A Short Thought on Vaccines

My aunt was just visiting.  She enjoys books with very dark themes and story lines.  I explained that I have never liked anything especially scary but that during residency and became a total lightweight when it comes to reading.  My sister now pre-reads everything for me to make sure NOTHING awful happens.  I read a lot of books written for tweens.

My aunt wanted to know what happened that changed that.

A lot did, but I told two stories.  One was a horrible accident in which a minivan full of kids and parents was smashed up pretty badly.  No one was wearing a seat belt or sitting in a car seat.  We were all called to the ER to help.  It was awful.

The other was a woman whose baby died at full term…she came into the hospital thinking she was having her baby and I had to tell her that her precious child was dead.  I will never forget her gut wrenching sobs.  Never.

Those were just two of many incidents that taught me just how precious life is.

When I became pregnant with my son, I would go up to labor and delivery every time I was on call and do a quick ultrasound, standing in the little alcove in the hall where the ultrasound machine was stored.  I didn’t care that it was a little ridiculous and someone might see me standing there with my scrub top hoisted above my pregnant belly.  I wanted to see that my child was still alive.  I would stand there as long as I could, just gazing at that tiny heartbeat, the kicking legs and waving arms.  Alive.

After he was born, my greatest fear was that either my child or I would die.  I decided I could handle anything else.  But not that.

When he was three, my son was diagnosed with multiple special needs, some conditions he might or might not outgrow and some he’ll have for the rest of his life.  I was devastated.  But my next thought was that at least he didn’t have something fatal.

Now my son is a charming, creative, energetic six year old and I also have a two year old daughter.  I love them both more than I can ever express.  And I will, no matter what happens to them or how successful they are in life.  Which is why they are both fully vaccinated.  The risks of vaccines are much lower than the risk of death from the diseases they prevent.  And I’d rather have my children alive and in my arms.

Here’s an article written by a mom whose child has autism.

Many Thanks to South Metro Health Alliance!

I was honored to be a part of South Metro Health Alliance’s Heart of Hope fundraiser this year.  I was given the opportunity to encourage all the other attendees to consider addressing medical needs as part of their mission, whether directly or through referrals.

I was also honored with one of their humanitarian awards.  I am so grateful to the wonderful people at The Well, especially Audrey, my right hand.

Here’s a great video about it: http://video214.com/play/I34018OkzpiXoUZ9OBG09Q/s/dark

Some Total Transparency

My hubby just sent me the TED talk by Dr. Leana Wen about the importance of physicians being totally transparent.  Transparent about our educations.  Transparent about how we get paid, not just whether we get bonuses for being shills for pharmaceutical companies but also if we make more money doing a procedure than we do to just talk to someone. Transparent about about where we live.  Transparent about our practice philosophy.

When I was in training, I remember being told to guard my personal life closely.  Do not talk about myself.  Definitely not about my family.  Or about my own experiences.  No family photos.  I even met some physicians who removed their wedding bands at work in order to present a completely blank persona, as if a doctor is nothing but a doctor.  It reminds me of the classic childhood belief that the teacher lives at school.

What surprised me was not Dr. Wen’s insistence that physicians tell the truth about themselves but the extreme negative reaction from other doctors.  Really?  It’s so scary to have someone suggest voluntary disclosure that you must threaten or try to destroy the career of the woman who suggests it?

Louisa May Alcott (of Little Women fame) wrote a charming book called Eight Cousins and its sequel Rose in Bloom that are essentially a palatable version of her father, Bronson Alcott’s views on education.  At one point Rose, the protagonist, is caught reading a French novel (shocking!)  She tries to hide it but then argues that what she’s doing isn’t wrong.  After some discussion, she realizes that she knows inside that what she’s doing is wrong because she had that instinct to hide it.

Perhaps the doctors who aren’t comfortable with being transparent should take some time away from JAMA to read Rose in Bloom.  If they are so embarrassed about what they are doing that they need to hide it from view, perhaps they actually know that they shouldn’t be doing it.


So, in the interest of complete transparency, here’s the dirt on me:

I am board certified in Family Medicine and belong to the American Academy of Family Physicians (AAFP).  I went to University of Denver for undergrad (on scholarship so all my student loans are from medical school) and University of Colorado for medical school.  I completed my three year family medicine residency in Pueblo at St. Mary-Corwin.

