Colorado Access-Letter Sent in Error

We have received numerous calls on the non-urgent and urgent line along with messages via the patient portal regarding a letter than was sent to Medicaid patients in error. This letter states the practice is closing on 6/25/20-which couldn’t be farther from the truth. We are so sorry for the anxiety and panic this has caused. I am actively working with them to see why this occurred. Please disregard!

Jenn & Robin

Common Questions and Worries

Today I want to address some common questions and worries.  There is a lot we don’t know right now, but I’ll try to give you the best information we have currently.

But first let’s talk about worrying (this doesn’t mean I’m minimizing the pandemic, just that worrying doesn’t help anyone):

  • Our ears make earwax, our mouth makes spit, our brain makes thoughts.  That doesn’t mean we need to analyze those thoughts and focus on them anymore than we analyze and focus on our spit or earwax.  If you have scary fears, you can just note them the same way you would a weird glob of earwax. “Huh, that’s a weird glob of earwax” or “Huh, that’s a scary thought.”  Thinking it doesn’t make it true anymore than your earwax is some fount of truth just because you pulled it out of your ear.
  • We all tend to suffer significantly more from worrying about things that never come to pass than from what actually happens.  Even if something scary does actually happen, worrying does not prepare you for it. People have often told me that worrying will make it less of a shock when it happens.  The opposite is true–people who choose to stop worrying are better prepared for whatever actually happens.
  • I used to be a world class worrier and I know from experience that it’s impossible to just stop worrying.  Worrying is almost like an addiction–it gives the worrier something of a high (a cortisol and adrenaline rush) that can be hard to walk away from. Normal life just isn’t as interesting! Learning to not worry is something you practice, like doing planks. It’s hard and it’s worth it. The first time you won’t last very long but over time you’ll get stronger and stronger.
  • Trying to completely dam up your thoughts is just as possible as damming up the mountain creeks–they just overflow.  But you also don’t need to chase the thought downstream–you’ll end up where you didn’t intend to be very quickly. Instead, just note the thoughts floating by and let them float away again.  If you find yourself fixating on your scary thoughts, just gently guide your mind back to where you want it to be.
  • Limit your exposure to the media–if something important happens, you’ll know.  You don’t need to be reading/watching every single thing as it comes out. Most of it is just generating something to catch your eyeballs so that  you’ll watch ads and they make money off of you. Don’t let them. Feeding that adrenaline/cortisol high with videos, articles, and podcasts feels exciting. But if you aren’t calling your officials and demanding change, that information overload isn’t helping anyone.  And you don’t need every detail to demand change.  Don’t passively consume scary stuff.
  • Fill your mind with something else.  I would highly recommend the podcast The One You Feed (click on link) . I listen with my kids because I want them to develop resilience through a deeper understanding of mental health and how to take care of themselves. I read a lot, and many of the books I’ve read and recommend have been covered on the podcast through interviews with the authors.  It’s not quite the same as reading the whole book, but you’ll get the main ideas and be able to decide if it’s worth getting the book.
  • If you are spiritual, now is the time to focus more on your practices. If your own place of worship is closed completely, there are many providing virtual services right now.  My family participated in our usual church on the sofa on Sunday. The kids chimed right along with the liturgy and we were all glad we’d participated. Regardless of your religion, there are virtual options right now.  Please avail yourself of them.

What do I do if I have cold and flu symptoms?

  • If you do not need medical care then please self-isolate (click on link for CDC guidance). Or if you prefer a more user friendly format, click on this link for a Vox article.
  • If you do need medical care (have concerning shortness of breath as described in yesterday’s email or are at higher risk from coronavirus and have worsening symptoms): go to the ER and tell them why you are there.  Try to cover your mouth and nose with a mask or scarf if it doesn’t make it too difficult to breathe.
  • If you aren’t sure whether you need medical care, give me a call and we’ll sort it out.  In general if you are under age 50 and low risk, make the decision in the same way you’d decide if you needed medical care for a cold or flu.  If you are miserable but breathing, take care of yourself at home. If you are having significant respiratory distress, go in.
  • Thankfully, children have relatively mild infections from coronavirus.  But it’s still RSV and croup season so don’t ignore concerning symptoms.  Your little one could still have one of the other common bugs.

