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Family Medicine Holistic Covid Consideration

Sun, 15 Nov 2020 13:08:57 GMT

Wow! What a title! It packs a LOT into a few words.

When a family physician, a primary care physician, has to consider how to advise a patient, this is going to include what is called "shared decision making." And never has this been more relevant than during the current times.

As we head into Thanksgiving and Christmas, with the Heartland of our nation facing unprecedented sickness and deaths from COVID 19, we ALL must make difficult decisions about personal safety, but also that safety of those we love.

Here's a tool to help with decisions about group gatherings heading into Thanksgiving and Christmas. The risk for your county includes a gathering of a chosen size, for individuals from the SAME county. If you are considering having people come in from a different state or county, you want to look at the risk in THEIR county.

Some things to consider also include:

the risk of severe disease of anyone who would be attending

presence of hypertension, diabetes, obesity

age (risk goes up quickly with age)

likelihood/ability of those invited to wear masks and socially distance

indoor vs. outdoor celebration

ability of anyone who gets a confirmed exposure to quarantine -adverse effect on the person's business and family?

exposure/quarantine effect on children's education

These decisions aren't straightforward, but by considering your circumstances, and those of your potential guests, considerate and caring decisions can be made that will allow everyone's safety and personal joy to be maximized during this trying time

Your primary care physician can also help you navigate these important decisions.

Stay Safe.

https://covid19risk.biosci.gatech.edu/

Primary Care PTSD

Sun, 09 Feb 2020 13:02:15 GMT

This is a confession. It's not pretty. But it happened and reminded me of my commitment to justice in medicine.

My partner, Althea Tyndall-Smith MD, and I left employed positions as Family Medicine physicians in order to practice medicine in a manner that honored ourselves as physicians, as wives and mothers, and that honored our patients just as much. We stepped off "the treadmill" of frantic running from room to room, documenting enough "bullets" on our EHR notes to make sure and capture all the RVU's ($$$$) our employer would hold us accountable for, and always feeling like we never made anyone happy: not ourselves, not our patients, not our employers.

So, after four months of building Gainesville Direct Primary Care Physicians, LLC, and 17 months of being officially open, we can say, we have succeeded. We have succeeded in building a practice that honors our patients, and ourselves. We are happy. We have meaning. We practice REAL Family Medicine, seeing newborns through elderly, doing procedures, learning new skills, and keeping our promise to ourselves and our patients that we have no profit in what we do other than the once-monthly completely transparent membership fee, that is more affordable than most cell phone bills or nail salon habits.

So then why, last week, did I have a "primary care PTSD moment?"

This has been the busiest time of our practice, yet. Influenza, Strep pharyngitis, Epstein Barr Virus infection, norovirus, and common pharyngeal viruses have made our patients sick....and we've been there for them. Its wonderful. I love having time to see my patients, to thoughtfully consider the cause of the illness, and to have time to explain how they can get better. Not giving antibiotics is not problematic when physicians have time to explain why it won't help, and patients know their doctor will be available just in case things worsen. But then I receive the request from my MA to work in a patient with "ear pain" real quick, just to check. And then comes the next thought, unbidden, and unwelcome, but intrusive and unavoidable. The thought was, "great - that's an easy 99213."

What the heck was that!!!! Where did that come from? For those of you who don't understand billing codes, that is the code for moderately complex visit, that generates something called an RVU. This is a way that employers drive employed physicians to produce money in a practice. Physicians have an "RVU goal." If we don't meet our RVU goal, we get threatened with a demotion, decreased pay, or being fired. So the RVU goal is nothing more than a quota. Its a number of widgets required to be produced. So every time a physician sees a patient - and the patient MUST be SEEN - RVU's are generated. The more a physician does during the visit, the more RVU's are generated. So if a physician circles more things on your patient "encounter form," (that piece of paper you notice being put on a chart when you check in, and that is used to bill you when you leave), the more RVU's are credited to the physician.

Does anyone see a problem with this now? So you have physicians who have an RVU goal at a threat of significant problems or loss if it is not met, but you trust this person to ONLY do what you need, and cost consciously, too. Yeah. There's a problem. There's a conflict of interest here. And no one discusses it.