I do not receive any payments or gifts from any pharmaceutical or medical device companies or anyone else and I do not sit on any boards (paid or unpaid).  Drug reps don’t ever visit me…I’m just not worth it because I won’t listen or accept any offers of “informative lunches,”  My only patients who suffer from lack of samples are those with asthma.  Pretty much everything else can be managed affordably and the samples only provide a false sense of getting something for free because then you’re stuck on a super expensive medication long term.

100% of my income is from my clinical work.  Approximately half is from monthly memberships and approximately half is from Medicaid.  With the memberships, I obviously get paid the same amount no matter what I do.  That was the point.  With Medicaid it sort of comes out the same…no matter what I do, they don’t pay very much.  🙂  That’s it.  No other income

I do take grad student who are applying to medical school and PA school, but I don’t get paid for that.

I live three blocks from my office and usually bike in.  I have on a few occasions forgotten to wear a helmet and it’s guaranteed one of my patients who lives in the vicinity will see me not following my own advice, Murphy’s law.  I sometimes have to bring one or both of my children with me if someone needs to be seen after hours.  They usually play nicely in the other room but they occasionally throw puppets or color on the wall.

I don’t kick anyone out if they suddenly find themselves with lots money and good insurance, but I do mostly see those who don’t have either.  I have recent experience with high deductible (aka “crappy” insurance, but before the Affordable Care Act so before it was actually required to cover a few things) and Medicaid.  I am always willing to discuss how much something will cost because I know that a majority of my patients have gone without medical care due to cost in the past and I don’t want that to happen again.  Together with a wonderful nurse, I also started a free clinic at Wellspring Church here in Englewood at which we mostly care for Englewood’s homeless.  We now have another physician and team of volunteers so we’re able to provide care every Sunday.

I also see mostly people who are a little different from mainstream (whatever that is!?).  Homebirth families.  LGBT families.  Homeschool families.  Small business owners and people who work for small businesses; electricians, plumbers, HVAC, construction, grocery, restaurants, animal breeders, etc.  Families who belong to Christian cost-sharing.  A surprising number of tattoo artists, photographers, painters, and a comic book artist.  Alternative care practitioners.  Homesteaders and urban homesteaders.  People who don’t want to take medication or get vaccines; because yes, they need medical care, too.  I love seeing such a wide variety of people; every day is interesting.  And because I homeschool, keep chickens, had my second baby at home, and have many friends and family who are artists or LGBT or hate Western medicine as a rule, most of my patients could easily be my friends as well.

At the same time, I am a medical doctor.  I am trained in medical problems and medical treatments.  I want to help people avoid them whenever they can, but I can’t and won’t prescribe herbs and treatments that I know nothing about.  I do prefer prevention to treating a problem, which is why I try to catch any risk factors early and recommend simple fixes like exercise, dietary changes, counseling, vitamins, and finding interesting hobbies.  I recommend books a lot.  And YouTube videos.

I am a proponent of universal healthcare here in Colorado, even though it means I’d have to give up on my dream of a membership based practice.  Because it’s more important to me that everyone have access to this basic necessity.  Civilized people make sure everyone has medical care.  In the spring of 2015, I’ll be collecting signatures to hopefully put this on the ballot in 2016.  While I know that I’m making a difference in my little corner of the world, policy change can help more people.

I am also a vocal advocate of SNAP (food stamps) after my own experience being on them after my strokes two years ago.  SNAP is a critical safety net that ensures that people have access to food regardless of their income.  It’s a basic, civilized thing to do.  As a physician, I support SNAP (rather than relying on charity like food banks and food baskets) because it allows my patients with diabetes to choose low carb foods, my patients with celiac to choose gluten free foods, and all my patients to have access to fresh fruits and vegetables that are rarely available at food banks.  We still need food banks and I am good friends with people who run food banks.  But SNAP should be the foundation.

