My Doctor Medical Group Update 04-10-2020

Sent to the patients of My Doctor Medical Group on 4/10/2020 by Paul Abramson MD

To Our Patients,

Keep reading for more information about how to get medical care during this difficult time, how to provide support and two free therapy sessions for first responders/front line medical professionals, and how we are providing medical services while we are sheltering in place.

Answers to the most commonly asked questions about COVID-19:

Paul Abramson MD
Medical Director

Q: What's the status of COVID-19 in San Francisco?
A: “Flattening the curve” seems to be working, so far. ERs and hospitals are not busy and not full as all elective surgery and almost all outpatient activity was cancelled. We’re seeing lower rates of heart attacks, hip fractures, appendicitis, and many other illnesses as fewer people are exposed to risky activity or other diseases.

Q: Should I be afraid of going to the ER for a non-COVID illness?
A: No. Hospitals are not full, resources are plentiful, and access to emergency care is excellent. Dr. Abramson can get you a private room directly at CPMC, St. Francis or St. Mary's on short order. There's no current reason to be afraid of needing hospital care.

Q: What's up in at My Doctor Medical Group?
A: We’re here. We're all-hands-on-deck working hard to serve our patients. Your options for care are during this time are:

Online video conference: Speak with any of our doctors and staff through video chat. Over 95% of our patients are pleased with this option.
Home and hospital visits: Dr. Abramson, Justin Davis, and our affiliated physicians can visit you, as needed, in full PPE to reduce risk of infection.
Office visits: SIP guidelines allow for visiting doctor’s offices and pharmacies. We have a dedicated safe space at our office for urgent care.
COVID-19 Testing: Both PCR swabs and antibody testing are available in the office or at your home or workplace. Employer based testing can be arranged for groups, too.

Q: What hospital should I go to if I get sick in or near San Francisco?
A: We recommend one of the hospitals where Dr. Abramson and his team have privileges:

First choice:

Sutter CPMC Van Ness Campus (1101 Van Ness).

Alternatives:

Sutter CPMC Davies (45 Castro) or Mission Bernal Campus (3555 Cesar Chavez).
St. Francis Hospital (900 Hyde)
St Mary's Hospital (450 Stanyan St).
If necessary: UCSF

First Responder/Health Care Worker Support

Our team is actively working with our patients on stress-related issues. All of these services are available over video chat. We offer:

Free counseling for front line personnel. We are offering two free video counseling sessions after which continuation in our practice is possible or referral elsewhere. Go to https://mydoctorsf.com/contact to schedule a session.
“Psychological First Aid” is available for those suffering from acute symptoms and need immediate care and support.
Psychotherapy: Our three expert psychotherapists are available as always.
Stress support: Some people are benefitting from (safe) medications and/or dietary supplements for anxiety, sleep, and other stress-related issues. We are very thoughtful in our prescribing.
Regular check-ins: Regular chats with a doctor who is up-to-date on the current COVID-19 situation and government guidelines can address any new or on-going non-urgent concerns.

I hope this message has been helpful to you. We're in the office M-F 9am-5pm and available for urgent issues 24/7.

This information is also available for reference and/or sharing at https://homecovidtest.com/blog
Our practice web site is https://mydoctorsf.com

Sincerely,
Paul Abramson MD

Medical Director, My Doctor Medical Group
Assistant Clinical Professor, UCSF
415-963-4431
[email protected]

Plague in Madagascar

World Health Organization Advisory: Plague in Madagascar: October 2017

As of October 4th, the Ministry of Public Health of Madagascar reports 194 cases of plague, including pneumonic, bubonic and once case of septicemia, with 30 deaths in 20 districts and cities across the country.

Implications for travelers:

The risk of infection with Yersinia pestis for international travelers to Madagascar is generally low. Plague is endemic in Madagascar where cases are reported every year. Due to current cases reported in several cities (including the capital Antananarivo) and the start of epidemic season (September to April) further spread is likely.