Why can’t I get tested?

  • It is ironic that for a country that is typically all about getting tests done, more so than other countries, we currently can’t.
  • We have a severe shortage of tests, testing supplies and personal protective equipment right now so they are being saved primarily for people who are severely ill in the hospital and for healthcare workers.  Even though places like LabCorp are running the tests, doctors offices (including CSFM) don’t have the supplies necessary to collect the specimens.  Politicians keep saying that testing is available but the reality on the ground is that a lot of small practices don’t have what we need and the larger practices and hospitals have to ration the supplies for the most vulnerable.  It’s not an ideal situation.
  • The PCR test is actually very simple and can be run by many labs–the problem is getting permission to do so.  Hopefully these kinks will be worked out soon since it’s not a matter of coming up with a complicated new test, just getting everything up and running.  Remember, much smaller and poorer countries than us are able to run as many tests in a day as have been run total here. So it’s possible.
  • For most people, getting tested will just let you know whether you have it or not but won’t give us any information about what to do–we should all do the same thing.  Do the Five, isolate if you are feeling at all under the weather.  See above for what to do if you have symptoms of coronavirus.
  • My hope (based on what is possible, not on what’s happened so far) is that there will be multiple drive-through testing facilities set up in the coming days so that large numbers of people can be tested.  But that’s just a hope right now.

Is it going to be like Italy here?

  • It all depends on how quickly and thoroughly the current CDC recommendations are enacted.  The good news is that the measures we’re living with now (staying home from school and work, cancelling weddings, Doing the Five, etc) are probably being done much earlier in the course of the spread here than they were in Italy.  Both the U.S. and Italy started these restrictions when we were at around 3000 cases. But Italy has a population of 60.5 million and we have a population of 327.2 million.  While we don’t have as much testing so aren’t entirely sure, the death rates give similar information and those are much more accurate.
  • We should look at Seattle to have a better idea of what it might look like here. As of this writing, more than half the deaths in Seattle have been from one nursing home.  This is definitely turning out to be more deadly than influenza (probably 10 times more deadly). And at the same time, it’s the huge number of people flooding the healthcare system combined with the number of healthcare providers incapacitated by illness that is the biggest problem.  We have time to make plans and changes.  
  • If it does turn out to be as bad across the country as Seattle or Italy, most people will still be fine in the end so panicking now will not help.  I know that the majority of my patients have been through very difficult experiences in their lives and you are all resilient people who will do what needs to be done and get through this too.  Our lives may not be the same but we will adjust to a new normal.  
  • When something horrible happens, a lot of good always comes of it too.  The schools being closed mean that there won’t be any school shootings. The bars being closed and having nowhere to go should hopefully cut down on drunk driving deaths.  Most people I know are discovering that more time quietly with their families is causing them to rethink their values and previous pace of life. We can be grateful for the good even as we mourn for those who are suffering.

I’ve heard coronavirus is really contagious so why aren’t healthcare workers wearing the full body suits and goggles like I’ve seen on the news in other countries?

  • The doctors and nurses caring for people with known coronavirus are wearing full protective equipment.  The bigger concern right now is that in other countries where their numbers are coming down, they are also completely separating people who COULD have coronavirus from everyone else, sending them to separate hospitals, never to the usual ERs and primary care offices.  And caring for them in everything from hotels to gymnasiums so that they aren’t spreading the illness.
  • In place of these measures, our country is trying to move as much medical care virtual as possible and keep potential cases tucked up at home.  It’s imperfect but it’s better than having everyone coming in and out of a doctor’s office spreading disease. The goal is to keep everyone (healthy or sick) at home unless they need emergent medical care.
  • Coronavirus is very easy to transmit. That is why social distancing is so important.  Our bodies and body fluids and anything coming off our bodies need to not be in the same space with other people.  The virus can stay alive on surfaces for hours to days (they aren’t quite sure how long). But normal household cleaners work, so sanitize frequently.
  • Doctors are connected through online groups and are spreading information quickly.  Please trust that doctors know more than the media and are working behind the scenes to be ready.  Politicians don’t stop healthcare workers from coming up with solutions. These are real people working in hospitals and medical offices who don’t want it to be like Italy either.
  • Any also, social distancing.  Read my previous emails about it.  Please practice it.
  • It’s now pretty clear that you are contagious TWO DAYS BEFORE having symptoms as well as 14 days after.  Those two days are a great reason for everyone to just stay home. None of us want to find out we have coronavirus and have been spreading it without knowing.

