The office will be closed for presidents day on Monday Feb 18. Please enjoy the long weekend!
I am excited to announce that I am hiring a nurse practitioner to join me at Sequoia MD. Kristen brings energy, passion for great care, experience, and kindness to the team, and will be a wonderful addition to the office.
Kristen’s hire strengthens the core pillars of what this practice is about— a long term relationship with your doctor, availability when you need it, a caring place to come when things are not going well, and a place to get your needs met.
For the first few weeks she is in the office, she will be spending a lot of time spending time with me during appointments, and learning the ins- and outs- of how the office works. Since the practice has opened, I have been frustrated that I have no one available in the office on the days I am out. That will no longer be the case.
Lastly, a word or reassurance. I know in a lot of offices, nurse practitioners are hired to make it more difficult to see the doctor. I want to be very explicit that her hire represents a great addition to the team taking care of you, not a gatekeeper to prevent you from seeing me. You can never have too many people on your side, and I hope that with time, she will be as helpful to you as I am.
As always, should you have any questions or concerns, please get in touch.
Today is Election Day, which means I hope you going out to cast your vote.
One of the challenges we face (and which is reflected in our politics) is a lack of community. The importance of having community I have brought up with many of my patients, and it is particularly relevant today. While we all have our opinions (sometimes the same, sometimes different, sometimes strongly held, sometimes not), we all share a need for human connection.
There is an ongoing study out of Harvard that examines the effect of community on our health. One of the most important findings from it is how loneliness (the lack of community), is directly detrimental to our health. In the words of the study’s lead investigator, “Loneliness is Lethal.” You can see a great talk on it here.
So, when you vote today, say hello to the people who are also waiting in line. When you get home, chat with the neighbor. Community is not created overnight, but perhaps today is a good day to start.
Being a doctor, family members often ask me medical questions. “Should I take this medicine at night or in the morning?” or “Is there anything else I can do for my arthritis?” While I don’t mind helping out with these kinds of things, really, it be nice if everyone had a doctor in the family— so something close to it.
That idea is a big part of what Sequoia MD specifically, an direct primary care more broadly, is all about. The entire premise of the practice is that is is built around a relationship. It used to be the norm that your doctor knew you, knew who you are. While that still exists some places now, it is, unfortunately, the exception. I want to bring it back.
I like the fact that sometimes, I see my patients at the park, or at the grocery store. I like the fact that my patients are a part of my community. I think its important to be there when things come up, they can call me— even if its just a small question, or something that you forgot to mention at an appointment.
Its not for everyone. Some people like big institutions. Some people prefer complex systems of care. Me? I prefer relationships with my patients, and I feel incredibly lucky that I get to have that, that I get to the be doctor in not just my own family, but in many families.
Its open enrollment season, and that means it may be time to re-evaluate your insurance coverage.
For those of you who purchase your own insurance (I recommend you have it!), as well as for those who get it through your employer, I put together a brief guide to the types of insurance that generally work best with Sequoia MD. I am not an insurance broker, and you need to make the decision that is the best fit for you and your family. However, below are some general guidelines on coverage that works best with the practice. If you have specific questions, please ask me, or your insurance person.
First, a quick note on how insurance works (apologies if you already know this). Every month, you (or your employer) pays a premium— the cost of your insurance. In exchange, your insurance pays for your medical services. While its a bit of simplification, the more premiums you pay, the less you expect to may out of pocket (the more your insurance pays).
Under most circumstances, lower premium/higher deductible plans work better with my practice. Because you have such good access to your doctor, there are a lot of things most people need insurance to cover that is already paid for through your membership.
Generally PPO plans are much easier to deal with than HMO plans. It is generally easier to get you in to see specialists, get tests covered, etc., than with HMO plans.
Coupled with an HSA (Health Savings Account), this is often a great way to save some money.
Kaiser is challenging to mesh with Sequoia MD. Kaiser is a closed system, so of all the plans out there, it is most difficult to get Kaiser to pay for anything that I order or prescribe for you. You have to go through the Kaiser system if you want Kaiser to pay for it.
I understand health insurance can be confusing— finding the right plan, signing up, figuring out what your benefits are— it can be difficult to understand. For that reason, I have spoken with insurance brokers who understand the way my practice works. If you’d like some names, please get in touch.
