Health Care

The Last Tale From the Clinic

Posted on by writenp

I started this site when I was working as a nurse practitioner at a community health center. I stepped back from a clinical role almost a year ago and while I still have many tales to tell, was not motivated to write about them. Until now.  No, it’s not about the recent election. This is an issue that predates that by at least 10 years.

The clinic is broken. Well, health care is broken, especially when it comes to primary care.  And I don’t know who is more unhappy about that, patients or providers. I can’t speak for doctors, but I can speak about what my fellow nurse practitioners tell me.

It doesn’t matter if you work at a community health center, one of the new, streamlined, tech-driven companies such as One Medical or Forward, or  a private medical practice, whether or not is now owned by a hedge fund.  Although, at least in the New York Metro area, it seems that most of them are.

You might wonder why non-profits push nurse practitioners to see more patients. In the case of community health centers, the push comes from meeting quotas to get or maintain grants, and the need to bring in enough money to keep the place open. Since no one is turned away, unpaid visits have to be made up for by paid visits.

Wherever they work in primary care, nurse practitioners are stretched, pushed and pulled to see more patients. Complicated patients. Patients who in some cases, should be seeing an MD. Patients who deserve more than a 15-minute visit (which, by the way, is every patient). Many nurse practitioners are not receiving a fraction of the support doctors do.  And many do not have the support of doctors who are also too harried to answer questions or consult on a patient. And while it’s not just about the money, it is worth noting nurse practitioners make a fraction of what doctors do but are expected to carry the same caseload.

None of my nurse practitioner friends are happy in their jobs. Is it being a mid-level provider that’s the problem, or is it primary care?  Being in a specialty seems a better option but my friends are concerned about losing their skills, about doing basically just one thing, as they see it, if they worked in a specialty.  And they would miss their patients. They went to school, sacrificed, so they could become primary care providers. And they are needed more than ever, and not just in rural or poverty-stricken areas.

So what is the solution? Increased staffing would help, but it has to be more thoughtful than that. Most of the NPs I know prefer working collegially with doctors who are on site. Like all providers, including doctors, they would like more time per patient visit. And they would prefer to leave the medically complicated patients to the doctors who were trained to take care of them.

But where is the money to finance such a scenario going to come from? Certainly not the hedge funds, who are buying up practices and hospitals because they think, without knowing anything about health care, they can make practices and hospitals more profitable. They  “do it better” by squeezing the most productivity they can out of providers.  The result has been a mass exodus of providers in private primary care. In many cases, these providers (mostly doctors) go to concierge medicine, leaving the mid-level providers, the NPS and Pas, to pick up the slack. Until, of course, they are too burned out to do so. It’s a sad, dangerous situation. I wish I had a better tale from the clinic. Until I do. I’m signing off.

Doing Nothing and Nothing Doing

Posted on by writenp

Even when I am not “working” as an NP, friends and family still solicit my advice. That’s no problem. I can’t stop thinking like a nurse practitioner, keeping up with new advances in health care or wanting to help people negotiate our health care system, which is broken, in so many ways.

What advice do I give? Sometimes it’s a matter of using the right lingo, even some key words, emphasizing one symptom, and being persistent. It also helps to put yourself in the shoes of your health care provider. NPs, MDs, PAs, we all want to solve your problem. We love a mystery, and most of us really care about making you feel better. So if you finally get an appointment and describe your problem — back pain, say — the assumption is that you want it to stop, at all costs.  But is that really the case?

Maybe you can put up with the pain. It’s not that bad really and gets better as the day goes on. But you want to make sure the pain is not caused by anything serious, and rightly so. A malignancy is always in the back of one’s mind, as well as that of your provider. Or maybe it’s something that, if not treated, is sure to get much worse. You don’t want that either. Providers get 15 minutes a visit, if they are lucky, and they have a lot of mandatory charting to do on the computer. You have to distill your symptoms and your concerns and communicate them succinctly. That is just the way it is these days.

Perhaps the next step is some kind of imaging, an ultrasound, Xray or MRI. The radiologist who reads the image is likely overworked and usually errs on the side of caution. So further imaging might be suggested to rule out “something bad.” MRIs and ultrasounds are fairly benign in that they don’t expose you to radiation. CT scans do and the exposure is cumulative over a lifetime. What you decide to do is dictated at times by the level of uncertainly you are willing to live with.

Sadly, this can be a slippery slope. You then see an orthopedist who tells you your pain is caused by a benign cyst pressing against a nerve on your spinal cord. You could get it removed or injected with a steroid, which might alleviate pain or cause it to “pop.” The orthopedist gives you these options because you consulted her about your pain so obviously you want her to make it go away. Now you are on to invasive procedures and invasive procedures, every one, has the potential of making things much much worse.

Always ask what happens if you do nothing. Might it get better on its own? Might it just stay the same? Consider if you can live with this new normal. And of course, there is always a second opinion.

