PDPC logo small.png

Beyond 7 minutes

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.

Advances in Medicine

The Cost of Cellular Therapies

As a family doctor I try to stay up to date on the most recent research. The most interesting article I have read in some time was in the New Yorker magazine, “The Promise and Price of Cellular Therapies.” It talks about advances in cancer treatment. There is some interesting research going into using the body’s natural immune defense to fight cancer. The research is still in its preliminary stages but could change the way we treat people with cancer.

The article was at the same time inspiring and frustrating. The idea of a medical breakthrough gives hope to people who are burdened with disease. The problem is that these promises are not always borne out.

History shows us that things that we hope will revolutionize medicine are often hard to develop into useful tools. Gene therapy and personal genomic pharmacology are just two examples of medical technology that have promised to change the way we treat disease but as of yet have not delivered on those promises.

Proven Treatments

On the other hand, as a medical system we have a whole range of low-cost proven treatments, which we know save lives, that are not being used to their full potential. These are things like colon cancer screening, smoking cessation programs, blood tests for communicable diseases like HIV and hepatitis C, blood pressure control, as well as vaccinations which prevent diseases.

These are not glamorous new inventions, so they tend not to get the same attention as a new designer drug or scientific discovery. The important thing is that we have robust data to support these as proven interventions that prevent disease. Beyond extending lives, they are relatively inexpensive.

Scientific discovery is important. Without it we would still be treating common maladies with bloodletting and mercury. However, we are neglecting discoveries of years past only for the potential promise of new discoveries that may not even work. If we redirected even part of the money that we spend on research and development to support proven public health interventions, we could help people live longer healthier lives.

One example would be making colon cancer screening free whether you have insurance or not. Another example would be holistic support for smoking cessation not just free gum and a phone number.

 

The backbone of any of these interventions should be low cost comprehensive primary care to help people control common diseases like diabetes and high blood pressure that we know how to treat. Accessing this type of care is only possible if people can establish care with a primary care doctor they trust. Through these relationships we can help people quit smoking, bring the blood pressure down to a normal range, eat healthier, and feel happier. It may not be glamorous, but at least we know it works.

RESOURCES

Siddhartha Mukherjee, Siddhartha. “The Promise and Price of Cellular Therapies.” The New Yorker, July 22, 2019.

This story was also published in the West End News, September 2019

https://thewestendnews.com/

WLOB Radio Interview

Great conversation with radio host Ray Richardson, myself, Dr. Mike Ciampi, and Dr. Bud Freeman about Direct Primary Care and being accountable to our patients. We are lucky to have a robust group of forward thinking docs in the state of Maine and a host willing to put us on the air!

oren gersten
How to Make a Stellar First-Aid Kit

A first-aid kit can come in handy on a hike or even just around town. A kit for the car and another to carry in a bag will help make sure you have it when you need it. 

Put some thought into what might be most useful. A lot of what you pack depends on what you intend to be doing. A longer hiking trip requires more supplies than a quick trip to the park. Also who the intended user is can make a difference. Kits for kids will likely contain different supplies than kits for adults. Despite these variations there are some common themes. 

Wound Care:

  1. Fresh water: a commonly overlooked step in wound care is rinsing the wound thoroughly with fresh clean water. In the medical field we like to say “the solution to pollution is dilution”, meaning that washing dirt out of a wound is the best way to prevent infection.

  2. An antiseptic: two commonly used antiseptics are alcohol pads and iodine. Both of these come in waterproof single use containers ideal for travel. After thoroughly rinsing a wound these can be used to add an extra layer of cleaning. 

  3. Pain medication: an over the counter pain medication such as Tylenol can be useful in treating the pain from cuts, scrapes, and bumps. 

  4. Band-Aids!

Allergic Reactions

  1. Benadryl is an antihistamine available over the counter to treat allergic reactions. Refer to the label for dosing. 

  2. Calamine Lotion: this topical lotion can be great for camping trips where the mosquitos are out. A dab on particularly itchy bites could be the difference between a good nights sleep and staying up itching and scratching. 

  3. Depending on a person's medical history albuterol inhalers, epi-pens and other prescription medications should be easily accessible for surprise situations.

