IMPORTANT MESSAGE FROM DUPAGE FAMILY MEDICINE

Good morning everyone, I wanted to take a few minutes to update you in light of the events with the C19 virus (no more calling it Covid-19, which is anxiety provoking) and Governor Pritzker's "shelter in place" mandate, which is scheduled to go into place at 1700 tonight, ending on April 7.

It's going to be easier to do this with bullet points - so here we go:

1) First and foremost, we are here for you.  Let me repeat that, in caps - WE ARE HERE FOR YOU.  There are stories (unfortunately true) that patients cannot get care and are being turned away from urgent cares and emergency rooms.  This is understandable, but necessary, which is scary.  So if you are sick, please, CALL US FIRST.  Let us attempt to triage you and treat you without having to suffocate our emergency departments who are already knee deep in this. 

2) We are open regular business hours, 8 am to 5 pm, for now.  We will likely be adjusting these to 3 pm, but we will be open Monday through Friday as normal. 

3) We have "built" a separate area of our office to see sick patients.  This segregates the sick from the asymptomatic, and is necessary for all of us.  So, if you have a sinus infection and want to be seen, we will be able to see you.  

4) We have started to perform virtual visits.  We do this through Facebook Messenger as well as Apple Face Time.  The visits we've performed so far went incredibly well, and we expect to see a significant rise in this type of visit as patients sequester at home during the outbreak. 

5) We are completely disinfecting our office twice a day.  Full 5% bleach solution wipe downs of all surfaces.  We are doing this to decrease the spread of ANY contagion, but especially C19. 

6) If you have an appointment, you can keep it.  Doctors visits are allowed.  If you come in for a visit, see the next three bullet points.

7) For all visits, we will room you immediately.  No sitting in the waiting room.  When you are finished, you can stop briefly at the front desk to schedule a follow up or discuss other needs, but we will attempt to keep this face to face interaction brief.

8) We ask that you attend your appointments alone.  Family members will be asked to wait in their cars.  For pediatric examinations, we ask that only one parent attends the appointment and that other children remain at home.

9) The closest person-to-person contact will be when Karla or I examine you.  This typically lasts less than 30 seconds, and we will be gloved and masked during the contact. 

10) Despite C19 dominating every aspect of our lives, all of you still have your health needs that need attention and monitoring.  We need to ensure that you stay healthy with those, which is why we are and will stay open during this unprecedented event. 

11) We ask your patience as we work tirelessly to keep all of you healthy, which includes the behind-the-scenes work of prior authorizations, medication refills, and doctor-to-doctor communication that is so necessary for your health. 

I am going to be writing regularly, with more precision than this general-type of message.  Please keep reading, and feel free to share.  I will attempt to give you boots-on-the-ground updates from the trenches, as well as practical ways to stay healthy while sheltering in place. 

Lastly, thank you for trusting us with your care.  I cannot tell you the strength that gives us, your physicians.  We took an oath to care for the sick, and we hold that oath as absolute and unwavering.  God Bless all of you, stay well, and see you soon. 

JC, MD

Great weight loss app

I've been polling some of my patients about what apps they use to track their healthy behaviors.  Hands down, this app has gotten the highest recommendations - Lose It.

I've test drove the app for the past week.  I am beyond impressed with how in-depth the app is.  It allows you to track both caloric intake and exercise (or calories burned).  It allows you to see up a caloric budgets - this is great for diabetics who need to stay on a calorie-restricted diet.  It also allows for social media sharing.  There is no doubt that weight loss programs are more successful when they are undertaken with friends.

Let me know what you think.  If you have any other health-related programs or apps you'd like me to talk about, email me at jcunnar@dupagefamilymedicine.com.

Resolutions

Happy New Year!  I hope everyone had a great holiday season.  It's the morning of January 1 here in Aurora, IL.  The family is still asleep, and I've got a nice hot cup of Joe, my MacBook and a New Year's resolution in place.

Like most people, I make New Year's resolutions.  I tend to be reflective at year's end, both personally and professionally. Being goal oriented, I enjoy the exercise of seeing if I can come up with new goals for the upcoming year.   The first day back to work after New Year's Day is full of energy for me.  I come in with a head of steam to get the resolutions rolling.  Unfortunately, after a few weeks or months, the majority of my resolutions dissolve back into the haze of hectic insanity that is my life.  I know I'm not the only one this happens to.  Ever wonder why that is?