If you aren't convinced that there's some scheisterism involved in this, consider that there's a very important aspect missing to this encounter form/RVU goal situation: the prices. Next time you visit your "industry health" physician/clinician, ask him or her to show you what is circled on the encounter form (or other form that is used), and tell you the price you will be charged for each thing. There are no prices on the form. There never have been. And while you are at it, ask what his or her RVU goal (widget quota) is in dollar amounts. He or she won't know. Physicians aren't told a money goal. It is hidden from them, and they don't ask. How hard is it to list the price for a 99213 visit next to the code? Or the price for the urine dip? Or the strep swab? Or to know how much money you have to make to keep your job? Why the secrecy?

In our direct primary care practice, we not only can tell you EXACTLY how much each thing we recommend costs, we tell you how much profit margin is built into any of these charges. Its really easy, because its $0. The ONLY thing we charge that is profit is the monthly membership fee. Other charges may be passed on to the member, but never for our care. All of our physician care is included in the affordable membership fee.

So when my MA asks me to work-in a patient, not only now do I have TIME to do it (because I no longer have more than 7 patients scheduled regularly per day), but I don't have to worry about making money off of a patient's illness. I see him or her because I CARE. Dr. Tyndall-Smith and I have a sense of OWNERSHIP over our commitment to our member patients health. We don't see our patients for a profit incentive. We are free to see our patients because we CARE about them. The unbidden thought of the 99213 RVU stands for everything we struggled with in practicing medicine before direct primary care saved our physician hearts. The reason I call it PTSD is because this thought is born of trauma. There is moral injury to physicians working in this type of a system.

When you are ready to abandon a profit-centered fear-based incentive medical system, call us. We are ready to CARE for YOU!

Coronavirus: Should You Be Concerned?

Wed, 29 Jan 2020 12:55:14 GMT

Coronavirus, named by the CDC 2019-NCoV, has arrived in the United States. Reports of severe illness, hospitalization, and death have prompted many questions about the risk to ourselves and our families here in Gainesville, Florida.

When faced with questions regarding communicable diseases, the best source of information that I have found is the Center for Disease Control website: CDC.gov . It is CRUCIAL that objective, scientific sources be sought instead of second or third (or fourth or fifth) - hand reports from friends, social media, and even news reports.

While a physician such as myself may revel in the opportunity to dig her metaphorical hands into a great scientific perusal of information for healthcare professionals at the CDC website, this may not be the layperson's cup of tea. The website DOES have a public page on the virus that is excellent, and I encourage you to take the opportunity to go to the site and learn first-hand about the coronavirus, the symptoms of its associated illness, and its transmissibility.

This is the most recent report from the CDC of the presence of cases of 2019-nCoV in the United States. There is no current recommendation for identification of people with respiratory illness that have traveled to those states.

However, there is a decision -tree algorithm that hinges on TWO things: symptoms, plus exposure to a person known to have the virus, or travel to Wuhan China within the past 14 days. The following chart is directly from the CDC website.

Clinical Features & Epidemiologic Risk

1) Fever and symptoms of lower respiratory illness (e.g., cough, difficulty breathing) and In the last 14 days before symptom onset, a history of travel from Wuhan City, China.

– or –

In the last 14 days before symptom onset, close contact with a person who is under investigation for 2019-nCoV while that person was ill.

2) Fever or symptoms of lower respiratory illness (e.g., cough, difficulty breathing) and In the last 14 days, close contact with an ill laboratory-confirmed 2019-nCoV patient.

How the virus is transmitted is currently under research. Scientists are following models they used with the MERS and SARS outbreaks to evaluate this. Right now, the theory is that it is spread via respiratory droplets. Someone coughs, sputum containing the virus exits the person's body, the sputum is picked up by another person and enters his or her body through the mouth or nose.

In the meantime, the best way to avoid infection with 2019-nCoV is the SAME method to prevent transmission of other illnesses:

1) cough into the crook of your arm, not onto your hand

2) if you have a respiratory illness, and must be among others, consider wearing a face mask

3) use hand sanitizer frequently when soap and water are NOT available. Soap and water handwashing is better than hand sanitizer in preventing some virus spread (norovirus).

4) TEACH YOURSELF NOT TO TOUCH YOUR FACE, especially your mouth or nose.

These are the methods that we use in our practice at Gainesville Direct Primary Care Physicians, and we see sick patients every day.

Please contact your physician if you meet the criteria above, and as always, we remain available to our members for questions and concerns about the coronavirus outbreak.

Screening: Looking for Something Wrong when Nothing Is Wrong

Wed, 22 Jan 2020 12:46:30 GMT

The most common reason that people come to the physician is that something is wrong. Often, it is due to symptoms that have either not responded to normal over-the-counter medications and "tincture of time," or it is due to the patient being concerned that it is more serious than the troublesome but largely benign viral illness or rash.