Case in point: I am a runner and developed arthritis in one foot that caused significant pain after, but not during, a run. I consulted an orthopedist who was touted as being a runner who specialized in foot problems to see if there was any recourse. Orthotics, joint replacement, I was open to hearing about options. I was concerned it would get worse and prevent me from running. First red flag was when he was surprised at how far I ran – 6-8 miles.  He was a runner, after all, that distance should not have surprised him. Then he suggested a little surgery to “clean the area up.” There is not such thing as “a little surgery,” but I had already written him off by then. I sought out another orthopedist specializing in feet, who looked at the Xray, did a quick exam and said he would never operate on me because, although only a surgical fusion would relieve the pain, I would no longer be able to run afterwards. He suggested a steel orthotic available on Amazon. Six years later, I am still using it and still running.  

When to Start and When to Stop

Posted on by writenp

Can you have too much a good thing in health care?  Most definitely. Too many tests is never a good thing, which new providers learn fairly quickly as they struggle to follow up results that likely will have no impact on the patient’s health but now must be dealt with.  Which can lead to more unnecessary tests, invasive procedures, added expense and patient anxiety, which is never benign.   

Many people don’t know when it is recommended to stop certain screenings.  While some screenings for cancer are pretty innocuous in terms of the actual examination, i.e., a PSA blood test or a skin cancer screening, there are others that are well, a bit more unpleasant.  I’m talking about pap tests, colonoscopies and mammograms.   Yet these are the very tests many people faithfully have on a regular basis, without thinking about whether they are still needed.

Before I go further, I must stress that these are decisions that you should be making with your health care provider, based on your individual state of health, family history and attitude towards testing.   More about that later.  But feel free to read on and bring any questions you may have to your next appointment. Or me, if you’d like to engage that way.

The pap smear is a familiar but antiquated term for the screening test for cervical cancer.  Antiquated because cells are no longer smeared onto a slide but instead, mixed into a liquid medium. Pap test is more descriptive.  The Pap test is the poster child of preventative screenings, its use having resulted in a remarkable reduction in the incidence of and death from cervical cancer worldwide. But today the pap, which examines the cells of the cervix, is no longer the only test for cervical cancer. Once the link between the Human Papilloma Virus (HPV) and cervical cancer was clearly established, a test was developed to check for it, and a vaccine (the HPV vaccine) was developed to prevent it in the first place.  OB/GYNs are the providers most people think of as performing pap tests, but so can nurse practitioners, physician assistants, and Family Medicine doctors.  In fact, any practicing doctor can perform it but most non-gyn specialists do not, nor do most internists, I guess by choice and subsequent lack of supplies. I am always intrigued by the unwillingness of internists to do an internal exam.  But I digress.  

First, be aware these guidelines only apply to asymptomatic women without any known risk factors or prior abnormal paps.  In fact any test called a screening is by definition intended for those with no symptoms. Depending on the guidelines used (I tend to use the United States Preventative Services Task Force (USPSTF), which has a community health focus) the tests should be initiated at either age 21 or 25 (the American Cancer Society (ACS)), regardless of sexual activity or vaccination status.  For ages 21-29, pap tests every 3 years.  For age 30 and above, a pap test every 3 years, a pap test/HPV test combo every 5 years, or an HPV alone test every 5 years. The HPV test alone is not widely available yet but can easily be added to the same sample from a pap test, which becomes the combo.  The reason testing for HPV is only initiated after age 30 is because many women under 30 have benign HPV infections which could clear without treatment, and additional testing/biopsies are avoided this way.  When to stop pap/HPV testing?  For asymptomatic women who’ve been tested regularly and the last 2 Pap/HPV tests have been normal and have never been diagnosed with pre-cancerous lesions or cervical cancer, the age is 65.

Continuing with women’s health, the advice about mammograms also varies depending on which guidelines you use. The USPSTF advises, for asymptomatic women without known risk factors or family history, a screening mammogram every 2 years starting at age 50.  The American Cancer Society advises starting at age 45, doing a mammogram every year until age 55 and thereafter every 2 years up through age 74.   The consensus for stopping in asymptomatic women without risk factors is 75, unless the patient has a greater than 10 year life expectancy at age 75.  With all these screenings, they are deemed worth doing if your life expectancy is 10 years or more. As much as people loathe these tests, it’s not easy hearing that you don’t need them anymore.  So cancer could go undetected?  That’s a frightening thought for most people.  It’s more like it’s not the cancer that will kill you so why go through testing and treatment, when you are more likely to die of something else.  Mortality is concept most of us can’t truly grasp or accept, surely a topic for another post.  

For male-specific screening tests, we are talking prostate cancer.  Here, it is all about shared decision-making because there is no clear consensus about the benefits of screening asymptomatic men at average risk for prostate cancer across a population. Most guidelines say if you choose to do it, start at 50 in men without a family history of the disease, and discontinue at age 70.  The dreaded digital rectal exam (DRE) is not recommended for screening because it has not proven to lessen mortality.  What is shared decision-making, exactly?  It’s when you and your provider discuss pros and cons of testing, including false positives (which lead to unnecessary biopsies and other tests and of course anxiety), false negatives (missing a cancer that is present), and overdiagnosis. 

