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Lessons Learned in Haiti

Does anyone have any questions?” I am standing inside an 8 foot by 8 foot corrugated metal shack with a fabric roof in Port-au-Prince, Haiti.  It is stiflingly hot with not a breath of wind.  It’s hard to imagine spending a half hour sweating inside this metal box let alone living there.  But it is the home of a single mom who is resolutely raising her daughter with a little help from her church (whose pastor has asked whether we have any questions) which is in turn helped a bit by an American church.  But there is no mistaking that if there is a hero in this little room it is this uncomplaining resilient mom.

Unable to think of what to ask I just inquire whether the fabric roof keeps off the rain when it comes.  Through the interpreter, the mom responds with soft strength, “We do fine when it rains; we are OK.”  And she smiles with her arm around her daughter’s shoulder.  Honestly my gut instinct is to bow at her feet, to somehow honor her.  Instead I merely tell her it was so very good to meet her, and head back to our vehicle.

Over the next two days we see several hundred Haitian children and adults for a range of medical problems.  Most of them are caused by their environment: parasites from contaminated food and water, anemia and nutritional problems, neck and back problems from the loads carried on their heads, eye irritation from the dust and headaches from the heat.  We give medicines to treat the parasites, knowing that they will be re-infected by the same food and water in a matter of days.  But at least we can knock back the body’s burden of parasites temporarily and allow them to rebound a bit nutritionally.

The chronic problems like diabetes and high blood pressure cannot be adequately addressed.  The numerous blood pressures in the 200’s over 120’s or 130’s that would punch a ticket to the ER in the states, can only be given a short supply of BP meds with the advice to be sure and see another doctor before they run out.  But the odds are hundreds to one against that happening.  There is no access and no money for such things.

And so we put the equivalent of band aids on gaping wounds because it’s all we have, and hope that the brief attention given them brings some bit of comfort.  They are amazingly grateful.  The rest of the team prays with them, gives the children balloon animals that light up their faces and generally tries to minister and encourage.  In the end we hope we have left some small drops of blessing in this ocean of need.

What have we taken back?  A conviction that we need to complain far less and give thanks far more.  We also understand that we cannot fix the whole of Haiti, or even this little section of Port-au-Prince.  Yet, through this church in Haiti that ministers to and knows these families, we, as representatives of our church can minister to twenty orphans and vulnerable children.  They are given help to attend school, eat a good lunch, live within a family setting, and get to know the God in whom they find ultimate hope.  The group facilitating these church to church connections is World Orphans, a ministry that has earned its stripes over many years and has become wise in a type of helping that really helps. This steady life-on-life help and attention over many years, given by those who know and love these children best is where there is hope for at least some in Haiti.

In all this I am reminded of the quote by Edward Everett Hale, “I am only one, but I am one. I cannot do everything, but I can do something. And because I cannot do everything, I will not refuse to do the something that I can do.”  We got to do something for a short time in Haiti.  A Haitian mom, uncomplaining in her small metal shack, continues to do those things she can do every day to see her daughter grow up strong.  In my mind I still bow at her feet.

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DPC: Subtracting the Guesswork and Adding Back the Relationship

This week my partner, Jackie Hone, was seeing a new patient who had driven an hour seeking her help in sorting out his health situation. She spent an hour seeking to undo the damage done by miscommunication from multiple encounters in varied medical settings. Her patient had been left confused, upset, and almost ready to give up. He was uninsured and prior to his current problem had been quite healthy and had no primary care physician. But following his recent shoulder surgery he experienced a concerning post-operative symptom, was sent to one ER, transferred to a second hospital, had his diagnosis changed several times, was admitted for a 4-day hospital stay, and was finally discharged still lacking a definite diagnosis, plan, or prognosis. Of course his medical bills are staggering from all of these encounters. He was left pondering, “If medical care costs so much, why is it so poorly delivered?”

Most of us somewhere along the way have had a frustrating medical experience: maybe we received only a fleeting explanation about a procedure, medication, or treatment being recommended. Or perhaps we received a surprisingly huge bill after the dust settled on our medical care. Or we had follow-up questions but couldn’t reach anyone to answer them. Maybe all of these. So, is that just the way it increasingly has to be, or is there a better way?