Lastly, as a reminder, Sequoia MD is not insurance. If something comes up that is beyond what I can handle for you (car accident, surgery, etc), its important you have coverage for that.
Flu shots are in! Should you get one? Almost always, the answer is yes. I will be discussing them as you come in for regular appointments. If you just want to pop over and get it taken care of, we are planning on having drop-in times Monday and Friday afternoons, as Doris will be available without an appointment.
Every year, tens of thousands of people are hospitalized with influenza and its complications, and thousands die from it. While the flu shot is not a guarantee that you will not get the flu, it greatly lowers your risk. Below are some additional specifics of getting vaccinated:
Who: Essentially everyone. There are some people who should not be vaccinated (for medical reasons) and others who choose not to— however, I would recommend it.
When: Soon. Influenza season is around the corner, and the shot needs a few weeks to begin to be effective.
Where: In the office.
Additional Information: The cost of the shot will be $20.
So, incredibly cheap medications are a known benefit of being a part of Sequoia MD. Everyone knows that. So, what could be better than the medications you need, at a completely affordable price?
How about even an even cheaper price? I recently added another medication supplier, that has some even better deals than what I have been able to offer. It will not be for every medication, but for several medications, the cost will come down even more. I love it.
This will slowly filter through my stock. As I order new medications at (hopefully) lower prices, those cost savings will be passed along. Depending on the medication, this may take a little while to work through the inventory, and will not, unfortunately, apply to everything. I also ask for your patience in advance, as I anticipate having multiple suppliers may cause some small challenges with keeping things in stock.
Still, pretty cool though, right?
This article hits the nail on the head around a lot of the current issues around chronic pain and addiction. It also is another example of another huge challenge in healthcare.
One of the biggest challenges I see in medicine is the idea that "someone else" knows better. For any individual patient, that patient, and the doctor taking care of him or her, are going to make the best decision. It won't always be right, but it will certainly be a better decision than one make for 2.000 miles away. Politicians, insurance company administrators, bureaucrats, "policy makers." and a long list of other people are going to know less about any given situation than the patient and the doctor. And yet, they often have as much (if not MORE) influence, in how an individual patient gets treated.
This is true with managing pain. For a long time, doctors were very concerned about the dangers of prescribing opiates. Then a whole host of other people got involved, and basically told doctors they were not doing a good job, because we weren't controlling patients pain, not prescribing enough. Now, those very same people, are coming back and telling us we are not doing a good job because they are being prescribed too much.
How about we let doctors work with patients to come up with the best treatment for that individual person? Complicated? No. Revolutionary? Maybe...
The last post on language, diabetes, and blood sugar numbers applies not just to diabetes. It applies to most chronic health conditions. Take blood pressure management. Or cholesterol. Or any one of a number of things that are related to health.
We all want to be healthy, and we want indicators that are health is good. But the reality is that sometimes, we have work we need to do. However, instead of viewing a high blood pressure as a sign that "I am a bad person" try re-framing that to, "I'm glad I have that information, so that now I can take care of it." Instead of and elevated LDL (cholesterol) being something bad, view it as an opportunity to focus more on exercise; or on gratitude that we have found out that its high, so that we can address it with medications.
When it comes to data related to your health, good and bad are in the eye of the beholder. Focus on the data, not the baggage that comes with it.
Language matters, and the language we use to talk about blood sugars matters a lot. Sometimes, blood sugar are discussed as either “good” or as “bad.” Oh, your blood sugar is 105mg/dl, that’s a good number. Hmm, your blood sugar is 248mg/dl, that’s a bad number. Its important that you test your blood sugar.
The trouble with this is that no one wants a bad number. As a patient, you’ve put in all this work to take care of yourself, and then… you don’t get the result you want. You get A BAD NUMBER. You feel disappointment, discouragement. Thoughts like, “If I do everything I’m supposed to, and it still doesn’t work out, why bother trying.” Or, when you test your blood sugar, that might be a test that you fail.
But guess what? Type 1 diabetes is difficult to manage. You can be doing everything right, and blood sugars still aren’t where you want them to be. You can be checking constantly, carb counting, exercising, you name… and still blood sugars are high. That alone is frustrating enough, but when you then feel like you have failed, and gotten a bad number, its enough to make you throw up your hands and say, “I quit.”
