for quite a while.

National Guideline Clearinghouse Goes Kaput

Although the practice of medicine has existed for thousands of years, it substantially improved with the implementation of the scientific method. Experiments and research studies improved diagnosis and treatment. Now so much information is published that no person can read everything unless, possibly, it’s limited to an extremely narrow subspecialty.  In addition, different studies can come up with opposing results, and it can be difficult to make sense of all the available information.

To remedy that, various groups have published guidelines to help clinicians decide what to do. For example, new guidelines for high blood pressure were recently published. The American Diabetes Association just updated their guidelines for Standards of Medical Care in Diabetes.

So how does one find out about existing guidelines, other than doing a web search or coming across it in a journal? Well in 1998 the National Guideline Clearinghouse was created. It formed a collection of guidelines that met minimum quality criteria. By June 2018 there were more than 2000 guidelines listed that could be searched by specialty. In July of 2018 all of that information became unavailable on the website because of federal government budget cuts.

The website was originally created by the Agency for Healthcare Research and Quality (AHRQ), in partnership with the American Medical Association (AMA) and the American Association of Health Plans (now America Health Insurance Plans).

In the last year of operation, the National Guideline Clearinghouse’s budget was about $1.2 million dollars. This is only about 1% of the money spent globally on developing guidelines, and an even much lower percentage of the cost of medical care. The guidelines can improve care and save money, but only if people can find them. Both my company’s electronic health record and my county medical society’s website have the National Clearinghouse Guidelines integrated to reach them with a click. I’m sure we’re not the only ones who routinely used it.

Perhaps a better repository can and will be built, but in the meantime I think the government should fund the National Guideline Clearinghouse and bring it back online.  This was not a case of trimming fat from the national budget, but a self-inflicted stroke where the government cut off the blood flow (money) to a portion of our collective brain. We’re the worse for it.

Fever – Hot Off the Press

Whether your mother taught you, or you learned it in medical school, chances are you’ve been told that 98.6° F (37° C) is the normal body temperature, and greater than 100.4° F (38° C) is a fever. It turns out it’s more complicated than that.

Those numbers came mainly from the work of Professor Carl Wunderlich. In 1870 he published an enormous study of over 1 million temperatures taken from about 25,000 patients. The thermometer he used was calibrated differently than modern thermometers, and he took temperatures in the axillae (armpit), which varies from oral (under the tongue) or tympanic (ear) measurements. He found that temperatures tended to be higher in the morning, and higher in women.A study published in JAMA in 1992 looked at patients 18 to 40-years-old who were hospitalized for a vaccine study. Prior to getting the vaccine, their temperatures were check 4 times a day for 2 ½ days. They found the upper limit of normal to be 98.9° F (37.2° C) in the early morning, and 99.9° F (37.7° C) overall.

A study that looked at 18,630 individuals from 20 to 98-years old showed women’s temperatures ran 0.3° F higher than men, and temperatures tended to decrease with age, with a 0.3° F difference between the youngest and the oldest.

An article published 13 August 2018 used an iPhone app called Feverprints. They looked at  11,458 oral temperatures recorded from 329 healthy adults and found an average normal temperature of 97.7° F, and that a fever started at 99.5° F.

I’ve often had patients tell me that a temperature we would normally consider within normal limits is high for them. That’s a good observation. There is a certain amount of normal variation in temperature by individual and time of day. It doesn’t necessarily mean it’s something that should be treated, but it may be a sign of infection and should be considered accordingly.

Drawing Lessons From a Disaster

Three days ago an engine explosion on Southwestern Airlines Flight 1380 caused a sudden cabin depressurization. Oxygen masks dropped as designed, but as reported by the New York Times, photos showed that many people had the mask over just their mouth, and not the nose and mouth as instructed. The conclusion? Passengers didn’t pay enough attention to safety instructions.

Although that is probably true, I don’t think reminding people to pay attention is really the answer.  As a physician, I have to re-certify in CPR every year. It’s not just the knowledge, it’s practicing it and getting muscle memory. Even with that, my skills surely deteriorate as I rarely have to do CPR now, and practice makes perfect. The key point is that passengers don’t get to practice. If you’ve ever taken a cruise, you know that shortly after you board, they have you actually go your assembly point and actually don a life vest. They don’t have you watch someone put on a vest, and they don’t point to where you should go.

As a medical student in the Air Force, I had the opportunity to take altitude chamber training. This is where you are in a chamber where the oxygen and pressure simulates being at high altitude, such as 25,000 feet. You then take off your oxygen mask to learn how you are affected by hypoxia (low oxygen). You are supposed to observe a few of the effects, then put your mask back on. I remember noticing some of the changes with curiosity, then someone tapping on my shoulder and telling me I had passed out. When I told him I hadn’t, he asked me who put my mask back on. At that point I realized that I had passed out, and it drove home the point of why they tell you to put the mask on yourself first, before helping your kids or anyone else. Otherwise you may pass out, then you are not in a position to help anyone else.

The article quoted a retired flight attendant as saying it didn’t matter that people didn’t have the mask over their nose as they could breath through the mouth. Although that’s true, that doesn’t mean they necessarily did. Many people breath through their nose most of the time, and in a high stress situation they may not necessarily realize that the mask is not covering their nose, or if they do, that they should breath through the mouth.  A better option might be to make the masks shaped more like a mask designed to cover the mouth and nose. You know, kind of oval shaped, not a circle.

It certainly not possible to put everyone who flies on commercial planes through altitude chamber training, but actually practicing putting on a mask would make people more proficient if they needed to do so in an emergency. On an airplane it may not be practical to do so because of the need to clean the masks, but in the terminal they could put booths where people could practice putting on masks, that could be cleaned and reused, and life jackets  to practice putting on, all while waiting for their flight. They could encourage participation by giving people who do so coupons for a snack or to be eligible to win a prize each flight.

Wasting Resources – A Day in the Life of Yours Truly

I’ve written before about some of the things that waste physicians time, and how trying to be a good steward of resources can be frustrating. As the saying goes, no good deed goes unpunished. So here are three such things I dealt with the day after April Fool’s Day.

I prescribed the diabetic medication alogliptin, the generic of Nesina, for one of my patients on a Medicare Advantage plan. I was told it wasn’t covered, but they would cover substitutes, including Januvia (sitagliptin). The cash price is a little over 4 times as much for Januvia! I don’t mind using Januvia from an efficacy point of view, but it was a waste of my time having to make the change, and tax payers are wasting money buying a more expensive drug. After any negotiated deals it may not be 4 times as expensive for the plan, but it’s hard to imagine it would be a cheaper option than what I prescribed.

I ordered a head MRI for one of my patients. A week ago I called Molina insurance after receiving a message that they required a peer to peer phone conversation with another physician. After 10 minutes on hold I left a message explaining why I had ordered the MRI (which I had already explained in my note and on the MRI request). As they still hadn’t approved it, I called back again today. I spent 3 minutes on hold, then 8 minutes talking to a staff member before she transferred me to a physician, then 3 minutes with him as he gathered the basic information then approved it. I did not give him any more information than I had provided in the first place. He said he didn’t have any information on why I had ordered the test or he would have approved it right away.

And the third thing? I can’t remember. No fooling!