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Dr. Gersten’s health news

Keeping a spring in your step

Maine is a great place to get outside. No matter what your activity inclination there is something for everyone. Beautiful walking trails, mountain hikes, water activities and bicycling are all within easy reach. Of course, with all that activity comes the risk of injury, overuse, and environmental exposures. So, a little pre-planning can maximize enjoyment of the warm weather.

From Biking to Hiking… Be Safe Out There!

For cyclists it’s important to make sure your bicycle is in good working order before heading out. Cables and brakes can stretch over the winter. At a minimum folks should be doing a basic safety check on their bike before taking them out, including steering, brakes, shifting, and tire pressure. If you are not confident a bike mechanic can be very helpful. As always don’t forget about lights and a helmet!

Walking, running, and hiking are great for physical health. Remember just because you were able to hike five miles at the end of last summer doesn’t mean you should start off with that same distance in the spring. Working up to your goals with shorter hikes, walks, or runs will go a long way in preventing early season injuries.

In addition, footwear is key for these sports. A bad blister can prevent enjoyment of sports for weeks right when the weather is getting good. A common rookie mistake is to wear a brand-new pair of hiking boots on a longer hike, which usually results in a blister. Better to break-in new boots or shoes around the house and around the block for a few weeks before getting on the trail.

Sun and Allergens Don’t Have to Stop the Fun

In terms of environmental factors affecting health in the spring, sun and allergens are probably the two most common. Springtime brings a variety of allergens into the air which can cause sneezing, watery eyes, sore throats, and overall fatigue. Depending on the severity of your allergies there are a number of over the counter options available for treating symptoms. Talk to your primary care provider or local pharmacist to find something which might work for you. But if things become more severe you may need to talk to an allergist about immunotherapy, which now comes in two forms: shots or sublingual pills.

Sun can also become a problem in the spring. There is a solid body of evidence recommending sun protection for all ages. The surest way to prevent sun damage is to wear clothes that cover exposed skin. When this is not possible an SPF sunscreen is the next best.

A common mistake in the summer is to use a “swimming shirt” for sun protection. A wet t-shirt worn to swim only has an SPF equivalent of 3! So, it is better to use a garment with a UPF rating or use water resistant sunscreen – especially for kids.

No matter what activity you enjoy this summer a little pre-planning can go a long way to maximizing fun and minimizing injury.

A version of this article was also published in the West End News 5/3/19

http://thewestendnews.com/keeping-a-spring-in-your-step/

Financial Harms

A doctor's oath is first, to do no harm. That has traditionally been interpreted to apply to in the office, to the prescription pad, and under the knife. Yet everyday patients are leaving appointments only to face astronomical medical bills, high insurance prices, and crazy prescription drug prices that are harming them financially. Although doctors do not set these prices directly, they are still the integral link between diagnosis and treatment. I firmly believe these are good people in a bad system. However every clinician is complicit in this system. It could not go on without us. I believe we have an imperative to help fix it.

For too long doctors have been blinded to the price of care. We have become so far removed from the economics of medicine that we have neither the awareness or agency to control costs. The economic transaction of paying for care often take place weeks to months after the care in question by people who ultimately had nothing to do with it. This disconnect leads to frustration on all sides.

There is interesting work happening at a legislative level to increase price transparency of medical procedures. Maine passed the right to shop law in 2017, which encouraged doctors to give patients choices in where to receive care. It also incentivized insurance companies to reward patients for making smart choices. The accessibility of Health Savings Accounts (HSAs) helps consumers feel like they have some choice in where their health care dollars go. Despite this progress over the last year, many patients are still finding that medical care is unaffordable.

On a broader scale in January of 2019 Federal rules mandated that hospitals make available prices for the services they offer on their website. The website comparemaine.org is also a new resource utilizing this data for cost comparison. The idea is that by printing prices consumers will be able to make more informed decisions about where they choose to receive care.

Simply listing prices does not appear to have encouraged competition. When I browsed the lists from 2 local hospitals I found a common office procedure, removal of benign skin moles, cost $70 and $170 at another facility. Since this is such a common procedure, often done is a primary care office, it's doubtful that many consumers would spend the time to shop around before having this done.

Health Care will always cost money. What we need to work towards are reasonable prices for health care that helps people. If we acknowledge that financial well being can and should be under the purview of the providers recommending the medicine it allows an alliance between doctors and patient to try and restore sanity to a broken system. These are good people. Let’s work to create a good system.