Non medical tools

  1. Flashlight: what good is having a medication with you if you can't read the label?

  2. Pen and paper: great for recording medication dosing, symptoms, and important phone numbers

  3. 24 hour poison control number for Maine: 1-800-222-1222

Handy Tools

  1. Tweezers for splinters

  2. Blunt tipped scissors for trimming bandages or mole skin (blister prevention)

  3. Medical gloves - always protect yourself from bodily fluids

  4. A first aid reference book can be nice or there are also apps for your phone

As always common sense is a good first line of defense. Having a medical professional who you know and trust can help prevent minor mishaps from becoming major catastrophes. 


oren gersten
5 tips to get the most out of your prescription medications

Americans spend more on health care than any other nation. Consumers often feel powerless to control the costs associated with health care. Many doctors are not much help, as they are disconnected from the actual costs of the care they provide. An area where I would encourage patients to exercise some “smart shopping” is in buying prescription medications.

Deprescribing is a concept that a doctor can recommend stopping a certain medication, rather than starting new ones. In some cases being on fewer medications will help a person feel better. Especially in elderly populations medication lists can grow to be ten or more medications. It is not uncommon to have a medication prescribed just to combat the side effects from another medication.

An experienced doctor can come up with a plan to whittle down the medication list to only the essential medications, saving patients money and harm from adverse side effects. Sometimes a change in diet or weight loss may be just as effective as medication. Medication lists should be reviewed with your doctor on a periodic basis.

The vast majority of pharmaceuticals on the market have generic equivalents that are just as effective as the brand name. For example, a common blood pressure medication called metoprolol has a cost of $44 per month for brand name and $13 per month for generic. Buying a 90-day supply of the generic would bring the per month cost down to $8 (prices obtained using GoodRx.com).

There are some medications such as infusions used to treat auto-immune diseases, which are only available as brand name meds. Add to this that these infusions require medical supervision while being administered and the cost of these medications quickly adds up. Although a generic alternative is usually not available, patients have choices in where to receive the infusion. In general hospital-based infusion centers charge more than other outpatient sites like urgent cares, which offer comparable medical supervision for a better price.

As always having a good primary care doctor to guide you through this process is essential in making sound decisions.

5 tips to get the most out of your prescription medications:

  1. Make sure you know what your medications are for and why you are on them. The cheapest medication is the one you don’t have to take.

  2. Using insurance is not always the cheapest way to buy a medication. Use the GoodRx app or ask your local pharmacist or primary care doctor about cash pay pricing.

  3. For long term medications, asking for a 90-day supply may be more cost effective.

  4. Infusion centers, such as those at urgent care centers, are often cheaper than hospitals for medication infusions.

  5. In almost all cases generic meds work just as well as brand name.

A version of this article was published in the West End News 7/17/19

oren gersten
A Firsthand Perspective on Physician Burnout

Residency training is between 3 and 7 years. All Resident Doctors carry a medical

degree and have passed all the necessary training to provide medical services. In

fact step into any major hospital in the US and your treatment from start to finish is

likely to be carried out by a resident doctor.

Some might question how someone could become burnt out only 3 years into a

career that is supposed to last decades. Picture this: 28 of your last 30 days have

been spent in the hospital. Each of those days has consisted of waking up at 5AM

and facing one life-threatening crisis after another. After about day 14 of this you

think, “I’ve hit my breaking point.” The day consists of working, sleeping, and eating

in that hierarchy. You do this willingly day after day, year after year because that is

what doctors do. And after you think you’ve found a balance, where this just might

be sustainable, something breaks.

For me that breaking point was my Grandma getting critically ill. She was in the ICU.

It doesn’t take a doctor to know that it isn’t good news. Everyone processes these

kinds of things in a different way. I went to the chapel, closed my eyes and cried. I

cried for my grandma. I cried for my family who was about to enter a medical

system fraught with hard decisions that is all too often not personal. I cried for

myself because I was at the edge and I truly felt I had nothing left to give.

I am incredibly lucky to have a supportive family as well as colleagues. I write this to

illustrate that one unpredictable event in a physician’s life can push them from what

is already a stressful job over to the point of burnout. For me this story has a happy

ending. My Grandma is OK, she made it out of the hospital. I’m also OK. I have

chosen a career outside the hospital in Direct Primary Care where I have more

control over my hours and stress level. History has shown that the same cannot be

said for other Resident Doctors in my position experiencing burnout.

Being a doctor is a privilege and an honor. We do not deserve special treatment. In

fact, I think that we need better working conditions for all people. I can only speak

from my experience in my chosen career. At the very least there needs to be a shift

to accommodate bereavement time for physicians who find themselves in a position

such as mine. We should not encourage a system that pushes physicians to the point

where they are only one family crisis away from going over the edge of critical

burnout. It happened to me, I know it has happened to others, all I can hope is that

future generations of healers my have more protections than we do now.

A version of this story was also published in the June edition of the West End 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