Madagascar is well linked by air both regionally and internationally. One visitor from the Seychelles who was participating in a basketball tournament was infected and died. Travelers to rural areas of plague-endemic regions may be at risk, particularly if camping or hunting or if contact with rodents takes place. In addition, travelers to previously non-endemic regions from where cases of pneumonic plague have been recently reported should avoid crowded areas, avoid contact with dead animals, infected tissues or materials, and avoid close contact with patients with pneumonic plague.

Travelers can protect against flea bites using repellent products for personal protection against mosquitoes, fleas and other blood-sucking arthropods. Travelers returning from Madagascar should seek immediate medical attention if they experience symptoms of fever, chills, painful and inflamed lymph nodes, or shortness of breath with coughing and/or blood-tinged sputum.

Based on the available information to date, the risk of international spread of plague appears very low. WHO advises against any restriction on travel or trade based on the available information about the plague in Madagascar.

Reference (NPR): http://www.npr.org/sections/goatsandsoda/2017/10/04/555338600/why-plague-season-is-a-big-worry-in-madagascar-this-year

Source: WHO: Plague in Madagascar: Disease outbreak news

KQED Science: Dr. Abramson Interviewed on NPR About Health Technology

Dr. Abramson was interviewed on NPR Morning Edition by Amy Standen yesterday about the role of wearable technology and health apps in the doctor's office.

Take, for example, Dr. Paul Abramson, a primary care doctor in San Francisco’s financial district.

Abramson is no techno-phobe. He sees patients in a sleek white office with a hydraulic standing desk from Denmark and listens to their hearts with a digital stethoscope.

“I like gadgets,” Abramson explains.

Abramson sees many patients from the tech industry. More and more, he says, people are coming in with data collected from consumer medical devices. One recent patient took this to an extreme.

Listen to the show or read a transcript here:

Do Wearables and Health Apps Belong in the Doctor’s Office?

Giardia: Not a Traveler’s Best Friend

Giardiasis is a fairly common infection of the small intestines caused by the organism Giardia intestinalis (also known as Giardia lamblia). Giardia is a protozoan parasite that thrives in the intestinal tract of mammals and that reproduces by forming cysts, which are transmitted from host to host through the feces of an infected person or animal being ingested by another. The cysts are very resistant and can survive for long periods of time in fresh water, such as lakes, streams and reservoirs.

While Giardia is a common issue in backpackers in the United States (it is present ubiquitously in all states), it is also an under-recognized issue in travelers to developing countries where the water supply can be contaminated.

You can acquire Giardia by:

Eating contaminated food or drinking contaminated water;
Taking in water while swimming in contaminated lakes, ponds, and other fresh water;
Ingesting contaminated feces, including via sexual contact.

Infection is only symptomatic 50% of the time, and it may take up to three weeks or longer for symptoms to occur. However, symptoms are often severe when they arise:

Diarrhea
Gas
Greasy stools that float
Stomach pain and cramping
Nausea
Dehydration
Weight loss of ~10 pounds

Symptoms may last 2-6 weeks before resolving, or can be longer-lasting. Once diagnosed, treatment is always a good idea. To properly diagnose Giardiasis, a doctor or other licensed health care provider must order a stool test for specific Giardia antigen testing, since regular ova and parasite microscopic exams often miss this organism. But it's important to do the microscopic exam for other ova and parasites as well, since multiple microorganisms are sometimes contributing to symptoms.

The complications of Giardia can be frustrating. Some people find that they are lactose intolerant or have developed irritable bowel syndrome (IBS) after Giardia intestinalis infection.

To avoid Giardia, take the following steps:

Practice good hygiene and hand washing
Avoid possibly contaminated water
Use a UV water purifier, halogenation, or a filtration device small enough for parasites
Boil water long enough to kill cysts (one minute, or 3 minutes at elevations of 6500 feet)
Avoid contact with feces
Avoid uncooked foods while traveling

If you suspect that you do have Giardia, seek medical attention and get a specific stool test, since usual antibiotics for travelers diarrhea (ciprofloxacin or azithromycin) will not cure this infection. If you have more than one type of infecting organism, you may need multiple medications to treat them all.