If you think about it, resolutions are a mental contract with yourself to change.  I bet you've never thought if it that way.  Change is hard.  Human beings HATE change.  It is simply easier to take the path of least resistance, the status quo, and continue on.  When we try to change, it can be frustrating, anxiety provoking, irritating and flat-out infuriating.  Because of this, we slip back into what we know, what is comfortable.  No wonder New Year's resolutions tend to fail.

One of my goals of 2011 was to start this blog.  My goal was to write once a week, which unfortunately didn't happen. Despite an increasing gap between my posts, I'm up early on New Year's Day, writing my first post of 2012, excited about the New Year.  One of my 2012 resolutions it to post to this blog more than I did in 2011.  I am going to build off one of my successful resolutions of 2011.  That is a great feeling.  Today is the start of that goal.

Here is a toast to new beginnings.  May 2012 bring you health, happiness and peace.  Whatever your resolutions for change are, don't give up on them.  Understand it isn't going to be easy.   If you stick with it, keep working on it, what will happen will be amazing.  The change you wanted will become reality.

PSA recommendations - is it sexism?

Sorry for the significant delay in blog posts.  It's been a long couple of months at DuPage Family Medicine.  We were forced to terminate the services of a long-time employee, all while having to deal with a 6+ week disruption in our phone service.  It's been a stressful couple of months, but we are starting to see the light at the end of the tunnel, and it's time for me to start writing again.

Last week, the U.S. Preventive Services Task Force (USPSTF) recommended against the use of prostate-specific antigen (PSA) testing for routine screening for prostate cancer.  The USPSTF states that the risks of screening outweigh the benefits, arguing that certain treatments for prostate cancer can actually increase mortality.  Other arguments against PSA testing include the morbidity associated with the diagnosis and treatment of prostate cancer, such as impotence and incontinence, as well as the emotional stress a false-positive test can cause the patient.

In my practice, I begin doing prostate exams at age 40 on all men.  PSA testing usually begins at age 50 for low risk men.  For higher risk patients, I begin screening at age 45. These patients are men of African-American heritage and men who have a family history of prostate cancer in a first degree relative (brothers or father).  Using these guidelines, I have diagnosed 7 men with prostate cancer under the age of 50, about one patient in this age group every 2 years.

A few years ago, the USPSTF recommended against the use of annual mammography to screen for breast cancer in women.   There was immediate backlash from the public and physician groups.  That recommendation was based on statistics and data that showed that annual testing led to more procedures, and didn't necessarily improve outcomes, almost exactly the same argument against PSA testing.  The public outcry over the mammogram recommendations was loud and clear, but unfortunately, there hasn't been the same kind of backlash against the new PSA recommendations.  I find that extremely disappointing.

It is unfair to recommend against the only screening test men have for prostate cancer, even if it has drawbacks, when a similarly mediocre screening test continues to be a mainstay of diagnosis for breast cancer in women.   We need to support researchers to find better screening tools for all cancers, not just prostate and breast.  Specifically speaking of prostate cancer, if researchers can give us a test that can tell the difference between a slow growing cancer and an aggressive one, we can eliminate a large number of invasive surgeries, significantly decreasing the morbidity of excessive treatment.

I respect the USPSTF and most of their recommendations.  They tend to be conservative, with recommendations that are based on the data. The problem with the new PSA recommendation is that we don't have an alternative.  Just because some of the treatments for prostate cancer lead to increased morbidity doesn't mean you eliminate the use of the only screening test we have available.

I am planning on implementing the recommendations as follows.  For any patient with an abnormal exam (enlargement of gland, asymmetry, etc), they will continue to get annual PSA levels independent of age.  For low risk patients and men with stable prostate exams, I will do PSA levels every 2 years.  All of this will be dependent on the patients comfort level.  If they want an annual test, then we'll order it.

Recommending against PSA testing, yet continuing to recommend mammography, seems a bit, dare I say, sexist.  But then again, I'm a guy.