One of the most IMPORTANT reasons to establish with, and come in to see, your physician is for health screening. A screening test or evaluation is something that is done to look for a problem when there are no symptoms or signs of the problem. An example would be a screening mammogram, or a colonoscopy for someone who has reached the age of 50. The goal of these tests is to either catch a disease early, and thus decrease the harm it may cause (such as cancer), or to prevent disease altogether (such as with checking lipid panels to prevent heart disease).

Over the years, physicians have come up with many different hopeful screening tests, but some have not stood the test of time. Others have been adapted as data on their effectiveness has made it more clear. Recommendations change depending on new evidence. An example of the latter is the PAP smear, which screens for cervical cancer. Previously done yearly, it is now done with or without high-risk HPV screening at either 3 year or 5 year intervals.

An excellent source for what screening tests are indicated is the United States Preventive Services Task Force. Their recommendations take into account the quality of evidence that supports the screening test.

In our direct primary care practice, we have found an increased effectiveness in using the screening recommendations for our patients because we have time to get an excellent family and personal history. We also have time to explain the data behind the screening recommendations. This allows for what is called "shared decision-making" discussions that are meaningful. In shared decision - making discussions, we are interested in finding out what the patient cares about, and not just recommending things according to guidelines.

If you would like to find out more about how we are better able to provide screening testing that complies with guidelines AND with shared decision-making discussions, please call to set up your free meet-n-greet with one of our physicians. The number is (352)204-0120 .

Why a Physician?

Tue, 05 Nov 2019 22:11:14 GMT

Gainesville Direct Primary Care Physicians currently offers patients a choice between Althea Tyndall-Smith, MD, and Shenary Cotter, MD. Both physicians graduated from accredited schools of medicine, and completed three year residencies in Family Medicine. In addition to completing residency, multiple arduous and comprehensive tests were successfully completed in order to get into medical school, pass from the second year to the third year of medical school, pass each clinical rotation during medical school, after the first year of residency, and after the 3rd year of residency. Additionally, every 3 years, a Board Certified Family Medicine Physician must complete more testing, and once every 10 years every physician must RE-TEST .....pass a comprehensive Family Medicine Board Certification Examination that takes a full day to complete, and includes information from the entire scope of the field of Family Medicine.

Frequent questions that I get when patients are looking for a potential physician is "do you do more than just prescribe medications/push pills? Do you look at the whole individual and at the causes of problems? Do you have a holistic approach to taking care of patients?"

These questions make me sad. I have no idea where the idea took hold that Family Medicine physicians DON'T look at the "whole" patient when evaluating for health or causes of illness. When did I become a "pill pusher" in the minds of the general public?

One of the sources, I believe, has come from what we call "industry healthcare." Industry healthcare is the medical setting that has physicians seeing 25 - 30 patients a day, barely spending 15 minutes per patient, constantly running late, and being unavailable to see patients when they need to be seen. This unnecessarily pushes patients into urgent care or emergency department settings when these should have been handled in the office of their very own physician.

Physicians need to apologize for participating in this. Most all of us didn't mean to cooperate in this for greed. We thought we were trying to help more people. I apologize.

Dr. Tyndall-Smith and I don't participate in that any more.

Other reasons patients sense physicians are "pill and problem based" include receiving that message, incorrectly, from some others who wish to practice in the heatlhcare setting but in a field other than medicine: this can include nursing, chiropractic, chinese medicine, accupuncture, and naturopathy and homeopathy. In an effort to explain why a patient should NOT choose a physician and choose them instead, some members of these fields will focus on what they believe physicians aren't. The idea that anyone has to denigrate physician care in order to promote their own care is unfortunate: each of these areas has definite unique positive things to bring to patient care without insulting or belittle medical doctors and our sacrificial and extensive education and training, the high standards we are held to, the legal standard we answer to, and our dedication to helping patients.

Also problematic for the patient is understanding what type of "doctor" they are seeing - because it has become more commonplace for healthcare practitioners from fields other than medicine to refer to themselves as physicians and "doctors" without ensuring that patients understand exactly what type of doctor they are. There is a difference between having earned a doctorate degree, and being a "doctor" in a healthcare setting.

At Gainesville Direct Primary Care Physicians, we are very transparent about who we are and what our qualifications are. We clearly and accurately represent ourselves, our education, our Board certification, and our titles. Our patients will only receive care from a physician. We have the time in our direct primary care setting to spend time with patients to take care of them in a truly holistic fashion, combining the best of science has to offer with our ability to connect with and relate to our patients.

