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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.

Posts tagged primary care
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/

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

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.