Overdiagnosis is a problem inherent in many cancer screening tests, not just prostate, and most notably mammography.  It occurs when a cancer is detected, but it is so slow growing it will not affect life expectancy if left untreated.  But because it is very difficult (the technology is just not there yet for some cancers) to determine that a cancer is harmless, if you will, once it’s found, the push is to treat it.  With prostate cancer, there is the option of watchful waiting, also called active surveillance for certain men (it depends on age, frailty, comorbidities and life expectancy) whose cancer is found to be, through biopsy, imaging and DRE (the digital rectal exam is employed in risk stratification of the cancer), very low-grade.  Even in this case, many men, knowing they have prostate cancer, will opt for treatment to avoid the anxiety of close follow-up and repeated testing. And with treatment often comes morbidity (illness to the layperson), expense, possible loss of employment, and anxiety. There is no getting around anxiety with a cancer diagnosis no matter what you do.

It could be argued that of all the screening tests, the colonoscopy is the most dreaded.  It takes up at least two days of your life, what with the prep and the actual procedure and post-anesthesia recovery of a few hours. The prep is probably most dreaded, when it’s just you and the awful tasting drink to cleanse your bowels.  Cleansing the bowels, that doesn’t sound too bad, right?  What it means is hours of diarrhea, where it is now just you and the toilet.  And when it’s time for the procedure you are weak, and surprise! – at least mildly dehydrated, which usually makes the placing of the necessary IV line more difficult. But there is a silver lining.  The drugs.  Usually now it’s the same drug, propofol, which Michael Jackson got every night to sleep.  And it works so well, you could almost understand his affinity.  One minute you are in the hospital bed after the difficult IV insertion, the next in some zen paradise you most reluctantly emerge from to find yourself in that same hospital bed with a loved one or close friend staring at you worriedly.  It was nice while it lasted.

Colonoscopy is not the only game in town but it is considered the gold standard because it not only can prevent death from colon cancer but it can prevent the cancer from occurring by removing precancerous polyps.  And if yours is negative, you can wait 10 years to do it all again. Another way to screen is sigmoidoscopy, an office procedure where the most distal portion of the colon (so not the entire colon as in colonoscopy) is visualized and any polyps found can be removed and later biopsied This does not require sedation but does require some bowel prep. It is not a popular or promulgated choice because at that point, why not go for the colonoscopy and at least get the drugs?

The other options are stool-based, that you can do in the um — comfort of your own home.  They are pretty good at detecting cancer but not so good at detecting precancerous polyps.  Depending on the test, the suggested frequency is every one to three years. If any of these tests is positive or abnormal, of course you would need a colonoscopy.  Same is true of the so-called virtual colonoscopy that uses a CT scan, which has fallen out of favor lately. 

Screening for colon cancer is recommended starting at age 45 for asymptomatic individuals without any risk factors, since recently there have been more people under 50 diagnosed with colon cancer for unknown reasons.  The stop point is 75 as long as life expectancy is 10 years or greater.

Lastly, there is skin cancer screening.  And I must tell you I was most surprised that there is insufficient evidence to recommend that asymptomatic individuals get a yearly skin check by a dermatologist, especially to rule out melanoma, a skin cancer that can be deadly.  Different guidelines support that providers counsel patients, especially those most at risk with fair skin, to avoid unprotected sun exposure, and to check their own skin for new or suspicious lesions.  I know that as a health care provider, I do counsel sun protection and look at a patient’s skin for anything glaringly abnormal.  But frankly there is so much to cover during a physical, and so little time. For those who can afford it, I advise a yearly skin check with a dermatologist, who will examine every inch of you under very good light, and I practice what I preach. For those who can’t, I tell them the general guidelines of size, color and change in lesions and if anything seems abnormal, to have it checked.  Skin is an organ that should be checked from birth.  As to when to stop checking, no consensus on that either.  Maybe when you no longer feel the need to look in the mirror?  That says more about life expectancy than anything else.

#healthcoach #knowingwhentostop #prevention

N95s and a Tale of Two Diseases

Posted on by writenp

In the arsenal used to fight COVID, there’s no doubt that vaccines are the non-human heroes of the pandemic.  A close second, though, is the once lowly, often stuffed-in-a-provider’s-desk-drawer, N95 mask.  Before the pandemic, not a lot of people outside of healthcare were familiar with it.  We healthcare providers kept our own N95s stored in a paper bag with our names scrawled on it, out of sight and usually out of mind. These masks had one sole purpose — to protect us from tuberculosis (TB) if we took care of a patient who had active TB. 

We were “fit-tested” once a year to make sure the mask would function.  The fit test was basically, well, weird.  You donned your N95 mask and the occupational health nurse would put a kind of plastic dome over your head.  Then they sprayed a chemical with a sickly-sweet floral fragrance under the hood.  If you could not smell it, you were good.  If you could, you needed a new, better fitting mask. And, we were cautioned, once the mask was used, particularly in a verified TB situation, it was to be thrown out. It was contaminated and should not be used again. 