What do I do for someone who is high risk?

  • Keep that person in a bubble–no going out in public and every person around them should be conscientious about Doing the Five
  • Don’t visit them if you don’t live with them.  The fewer people they come in contact with the better.  We now know that coronavirus is probably contagious for about 2 days before symptoms appear.  You don’t want to share. My sister has offered to set up my mom to Duo with the rest of the family so we can all spend time face to face without sharing germs.  (My mom also receives these emails…Hi Mom!)
  • Monitor your high risk loved one carefully and have a lower threshold for going to the ER.  People who are high risk can get dramatically worse over the course of just a few hours. So if they are getting worse rather than better, take them in for medical care right away.

We can all do our part to prevent the spread of the virus.  If we can flatten the curve, we can significantly improve outcomes.  Stay home if you don’t need emergency medical care and try to make the most of this forced quiet time.  

If you have any questions or thoughts feel free to reach out at any time.

Social Distancing and Staying Sane

Why we are staying home (aka “Social Distancing”):

  • A lot of people don’t understand why we’re all staying home for a virus that is only dangerous for a small number of people.  First of all, it can still be deadly for people you love.  If you know a pregnant woman, a person with an autoimmune condition requiring immunosuppressive medications, or anyone over 60, this matters to you.  But more importantly, we are the ones spreading it to the medically vulnerable.  By staying home (and keeping our germy kids home), we are preventing the spread of the disease.
  • Click on this link to work through a very cool simulator of why social distancing works. I went through it with my kids this morning so that they would understand why we’re staying home.  Maybe because they are doctor’s kids and have watched me struggle to keep up with cold and flu season, they immediately saw the problem with the steep curve, “Mom, if everyone gets sick at once then there aren’t enough doctors to take care of them all.”  Exactly.  And the mortality rate is significantly higher if people can’t get the care they need.  Not just the mortality rate from coronavirus itself but from all the other medical problems that don’t just go away–heart attacks, strokes, cancer, etc.  We all need access to a hospital sometimes and making sure the hospitals can do their job is really important.
  • Why 2 weeks?  Well honestly, I think because it’s convenient and doesn’t scare people.  Run the simulator above and imagine what would happen if part way through the simulation of social distancing everyone stopped social distancing…we’d still get a really steep curve.  Two weeks would work well if the incubation period (time from when you get exposed to when you have symptoms) were a day.  But with an incubation period of up to 14 days, we really need 8 weeks to have the biggest impact.  But we’ll see what happens over the next 2 weeks as the situation develops.  This also doesn’t mean that you’re locked in your house for 8 weeks–it just means that you avoid people as much as possible, use delivery if possible, and stay 6 feet away from people at the grocery store.  Even in Italy where they are trying to stop the exponential growth and are rationing ventilators, the grocery stores and pharmacies are still open.  We’ll still have access to everything we need.
  • What in the world is the UK doing?  They are trying an experiment of separating everyone into two groups and letting the low risk people (middle aged and younger without serious medical conditions or pregnancy) catch it and develop herd immunity to protect the high risk group.  I’m guessing this is going to look a lot like the second simulation in the above link if it’s done extremely well (forced quarantine).  But I can’t imagine how that would work in reality since most people live and work together and completely separating the high risk people is basically impossible. Because they have universal healthcare and a fairly good social safety net, they may have the structure in place to pull it off.  But it if fails, it could fail dramatically.  It’s a real gamble and not one I would take.
  • But Singapore didn’t close everything and they seem to be fine? That’s because they responded very strongly from the very beginning with everything from screening every traveler to mandatory quarantines for people who could be infected.  Unfortunately, the response in our country was very slow so it’s too late for that.  Once the virus starts spreading in a community, good hygiene and social distancing are the weapons of choice.