Having a relationship with a physician who knows us in times of health and sickness is valuable. Likewise having a doctor who can be reached in an emergency is huge. And having a physician’s office that can help us navigate complicated medical tests and specialists to anticipate and manage costs is something for which most can only wish. But maybe these things are not impossible to achieve.

My partner and I believe that a return to direct agreements between doctor and patient is the first step toward providing this experience as the new normal in primary care. I am referring to the medical care model known as Direct Primary Care (DPC). It is so named because patients deal directly with their doctor to form an agreement defining what services and care will be provided for a known and affordable monthly membership fee, rather than billing for services through the middle-man of insurance. One recent joiner to DPC had calculated that his medical cost for primary care would only be about 30% under DPC compared with what he had paid for primary care coverage by insurance the previous year.

Now that Dr. Hone has been practicing a DPC model for the past seven months, we can report that patients in this model are very satisfied with their care, are able to communicate efficiently with our office, and can be seen when needed. Their visits are not so rushed, their wait times have been reduced, and cost is highly affordable due to the reduced overhead from not having to jump through the countless hoops of insurance companies.

The basic fee, not much different than a cell phone contract, covers all basic primary care including normal labs, physicals, maintenance visits and sick visits. Any procedure or lab not included in the membership agreement is offered at a low cost compared to insurance rates, and is discussed in advance with the patient. The lower patient volume in DPC allows more “face time” with patients which translates to better communication all around, the chance to be heard by the doctor and ask questions, and the efficiency of handling more than one complaint at a visit. Because payment is based on a monthly fee, rather than an office visit, communication by phone and email is welcomed rather than discouraged (as it often is in an insurance-based model). Finding the right catastrophic coverage that provides for unforeseen emergencies, imaging, or specialists, is important to complete the picture.

Of course there are still a few folks who have great insurance and may not need Direct Primary Care to help healthcare be affordable and personal. But for many patients we have found that it works wonderfully, saves them time and money, and improves their overall healthcare.

In light of all this Dr. Hone and Trinity Medical are celebrating the Grand Opening of her new office next to Sonic at 1515 E Lamar Alexander Parkway on Thursday, August 11th from 11:00-1:00pm. If you have a few minutes, check it out and find out a bit more about how Direct Primary Care really can be a better way.

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Sore Throats – More Complicated Than You May Think

I returned to the exam room with the results of the five minute rapid strep test on an elementary school boy whose mom had brought him in with a complaint of a very sore throat.  “His strep test is negative Mrs. Thompson.”

Well that’s a relief!”

My own thoughts about it were a little more mixed.  Most of the non-strep throat infections are viral so you are left to just letting them run their course.

Pharyngitis is the medical term for infection or inflammation of the throat, generally causing the symptom of a sore throat.  The problem is, someone with a bad sore throat is usually hoping for antibiotics to help them get better.  In fact up to 70% of patients going to a doctor for a sore throat (and there are about 15 million people in the U.S. who see the doctor for a sore throat every year) receive antibiotics.  At the same time, only about 20 to 30 percent of children and just 5 to 15 percent of adults with a sore throat have strep.  Most of the rest have viral infections where antibiotics only contribute to side effects and more resistant infections, while providing no benefit..

So how do we sort out which infections are strep and which are probably viral?  First there are other symptoms that help greatly.  If there is a runny nose or cough with the sore throat it is almost certainly viral and not strep.  A classic strep throat has fever and sore throat without runny nose and congestion, but often with nausea or headache.  Also, age matters: strep is uncommon under 3 years of age, peaks between 4-7 years of age, and becomes less common in adults, though still showing up sporadically.

It has been shown repeatedly that even experienced doctors can’t reliably tell a strep pharyngitis from a viral one just by looking – there is too much cross-over in how they appear.  So a rapid strep test really is needed for accurate diagnosis.  These are up to 90-95% accurate and only take a few minutes.  Recently it has been recommended that the old routine of double-checking a negative rapid strep test with a throat culture be abandoned as it adds cost without any measurable additional benefit.