A version of this story was published in the West End News 4/5/19

http://thewestendnews.com/do-no-financial-harm/


oren gersten
How to Beat Flu Season

I trained as a Family Doctor so that I would be ready to help patients with any challenge. The old school family doc used to take that skill set out into the community on house calls, sports sidelines, and town hall meetings. At some point the job description was boiled down into a job that started and ended with a 7 minute office visit. That setup is not good for patients, and it's not good for doctors. In this column I hope to start to push the boundary of where the doctor patient interaction takes place - onto the page, into the community, and beyond 7 minutes.

This year in Maine there have already been 3,931 documented cases of flu (Maine DHHS surveillance reports through 2/16/19). As a primary care doctor I deal with the prevention, diagnosis, and treatment of disease. Although I do recommend flu shots for my patients, if the conversation simply begins and ends with a flu shot important information has been lost.

Prevention starts with limiting exposure to germs. The mainstay of any infection control measure is handwashing. Especially during flu season using soap and water or an alcohol based hand sanitizer is vital in preventing exposure to viruses.

Many health care professionals will keep a container of hand lotion close by during the winter because hand washing and cold weather can lead to dry cracked skin. Open skin is a risk factor for infection.

Beyond hand washing, limiting exposure to others who are sick is crucial. Right now Earned Paid Sick Leave provisions are being discussed on the state and local levels. Proponents argue that allowing workers to take paid sick days prevents the spread of germs at work places. Especially for those working in education, restaurants, or other service industries the best thing to do if you become ill is stay home.

Even with proper hand washing, a yearly flu shot, and precautions at work it is still possible to catch  the flu. It is important to understand that not all winter illness is the flu. Technically speaking the flu is an illness caused by the influenza virus characterized by high fever, body aches, abdominal and respiratory symptoms, and fatigue.

In order to differentiate the different causes of winter illness a health care provider will often elect to perform a rapid flu test. This involves using a small soft tipped swab to collect a sample from the very back of the nasal passage, which is then tested for flu virus. This can be done in most doctors offices.

Depending on the severity of illness there are options for treatment. The mainstay of any treatment is supportive - treating symptoms, assuring adequate hydration and rest. In some cases people may benefit from an antiviral medication such as Tamiflu or Xofluza. These medicines are FDA approved for treatment of flu but they are not curative. They are best used for severe symptoms which started in the last 2 days and may shorten the severity and duration of the illness.

Having a skilled health care provider who knows you and can guide you through the process of getting well will lead to a better experience.  

See Dr. Gersten’s column in the health and wellness section of the West End News

http://thewestendnews.com/

oren gersten
Finding the Right Primary Care Doctor

Choosing a doctor can be a daunting and sometimes confusing process. Many people look over the list provided by their insurance company and understandably become overwhelmed. There are many great doctors out there, but each will have their own style. Finding a doctor whose practice style fits your needs and personality can make a big difference in how helpful the healthcare experience can be. Just because you chose a practice off a list years ago doesn’t mean you are stuck there. Here are a few tips to consider when choosing a primary care provider.


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Accessibility

There are a few layers to accessibility. The first layer includes how easy it is for you to get to the place your doctor practices. If you live in a rural area, driving 50 miles might be the only option. If you live in a more urban area finding a doctor in your neighborhood can make office visits much easier. Some offices even offer home visits, where the doctor comes to you.

The next layer includes how easy it is to access care when you get sick. Some practices will offer a certain number of same day sick visits. It's nice to know you will be seen right away if you’re not feeling well. Not every malady needs an office visit to diagnose. Some practices offer virtual visits or phone calls with a provider. Another thing to consider is what the after hours coverage is like. It’s good to know who you will reach if you have a questions on a weekend or evening.

The last layer to accessibility is what the coverage system is like if your doctor is unavailable. No doctor can work 24/7 365 days per year. If you take the time to get to know your doctor it is helpful if you will see them for most, if not all, of your visits. In the event that your doctor isn’t available, you’ll want to make sure whoever is covering for them is also a good fit for your needs.


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Training

There are many different people who can fill the role of a primary care provider. It's important to understand the different levels of training, and what may work best for you. A primary care doctor will have either an MD or DO degree. DO doctors have a little extra training in osteopathy - which includes adjusting people's bodies when they are out of alignment. Both MD and DO doctors have completed an undergraduate degree and at least 4 years of medical school training.

Most people will look for a board-certified doctor, meaning the person has completed residency training after medical school and is in good standing with the board that oversees their particular specialty. Primary care doctors are traditionally trained in either Family Medicine, Internal Medicine, or Pediatrics. Pediatricians take care of children only, Internists take care of adults only, and Family Medicine doctors are trained to take care of both. Family Medicine doctors receive a breadth of training in procedures and women's health including things like minor skin surgery, contraceptives, and sports medicine. Every provider will be different in terms of what services they can provide, which is why it's important to ask.

