Archive for January 2016

Upper Respiratory Infections

Now that Christmas is over, tis the season for coughin’ and sneezin’.  This is the time of year when legions of folks dealing with some kind of upper respiratory symptoms try to decide whether or not to make the trek into their doctor’s office.  Let’s see if we can help sift through some of the factors involved and maybe save a few trips.

Upper respiratory infections (URI’s) include the common viral illnesses (where antibiotics are useless and just add cost, side effects and resistance) such as colds, flu, viral sore throats, bronchitis, laryngitis, croup, mono, and viral sinusitis.  As well, there are the much less common bacterial URI’s (where antibiotics may be appropriate):

  • Bacterial sinusitis – about 2% of viral URI’s progress on to this
  • Bacterial bronchitis – again, far less common than its viral cousin
  • Whooping cough – still very common and deadly in poorly immunized countries and raising its ugly head in pockets of this country having poorer immunization rates
  • Strep throat – comprising less than 10% of sore throats and rarely occurring in children less than 2-3 years old.

Overall, URI’s are the most common acute illness seen in medical offices.  In the U.S. we have about a billion URI’s per year. Children have about 3-8 viral URI’s per year, adolescents and adults have approximately 2-4 annually, while people older than 60 have fewer than 1 cold per year.  With the average URI lasting a few days to nearly two weeks start to finish, that’s a lot of days with symptoms.  The flu affects 5-20% of the US population during each flu season.

So which symptoms are worth a trip to a doctor, and which ones are just viruses that need to run their course?  Your typical cold, viral bronchitis or sinusitis rarely benefits from a trip to the doctor.  This would include your typical runny nose, cough, sore throat, headache type of illness and it is the vast majority of URI’s.  As stated above, antibiotics are worse than useless for these.  Drink lots of water, take acetaminophen or ibuprofen for higher fevers (101 and up as a rule of thumb) and general pain, and consider something like Mucinex DM if you want to further thin out the mucous and quiet a cough.  Take a long shower in the morning and blow and cough out everything you can from the night before.  Of course try not to pass it on to your family, friends and co-workers.

So when should you come see the doctor with URI symptoms?:

  • If the symptoms worsen after initially improving for a time
  • If the symptoms are more severe (shortness of breath, wheezing, dehydration)
  • If the symptoms are not gone or nearly gone within 10-14 days
  • Go in as soon as possible if moderate or severe flu symptoms hit (cough, congestion, fever, body aches) during flu season (fall to spring) as prescription flu medications only help if started within the first 48-72 hours of illness.
  • If you have a bad sore throat, possibly with headache and nausea but without runny nose or congestion as this kind of symptom combination is more often strep throat (or mono if you are in your teens or 20’s).  An antibiotic is then appropriate if a strep test confirms strep throat.
  • If you or the person with symptoms is frail and in poor overall health, including the very young and the very old.
  • If URI symptoms have led to severe ear pain.
  • As far as sinusitis, the recommendations say “Uncomplicated sinus infections typically clear up without antibiotics. Antibiotics should be prescribed only if there are persistent symptoms for more than 10 days, or if a patient develops severe symptoms or a high fever, has nasal discharge or facial pain for at least three days in a row, or ‘worsening symptoms following a typical viral illness that lasted five days, which was initially improving.’”

One final thought: I cringe at the idea of telephone or internet medical care where a person pays to call a doctor, have a phone diagnosis, and get a prescription called in.  The likelihood of overprescribing antibiotics for viruses will be even higher as well as missing more serious infections such as early pneumonias.

I hope that helps give some idea of when it’s more worth coming in and when it may not be.  Certainly, when in doubt, check it out.

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Direct Primary Care News for January 2016

Here are a couple of reminders for our Direct Primary Care members and prospective members for the upcoming weeks.

Saturday Walk-in Clinic:

  • Dr. Hone, our Maryville office DPC physician, will be staffing the Saturday walk-in clinic this weekend at Trinity’s Fort Sanders West office.
  • DPC members may utilize the Saturday walk-in clinic as part of their membership whenever Dr. Hone or Dr. McColl are staffing the clinic.
  • Walk-in clinic hours are Saturday 8:30-11:30am.
  • We will continue to post which clinics are staffed by DPC physicians.
  • All patients of Trinity are welcome to use the walk-in clinic for sick care as the need arises.

Direct Primary Care Presentation

  • Dr. McColl and Dr. Hone will host the next DPC presentation this Saturday at 10am in the main lobby of Trinity’s Fort Sanders West office.
  • They will discuss the DPC program for anyone interested in understanding how it works and the benefits of having a low-cost, insurance-free, full service primary care membership.
  • They will also update you on the legislative efforts that support placing the patient back at the center of health care policy and decision making.  There has been some good progress at the state level this year already.

 

 

Advantage: Patient. The benefits of DPC membership in getting things done.
by Mark B McColl, MD

In a traditional primary care office the pace can be incredible. Trinity is known in the community as an office that doesn’t have an enormous volume of daily patients.  Due to the wisdom of our founding physicians, Dr. Allsop and Dr. Pardue, we have set the standard in our office to take nearly twice as long with each patient as the national average.  We have fought to protect that time with our patients for nearly 25 years.   Even with that extra allotment, it is very difficult to ensure that the unique needs of each patient can be addressed in the midst of busy work day.