Consider the following thought experiment: a person with type one checks their blood glucose 4 times per day (or checks a CGM 12 times per day)
(4 times per day) x (365 days per year) x (50 years) = 73,000
(12 times per day) x (365 days per year) x (50 years) = 219,000
Tens of thousands (or hundreds of thousands) of numbers. If every time someone views a number, they are thinking about it as a test that can be failed, guess what? No one likes to fail tests.
So, no more good or bad numbers. A number is just a number. Its a piece of information, like the weather. Its helpful information, so that you have data you can use to take care of yourself. No more testing (how about checking?)
Its just a number. Its just data. Use to to take care of yourself, nothing more, nothing less.
As many of you know, I spend a good amount of time each summer at Bearskin Meadow Camp, in Kings Canyon/Sequoia National Park. Its beautiful up in the mountains, and a tremendous amount of fun. The camp is for children and families who live with type 1 diabetes. My first summer there was over 20 years ago.
There are many amazing things about camp, but one of the things that I took away most strongly from this summer is the community that camp offers. People living with diabetes often feel tremendously isolated. Many of the campers and staff that come to camp feel that most of the year, no one “gets it.” In contrast, while they are at camp, everyone “gets it.” There are a whole host of issues that living with diabetes comes with, and spending time with people who have shared those experiences, is profoundly healing. Why? I think, because it dispels the notion of “I am alone.”
I like to say that the antidote for isolation is community.
The challenge is that the feelings of isolation that go with living with a chronic illness are not isolated to diabetes. In fact, many of the patients I see daily struggle with this feeling. The irony is that this difficulty connecting with others is universal human experience. Everyone feels it, to a greater or lessor extent.
So, for people who are lucky enough to be able to go to camp, come to Bearskin. But, everyone and anyone can practice creating community. If you are feeling nervous about striking a conversation with someone— a neighbor, a friend, someone in the checkout line— know that they are probably just as nervous as you are. And know that both of you will be richer, less lonely, and less isolated, with a bit more human connection. Whether at camp or at home, practice building community.
Isaac Newton’s first law says something to the effect of, “An object in motion tends to remain in motion, and an object at rest tends to remain at rest, unless acted on by an outside force.” This is true in physics. This is true in managing a chronic health condition. This is true in life. The course we are on (or that we set ourselves on) tends to remain, unless we make an effort to change it.
Most people will stick with a current job (even if its lousy!) unless really compelled to change for some reason. People will stick with a broken system (ahem, healthcare), unless really compelled to change. People will continue exercising (if that’s the habit) or not exercising (if that’s the habit), until something spurs change. The interesting thing is, even when you recognize that something is not working, the perceived effort to change it is often greater than the perceived benefit.
Change is hard. Always has been, always will be. The good news is that the effort to change is not required all the time. For example, when I see patients who have been using opiates or alcohol, they have been using consistently for quite some time. Why? Because change is hard, and inertia is working against them. Inertia is pulling in the direction of continuing to use. However, once people start treatment, inertia is working for them. While things don’t always go smoothly, life is now moving in a better direction, and inertia will likely keep things moving in that better direction.
So, its important to get on a good path, to let inertia be your ally, not your enemy. If your inertia, your habit, is to buy healthy food at the grocery, odds are you will continue to do that. If you habit is take your insulin regularly, odds are you will continue to do that.
Is inertia working for you, or against you? Is your daily routine bringing you happiness, or bringing you closer to your goals?
The Chains of Habit Are Too Light To Be Felt Until They Are Too Heavy To Be Broken (attributed to many people, including Samuel Johnson, Benjamin Franklin, and Warren Buffett)
To review from the last post, the scientific method is essentially a 4 part process that can be applied almost anywhere, or to anything: 1) ask a question, 2) create a hypothesis, 3) do an experiment to test the hypothesis, and 4) analyze the results and drawn conclusions. In this post, we will use this approach to explore how to make become happier.
The method first starts with a question— Am I happy? If the answer to this is yes, and you do not feel like you have improvements to make, you can skip the rest of this article. If you feel there is some room for improvement, continue asking questions: What is causing my unhappiness? Why am I not content? Asking these questions should lead to a hypothesis about the problem you are facing.
