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

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

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

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

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!