Here is a question that is not as obvious as it first appears: why do we even want to treat strep throats with antibiotics.  It surprises most people to hear that strep throat will usually clear up in a few days (about 7 days on average) even without antibiotics.  The benefits of the antibiotic (usually penicillin unless a person is allergic to it) are that they:

  • Slightly shorten the course of the infection (by 12-16 hours)
  • Render the person non-infectious more rapidly (usually within 24 hours of starting the antibiotic)
  • May minimally reduce complications such as abscesses of the tonsils or ear infections
  • May possibly help prevent serious other complications of strep pharyngitis. But this is controversial as they have never been proved to prevent the kidney disease called post-strep glomerulonephritis. Likewise many argue that rheumatic fever (a serious complication permanently damaging the heart) doesn’t seem to be caused by the vast majority of the strains of strep currently occurring in the U.S.

So the benefits of antibiotics for treating strep throat are sketchier than they were once thought to be.  And on the other side of the coin, about 10% of those treated with antibiotics get diarrhea, occasionally a serious type caused by C. difficile.  Also 0.24% have a life-threatening allergic reaction. This means that out of 10 million patients treated with antibiotics, as many as 24,000 of them will have fatal or near-fatal allergic reactions.

Most sore throats get better without treatment, even including strep pharyngitis. So the decision to test and treat is a bit more complicated than it was once thought and deserves some individual thought on a case-by-case basis.  As a little side note, that’s why the emergence of telemedicine (where patience are diagnosed and treated by phone) holds as much concern as promise. The tendency to misdiagnose illnesses and misuse prescriptions will only grow with this looser connection between patient and physician.

So who thought something as “simple” as a sore throat would take two articles just to summarize?  But we haven’t even mentioned mono or the non-strep bacterial culprits that can be other serious causes of your sore throat.  More on that next time.

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Pulmonary Hypertension

Mr. Beeler, a fiftyish guy was perplexed and worried: “I just don’t get it.  My mail box is maybe a hundred feet down the driveway.  Used to be nothing to march down to it, grab the mail and hoof it back and never think about it.  Then I started getting a bit winded on the uphill walk back.  Now I’ve got to stop once on the way down and two or three times on the way back up to catch my breath.  I’ve never even been a smoker; what’s the deal?”

Ok, this one is a bit more complicated, but common enough to be worth knowing something about.  Pulmonary hypertension (PH), which is what Mr. Beeler ended up having, is where the blood pressure in the lung part of the circulation has become elevated.  So, what does that do?  That means the part of the heart that has to pump blood through that higher pressure system has to work harder.  Over time the blood vessels change in ways that cause oxygen to be picked up more and more poorly by the lung’s circulation.  Likewise the right side of the heart that serves as the pump for the lung circulation can get weaker and weaker.

A person developing PH may notice that it takes less and less effort to make them feel quite short of breath.  They may also notice fatigue, chest pain with exertion or even passing out with exertion.  Often they end up needing to be on oxygen to keep their blood oxygen level normal.

The causes of PH are quite varied — everything from heredity to COPD (chronic lung disease) to various heart conditions to a range of medicine and toxin side effects to a further laundry list of causes.  While it is relatively rare in otherwise healthy folks, it can afflict up to 1/4th of people with COPD and one out of five with sleep apnea, just to name a couple of diagnoses.

It is often the shortness of breath that eventually brings people in to get checked by their doctor.  The high pressure in the pulmonary (lung) circulation is often noted on an echocardiogram (an ultrasound of the heart). Other tests such as a heart cath, if needed, can be even more definitive.

Treatment for PH can be challenging.  If there is some specific cause found for it then treating that underlying cause may help.  If it is determined that the PH seems to have developed without some other trigger then there are a number of other treatments that are sometimes helpful in reducing the pressure and improving oxygen levels.  One treatment even involves using the active ingredient in Viagra.  At the far extreme of treatment, lung transplants are occasionally undertaken.  Obviously along the way having a specialist involved can be vital.

So, worsening shortness of breath with exertion is never something to be ignored.  And getting it checked sooner rather than later can sometimes make a significant difference in the success of treatment with several of the causes, including the complicated problem of PH.

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