Primary care is also seeing many skilled Nurse Practitioners functioning as primary care providers. Where doctors have to master everything from emergency medicine to delivering a baby, many NP training programs focus exclusively on primary care, creating a real depth of knowledge. NPs in general also care for a smaller panel of patients and therefore are often easier to schedule with.


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Cost

The last, and often overlooked aspect of choosing a doctor is how much it will cost you. Most people use insurance to pay for their care; however, you can still get excellent care with or without your insurance. People often assume that if they have insurance they will have good health care. On the other hand, people also assume that if they don't have insurance, or if they have a high deductible plan, there is no way they can afford to go to the doctor. The truth of the matter is insurance and healthcare are two different things.

This is where Direct Primary Care stands out from the crowd. A DPC doctor looks out for their patient’s physical, mental, and financial well-being. Because we are not beholden to the insurance company, we can set our own affordable prices for things like labs, medications, as well as the primary care membership. In a direct primary care visit, your doctor can share with you the cost of things before they are ordered - that way you can make an informed decision together.

Even if you don't have a Direct Primary Care doctor, you can still use resources like GoodRx.com to shop around for deals on medications. Some imaging centers will offer cash pay discounts for MRI’s and CT scans, which end up being cheaper than paying the deductible to your insurance company. Many hospital-based clinics will have payment plans or charity care programs to help people who can't afford to pay for care. No matter where you choose to get your care, remember to be an informed consumer and don't be afraid to ask questions.

oren gersten
Headline - Sauna Use Decreases Heart Attacks

Part of the job of any primary care doctor is staying up to date on the latest medical research. There are numerous medical journals each publishing a range of research topics every week. Article topics can be very specific, technical, and dare I say - boring. When an article comes across my desk that is not only useful but FUN that is a good day.

So it is with this article published in the British journal, BMC Medicine. The study came out last year but is certainly still applicable. Researchers looked at a cohort of 1,688 middle aged men and women in Finland and analyzed how often they used a sauna and the risk of dying from heart disease. What they found is that people who used a sauna more often were less likely to have a fatal heart attack. The amazing part of the study is that the effects were so significant. Using the sauna 2 or more times per week led to a 77% reduction in fatal heart attacks. That effect is far better than any drug on the market!

A real strength of the study was that it followed individuals for 15 year, which by medical study standards is quite a long time. Another key point of the study is that there were different “doses” of sauna exposure. To really show that sauna use is helpful you would like to see more use resulting in better outcomes - which this study does show. Finally the study did not have any conflicts of interest. It was funded by The Finnish Foundation for Cardiovascular Research. If it was funded by a sauna manufacturer I would be much more skeptical of the results.

A good scientist should always be skeptical of new information. Can we really trust this data? Overall I think this is a good study; however, there are a few areas I question. First, they only studied Finnish people. I wonder if this is broadly generalizable to the rest of the world? Could there be something special in Finnish genetics or body makeup that makes sauna especially healthy for them? Second, there was no placebo group. Who’s to say it wasn’t simply the relaxation in a social setting - not the sauna itself - that protected against heart attacks. Lastly, someone who has 6 hours per week to spend in a sauna likely has a pretty good life to begin with; eats good food, exercises, and is less stressed. The study did attempt to account for this by statistically tracking socioeconomic status (individual income), and physical activity levels. Even with those taken into account the protective effect of sauna were still present.

The real utility of this article (really any science for that matter) is if it can help people live better. We need to analyze new information in the context of ideas that we already hold to be true. Here are my take away points from this article:

  1. Self care activities aimed at relaxation, including activities like sauna, help us live longer and better lives

  2. Medication is not the only answer protecting people from disease

  3. There is evidence that sweating it out in a sauna 2 or more times per week could reduce the risk of heart attack by 77%

So whether its a hot cup of tea, snuggling up in your favorite blanket, or jumping into a hot sauna take some time to treat yourself this winter. The health benefits could be more than you know.

citation:

Laukkanen T, Kunutsor SK, Khan H, Willeit P, Zaccardi F, Laukkanen JA. Sauna bathing is associated with reduced cardiovascular mortality and improves risk prediction in men and women: a prospective cohort study. BMC Med. 2018 Nov 29;16(1):219.