For lack of a more nuanced reaction to this bit of history — Ha.  COVID made the lowly N95 mask a superstar, elusive and sought after.  Everyone wanted one. There were dire shortages.  People were stealing them and they had to be kept under lock and key.  And now apparently they could be used countless times even after contact with infected people. Just like that.  And we found that a properly fitting N95 was a very uncomfortable thing to wear all day.

But this post isn’t really about the N95.  It’s about public health and the role it still plays in mitigating another highly contagious disease in the community, the eroding concept of the common good, and vaccine hesitancy.

In the time before many vaccines were available, there were numerous outbreaks of dangerous diseases.  Typhoid, diphtheria and polio come to mind.  Health departments enforced quarantines, complete with signs nailed to front doors. No one questioned this because it was so obviously for the common good.  No one wanted themselves or their families to become sick and die.

Tuberculosis, while not as virulent or as lethal as the aforementioned diseases, was a bane nonetheless. Many people died of TB, including two of my grandparents, in the first part of the 20ieth century.  It was generally a disease that attacked people in poor health, living in crowded conditions, which then as now, unfortunately goes hand in hand with poverty. TB is just as contagious as COVID but here’s the big difference.  Most healthy people exposed will develop latent tuberculosis infection or LTBI, which does not make you sick or contagious. It will however, make a TB test positive, because the dormant bacterium that causes TB (mycobacterium tuberculosis) is still detectable, even though your immune system has walled it off and made it inactive.   

To this day, healthcare providers are tested once a year for TB.  If the test is positive, it signifies exposure but not necessarily active disease.  The next step after a positive test is a chest x-ray which would detect active, and thereby contagious disease.  I have known many providers who were exposed, some knew it, some didn’t, and their tests were positive, and remain so.  There is a treatment regimen advised for people with LTBI.  The reasoning is that that the disease lies dormant until the host weakens, whether from illness, old age or even pregnancy, and then reactivates, becoming a contagious and potentially fatal disease. The treatment for LTBI consists of daily meds for a few months and some of the medications are not well tolerated. If you are deemed young enough and well enough to take the regimen (some of the meds could be toxic to the liver), it is advised to do so in order to prevent reactivation in the future. While the incidence of tuberculosis has decreased in this country, the advent of HIV/AIDS produced drug resistant strains, which requires more discussion than feasible in this post.   

You might ask why I’m discussing tuberculosis at all when we are still in the midst of a pandemic of a much more dangerous disease. It has to do with my commitment to public health and my struggle to understand COVID vaccine hesitancy and anti-maskers. Public health authorities were instrumental to and successful at controlling TB.  And most people were grateful for it, which is so very different from what is happening today amidst a battle with much more dire consequences if lost.

There was a thought-provoking essay written by a community health physician (Anita Sreedhar) and a sociologist (Anand Gopal) in the New York Times last week (Behind Low Vaccination Rates Lurks a More Profound Social Weakness https://www.nytimes.com/2021/12/03/opinion/vaccine-hesitancy-covid.html?smid=url-share) that helped me understand that the points of view of some anti-vaccine and anti-maskers can be attributed in part to a number of factors, including: a distrust of a government which has not helped them in the past, a differing hierarchy of needs for people living on the edge vs the rest of us, and the rejection of the concept of the common good, which emanates from feelings of being abandoned by the powers that be. The resulting mindset is that everyone has to look out for themselves, and no one else.  Individual freedom above all else.  It makes sense as a rationale for this thinking but it doesn’t solve the problem.  Which brings me back to TB, specifically how public health departments handle TB to protect both the community and the individual.

If someone is diagnosed with active TB, they are mandated to take medication, and if they are not deemed reliable, they are brought in to a public health facility (or someone goes to their home) so they can be observed taking the medicine.  This is called Directly Observed Therapy (DOT).  It’s most definitely a thing as is the power of the health department to isolate contagious individuals and at times commit them to a facility until they have completed treatment (which is always a last resort and rarely happens.)  Ensuring that these individuals are treated is in everyone’s best interest.  It protects the infected by curing their disease and also protects the community at large from becoming infected.

So say one is anti-vax and anti-mask and anti-mandate and your next door neighbor who frequents all the public places you do and volunteers at your kid’s school has been found to have active TB. Would you fight for the individual’s right to sovereignty over their body even though they have the potential to infect the community and sicken the most vulnerable? Is it their right not to take the medication? If you are healthy, maybe you would only get LTBI if exposed, no big deal for now.  But what if you are still recovering from the flu (you don’t get the flu shot, after all) and your immune system is weakened.  What if one of your elderly relatives volunteers at the school too?  Now TB is not the scourge in terms of virulence that COVID is. It spreads in the same way as COVID, through airborne droplets, but is not going to cause a pandemic because TB is slow while COVID is fast, and in many cases TB can be cured with medication.  Also it can take a few weeks to become infected and contagious after a TB exposure, and as explained before, the latter might not happen if you are healthy.  Still it is a nasty, potentially deadly disease with drug-resistant strains and life-long effects on health. 