If you have after-effects of Giardia infection, medical attention may also be of help in remedying persistent symptoms.

And before you travel to developing countries (including Mexico), consider having a professional travel medicine consultation.

References:

Giardia Treatment and Diagnosis (Stanford)
Patient Information: Giardia (Beyond the Basics), UpToDate.com
Giardiasis, Mayo Clinic
Giardiasis, Clinical Key
Giardia Infections, Medline Plus
Giardia infection, National Library of Medicine

Paul Abramson MD Interviewed On Doctors Who Accept Bitcoin

Health IT News ran a piece this week about physicians who accept payment in the virtual currency Bitcoin. Dr. Paul Abramson was interviewed on his experiences taking Bitcoin at My Doctor Medical Group in San Francisco.

Abramson, founder of My Doctor Medical Group, is a former software programmer and trained electrical engineer with a significant personal interest in privacy.

It was privacy that drew him to learn more about bitcoins. Early assessments of the technology suggested the bitcoin exchange system had significant anonymity protections that could augment existing medical privacy laws and allow patients who sought the ultimate discretion a nearly invisible form of payment.

“It's important for people to be able to maintain their privacy” about all things, but particularly medical issues, Abramson said.

However, as bitcoin use has expanded, further exploration of its privacy protections has shown that, while it does take some effort to uncover a bitcoin user's identity, it is possible.

You can read the whole article here:

Healthcare IT News Interview

For Reddit r/bitcoin commentary: Reddit commentary on interview

For more information on Bitcoin at My Doctor Medical Group: A Doctor Who Accepts Bitcoin

The Quant-Friendly Doctor at the Quantified Self Conference 2013

This past Thursday, Dr. Abramson and I attended the Quantified Self Conference in the Presidio in San Francisco. We hosted a morning breakout session titled “Quant-Friendly Doctors and Doctor-Friendly Quants” that drew a very passionate and diverse crowd. We began by describing what exactly it is we are doing in our medical practice with self-tracking and our unique Quant Coaching Program. The questions and debates sparked were interesting and at times emotionally charged. Little did we know that one astute woman in the audience was live tweeting the whole thing!

Whitney Boesel is a sociology PhD student who writes for Cyborgology, and studies mood tracking and the sociology of new technology. During our hour-long session, Whitney tweeted 29 times. She was able to boil down some of Dr. Abramson’s core values and aspects of our Quant Coaching Program to a series of 140 character messages.

Among QSers there’s a wide range of interest in institutional medicine/willingness to even talk to a doctor.

Similarly, doctors range widely in their willingness to work with QSers- some are not willing to give up authority and control.

@PaulAbramsonMD has a quant coach in his practice – someone to help with your project/process, but not at MD rates.

Some of @PaulAbramsonMDs quant patients are still tracking with his office, some had had problems solved, others have dropped out.

@PaulAbramsonMD not surprised that some quant patients have stopped tracking; tracking can be exhausting, especially over time.

“This is an individualized approach. We WILL NOT turn it into a study.” @PaulAbramsonMD re: outcomes/tracking as intervention.

Once patients start tracking something, experiment protocols and treatments usually end up changing. Lots of unexpected findings!

The more interesting stuff in tracking is the *missing* data – for instance, what happened for the 3 meals that someone *didn’t* photograph?

Passive tracking is much less interesting -@PaulAbramsonMD finds patients learn more with manual tracking (& data review w/ coach).

@PaulAbramsonMD: Self-tracking data belongs to patients; their data itself does not go into their medical files (in his practice).

Part of why @PaulAbramsonMD can work w/ quant patients is that he doesn’t take insurance (though many patients get reimbursed).