And also hygiene:

  • Wash hands frequently (before and after eating, after using the toilet, after coughing or sneezing, before preparing food, before and after picking your nose, before and after touching your face)
  • Sanitize high-touch surfaces daily (doorknobs, light switches, keyboards, computer mice, phones, counters, tables, etc)
  • Use good cough and sneeze hygiene (cough or sneeze into your elbow or a tissue that your throw away, wash your hands afterwards)
  • Stay away from other people in your household if you are sick and if you can’t, wear a mask.  If you can’t wear a mask and can’t stay away from them, try to at least keep 6 feet away and use the hygiene recommendations above, sanitizing and hand washing more often.

How to stay sane while cooped up at home:

  • My biggest concern for most people is mental health.  Call the Colorado Crisis Line (click on link) to talk if you’re feeling overwhelmed or you can text “TALK” to 32855.
  • Try to keep a regular daily routine.  I have created a loose schedule for my family of a morning routine (including getting dressed and “ready” even though we’re not going anywhere), work/school time, lunch, more work/school time, family/quiet/supper time, bedtime.
  • We’re also sanitizing surfaces twice every day.  My son has OCD and I don’t want to trigger him by being hypervigilant about germs so we’re just making it a quick, fun, scheduled activity.  We each have our regular assignments so we’re getting pretty efficient.
  • Figure out ways to stay connected with friends and loved ones.  Reading scary articles that someone shared on Facebook does not count as maintaining social interactions!  Consider calling, texting, and emailing friends.  Use Hangouts, Duo, Skype or other similar free apps to see people face to face.  You may find you feel more connected than you did when you were in the same room and not paying attention to each other!
  • My favorite way of connecting when I’m feeling down or anxious is to send off a quick thank you email.  I’ve sent emails or letters to all sorts of people over the years, including my high school chemistry teacher who took me to visit colleges and the custodian at the Museum of Nature and Science who took the time to answer my kids’ questions about the plumping.  Most people are never thanked for what they do and you would not believe how many times I’ve received a reply that my email was read at the all-staff meeting or resulted in someone getting a bonus.  There is good evidence that gratitude decreases anxiety so decrease your own anxiety and give joy to someone else!
  • Make time and space for your hobbies.  This is a great time to do the things you’ve always meant to do but haven’t.  Draw every day, pick up your guitar, memorize the lyrics to your favorite songs.  If you typically go to a gym, figure out what you can still do at home.  We have a runner through our living/dining room that is against a wall and we can all jump rope there without danger to the nearby furniture and knickknacks.  Our rooms are only 10 feet across so we if we can figure out a way to stay active at home, I’ll bet you can too!  It may require changing some rules but it’s fine to change rules for a pandemic.  It’s a once in a lifetime opportunity! (Hopefully…)
  • This is a great time to think about how you’re using your space.  I’ll give you an example of what we’re doing so that maybe you can rethink your own space.  We have a small 1920 bungalow with four people including two very active kids so we sat down last night to figure out some solutions.  We rated each room for whether it has a vital function (like the bathroom), how many times we go into the room each day (like the laundry room, which is also our only clothes closet), and how many hours we spend in the room (like our dining room, which is the hub of our family for everything from school work to eating to just hanging out).  And then we discussed how to make the low-utilization rooms more effective.
  • We’re also working to create spaces and times to be apart.  The kids share a bedroom and they have to go through my bedroom to get to theirs (gotta love old houses!) so we don’t have a lot of privacy.  Planning ahead to not drive each other crazy will go a long way towards our sanity. I imagine many of you have similar challenges and will benefit from thinking ahead on this too!
Please follow all current recommendations for social distancing and for good hygiene.  We can work together to change the course of this pandemic and use it as an opportunity to live according to our values and spend time at home with the people, animals, and activities that we love.