When I think of tuberculosis, I can’t help thinking of our public health departments and how important they are to the community.  Humans are drawn to community for protection and social interaction.  We naturally want to belong — to our families, our social groups, our local communities and yes, our country.  Today our country is so divided.  I wish more people could understand that the individuals working in public health, imperfect and strained as they all are, are doing the best they can to safeguard the health of as many people as possible, and this in the face of so many unknowns.  That essentially, is their mandate. That’s what the common good is, the best outcomes for the greatest number of people. It’s hard to argue with that.  Because if we are not all in this together, then what’s the point of being here at all?  #thecommongood, #vaccinehesitancy #N95s #WritingCommunity #weallwanttobehealthy #tuberculosis #LTBI #Covid #endthepandemic

Balance

Posted on by writenp

I’ve been thinking a lot about balance lately. Well balanced meals. Work life balance. Balancing needs in a relationship. Actual physical balance as in yoga and most other exercise practices.

Balance is a good thing, most people would agree. Balanced doesn’t have to mean even, it just means that there is some weight on both sides, even if unequal.

In health care, balance is most difficult to achieve.  Even in a community health center (and I shudder to think how it is in a for-profit practice), providers are pulled in different directions. See as many patients as possible, stay on time, keep up with your charting and labs.  Oh, and don’t forget the metrics that measure the quality of your performance.  It’s one of the ways health care providers are evaluated these days. If you don’t press the button or check the box, your care isn’t up to snuff.  Even if you took well-documented excellent care of your patient. How can that be right?  The measures are correct, but the requirement of sometimes having to do double work to get credit for them, that’s not correct.  Maybe in the future AI can read the note and give you credit for your thinking and care without you having to stop and toggle.

Don’t get me wrong, I love metrics.  I have a probably unhealthy attachment to my Peloton and my Garmin watch which track my workouts.  But when I’m using them, I’m just in the moment, exercising,  I don’t have to do anything but what I’m doing to get “credit. “

I like to think I have a balanced approach when seeing patients.  Open to their unique perspectives and ideas about their maladies but not so much that I don’t consider the other possibilities.  That is, in fact, my job.  Or as we say, taking into account the differential diagnoses: a list of possible explanations for a specific set or subset of symptoms.

There has to be balance in our communication with patients.  You want to really pay attention to and listen to them but you don’t need their life story, and in 15 minutes there is also not much time for small talk.  You have to cut to the chase to get at that vital piece of information that will help you rule out or rule in a specific diagnosis.

You want to discuss the abnormal test results. But you don’t need to go down the rabbit hole of every possibility and scenario following that one test, which could lead to needless stress and worry.  One step at a time, together.

For both patient and provider, health care today requires a balance between the idealized view of practicing and receiving health care and the reality of too little time, too few resources and systems that seem to alienate the givers and receivers.  I hope we can do better.

#balance#metrics##healthcaretoday#theproblemwithhealthcaretoday#differntialdiagnosis#creditwherecreditisdue

Prepping For Your Yearly Physical

Posted on by writenp

No, this does not mean, swearing off carbs and beginning a vigorous exercise program in the weeks before your exam in order to appear healthier. First, it’s not possible, and could be dangerous. What I mean by prepping is having the information on hand that will help you and your provider make the most out of your visit.
I have my annual physical this year, with a young doctor I’ve only seen once but liked very much. I want to make sure she has what she needs to collaborate on my health care. While there have been studies that refute the value of a yearly physical, I, as a health care provider, think it’s important. Seeing someone when they are feeling well, getting labs when they are healthy, creates a baseline to refer to when there is an alteration in health, and also establishes a rapport which will help communication in the future. It is also the best time to evaluate the need for preventative health care measures or tests.
Sadly, your provider will not have a lot of time, likely no more than 15 minutes. So it’s up to you to prep for the exam, in order to receive optimum care. Here’s what you can do:
1: Have a list of medications that you might need he or she to refill in the future and ask how best to execute this request. Provide all the medication you take, even ones prescribed by other providers, because medication can alter blood tests. And if you’ve changed pharmacies, let them know.
2: If this is a new provider, or if you have gotten vaccines elsewhere, have a copy of your most recent immunizations. Same goes for any health screenings such as colonoscopies, mammograms, pap smears or bone density tests. Also helpful would be a printout out of your most recent blood tests.
3: Be able to provide the approximate dates and nature of any hospitalizations or surgeries, since your last visit (or ever, if this is a new provider).
4: Be knowledgeable about health problems that run in your family, and offer this information if you are not specifically asked about it. These can include heart problems, cancer, hormonal problems such as thyroid imbalances, and mental health and substance abuse issues.
5: If you have some health concerns, pick the two most important ones and plan to reschedule to address others. Do mention what these concerns are; if specifici lab studies are needed, you can have them done at the same times as the rest of your blood work.
Should go without saying, but you should tell the truth. Your provider will not judge and will appreciate honest information that will benefit your long-term health.
#yearlyphysical#preppingispower#optimizeyourvisit#itsyourhealth#youareinchargeofyourhealth