Many times I would find myself only able to perform tasks for patients if they were face to face with me at an office visit.  I’m sure many of you over the years have probably watched me type out you a letter you needed while in the exam room. I simply didn’t have the time to attend to any tasks outside of the scheduled office visit.

Direct Primary Care has changed all of that for me. Since the start of the program I have been able to do much more for my patients without them having to be present. I have coordinated three out-of-town specialist consultations for patients with unique medical concerns.  I have worked through two insurance prior authorizations that required a peer-to-peer review. (This is a tactic used by insurance companies to deny payment for an ordered test or service until I get on the phone and argue my case with their hired doctor.)  I have been able to arrange a records review from an outlying hospital and then coordinate further testing for that patient on a potentially life altering condition.  Lastly, I have been able to personally answer the phone and provide a medication refill for Mrs. ________ in about 30 seconds, twice.

I am thrilled at what I can now do for my patients.  I can meet them at the point of their need and focus my energy on solving their problem.  I consider that a win for patients and for me too.

mbm

 

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Direct Primary Care presentation January 30th at 10am

Trinity will host our next community presentation on the Direct Primary Care program next Saturday January 30th at 10am.

  • This presentation will be in Trinity’s west Knoxville office located in the Fort Sanders West complex building 4.
  • Both Direct Primary Care physicians, Dr. Hone and Dr. McColl, will be on hand to lead the presentation and answer any questions.

Please join us to hear the details about the program and an update on how Direct Primary Care is saving patients money every day.  We have many wonderful stories to share of patients receiving lower cost healthcare in a more personal manner.  Additionally, we’ll have an update on the legislative work in Nashville being pursued to protect individual liberty as it concerns to personal health care.

If you have questions please feel free to call Mel Moss, our DPC coordinator, at 244-1800 or email Dr. McColl directly at mbmccoll@secure.trinitymedical.net.

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Hypertension

“I was late rushing over here.” “Traffic was terrible.” “I just had a cup of coffee.” “Work’s been really stressful.” “My blood pressure’s only high when I’m here in the office. I can feel when it’s high and it’s never high at home.”

For some reason, when I mention that someone’s blood pressure (BP) is high (also called hypertension when it’s consistently high) more often than not some reason is given to explain it away. And there can be some truth to some of these reasons. For example, “white coat hypertension,” where someone’s BP seems to mostly be high from tensing up in the doctor’s office, is a real thing. However, even here, those who have it have been found to have increased risk compared to those who don’t.

The bottom line is that high BP is:
• extremely common, with about one in three adults, as well as many children (19% of boys and 13% of girls and rising) having it
• usually without symptoms (until it causes a catastrophe such as stroke, heart attack, heart failure, an aneurysm, kidney failure or loss of vision)
• crippling and/or deadly, as seen from the list of severe consequences noted above

So high BP is common and deadly but silent for years and so often ignored. In fact only about half of those with high BP have it under control. Although lots of folks think they can feel it when their BP is high, it turns out that when this is tested, almost no one can reliably tell whether there BP is high unless it is extreme (like 220/120). And we don’t want our first clue that we’ve had untreated high BP to be that we wake up with the squeezing chest pain of a heart attack, or that we suddenly can’t speak right, or our left side isn’t moving because we’re having a stroke. So the bottom line is you need to measure BP, preferably at various times of the day under varying levels of stress to get a sense of where your range is.

What’s recommended as a healthy BP? Well that number may have recently gotten a bit lower. In a recently published study, those treated to a BP under 120/80 did so much better compared to those only treated to the less aggressive goal of under 140/90 that the study was stopped early. It was considered unethical to not treat all of the patients to the lower goal. The top number (systolic) proved to be particularly important to control aggressively. Specifically, the group taken down to the lower (120/80 or below) goal had a 27% lower incidence of events such as heart attack and stroke. This study was comprised of folks who were over 50 years old and had at least one other risk factor for heart disease or stroke.

So, we can reasonably say that for the over 50 crowd with at least one other risk factor (such as smoking, diabetes, high cholesterol, family history of heart disease), shooting for the 120/80 goal is ideal if it can be done without a lot of side effects. Only about 5% of folks treated to the lower (120/80) goal had substantial side effects such as light-headedness with standing. And the percentages weren’t that different in the 140/90 treatment group.

Okay, then how do we treat high BP?
• If you smoke, you really need to quit
• Slowly shave off those extra pounds
• Regular aerobic exercise if your doctor clears you for it (such as a 3-4 MPH walk for 30 minutes at least every other day)
• Choose low salt foods (60% of people with high BP are made worse by high salt intake)
• No more than 1 (for women) or 2 (for men) alcoholic drinks per day
• Avoid decongestants and anti-inflammitants — they raise BP
• Manage stress (always easier said than done)

If in spite of your efforts the numbers just aren’t getting where they should be, it’s time to talk with your doctor about medicine options. It may not excite you to take a medicine, but it beats a stroke, heart attack or any of the other problems on the list. And there are enough medicine choices where you can almost always find one (or a combination) that doesn’t hassle you with side effects.

If I can be appropriately dramatic, untreated high BP is kind of like an axe murderer who we let hang around our home because he is quiet and polite and mostly stays out of our way… until one day he strikes, devastatingly. Likewise, when we treat high BP we won’t necessarily feel any better. But we will have tied up the murderer in a corner so that he can’t harm us.

So see if high BP is lurking quietly around your house. And if you find him, don’t explain him away; take him seriously, tie him up and then check on him often enough to be sure he stays put.

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