Short of providing my sex-and-substances history (one lifetime partner and one lifetime drink on Match Day in the company of my husband and close friends), I think I’ve disclosed pretty much everything. 🙂  If anyone is worried about something I’ve left out, feel free to ask.  Because I know the doctor-patient relationship is extremely intimate.  I carry the secrets of many.  I know things that people have never told anyone else in the whole world.  And to be worthy of that responsibility, I think it’s important to be honest and transparent, to have integrity of self.

And to Dr. Leana Wen, in the words of Colin Powell, “Being responsible sometimes means pissing people off.”

Healthy Eating

It seems that everyone is on a diet or feels they should be…Atkins is fading away, gluten free is so common that I have gluten free variations of all my standard recipes for when we have company.  South Beach is still around, Mediterranean is a pretty solid contender.  Then there’s Plant Based diet, the Nourishing Traditions take on things, and so on and so on.

So when someone asks me for the BEST diet, what am I to say?

For your heart, the Mediterranean diet may be the best…but there is no single Mediterranean diet.  So don’t get yourself in a knot trying to do it exactly right.  Remember, there are real people living in the Mediterranean area eating these foods and some of them probably dislike olives as much as I do.  Here’s a summary from the American Heart Association of the key points of the Mediterranean Diet.

The DASH diet is great for lowering blood pressure.

What I’ve seen work best for the majority of my patients, to help them lose weight, improve their blood sugars, and generally feel great is either a plant based diet or a paleo diet.  My favorite book on on plant based diets is The Complete Idiot’s Guide to Plant Based Nutrition.  If you can ignore the implication that you, the reader, are an idiot, please consider reading this book as a good introduction to the concept.  I don’t have a favorite paleo resource yet so if you have one, please let me know.

Ultimately, what all these diets have in common is lots of fruits and veggies, not many processed foods, and reasonable portions.  So do that with whatever you’re already eating and you’ll be on your way to a healthier diet.

Finally, a question I get quite often is: what do I do for my family?  In our situation we have two very active small children who limit our time and a very tight budget.  I would prefer to eat better than we do and better follow one of the diets above.  Instead, we eat a variation on a “real food” diet.  I like this woman’s blog on the topic a great deal.

At the same time, I recognize that for my patients and I, it is important to make concessions for our lives.  Lisa, from 100 Days of Real Food, did a 100 day budget challenge in which she fed her family by the real food “rules” (a la Michael Pollan) on $125 a week, which she really struggled to live by.  And making food by the rules is her current career!  Our usual food budget is $80 a week.  Clearly, we’re not going to be able to abide by the real food “rules” perfectly.  At the same time, we can try to make sensible concessions.  Buying our chickens from Costco instead of a local farmer is different than buying Chicken McNuggets.  I still use sugar when baking because it’s much cheaper than honey…but I use recipes that call for very little sweetening such as whole wheat pumpkin oatmeal cookies rather than sugar cookies.  We eat much less fruit than we’d like and more potatoes, but overall I know we’re feeding our family far better than we would if we ate a “standard American” diet.

Gardening can also be a difficult decision.  A garden can provide a family with good wholesome food that is very inexpensive if done with finances in mind (you can also very easily blow my entire annual income on your garden if you wanted to).  But it is definitely a lot of work (especially if you’re doing it cheap) and for families already struggling with multiple demands, it can be just one too many things to have to cope with.  My husband and I go back and forth on whether or not to have a garden.  So far, we’ve always decided to do it.  This year I actually decided not to next year…but then we started harvesting two or three cucumbers every single day and my son boasted to a neighbor about how he can pick and eat his peas any time he wants and I discovered that I actually like beets (if from our garden and steamed) and, well, I guess we’re doing a garden again next year.  

How do you make healthy food choices for your family?  How do you make those choices affordable?

What I Did Today…

A lot of people can’t imagine what a doctor spends her time doing.  Sometimes I wonder too…why don’t I just see patients and go home?  So today I tried to keep a list.  I thought I’d let you know what my (fairly normal) Monday looked like.  I know I left a bunch of random stuff out because I kept forgetting to list what I was doing, but at least you get the idea.  This is all the behind-the-scenes work that is invisible to people but has to be done at every doctor’s office across the country.