The argument for drug samples

Over the last few years, the pharmaceutical industry has gone through significant changes.  The days of free trips and rounds of golf are long gone (I'd be lying if I said I didn't miss the occasional round of golf on the drug rep's tab).  There has been significant consolidation, with larger companies purchasing smaller ones, leaving the landscape with just a few mega-companies who call on physicians,  detailing us on their products - the medicines we prescribe.

There have been many arguments against physicians giving out free "samples" of pharmaceuticals.  I understand what the experts say.  They argue that in the end, the free medicine costs patients more because we have a tendency to hand out the free, more expensive branded product before we consider cheaper alternatives.  They argue that visiting with cute (or handsome) drug reps will change the way we prescribe, specifically, that we will prescribe more of that sales reps product.  They argue that Big Pharma has built in so much profit into their branded medicines that the free samples are a drop in the bucket, and that even one new script will bring in profit enough to support the "hard sell" we doctors get from the reps.

I completely understand these arguments.  There is some validity to them.  However, I feel the need to offer some retort.

With so many excellent generic medicines available, a physician would have to be really disconnected from their patient to not reach for a generic first.  We may not like this, but with deductibles continuing to rise, we are stewards of our patients health care dollars.  It is in our best interests, outside of being incentivized to do so, to be as cost-effective as we can.  This is true for all aspects of our job, whether it's medicines, test ordering, frequency of medical visits, et cetera.

My biggest concern about turning off the samples is that there are some excellent new medicines that have come on the market that physicians will be less likely to try if they don't take samples or see reps.  It's not easy for us to learn about new classes of medicines.  If I didn't visit with reps, I suppose I could go to a symposium, corner a colleague at the hospital, or ask a local pharmacist.  Don't you think it is a little easier to have a brief conversation with a sales rep who can give you a 2 minute spiel, and leave some science behind?

Having samples allows me to test-drive some of these new therapies.  I can give 2, 3, or 4 weeks of samples to a patient to see how they respond to the therapy.  During this time, they can call their insurance to check on their out of pocket costs.  I always let the patient decide if the medicine is worth their cost.  In particular, with certain diabetes medicines like the new DPP-4 inhibitors, I will make a hard sell, because I truly believe that the cost is worth it.  These new therapies don't have the dangerous side effects some of their older generic counterparts have.

I have a well organized sample closet in my practice.  Honestly, we dispose of expired samples in at least a 6:1 ratio of samples we give to patients.   If a patient fails generic therapy, or, if your professional opinion is that a branded medicine is a better choice, let the patient take the new medicine for a spin, before they drop $35 on a branded co-pay.

We just need to put our patients first.  Period.  Be the smartest guy on the block.  Use your training and expertise to decide if you think a new therapy has merit, not the gleaming smile across the front desk or the Moo Goo Gai Pan they bring for lunch.  Explain your decisions about the medicine you are prescribing to the patient.  They'll understand.   Remember, we are supposed to be our patients advocates.  Let's behave like it.

Add it up

R. came in for a physical last week.  I've cared for him and his family for years.  They are the the type of family FPs love - nice, funny, engaging, cute kids.  R is in his early 30s and drives a truck.  Pretty healthy guy for the most part, except for one problem.  He weighs 325 pounds.

After a few minutes of chit chat, I asked him if there was anything on his list he wanted to address.  He said he was tired of being overweight, and he was looking for some guidance on how to begin losing weight.  You could sense that his weight has begun to bother him, not physically, but emotionally.  He seemed genuinely ready to lose weight, so we began our discussion in the usual place,  talking  about his diet.

I usually begin these kind of discussions asking about the typical "empty calories" that people take in, so I asked R about his soda intake.  R admitted that he drinks 2 Cokes per day.  "2 Cokes per day" can mean anything, so I questioned him further, and  it turns out he drinks 2 large Cokes per day, bought from one of the major  fast food chains, the one that has $1 sodas, any size.   He said he does this every day.  Even weekends.

I went online to try to find out how many ounces were in a large Coke from the above chain.  It turns out that a large Coke is about 24 ounces (2 cans), if one adds ice.   So, he was drinking the equivalent of 4 cans of Coke daily.