As physicians, we are held to a standard of providing evidence-based care. This means that we cannot simply claim that what we are doing works by giving anecdotal (story-like) evidence, or personal opinion, or quoting "evidence" from a single study that may or may not actually have studied what it claims to have studied. We have to prove that what we are doing works before we actually do it, with high quality studies that have been corroborated with additional studies and data, and agreed upon by a consensus.

If you are asking yourself, "Why a physician?" Come visit us for a free visit. You'll see EXACTLY why a physician.

Open Enrollment - Time to Make a Change to Direct Primary Care!

Wed, 04 Sep 2019 22:05:40 GMT

Fall is the Season of Pumpkin Spice, Gator Games, and .....open enrollment. This is a GREAT TIME to decrease your commercial insurance plan coverage (which will make your plan less expensive), and add a membership with Gainesville Direct Primary Care Physicians. The money saved by doing this, even with the added membership, most often results in a net savings for the member or family. Let's look at this more closely!

First, what exactly is "open enrollment," and why does it exist?

Health Insurance Companies want to count on their customers premiums, so a rule was established that customers can only sign up - or cancel or change - their health insurance plans during a very specific, and short, time each year . Exceptions are allowed. For example, if a customer has a baby, the baby could be added to the plan outside of the normal open enrollment period.

Many commercial insurance policies have two or three options. The most expensive plan offers the lowest out of pocket expenses for the customer (deductible, co-pay, co-insurance). the least expensive plan may not cover office visits at all, or requires the customer to pay $40 - $75 per outpatient visit. This plan also usually has a higher total deductible - meaning the portion the customer has to pay before the insurance "kicks in."

The latter plan works very well with Direct Primary Care! Because a member patient pays a low monthly fee to the direct primary care practice, and all outpatient primary care through the practice is included with this fee (including urgent care visits and procedures), the member patient actually ends up saving money.

This is also a fantastic way for employees with employer-sponsored health insurance to get affordable healthcare for family members that the health insurance may be too expensive to include. At Gainesville Direct Primary Care Physicians, family memberships are the most affordable plan we offer. There's a reason we are called Family Medicine Physicians, and that we love taking care of families!

Make sure and call us to talk about your specific needs. We are happy to meet with you and help you navigate these complex decisions! (352)204-0120

www.GainesvilleDPCMD.com

Althea Tyndall-Smith, MD & Shenary Cotter, MD

Direct Primary Care.....and automobiles? huh?

Wed, 14 Aug 2019 21:57:48 GMT

OK, hang with me here. We are going to start with an analogy.

Imagine that every issue related to your car was subject to the question, "does my auto policy cover that?" Yes, collisions and accidents, absolutely. But what about cleaning the fuel injector? Periodic oil changes? Replacing the tires as they normally wear out, with age and use? What about cleaning the carpet, or repairing upholstery tears? Periodic "check ups" and "diagnostics?"

If your auto policy "covered" these things, what would happen to the cost of your auto policy? What would happen to the cost of auto care, given that your mechanic is now responsible for dealing with insurance companies to get paid for every. single. thing. His costs go up. He has to hire staff to deal with this. He raises his prices. Insurance companies decrease how much they pay your mechanic for these services so he sees more "repairs" to try to stay even, while auto insurers raise their prices for their policies, and pay for fewer services, so automobile owners are now faced with paying out of pocket for things that are now MORE expensive!

......and on and on the cycle goes.

Exactly. And this is the current situation with unaffordable healthcare and health insurance that we experience in our country.

Direct Primary Care is a movement that is rapidly growing, as physicians interrupt this cycle in healthcare. Patients join a Direct Primary Care practice, paying a monthly fee that is usually less than half the cost of one "fee for service" appointment at a normal medical practice. The member patient comes in for care as needed, and there aren't additional charges for this care. Most practices see urgent patient issues - like someone needing stitches - outside of office hours, so patients avoid expensive urgent care or emergency room visits. And since the number of members is much less than a normal medical practice has, patient members can be seen quickly - usually the same day for urgent issues or within the following days for non-urgent issues.

Patient visits are longer - ours are at least an hour, unless a patient requests less time. Physicians and patients get to know one another. Relationship is formed.

The office atmosphere is peaceful and happy, without frantic rushing, long waits in the waiting room, and rushing staff and physicians.