  • Saw patients (everyone knows about that).
  • Fought with my internet…why oh why does it choose such inconvenient times to not work?
  • Finished appointment notes, sent summaries to portals (except for one patient who always takes detailed notes)
  • Got paged twice from pharmacies about prescriptions
  • Hunted down an x-ray result I hadn’t received, called the radiologist to discuss the situation, and contacted the patient with next steps
  • Looked up a study a patient mentioned, reviewed it, looked up medication conversion (I’ve learned that even pharmacists have to do this!) and replied to her questions
  • Put in referrals to specialists for two different patients.  This requires faxing medical records, demographics, and a letter from me.  Oh, and I wrote those letters too.
  • Called and scheduled my kids’ well child checks…I finally remembered to do this before 5pm!!!
  • Called Medicaid to do a prior authorization (also a before 5pm task)
  • Reviewed labs several patients had drawn late last week and the results came in over the weekend.  One required additional testing, which necessitated contacting the patient to discuss, contacting the lab to add the labs (terrible hold music!), then receiving the paperwork from the lab to sign and return to them saying that yes, I really did say that I wanted the additional labs. One set of labs needed to be faxed to a specialist with a note from me.  Of course all the results needed to get to their owners.
  • Reviewed echocardiogram results on a patient, determined what additional testing was needed, contacted patient to discuss.
  • Discussed doing additional labwork for a patient who HATES needles, recommended the Buzzy to help with that.  (Here’s a great TED talk about the subject).  Wrote order, faxed.
  • Checked messages and found that I had received several phone calls from patients about various concerns, returned each call…imagine the amount of time I spend on the phone with you when I talk with you, then multiply that by 4-16 calls a day!  (Typical is about 8).  Sent emails with resources to a couple of the people I spoke with.
  • Called people to schedule follow up appointments.
  • Did messages on the portal.  They ranged from a quick “great, see you then” to several detailed treatises on complicated questions.
  • Called the lab again to order supplies.
  • Called again because you have to call different numbers for different supplies.
  • Tidied up office, cleaned instruments, watered plants.
  • Thought about looking at beginning of the month finances but just couldn’t bear doing anything more today.

In a typical office, some of this could have been easily handled by staff (such as faxing).  Some of it would have been a message to staff, “tell patient she needs an appointment to discuss” instead of replying to those questions, or “tell patient to work on lifestyle changes” instead of the long discussion.  Some of it may have been handled by a staff member without my knowledge (finances, scheduling appointments, refilling prescriptions…which can present a problem when a particular number of refills was done to make sure a patient came back in).  But many of these tasks are things doctors do every day and no one thinks about it.  Reviewing labs.  Reviewing imaging.  Determining next steps.  Calling radiologists.  Contacting specialists.  Replying to messages and phone calls.  The stuff someone else would have done is fast and easy, almost a break from the work of doctoring.  But I love the doctoring part…I am so happy this practice gives me the time to do it right!

ACA (“Obamacare”) Questions (sort of) Answered

I’m getting a lot of questions about this now that we’re nearing the end of open enrollment (March 31, 2014).  Here is some basic information that may help.  To be clear, I don’t think the ACA solves all our problems.  Affordable insurance is not the same thing as affordable medical care.  Many people are still spending a lot of money for insurance they are hoping to never use because of a uselessly high deductible.  But it’s progress.  I’m hoping to never again recommend to a patient that they declare bankruptcy because of a twist of fate that landed them in the hospital for a few days.

Nothing significant is changing at my practice.  Medicaid has been expanded to include everyone under a certain income level (see below) so I am accepting Medicaid from current patients who now qualify.  People have asked why I’m not accepting new patients with Medicaid…it’s nothing against Medicaid, I assure you!  I just want to make sure I have room in my practice for people who are still uninsured or who have ridiculously high deductibles so still don’t have access to affordable care.  If you know someone who would benefit from joining the community ($30 a month for each of the first two members of a household and $15 a month for each additional member), please pass on my information to them.