Breakthrough

Posted on by writenp

My husband felt invincible after becoming fully vaccinated, but he got breakthrough Covid last month.  He thinks he caught it on a plane.  By then he was wearing a mask, just for show, really, and the comfortable cloth mask he wore was thin.  As was the mask worn by his seatmate who hunkered down in her hoodie during the two hour flight, refusing all snacks and beverages.  In retrospect, this was a huge red flag.  Because who turns down free Cheezits and Popcorners on Jet Blue? He had very little contact with anyone else before he became symptomatic three days later, so he is probably correct.

This is how it went down, with an onset that was slow and gradual: he started to get what he thought was a sinus infection, to which he is prone, followed by post nasal drip, some congestion and that was about it for a few days.  He began taking an antibiotic because of his long-standing sinus issues.  But unlike before, he didn’t get better after his third dose of Augmentin.  In fact he thought he might be feeling worse, more tired than usual.

I suggested testing and we kept googling (yes, even health care providers google, more than you’d think or maybe want to know) — sinus infection vs Covid symptoms, and Is it a cold or Covid?  Really it is impossible to tell because there are so many presentations and everyone is different.

I left, encouraging him to get tested but unaware that he was feeling progressively worse.  He bought a home Covid test and it was almost immediately, and very clearly, positive.  These OTC rapid tests are very reliable when the result is positive, especially in an area with high incidence.  (This was Florida.)  So we knew he had to self-isolate for 10 days from when he was first symptomatic. 

We kept in close touch and Facetimed.  I’d say he had about 2 ½ days of feeling quite miserable.  He had all the symptoms of a bad case of influenza: headache, fever, chills, fatigue, muscle aches, congestion and cough.  He never lost his sense of taste or smell nor did he have a sore throat.  He never experienced chest pain or shortness of breath but his pulse ox (which tells us how well the blood is being oxygenated) at the lowest was 92.  (Normal is 96-100, and we start to pay attention when it is heading down towards 90.)  When he started feeling better, his metrics improved accordingly.  We shudder to think what would have happened had he not been vaccinated.

At that time he was commuting to Florida about every other week for work and I spent an occasional weekend there.  I did not get sick even though we spent three days together unmasked indoors and in a car.  I took two OTC tests — one when I got home (three days past the first exposure) and one three days after that, both negative.  I never developed symptoms but if I had, and the OTC test was still negative, I would have gone for a PCR test. Of note, he had 2 Pfizer vaccines and I had 2 Moderna.

Having a background as I do in community health, it’s not lost on me that this breakthrough, likely caused by the Delta variant, will not become part of the data. I think this is the norm, unfortunately, rather than the exception and I’ll tell you why.  PCR testing is nowhere near as available and accessible as it needs to be. Really it should be on speed dial, 24/7, where someone will come to you and administer the test.  For free. Then we would have some real data.  But the reality is that, depending on the time of day, it can be difficult to get a timely appointment.  Plus going out is miserable when you don’t feel well and you run the risk of exposing other people.  

The next best thing is an OTC test for people who want to do the right thing and protect others.  Anecdotally I know of six individuals with breakthrough cases in my immediate familial, friend and professional circle.  All of them relatively young (well, under 65) healthy people. They all did the right thing.  To me it is apparent that breakthroughs are way more prevalent that the CDC would have us believe.  Maybe it’s because they don’t have the data but also likely due to a reluctance to say anything negative about the vaccines. Understandable given all the negative misinformation out there and the need to get more people vaccinated.  Sure it was always mentioned that the vaccines were not 100% effective at preventing symptomatic disease, but until Delta, people did think they were bulletproof. Maybe that’s just human nature.  And we were all very tired of masking and distancing.

But picture this.  I am flying home, double-masked (cloth over surgical) and notice many children with “colds” on the plane.  Lots of coughing and sneezing.  These families were returning home from vacation.  Were they going to have their child tested in Florida at the first sniffle and then isolate in a hotel room waiting for results and possibly a longer isolation?  No.  They needed to get home and get back to their lives.  Maybe they thought, ostrich-like, if there was no test, there was no Covid, or maybe they didn’t think about it at all.   I don’t know if the parents were vaccinated and of course, I don’t know if these children actually had Covid.  But they certainly could have, given the circumstances.  I wonder how many people on the plane later got sick.  

Would requiring a negative test or proof of vaccination decrease transmission during travel? Might a mandate like that also increase vaccination rates?  To me it’s clear that it would, but not without a great deal of pushback and negative impact on the airline and travel industries.  Apparently it’s hard enough to get some people to keep their masks on when traveling. It’s easy to imagine that such a mandate would simply transfer the disruptive behavior of anti-maskers on planes to the lines at the airport when the non-compliant are prevented from boarding.