An alternative way of approaching this is to examine the life of someone whom you admire, and ask what is different about the way that person lives, compared to myself. If taking this approach, be careful— our temptation is to focus on abstract things, like “She’s got more money than I do,” rather than concrete things, like “She exercises every day.” Try and focus on the latter.
Once you’ve formulated your hypothesis, its time to do an experiment to test it. This is key. Absent winning the lottery, its hard to test the hypothesis that a bunch of money will make you happy (the data says by and large no). But, if your hypothesis is exercising every day will make me happy, try it. If you hypothesis is that spending more time with my family will make me happy, give it a go. Do it for a while, a couple of weeks at least. Then, reflect and analyze what you have tried in order to draw a conclusion. Did exercising every day in fact make you happier? Did working longer hours make you feel better? Did spending more time with your family improve things? There is now way to know for sure except to try it.
I understand this whole process may seem kind of silly, or a bit forced and contrived. I know you may be thinking to yourself, “I can figure it out without trying it.” Or, “I don’t want to try it.” Or, “I know what would happen anyway.” I would argue that until you actually try making a change, its difficult to know if it is, in fact, beneficial, or to know just how beneficial it is. So, here’s an idea. Commit to try the process for one month. Pick two areas where you will experiment, and use the method. See how it works. Instead of trusting me about whether or not this whole idea works, try it for yourself. Come up with your own conclusions about if this process is helpful.
The scientific method is amazing. It is a process that has given us everything from penicillin to internal combustion engines, from the internet to solar panels. Most of the modern world we live in, and the advances we take for granted, have been driven by this method.
The scientific method is essentially a 4 part process that can be applied almost anywhere, or to anything: 1) ask a question, 2) create a hypothesis, 3) do an experiment to test the hypothesis, and 4) analyze the results and drawn conclusions. If it sounds simple, that’s because it is. It is also incredibly powerful. Most of us learned about this in school, but we often think about it only in the context of a classroom, or a lab, or things that feel like “science.” In fact, it can be applied much more broadly.
Let’s take a hypothetical problem of having trouble falling asleep at night, and apply the scientific method. First, we would have ask a question, “Why am I not sleeping well?” Then, we would need to develop a hypothesis as to why this is so. Perhaps, “I drink coffee too late in the day” or, “I watch TV too late at night.” Which of this is the answer? The scientific method teaches that the next step is to do an experiment. In this case, the experiment might be to stop drinking coffee after 11 AM. Lastly, we would analyze these results and draw a conclusion. My sleep is better (or not) because I was drinking coffee too late in the day (or not). If this answers the question, great! If not, the process can be repeated with the next hypothesis.
One of the pieces that makes this so powerful is that it systematic. In our example, not drinking coffee for one day is unlikely to yield useful data. We would have to stick with it for a few days to really test the hypothesis. Similarly, making several changes, such as not drinking coffee, starting to exercise, and not watching TV late at night would make it challenging to figure out what was actually causing the sleep difficulties. Was it the coffee? The TV? The scientific method also depends on our ability to observe what we experience. The practice of paying attention, of really noticing what is happening, can be challenging— particularly if we are not sure what to pay attention to, or if we are not sure what, in fact, is important. In this case, noticing changes in sleep is something that we could really focus on.
In the next post, I’ll talk about how this same approach can be applied not just to challenges like sleep, but bigger obstacles we face as well.
I recently saw a patient in the office who sees a specialist. His specialist had started him on a new medication (that I also prescribe sometimes), but the patient hadn’t picked it up from the pharmacy. He said it cost too much. This man is not particularly well off, but does ok. So I asked him how much it cost. I was thinking maybe I could convince him to pay for it for a month, see if it worked, and then make a decision.
“Eight seventeen” he replied. “Can you believe that?”
That didn’t seem too expensive to me, I though he probably could afford it, but maybe it just wasn’t worth it to him. Still, I could try and find him a lower price, I like solving problems for my patients. I asked him to wait for a moment. Maybe I could shave a a few dollars off, and that would be the difference. After a bit of looking, I found the medication and the price, and felt disappointment.