Meaning of “Short of Breath”

How to know when to worry about coronavirus symptoms:

  • Remember it’s still cold and flu season so you most likely have something else, not coronavirus.  This may change in the next few weeks if we don’t “flatten the curve” (see other posts) but for the time being, many people have other viruses.
  • If you only have symptoms in your head (runny nose, cough, normal headaches), you are probably fine.  If you think you have a sinus infection or ear infection, I can treat that via virtual visit.
  • If you have some chest congestion (like with influenza) but you can breath, walk up and down stairs, and talk in complete sentences, please monitor your situation but don’t worry excessively because you’ll probably be fine.  We can do a virtual visit to monitor your symptoms and decide if you need more care.  If you are in a high risk group (60 and over, with serious chronic medical conditions, etc) then please have a lower threshold to go to the hospital.  People in these groups can get dramatically worse over the course of hours.
  • Anxiety can make it hard to take a deep breath, which can then increase your anxiety.  So if you think you may be short of breath, first check your anxiety level.  Were you breathing fine while watching a movie or chatting with a friend and then started thinking about coronavirus and found it hard to take a deep breath?  Try some belly breathing (in through your nose and expanding your belly as round as you can, then make an “ssssssss” through your teeth as you bring your tummy in…it took me about a week of practice to learn how to do it correctly so keep practicing!)  Or just distract yourself for a bit, get a snack, etc.  If you can chew and swallow food (which requires holding your breath) without getting more short of breath, you’re probably more anxious than anything.
  • Lots of people don’t know how to tell if someone has respiratory distress.  Having a stuffy nose or post nasal drip can give you the sensation of being short of breath even though your lungs are working just fine.  The question is whether your LUNGS are having trouble breathing.  Breathing that is fast and labored (heavy) and prevents someone from being able to walk around doing their usual activities or talk in complete sentences requires immediate medical attention so if that’s happening, please go to the ER.  When you go to the ER please cover your nose and mouth with a scarf if you don’t have a mask until you’re able to get a mask there unless covering your face it makes it too difficult to breathe.  Tell the nurse exactly what symptoms you’re having so they understand how serious it it.
  • The vast majority of people with coronavirus will be just fine and have mild symptoms so if that happens to you, your only job is to not share the germs.  Many people with cold and flu symptoms will still just have a cold or flu because we were still in the thick of a pretty bad cold and flu season.  So remember, there’s a good chance your symptoms are not coronavirus.  And if they are, you will probably be fine.
  • If you are in the high risk groups (pregnant, on immunosuppresive medications, over the age of 60, with a history of diabetes or coronary artery disease or COPD), please stay home if at all possible.  Have someone do your grocery shopping for you or go at 6am when the stores are deserted.  But remember, even in the high risk groups, the mortality rate is as bad as 15%, which means 85% survive.  Nearly everyone has good odds.  Obviously, 100% survival would be a lot better, which is why we should all be doing everything we can to stop this from spreading (see other posts).  But many people are imagining that half the population will be wiped out.  While 15% is absolutely terrible, it’s not 50%.  So long as we can flatten the curve and not overwhelm hospitals, the majority of people with this will survive.

Coronavirus Message

I have not posted on my website in many years because I’ve been more focused on our time together in the office.  But with the current pandemic, the time has come to step up my game when it comes to virtual communication!

Here is the email I sent out today:

The current pandemic has caused a lot of questions for people.  Because we already know each other, I hope to be able to provide you with trustworthy information in the coming days and weeks.  I’ve also increased availability to provide you with the medical advice you need (see below for more details).  This email will hopefully answer some questions as well as keep you updated about the changes in my practice.

Coronavirus information (scroll down for important changes at CSFM):

