2 viral infections, 2 different outcomes

In the course of 3 days (last month), I saw 2 patients that presented with the exact same viral illness.

Mild sore throat, fatigue, subjective fevers, dry cough.

In both patients I suspected a viral infection that didn't require an antibiotic.
That's where the similarities ended.

Patient A was a 60+ year old male with a few stable medical problems who regularly came to our resident clinic. I saw him with our residents a few times before. She stated she get's this once a year and antibiotics always resolved it. When I suggested just symptomatic treatment and time, the visit turned sour. His wife who was also in the room, questioned the entire visit, suggesting I was making him suffer. The wife's doctor (from a different office) had already started her on antibiotics for a similar illness. It was a Friday and I promised I would call him Monday to reassess symptoms.

I called Monday, and  he said he was feeling a bit better, but had already gone to an urgent care center Sunday and received antibiotics.

"Sigh." I thought.

Patient B was a 50 year old male, and presented with essentially the same illness. I gave the same viral illness speech and offered the same follow-up call.

"you got it Doc!" 
And with a smile, he was off.

The difference?

Patient B 2 years prior, walked into our office with 3rd degree heart block.
 He credits us (and his cardiologists!) for saving his life that day.

A patient requesting antibiotics for a viral illness is a common event in primary care and can cause quite a bit of "agita" 

 I also know how hard it can be to say no to a patient.
I also know how in primary care, the amount of time we get with a patient really limits proper counseling.

Ultimately, it's a trust issue. Trust between a patient and primary care physician is a core principle that takes time to develop. I don't always have the luxury of rescuing a patient from the jaws of death and getting instant credibility. It takes a lot of time, effort, patience and counseling to develop a trustworthy relationship.

Unfortunately, in modern medicine, many elements undermine that trust. Until primary care physicians are given the opportunity and incentive to do what it takes to that build trust, our healthcare system will continue to erode and free fall further into the abyss.

Follow the bouncing DVT

This is about the fragmentation of our health care system
This is about accountability.
This is about a man, with limited transportation and a bad set of knees.

Mr. Pinball (name changed) is 80+ years old. A wonderful guy who unfortunately was diagnosed with an unnamed cancer . Fortunately, it was surgically resectable, and his surgeon did an incredible job of removing it, with no complication. I couldn't be happier for him.

Several days after surgery, while recuperating at home, he noticed worsening leg swelling. Because of his history of congestive heart failure, Mr. Pinball was worried he was retaining fluid (especially since his water pills were held around the time of surgery.) He called his cardiologist, who didn't think this was related to his heart. Instead he was advised  to contact the surgeon to be evaluated for a potential post operative complication like a DVT (deep vein thrombosis) i.e. a blood clot in the leg.

Dutifully, Mr. Pinball called his surgeon who also reiterated a similar concern for a DVT. He was advised by his surgeon to contact his primary care physician (me) to get evaluated for a DVT by getting an ultra sound.

 Mr. Pinball called us and I advised him to immediately come in for a look. He was able to come in to our office, thanks to a caring neighbor. Mr. Pinball, no longer drives.

Our suspicion for a DVT was high, so we quickly obtained the  necessary imaging, and he had what everyone expected. On a side note, he had to take a taxi home from the radiology office that night, because his neighbor left. For an elderly gentleman on a fixed income, a 30 dollar cab ride hits hard.

From his initial concern to our office visit, 5 days had elapsed. 5 days of bouncing around without anyone informing him of the potential seriousness of a DVT. Between doctors giving him the run around, and social circumstances limiting his ability to access healthcare, something bad could have happened.

Fortunately, nothing bad happened. Mr. Pinball is doing fine. But how many Mr. Pinball's are out there, victims of a fragmented healthcare system that has misaligned incentives and poor accountability?

How many Mr. Pinball's aren't being saved by the safety net of primary care that is stretched to its limits?

Step down therapy

 Insurance companies will list certain drugs as "ST" or step up therapy. A patient needs to fail the formulary alternatives before "Stepping up" to a medication that isn't covered.

I've been practicing a lot of "Step down" therapy, and here's why.

With the recent economic turmoil and high unemployment rates, we've seen many patients in difficult financial circumstances. Many patients have lost their employer based commercial insurance plans and switched to Medicaid. Unfortunately, many providers in our community don't take Medicaid and they end up switching care to our resident continuity clinic. This influx of patients (formerly with commercial insurance) has given me additional perspective on our healthcare system.

One of the first things we have to do with such patients is review their medication list and make changes. Most of the managed Medicaid companies have strict formularies and will not cover many brand name medications. Initially, my initial reaction was frustration. As a patient advocate, I want the power to give patients medications that I feel is appropriate, especially if they have a track record of success.

But once I began to peel away the layers of such cases here's what I found.

I've seen several patients on brand name medications that had never tried generic alternatives. Some were never offered it, and some showed aversion to generics, stating they never worked as well. When I asked them how they ended up on a specific therapy, several had indicated it started out with samples in their doctor's office. And once it was established that these brand name samples worked, nothing else was offered.

I also recall a patient who was dropped from their commercial insurance plan because he seeked overpriced out of network care at a place notorious from practicing what I would classify as fringe concierge medicine.

Shockingly, we had a patient on a brand name proton pump inhibitor, paying 75 dollars a month and never offered any of the myriad of generic options. He couldn't have been more thrilled at the opportunity to try something much cheaper.

This is a just small skewed sampling of issues I have seen. The vast majority of such cases have great positive outcomes that meet the expectations of both physician and patient.

It think it's great that our healthcare system provides choices for patients. That flexibility is a strength. But it comes at a price. The price is care that is subject to becoming bloated, overpriced and not evidence based.

My hope is that the medical community can continue to build trust with our patients and show them that cost effective care is just as good. What may be looked at as "step down" therapy is really a "step up" for the patient, physician and healthcare system at large.



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