“Sorry, I can’t beat that price. I can order it, but it would cost you about $12 or $13 to get it from me.” I was a bit bummed. I like to help if I can. Still, maybe I could convince him to try it for a month or two, see if it would help.
“That’s fine,” he said, “could you order it?”
I looked at him. Why would he want to pay be an additional 5 bucks for the the same medication he could get more cheaply from the pharmacy? He told me cost was the problem, but was willing to pay more to buy it from me?
“Sure, but why don’t you get it from the pharmacy?”
He looked at me. “Doc. I told you, they wanted eight seventeen for it. I can’t afford that.”
I frowned. $8.17 is cheaper than $12, $8.17 is cheaper than $13, this doesn’t make any sense. I mean, I can order it, but why pay more? You just told me, cost is the issue. Then, slowly, it sunk through my skull.
“DO YOU MEAN TO TELL ME THEY WERE TRYING TO CHARGE YOU MORE THAN $800 FOR THIS?” I felt like my head was exploding. I couldn’t believe it. The pharmacy was trying to charge him with insurance, $817. Eight seventeen. Eight hundred and seventeen dollars.
He looked at me and shook his head, “Yeah doc, that’s what I told you. They said it was eight seventeen. There’s no way I can pay for it. Go ahead and get it for me, maybe this one will work.”
I want to be clear: I don’t stock every medication. I can’t get every medication for less. But boy is it fun when I can save my patient $805 on a single prescription.
I am always looking for ways to lower healthcare costs for my patients, and so am excited to announce I just implemented new prices for labs that are even cheaper than before. How cheap? Very. Like, 10-80% cheaper than the already cheap prices you’ve become accustomed to. Now, I’m not saying this so that suddenly I start ordering lots of labs for you, but it is pretty nice to know that when you need them, you can get them with a minimum of fuss. And expense.
Healthcare can be expensive, but there are lots of ways to lower the cost of labs, medications, and other things that you and your family need. Lower cost, high quality healthcare-- that's what we are after.
I’m working on a few more projects that hopefully will help with this over the next few months as well, so stay tuned.
Have you ever gone to to pick up a medication at the pharmacy, and been told, “its not covered by your insurance.” Its annoying, right? Its also annoying as doctor when this happens: I pick what I think is the best medication for a patient, and then am told by an insurance company if this is ok, or not. You know what is especially annoying? When we are arguing over pennies.
I recently got a fax from a pharmacy. I had prescribed a medication to a patient, and before the insurance company would agree to pay for it, they needed additional justification as to why this was the right medication. Keep in mind, this was a medication to decrease stomach acid in a patient who was having heartburn. But before I spent 20 minutes filling out paperwork and faxing it back, I decided to check my inventory, and see how much it would cost the patient to get the medication from me. The answer?
You read that right— about half the cost of your morning coffee. Oh, and that cost includes my mark-up.
This is not an isolated incident, and is not the first time something like this has happened. I once had a patient wait 10 days to start a medication because the pharmacy had to get authorization for a medication for which I charge $1.53 per month (that is 5.1 pennies per day).
Now, I don’t think I can change the enormous healthcare system. I don’t think I will be able to change it even in California. But I do think I can change it for myself, and for my patients. Its a wonderful feeling; instead of getting angry about the absurdity of it, instead of trying to convince an insurance company to spend 5.1 pennies per day, instead of getting indignant because of the difficulties my patients are exposed to, build a solution that actually works.
I had to discuss a patient under my care with a colleague, who works as a major local healthcare system (name withheld to avoid embarrassment). I spoke with her nurse on Friday, and was told to call back on Monday. Ok.
I called Monday. I got a phone tree. I dialed the phone tree. I got a message, “Thank you for remaining on the line. Your call will be answered by the next available representative.” This helpful message would repeat every 30 seconds. I waited for 20 minutes (that's 40 times I got to hear it). Then Next Available Representative picked up and asked me for the medical record number of the patient at this [major medical institution].
“I don’t have that information”
“Ok” says the available representative. “One moment please.”
I call back. I dial the phone tree. I get the same helpful message, “Thank you for remaining on the line. Your call will be answered by the next available representative.” I wait. Again. For 10 minutes.
