Dr. Malia Reckons

I am sorry to say this, and I need to move beyond the emotion, but right now, I feel bitter.

This year, I have not been able to get a small order of 150 influenza shots. In past years I have had a couple flu clinics for my own patients on Saturdays and Sundays when I gave out about half my shots. The other half was given during appointments with high-risk patients, those I scheduled in October and early November with diabetes, heart disease, lung disease, chronic kidney disease, etc. Anticipating the flu shots, and trying to help them get better value from one appointment and not waste time and energy, I plan such appointments many months ahead of time.

Now, in an effort to get the influenza vaccine to high risk populations early, before the H1N1 flu vaccine is more available, and lessening the risk of confusing the two, the seasonal flu shots were sent from manufacturers directly to companies that run community outreach programs and large pharmacies.

That, by itself, would not be a problem if I also could get a supply to offer my patients in my own office. But, this year is incredibly frustrating, and I, like many, many other primary care docs around the country, am not getting an order of flu shots.

Adding insult to injury, at least one pharmacy is letting patients schedule times for flu shots but they do not yet have a formal protocol for giving them and therefore have to get a formal approval from me to give the shots. I'm spending time every day explaining to patients about the hassles I have had trying to get flu shots, encouraging them to get the shots, and then asking them to find the community outreach programs and pharmacies where the shots are available.

Like so often happens in primary care, this is a situation where I am trying to work for the benefit of my patients but then others in the system are getting paid while I'm left empty handed. It is a business model with fundamental flaws.

Consider this: for my own patients, with whom I have long, on-going relationships, and for whose care I maintain malpractice insurance, I spend time and energy getting them to go to a pharmacist (a pharmacist!) of a large corporation to get a flu shot. And, I must wonder, what happens to my patients if they have severe reactions? A post-vaccination reaction will be dealt with by whom? The pharmacist? Or me? Who gets the phone call if there are questions after the vaccination?

I am bitter, but not proud of it. I can not get flu shots, but large corporations can. I have to encourage my patients to get the flu shots, but then someone else in healthcare will profit from my efforts.

Watch for other blog posts later about this, but here I present a major problem in the American system and primary care. Society has two trump cards that get thrown at primary docs depending on the situation and on what the powers-that-be need at one time or another. Either docs are told: "this health care stuff costs a lot of money, so you better run a good business model and focus on value for the patients," OR, when it serves other needs, we are told: "but doctor, don't you have a moral obligation for the welfare of your patients and to not think of care as a business?"

In the end, the system is making doctors who can't maintain the business model and are so burnt out they can't maintain the proper moral tone. In discussion groups among doctors working hard to make primary care better, I see this feeling again, and again. And I fear the general public does not understand the situation or what the doctors are feeling.

I'm sorry, but, right now, I'm bitter.

--Timothy Malia, MD

Check out this video, The H1N1 Rap by family physician John D. Clarke, MD of New York City. It says it all.

As Dr. Clarke points out, for more information about the flu (seasonal and H1N1), there is plenty of good info at http://www.flu.gov/index.html

More influenza info at http://www.cdc.gov/flu/

Stay well -- Timothy Malia, MD

I just finished my Wednesday evening office hours. My last patient reported that almost 48 hours ago he had sudden onset of headache, body aches, fever and cough; but he had been well prior to symptom onset -- classic flu symptoms.

He already missed work yesterday and today.  He called me this afternoon, about 44 hours after symptoms started, and I fit him in this evening. His circumstances place him at high-risk for severe infection. A phone call to the pharmacy during the appointment will allow him to start the anti-virus medicine for influenza infection immediately. But I sure wish he had called yesterday so I could have evaluated him sooner.

Spread the word -- the antiviral medicines for influenza can only help if started within about 48 hours of the symptoms starting.  After that, the virus has multiplied in number enough that the meds won't limit them.  The meds only slow down the replicating (ie-multiplying) of the virus early on. If you take them in time, they can help lessen your symptoms, lessen how long you will be sick and lessen the chance you may pass the influenza virus to others.

IF YOU HAVE SYMPTOMS OF FLU (headache, body aches, fever, cough, fatigue... especially if sudden onset), CALL YOUR DOCTOR RIGHT AWAY so you can be evaluated the first day or so and possibly start the medicines that might help.

One point to consider, of course, is that the influenza medicines are meant for patients who are already quite sick or at the most risk of severe illness, especially those with other health problems (lung disease like asthma or emphysema, heart disease, kidney disease, diabetes, or if on medicines that weaken the immune system, etc). But I suggest you let your doctor consider your risk and total health, and whether the medicines are appropriate for you -- be in touch with your doc sooner than later.

Another thing to remember: many patients who die of influenza have pneumonia from a second infection on top of the initial flu infection. So, if you are being treated for flu, and you are feeling worse, or having problems with breathing, or having other difficulties, stay in touch with your doctor and get re-assessed.

For more information about influenza (no matter if seasonal flu or the 2009H1N1 flu), check these sites:

• http://familydoctor.org/online/famdocen/home/healthy/vaccines/477.html (good video explaining flu ... FamilyDoctor.org is one of my favorite health sites)

• http://www.cdc.gov/flu/ (has lots of information about both seasonal flu and the 2009H1N1 flu, or "swine flu")

Remember, the most common symptoms of influenza:

• fever
• cough
• body aches
• headache
• fatigue
• sudden onset of symptoms
• other symptoms may include sore throat, stuffy/runny nose, nausea or diarrhea, but those are less prominent.

If you have these symptoms, get in touch with your doctor right away so you can be evaluated, and, if needed, get treatment started as soon as possible.

Finally, below is a link to the CDC's latest flu activity map for the country which is updated weekly. Currently, most cases of flu are due to the 2009H1N1 virus.

http://www.cdc.gov/flu/weekly/WeeklyFluActivityMap.htm

Stay well -- Timothy Malia, MD

I have not touched on an actual health issue for a while. So here is a good one. 

With the cold and flu season approaching, you should consider how to keep yourself well -- and getting adequate sleep should be high on your priority list.

OK, this is not earth-shattering news, but it is now backed by some published research and is not just a casual recommendation.

I ran into this news in the NYTimes column called Really? which regularly looks at long-held beliefs or old wives tales about health and well-being to see if they hold water.  The piece about good sleep preventing colds can be found at http://www.nytimes.com/2009/09/22/health/22real.html?ref=health

The actual research was published in the Archives of Internal Medicine. The study found that adults getting more than 8 hours of sleep a night for two weeks were 3 times less likely to get a cold after being exposed to cold viruses than folks getting less than 7 hours. Also, better quality of sleep was protective. Here is a link to the article's abstract -- http://archinte.ama-assn.org/cgi/content/abstract/169/1/62

Basically, researchers monitored people's sleep for two weeks, then exposed them to rhinovirus, the pesky bug that causes the common cold. They then studied who was more likely to get a cold, and, lo-and-behold, less sleep and lower-quality sleep increased the risk of getting a cold.

So there is my advise to prevent colds: get your sleep, and don't forget to wash your hands.

Now, it's late (yawn), and we all should be hitting the sack (yawn), and preventing colds ... Good night ... Zzzzz...

--Timothy Malia, MD