Other needed services, like labs, radiography (including CT and MRI), and medications are at a very small fraction of the cost of "industry healthcare."

So, back to our analogy. Automobile owners have insurance policies to cover things that are unaffordable, and unexpected, expenses for their cars. We believe healthcare should return to this model, eliminating unnecessary profit margins for non-healthcare administration, bureaucracy, and insurance, and therefore returning care to an affordable level.

Insurance is appropriate for catastrophic needs, like a hospital stay or surgery. These policies are becoming less expensive, and there are non-insurance options to help with these that are very affordable, as well. Check out health cost sharing groups, like Medishare, Liberty, Samaritans, Christian Healthcare Ministries, and Sedera.

Unlike your automobile, which can be replaced if it wears out, your body cannot be so easily repaired or replaced.

At Gainesville Direct Primary Care Physicians, we believe "You Deserve A Doctor," and that it should be affordable for you, as well.

Please call us to help you take great care of your body's health - we want it to last a long time for you, and for you to have the happiest, healthiest life that you can have!

Megan, our nurse, actually did fix my car :)

What's a Board, and what does it certify?

Thu, 08 Aug 2019 21:44:36 GMT

Gainesville Direct Primary Care Physicians proudly promotes the Board Certification status of myself and my partner, Althea Tyndall-Smith MD. But what does this mean, and why should you care?

For physicians, Board Certification is a designation that requires three steps. The first two steps take a minimum of 11 years, and include a four year bachelor degree, four years of medical school, and a residency (apprenticeship training) of at least 3 years. The last step is an ongoing process that can be revoked in any 3 year period during which the ongoing criteria are not continuously met.

Additionally, physicians may complete a Fellowship in a specialty area beyond initial residency. For example, a Family Medicine physician who completed that 3 year post-medical school residency can do an additional 2 years and obtain the opportunity to sit for a Board Certification examination in Integrative Medicine, or Palliative Care, or Obesity Medicine. There are many others, as well.

The American Board of Medical Specialties (ABMS) oversees these certifications. There is a failure rate for the Board Examinations. For Family Medicine physicians, the examination requires weeks to months of additional study preparation, must be repeated a minimum of every 10 years and includes 360 questions that must be answered in 4 separate blocks of 100 minutes each.

Other types of healthcare professionals may also be "Board Certified." What is important to know is that there is not one "Board" that certifies different healthcare professionals with the same requirements. For example, advanced practice registered nurses (APRNs) may take an examination after two years (this varies) of post-bachelor degree education that board certifies them in Family Practice. The board that certifies them as such is a nursing board. An APRN who passes this examination in the area of Family Practice Nursing may self-descsribe as "Board Certified in Family Practice."

Other healthcare professionals who may be board certified include chiropractors, holistic healthcare practitioners, naturopathic doctors, and accupuncture practitioners. Each of these professionals will have certified under an entirely separate board than the ABMS.

Gainesville Direct Primary Care Physicians support and encourage our patients to explore all healthcare forms that have been shown by evidence to not be harmful and to help for the condition that it claims to help. We enjoy working with many different types of heatlhcare professionals and actively seek non-medication modalities to improve our patients' health, through what we offer as well as through our allied healthcare professionals. We recognize that there is everything to be gained by encouraging our patients to take responsibility for their health by exploring the breadth of what healthcare has to offer today. We also encourage our patients to understand exactly who is caring for them, and the qualifications.

Feeling Healthy?

Wed, 07 Aug 2019 21:34:40 GMT

It is a fantastic feeling - that vibrant sense of wellbeing when we are making all the right choices and effort, and we are seeing, and feeling the results. But "healthy" is more than what we are feeling. A rough night sleep, a car that won't start, a difficult interaction with someone at work - these are all experiences than result in feelings that try to lie to us. The lie says that we are failing, that we can't succeed, that trying is too hard, and that our efforts can't matter. The TRUTH is that each moment is a new start, with the potential to add great deposits into the figurative bank of our overall health. So - if you're feeling healthy right now? Great! Store some of that good feeling up for later, because you'll be able to access it during times when you don't feel so healthy. Not feeling it? It's ok! Be gentle with yourself. Give yourself some grace. Rest and drink a nice cold glass of water. And when you are ready, think of the next positive choice you can make for your body, mind and spirit, and do it!

Gainesville Direct Primary Care Physicians Shenary Cotter, MD and Althea Tyndall-Smith, MD, are ready to cheer you on during this health journey called life. You can do it!