There are no easy answers.  While some of us would do a great deal to end this pandemic, there are still some who doubt its very existence or have gone down the rabbit hole of misinformation, unlikely to surface.  For now, this much I do know: the fully vaccinated are not invincible and should continue to be careful when the situation warrants, especially when travelling or in areas with high incidence.  Stay safe out there, and do the right thing.

Look Both Ways: Advice for Before you Visit a Specialist

Posted on by writenp

I am always happy to give advice to friends and family, particularly on navigating the health care system.  While being underinsured is obviously a problem, having great insurance comes with its own particular challenges.

It would seem liberating and well, just better, to not have a “gatekeeper” policing your use of specialists and expensive medications.  Sometimes, indeed it is, but it depends.  And sometimes, seeing a specialist is the obvious route.  Ideally you are under the care of a primary care provider who will take the time to look at your case holistically and advise you about when to consult a specialist.  But sadly, the system is set up to not give the provider the luxury of time to do this easily in many cases, and a referral to a specialist is sometimes a way of passing the buck, even if that is not the intention.

Okay, I’m going to say it.  Specialists sometimes have tunnel vision, and this is understandable.   A provider sent someone to see them, indicating at least that they suspect the problem is in the specialist’s particular field.  But medicine is at times as much art as science, I’m afraid, and that is not always the case.  It could be more like a best guess, or even a scattershot approach –  fainting spells: neuro or cardio? Let’s do both. 

And while in the end, the specialist may report that the problem is not in his or her specialty —  your heart is fine, or your lungs, or your kidneys —   usually there are a lot of expensive and sometimes invasive tests, involved in coming to this conclusion.

I’d like to spare you this. If you have a new subtle symptom, by all means make note of it, when it began, what makes it worse or better, and simply observe for 2 weeks.  Note – and this should be common sense — fainting, chest pain, signs of a stroke like facial drooping or slurring words, severe pain of any kind, prolonged blurry vision, blood in urine or stool are not subtle and you should see someone right away.  Basically, if the symptom scares you, see someone right away.  But if it’s just a newly observed sensation, you may want to wait a little to see if it goes away on its own.  I’ll give you an example of what I mean.  When I was in nursing school, I developed, or should I say noticed, many new symptoms.   My leg throbbed at odd times.  I felt, if I really dug in, some weird bumps under my skin in certain places.  My knees sometimes made a creaking sound.  If I moved just a certain way, kind of like a cha-cha step, I got their strange pain in my hip for a moment.  My doctor would dutifully take note but also wisely took a wait and see approach.  And the next time I saw her, she’d ask about it and more often than not, I’d forgotten all about it.

There is a reason why the majority of health care providers do not utilize as much health care as non-providers.  Sure, they have more knowledge of the human body, but it’s more than that.  We know that every test we order has to be followed.  And the more tests you order, the more abnormal results you will find, that you may not have even been looking for, have nothing to do with the original problem and may have no effect on the patient’s future health.   But now you have to track every one of these down.  You might never find the answer – art vs science, remember? — but a lot of hours have been spent in its pursuit.  While many people want to have as many tests and imaging studies as possible as an assurance that “everything is okay,”  too often they don’t get this reassurance and in fact, might get more to worry about, whether justified or not.  It’s the reason I am leery of those full body scans that are marketed to the public, but that’s another issue. For now, the message is, don’t run blindly from one specialist to another without “looking both ways.”  Form a relationship with your primary care provider and make those decisions together.    

When Worlds Collide: Administering COVID-19 Vaccines at a Community Health Center

Posted on by writenp

Is it better to give than to receive? I wanted to find out if giving the vaccine was as gratifying as receiving it.  Since I already covered what it was like to get my shot, I am sharing my experience of administering COVID-19 shots, something I very much wanted to do, even though it’s not in my job description.  What I learned went beyond the comparison of giving and receiving, into the concrete disparities between private and public health care and the people served by each. 

But first, I got around the not in my job description part by volunteering (i.e., no pay) to administer the shots a few mornings a week. Instead of nice work clothes and a lab coat, I sported scrubs and white sneakers.  How liberating, how comfy.  It really took me back.  Actually the last time I wore scrubs professionally was on a medical mission to Guatemala, but that’s another story.

Here are the specifics on all three vaccines.  Skip to the next paragraph if you already know or are not interested in the nuts and bolts. All 3 of the COVID-19 vaccines are intramuscular injections into the deltoid muscle of the upper arm. At our clinic we have the Moderna which is a 2 dose vaccine, the second dose given 4 weeks after the first.  For a time we also had the Johnson and Johnson Janssen vaccine with is a one and done as they say.  Both are for people aged 18 and above, and the amount in the syringe is the same – 0.5cc. The Pfizer vaccine, which our clinic did not have, has to be mixed with a diluent (a special diluting solution) before being drawn up, and is 2 doses given 3 weeks apart.  The dose each time is a little less in volume than the other 2 vaccines – 0.3 ccs. That one is good for ages 16 and above.  The age ranges may change as the vaccines are undergoing testing for children. I won’t get into the efficacy of each one.  The studies were done in varying conditions. Each one works well enough to prevent the majority of people from contracting the disease, and is even better at preventing severe illness and hospitalization. And that of course, is what we were all most worried about.  Because if contracting COVID meant just a few days of feeling under the weather for everyone, it wouldn’t be a big deal.