Here’s some information about the Affordable Care Act that many people don’t understand:

1. While we are all expected to have coverage, we are not all expected to pay $1000 a month to get it.  How much a family pays depends on that family’s FPL (what percent of the federal poverty level they have gross income).  Here is a chart of FPL: http://www.familiesusa.org/resources/tools-for-advocates/guides/federal-poverty-guidelines.html.  Notice that the larger the family, the higher the income for a particular percent.  A baby in utero counts as an additional family member (so a couple with two kids and a baby on the way will be a family of five).  This is based on gross income in order to make it fair for everyone.  It’s basically adjusted gross income (line 36 on the 1040) but there are a few modifications that can be made so it’s called MAGI (modified adjusted gross income).  The MAGI is higher and includes things like student loan interest and IRA contributions that would not be in the AGI.  If someone is right on the border of getting or not getting a benefit they should discuss it with someone more knowledgeable than I.
2. If a family or individual makes less than 133% of the FPL they automatically qualify for Medicaid.  The entire family, not just mom, not just the kids. 
3. If a family or individual makes between 133% and 250% of the FPL they get both premium subsidies (to help pay their insurance premium) and cost sharing subsidies (to improve the value of the plan by decreasing maximum out of pocket/deductible/coinsurance/copay).  Kids and pregnant women in this group still generally qualify for CHP+.
4. If a family or individual makes between 250% and 400% of the FPL they get just the premium subsidy (to help pay their insurance premium).
5. If a family or individual makes over 400% of the FPL they don’t get any subsidy and should refrain from whining because they are better off than almost everyone I know.  🙂
6. The amount a family or individual pays is figured as a percent of their income and that percent is less for lower incomes and more for higher incomes.  With the premium subsidy, the subsidy amount is based on what a family would pay for the second cheapest silver level plan; however, they can take that money and use it to buy whatever plan they want.  If they buy a bronze plan they’ll pay less; if they buy a gold plan they’ll pay more.
7. All plans, even the cheapest bronze level plans. are required to cover preventative care (such as paps) without a copay/coinsurance.  That said, they will do everything they can to pay for as little as possible. 🙂
Here’s a calculator where you can find out about how much you can expect to receive in subsidy and how much you can expect to pay for a silver level plan per month:  http://kff.org/interactive/subsidy-calculator/
Here’s where you can go shopping for plans: connectforhealthco.com/get-started/individuals-and-families/

 One thing that has continued to confuse people is that everyone at a particular FPL is expected to pay the same amount for insurance whether they are buying insurance for one person or for eight family members.  What this means is that you may be in the income bracket where you should get a subsidy but you don’t, or you get less than someone else you know.  It’s because insurance is more expensive for larger families and for older adults.  If you are young and healthy and buying insurance for just one person, you may be paying less for insurance than the legal cut-off for your income.  This is especially true here in Colorado where people are generally healthier than other states so our insurance is more affordable to begin with.

If you need help figuring this out, I’d recommend you go to an assistance site for help.  The closest I know of is at DoctorsCare in Littleton.

One Reason I Love the Membership Model

Did you know that many primary care offices have a rule that if a question takes more than five minutes to answer over the phone, the patient has to schedule an appointment.  Do you know why?  Because that is time a doctor is spending that he or she isn’t getting paid for.  In a medical office, the physician is the goose that lays the golden egg…if the time a physician spends isn’t being paid by someone, then the practice as a whole and everyone who works there is that much poorer for it.

Here’s a chart showing the average time a primary care doctor spends in an appointment with a patient:

From Medscape Survey of Family Physicians 2013

From Medscape Survey of Family Physicians 2013

I usually spend 10-15 minutes on the phone with a member.  If I worked in a normal office, that would be money down the drain.  With the membership model, I don’t have to think about it.  If it’s a question that can be answered over the phone, I answer it over the phone.  If I need to see someone in person, we schedule an appointment (30-60 minutes) instead.

This month I’m accepting Medicaid for all current patients who now qualify.  I was surprised to notice my mindset changing automatically.  Have a question that requires a long conversation?  Better come in for an appointment…the better to pay me for, my dear.  I HATE thinking that way about patient care.  That’s not what I’m here for.  Now, please don’t get apologetic about having Medicaid.  You are entitled to it and I am accepting it for current patients because I support the Medicaid expansion.  But please forgive me when I ask you to come in for an appointment to discuss something…Medicaid and other insurers don’t consider a phone call to be “billable time.”