Tips to get through cold season

Staying Healthy

Winter time cold symptoms are annoying and tiring. Whether it’s a sore throat, runny nose, cough or all three being sick is no fun! Although there is no cure for the common cold, there are definitely things you can do to give yourself the best chance of staying healthy. If you do get sick, there are some great remedies to try at home. Of course, Portland Direct Primary Care is here if you need us. Advice from the internet should never be a substitute for advice from a doctor who knows you.

  1. Wash those hands. The benefits of hand washing cannot be overstated. With cold weather outside, don't forget to use a good moisturizer to prevent skin from drying out.

  2. Get plenty of rest. Sleep is restorative and healing. If you feel like you might be coming down with something going to bed extra early is never a bad idea.

  3. Take care of your stress level. Stress can lead to decreased immune function and open your body up to getting sick. Having a daily de-stress ritual such as meditation, yoga or journaling can be a great way to feel your best.

  4. There is some evidence from in-depth scientific reviews that certain supplements can help shorten the duration of a cold. A few things worth considering are Zinc, Umcka, and Echinacea.  


Sore Throat

Many times a sore throat is caused by a cold virus, although there are other things that can also cause a sore throat. If in doubt call (or text) your DPC doctor!

  1. Try a warm salt-water gargle.

  2. Over-the-counter medications such as Ibuprofen have been shown to be as effective as prescription pain medications in controlling throat pain.

  3. Cough drops come in many varieties. Try to find one with a numbing medication such as benzocaine which will numb the back of your throat. Use caution with children as a numb throat can create a choking hazard.


Stuffy Nose

  1. Protect the nasal openings from abrasion with a dab of Vaseline.

  2. Nasal saline rinses can help keep the sinuses clear. Use a sterile store bought solution or if using a netty-pot use distilled or boiled water which has cooled to room temperature.

  3. A gentle sinus massage can help alleviate some sinus pressure and clear the sinus cavities.


Cough

Cough is often the most annoying cold symptoms. Sub-acute cough after a viral infection can last for up to six weeks! There are many cough remedies at the pharmacy but none has been shown to be more effective than any other. Pharmaceutical grade cough medicines come with side effects, so why not go with a natural option?

  1. Herbal tea with a tablespoon of honey acts as a natural cough suppressant. Honey should not be given to babies less than 12 months of age.

  2. Humidified air can help to clear out mucus from the lungs.

  3. If the cough is triggered by throat irritation, treating the throat may help. See tips for sore throats above.


The Best of Both Worlds
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Direct Primary Care

The Best of Both Worlds

For many people the term ‘Direct Primary Care’ is something they have never heard of. Although the term itself may be new, the ideas behind it are tried and true. Our parents and grandparents remember a time when doctors would not only make a visit to someone’s home but would know everyone by name. There was a time when doctors had a list of services and associated prices so patients would know how much things cost right up front. There was a time when one medical office could handle most, if not all, of a person’s day-to-day health needs. It’s hard to believe this was the norm not so long ago.

The way we give and receive care has changed significantly in the past few decades. The modern doctor’s office is streamlined to accommodate large numbers of patients as efficiently as possible. Deciding what to charge for a medical visit has become so complex that most clinics hire specialists whose sole responsibility is to review medical notes to try and match a patient with a set of codes. In addition, providers are so far removed from the process of dispensing medications that all too often patients leave a pharmacy empty-handed when they find out a prescription their doctor has prescribed is too expensive or not covered by their insurance plan.

Over the same span of time there have also been some monumental advances in health care. We now have better and more far reaching ability to analyze and act on medical data for individuals and populations. We also have access to more evidence on which to base treatment decisions. There are studies being published every week comparing different medications and types of treatments, the results of which have the potential to help people live healthier and longer lives. Despite these advances, many people can’t help but feel neglected and left behind by the current medical system.

As a family doctor, I see Direct Primary Care (DPC) as the bridge between the old medical system and the new medical system. We can’t ignore the medical advances of the last century but at the same time, we can’t forget the incredible power of relationship-based care from a provider who knows you and takes the time to offer the best care possible. What this looks like in practice is smaller clinics with more time for doctors to give great care. If a medicine is prescribed, we can put it in your hand at an affordable price. It looks like full spectrum primary care for an up-front fee that is fair from both the doctor and the patient perspective. If something isn’t practical or safe to do in the office, it looks like having an advocate who will help navigate the medical system to find the best solution medically and financially, whether that means finding discount X-rays, MRIs or specialty providers who can give discount prices to DPC members. Direct Primary Care encompasses all of these time-tested ideas in a new package, giving patients and doctors the best of both worlds.