As I began writing this, the Johnson and Johnson vaccine has been all over the news due to a rare clotting condition exhibited by 6 women within 2 weeks of getting the vaccine, one of whom died and one who is in serious condition. That’s 6 cases among around 7 million people who received the vaccine.  When I learned they were all women aged 18-48, I immediately thought of oral contraceptives, which can cause blood clots.  But apparently most of the women were not taking them.  CVST (cerebral venous sinus thrombosis) is a very rare and very serious clotting disorder, which causes both clotting and bleeding.  For now the vaccine is on pause but that reflects an abundance of caution, when you consider the numbers.  The odds of getting that rare side effect are about the same as getting Guillain-Barré Syndrome (GBS) from the flu shot.  According to the CDC, studies suggest a person is more likely to get GBS from actual influenza than the shot.  Just as it is far more likely to get blood clots (and die) from having the COVID-19 illness vs getting the Johnson and Johnson vaccine.

This post was intended to be about the experience of giving the vaccines, so I will circle back. Every one of the people I inoculated was grateful to be getting the shot and grateful that there was a shot at all.  Nobody cried although I’ve heard that it has happened — tears of joy and relief.  I think the pandemic has made us all more emotional.  When I received my first dose of Moderna in January, it was as close to a religious experience as I think I will ever get.  Being able to bestow that feeling through vaccinating others amplified the exhilaration, the hopefulness.  So yes, in this case, it is even better to give than receive.

As a vaccination site, we are open to the community at large, anyone whom the state deems eligible to receive the vaccine. This should be true at all sites who applied to be vaccinators,  but in the local private practices at least, when they did have supply, they sent emails to their own patients with very specific admonishments not to forward the email. Point made. Conversely, in addition to our own patients, our waiting room fills with people who have never set foot in a community health center before, although most likely their housekeepers and nannies and landscapers have.  There was a little sheepishness at times, about snagging the vaccine in a place like ours, but also, I hope, a new appreciation for what we do.  To a person, they expressed surprise about how “nice” our offices were, how clean and professional.  A little insulting, to be sure (what were they expecting, a MASH unit?), but I hope, as they sat (socially distanced and masked, of course) among our regular patients in the waiting room, their eyes were opened.  I hope they realized how important high quality health care is to the people they employ or who serve them at stores and restaurants and grocery stores.  How important it is that these people have a “nice”, clean, professional and safe place to go.  Because the state of their health affects the health of the community as a whole.  And never has this been truer, nor the stakes higher, than during a pandemic.

Getting My Shot

Posted on by writenp

As an employee of a Federally Qualified Health Center (FQHC), I was in the first tier of health care providers designated by New York State to receive the Covid vaccine. I got my first dose of the Moderna vaccine on Monday and I was beyond grateful.  As I understand it, most providers in our centers felt the same way.  But about 50% of the other workers declined, despite encouragement and reassurances about safety from our medical director, who of course, led by example.  It’s hard for me to understand.  These are people who have face to face contact with potentially contagious patients and know first-hand how hard hit our community health centers have been. Our positivity rates are always much higher than the county’s, this week nearing 30%.

How I wish my husband had been able to get the shot at the same time, but even with a medical condition that could make him more vulnerable, he could not.  In fact, at the end of this week. our centers have to gather the unused vaccine supply and give it back to the state to be redistributed. Some might take exception to this, reasoning that we could have used the supply to protect our most vulnerable patients.  But our state is strictly operating from the top down, vaccinating the health care workers so they will be able to care for the sick.  I think of it like the airline safety rule about putting on your own oxygen mask before helping someone else. I’m okay with it.

My response to the vaccine was minimal: a sore arm for about 48 hours and maybe a tad less energy the day after. And you know, I was glad to have some reaction which could signify a robust (at least adequate) immune response.  I’ll feel as if I have some protection in 2 weeks. 

Just heard that Biden is planning on releasing more vaccine instead of reserving the second doses as is the case now.  More people will be able to get that first dose, which is good.  My extrapolation from the studies available is that after about two weeks following dose one, the vaccine might be at least 50% effective, so from a community health standpoint, it makes sense.  The risk is that there will not be enough second doses three to four weeks down the line.  I still think this is okay.  If the second dose is delayed by a few weeks, the only harm will be the first group will be less than fully protected. At least more people will be partially protected. And Moderna indicates they will be ramping up production. 

In all of this, the decisions we make today are based on the information we have at the time.  There’s a lot missing but we really have no choice.  And no certainty.  We all just have to do the best we can.