I again ask to speak with Dr. ______.
“Let me see if Dr. Is with a patient.”
Again, on hold. Wait 4 minutes.
Available representative comes back. “Dr. _______ is with a patient. Should I leave her a message?”
“I don’t know.” I respond. "I spoke with the nurse on Friday, and was told that to speak with Dr. _____, I dial this number, and ask to speak with her.”
“Ok” says Available Representative. “Let me check with the nurse.”
2 minutes later.
“Let me transfer you to a nurse”
Nurse, “Can you please verify the patient’s DOB?”
I give it to her.
“Can I put you on hold and see if Dr. _____ is available?”
“Sure” I say.
On hold. 2 minutes.
“Dr. _____ is finishing up with a patient, can I have her give you a call back?”
“Sure” I say.
So, it took me 45 minutes to discover a) the doctor was busy and b) she would call me back.
To be clear— this is a great doctor. I’d send a family member to her. She’s just trapped in a lousy system.
Want to know what happens when you call Sequoia MD?
You call the office. One of three things will happen: someone (usually me) answers the phone. Or, Doris answers the phone, or you leave a voicemail. If it happens to go to voicemail, things get really complicated, and you have to make a decision:
You leave a message and I call you back, usually within a couple of hours, always same day.
You try my cell.
You send me a text message.
You send me an email.
Don't believe me? Try it sometime, just to see what happens.
Often, complex ideas are better explained with a story than with charts, graphs, or statistics. This story comes from Buddhism, and is one of my favorites.
There was once a man on a long journey. As he walked the path, he found he continued to cut his feet on the sharp rocks in the path he walked. His feet were painful and bloody, constantly being cut. Being a compassionate man, he realized if the sharp rocks were cutting his feet, they were probably cutting the feet of other travelers as well. Resolving to do something about this, so set about covering the sharp rocks with leather, so as to protect both his feet, and those of his fellow travelers.
He resolved that this would be his great work-- covering the sharp rocks with leather, for himself and his fellow travelers.
However, the more sharp rocks he covered with leather, the more sharp rocks he saw. No matter how many sharp rocks he covered, there always seemed to be more. He and others continued to have cuts on their feet. Despite his great exertions, and thousands of sharp rocks that were covered with leather, the cuts persisted.
One day, a monk was traveling the path, and stopped and asked what he was doing. The man explained, and showed the monk his progress, as well as the continued challenge he was facing. The monk replied, “Don’t you think it would be better to put leather on your feet, rather than putting leather on the world?”
Last post, I discussed how we can view substance abuse through the framework of a chronic relapsing-remitting disease. This post, we will explore what that means for treatment.
First, the goal of treating any relapsing-remitting disease is to induce remission— make the flare-up, or the relapse, stop. This is often (though not always) achieved through medications. Once the disease is in remission, the goal is to keep it there.
So, how do we keep diseases in remission? Well, it depends on the disease. Hopefully, we have medications that patients can take to keep the disease at bay. Often, the first question that comes up with this is, “Does that mean I have to be on medications for the rest of my life?” The answer is not simple, and involves weighing the risks of taking a medication (with its potential side effects) against its benefits (a higher likelihood the disease remains in remission). This is not a one-size-fits-all question, and really involves discussions about the risks and benefits.
So, if remission is the goal, what about relapses?
Well, they happen. I wish they did not. I do not encourage them. The reality, however, is that they do happen, and when they do, its vital important that they are recognized as soon as possible, and addressed as soon as possible. This is true whether we care talking about Ulcerative Colitis or Opiate Abuse. The longer the relapse continues, the more damage is done; the sooner it is recognized, the faster we can intervene and get things back on track.
The goal with relapses is to make them as short as possible (an hour is better than a day, a day is better than a week, a week is better than a month), as infrequent as possible (once a month is better than once a week, once a year is better than once a month) and as little destructive as possible, both in terms of health and in terms of damage to those around us.
While this model is not perfect, it is helpful. And the good news, when it comes to treating opiate or alcohol dependency in particular, is that we have some very good medications that generally do not come with a lot of side effects. However, as with pretty much any chronic disease, the best outcomes are really achieved through a combination of medications and behavior change. Its not either/or, its both.
-Justin Altschuler, MD