A can of Coke has 140 calories.  So, R takes in 550 (rounded) empty calories every day.  When I told him this, he didn't look at all concerned.  We then talked about the number of calories men should consume per day.  Usually, men should consume 2000-2200 calories per day.  He still didn't seem to get it.  That is, until I did the math.

550 empty calories, every day, is 16,500 extra calories per month.  He is taking in 8 extra days of calories each month just in Coke.  Let's just say that this got his attention.  His jaw literally fell open.

I guaranteed him that if he could transition from regular Coke to something like Coke Zero, he would lose 10-15 pounds, without making one other change to his diet or exercise regimen (which was non-existent).   In 3 weeks, I'm going to go through starch reductions, increasing his protein intake, and how to eat healthy (speed of eating, water intake, snacking, etc.).  We should be able to get him under 300 pounds by Halloween.

Small changes seem just that, small.  But if you add up those changes over time, they will make a big impact.  So, if you are looking to make changes in your diet (or any behavior for that matter), start with something small and be consistent.  It will definitely make a difference.

Free advice to Big Box practices

We see about 40 new patients a month in our practice.  We've done this for years, without advertising.  We rely on the word of mouth of our patients and referring specialists to build our practice.  It's been a successful approach so far.

When I first meet a new patient, I ask them about how they heard about our practice.  The majority are referred by either friends or family.  Once I've established some repoire, I'll explain my practice philosophy, some of the history of the practice, and how the hierarchy of my practice is designed.  I make a point to tell patients that I am their physician, and that by coming to a small group, they will always either see me or my physician assistant Karla.

It never gets old to see how new patients respond to this.  They almost seem relieved.  I had one patient say to me, "Finally! I'm sick and tired of seeing every other doctor or assistant than the one that's supposed to be my doctor".  You hear this enough times from enough patients, and sooner or later, you come to the conclusion that the paying public is looking for something more than what they are getting.

The majority of our new patients are former customers of the Big Box Practice (BBP going forward) which has locations throughout the western suburbs of Chicago.  I have some fairly strong opinions about the way BBP does business, but in this post, I want to focus on the patient, specifically the patients who have left BBP as unhappy customers.

The number one complaint I hear from our new patients is that they "felt like a number" at the Big Box.  This criticism is a reflection on the business model that large medical practices have adopted.  Physicians simply want to dilute their duties among as many "partners" as possible, even if it means alienating the most important piece of the equation, the patient.

Primary care medicine should always be built on the long-term relationship of a physician and patient.  If you notice, the word "physician" in the last sentence is singular.  There is no feasible way to provide insightful care without getting to know your patient, and the only way to get to know your patient is for the physician to see and care for them, not their seven partners.  Patients shouldn't tell their friends and family, "I'm a patient of Big Box Practice".  They should say, "I'm Dr. (insert name here)'s patient".

So, as a small practice physician, I'm going to give BBP a free consultation.

First of all, it's OK to have a large group of physicians.  What you need to do is make that large group feel intimate, and that starts by having your physicians take ownership of their patients.  As important as it is for patients to identify with a specific physician, it's equally important for the physician to identify with their patient.  To do this, you need to break the large group into smaller parts.

It's not that hard.  If you have 8 physicians, split into four 2-physician groups.  When one physician is on vacation, the other physician can cover, and vice-a-versa.   When you shrink your practice down into manageable parcels like this, call becomes easy.  Trust me - I've done it for years.  We take care of 6000+ patients, and I'm lucky to get one call a night during the week.  On the weekends, divvy up the hospital call amongst the 8 of you.   Patients completely understand your need for some down time.

What this will do will be amazing.  Your patient attrition will slow down, patient satisfaction will soar, and  you will start to like medicine again.  I'm not say all physicians are unhappy working for BBP, but I can tell you that how they practice medicine isn't what they imagined when they went to medical school.  I take great pride that my patients are my patients.  I am protective of them.  I work harder for them.  I am accountable.

BBP docs, don't hide inside the big groups you have built.  Re-design the way you deliver care.  I understand if you do this, I may see less new patients coming my way.  That is completely fine with me.  It will mean that your patients are happier, and getting the care they deserve.  It will mean that your patients no longer feel like they are just a number.

Like I said, this consult is a freebie.  I'd be happy to talk about my going rate if you need any other advice.