  • Please follow the current health department recommendations.  Wash your hands frequently, avoid congregating with other people, and stay isolated at home if you are at all under the weather.  This article (click link) has a good summary of what to do if you’re worried that you have coronavirus.  At this point, 90% of the people who have been tested in Colorado do NOT have coronavirus–it is still the thick of cold and flu season so most likely whatever you have is one of the other viruses going around.  That said, people are dying of coronavirus, so do not ignore concerning symptoms out of denial.  Getting the help you need when you need it can save your life.
  • Most of us will not be affected medically.  We are responding as a community to protect our most vulnerable (pregnant moms, people over 60, and people with chronic medical conditions).  Very few healthy people under 50 will become seriously ill (end up in the ICU).  In Japan, as of this writing, they have had ZERO deaths in people under 50.  At the same time, even “mild” cases can be pretty miserable with anything from typical cold and flu symptoms up to viral pneumonia.  People who are seriously ill but do not die have a prolonged recovery in the ICU.  Most of us will not experience this but we need to make changes to minimize the number of people who do.
  • The reason Colorado is closing down schools, businesses, and events is to try to “flatten the curve.”  What this means is that instead of having lots of people all get coronavirus at once and overwhelm the hospitals, we want to slow it down to a trickle.  This will mean that the spread could last longer but every person with serious covid-19 can have access to life-saving treatments.  Be a good human and help slow the spread by following the current recommendations.  We want the hospitals to be able to provide the best care possible to the people who need it.
  • My biggest concern for most people is mental health.  Please try to keep up with normal routines, do things that are good for your morale.  I’m keeping my kids and I on a regular daily schedule with time in the backyard, work/school time, family time.  We’re using this as an opportunity to enjoy some more hygge (google it)!  Call the Colorado Crisis Line (click on link) to talk if you’re feeling overwhelmed or you can text “TALK” to 32855.
  • You do not need a three year supply of toilet paper, but please make sure you have an extra few weeks of basic supplies and medications.  If you don’t, you can just order for delivery if needed, but it’s more expensive that way. A number of pharmacies will deliver prescriptions if needed.  And my local yarn store will mail knitting necessities.  So you should be fine.
How CSFM is responding:

  • I have 10 and 20 minute phone and video appointments available seven days a week.  If possible, please try to schedule a time on the portal.  This way you’re not waiting for me to call back who-knows-when.  Instead, I can call when you are expecting and we can eliminate phone tag.  I’m hoping this will help with the high volume of calls currently and make communicating with me more convenient for you.  You are always welcome to also call in the usual way using the urgent and non-urgent lines.
  • Yes!  I said video appointments!  It’s really easy to set up–my first video visit was done with someone who has never used Skype/Hangouts/etc.  I’ve now done several and everyone has been really pleased with how accessible medical care is to them now–we can have a face to face visit from anywhere.  Right now please take a moment to click on the link in your email, which provides HIPPA secure video appointments.
  • For the time being, there will be NO in-person appointments (no appointments at my office).  I am doing this for several reasons.  First is that the vast majority of care can be provided remotely so I’m not concerned that people will suffer unduly in the next week or so.  Second is to be able to care for everyone.  I can only manage a limited number of in-person appointments in a day but I can do many times more virtual appointments every day.  With the high volume of patients needing care right now, this makes sure all of you can access me on the same day and not have to wait.  The third reason is to avoid spreading coronavirus.  I do not want to be the reason that one of you gives coronavirus to a fragile friend or relative.  I also do not want to fall ill myself–even the mild illnesses can make it hard to work at the pace necessary to keep up with the need right now and I do not want over 400 people to be without a physician.

This is not the first time we have experienced major crises as a country but this is the first time that most of us have experienced something that changed the way we live our daily lives and threatened the ones we love the most.  We can work together to change the course of this pandemic and use it as an opportunity to live according to our values and spend time at home with the people, animals, and activities that we love.

If you have any questions or thoughts feel free to reach out at any time.  If you aren’t able to access the patient portal, click on this link and then click on “forgot password.”

Be well!
Dr. Robin

Denver DPC

When I started my practice back in 2012, I thought I was the only one.  It turns out, Dr. Lisa Davidson (now a friend) was doing the same thing at the same time.  There is actually a whole movement called Direct Primary Care (or DPC).  Dr. Davidson’s practice is now full but a friend of mine recently opened her DPC practice in north Denver (Dr. Brie Seefeldt).  Each DPC practice is uniquely designed to suit the particular physician and her (or his) patient population.  We each have different office hours, different prices, and can provide different services.  But underneath it all, we are all trying to fill a need for a different way of doing medical care.  Both patients and physicians are getting burned out, slipping through the cracks, and hoping for another option.  It’s exciting that DPC is changing from something people have never heard of to something people are looking for.  So if you are hunting for DPC in Denver or DPC in Englewood, you have more choices than ever!


The ICU Vigil

Unfortunately, many of us will at some point have to spend some time waiting at a hospital with a critically ill or injured loved one. This doctor wrote an excellent piece filled with great advice. I’m honestly posting it here for myself as much as anyone else…if I ever need this advice myself, I want to be able to find it easily!

When a Loved One Is Critically Ill: How to Survive the Waiting Room by Dr. Richard Senelick