@PaulAbramsonMD: “in managed care settings, you never really get to the bottom of things” & never get to answer all the questions.

“There are a number of people for whom paleo is extremely bad” -@PaulAbramsonMD on why there’s no 1 size fits all nutrition advice.

Patients who are the most driven are most successful; others don’t track as rigorously (&don’t need/want to pay for help).

In quant patient practice, @PaulAbramsonMD puts more time in with patients in beginning; finds they need him less later on as a result.

“If you don’t have a serious condition, don’t track” -@PaulAbramsonMD thinks most ppl doing ‘curiosity tracking’ get bored & stop.

“They start taking pictures of their 5 bourbons a night…& we thought we were tracking for weight management!!”

Doctors who are too mired in 8-to-12-minute visit systems can’t do this -@PaulAbramsonMD re: his quant patient model.

I order WAY fewer tests now than I did working in managed care -@PaulAbramsonMD on his quant patient practice.

@PaulAbramsonMD jokes that MD stands for ‘Material Doctor’ – most patients are looking for physical reasons/triggers for problems.

“We’re trying to focus on each individual. we’re not focusing on populations.”-@PaulAbramsonMD on his ‘quant patient’ practice.

Q for @PaulAbramsonMD “how would you convince colleagues or other physicians to think like you?” (room chuckles).

“It’s the conversation abt the data that has value, not the data itself -@PaulAbramsonMD on why no self tracking data in patient files.

@PaulAbramsonMD “insurance companies have never really paid for prevention.” early detection is not the same thing.

“I want to work w/individuals, not theories. My bias is…I’ve never really been interested in pleasing The Man.” -@PaulAbramsonMD.

@PaulAbramsonMD defending his extreme disinterest in working directly w/ insurance companies or trying to change managed care.

“When I say I don’t want to work in the system or with insurance companies, ppl say ‘HOW DARE YOU’…but I only owe my patients.’ -@PaulAbramsonMD

Q re: avoid nightshades: “I haven’t met anybody…who figured out that kind of thing by listening to insurance companies, by doing whats prescribed.”

“I am 44 yrs old…I have limited # of productive years. This is how I want to spend them” -@PaulAbramsonMD on his own practice over activism.

We'd like to thank Whitney for her reporting skills, and look forward to next time! We will be happy to engage in discussion if one emerges.

SF Chronicle Interview: Paul Abramson MD on Medically-Supervised Self Tracking

My Doctor Medical Group founder Paul Abramson MD was interviewed this week in the San Francisco Chronicle about his use of self tracking technologies, in collaboration with “Quant Coach” Lauren DeDecker, to collaboratively help his patients in San Francisco solve vexing health challenges, taking the do-it-yourself Quantified Self approach to a professionally-supervised level.

Most importantly, Dr. Abramson emphasized that self tracking in a medical context has “..made me focus on the fact that medical care is more of a process .. It's more than just a result.” Far beyond simply using the “medical gadget of the day,” his practice offers a highly-supported environment for patients to gain self knowledge while conducting safe and effective physician-supervised personal health experiments.

An excerpt from the article:

When Dr. Paul Abramson treats patients, he has the usual assortment of medical tools, tests and protocols. And then there's the patient-gathered data he reserves for his most confounding cases.

Using an iPhone app, Abramson will have a patient with, say, mystifying migraines or seemingly inexplicable stomachaches self-track data such as how much sleep they're getting or what they're eating.

That information is eventually fed back to Abramson as potential clues to whatever medical mystery he's trying to solve. The result is a more complete picture of his patients that in turn makes it much easier for him to figure out what's going on. […]

Click here for the entire article at SFGate.com

For more information about medically supervised self tracking and the Quant Coach program at My Doctor Medical Group: Click Here.

Irritable Bowel Syndrome (IBS), When the Mind-Body Connection Short Circuits

So many diseases and conditions in America are automatically treated with a prescription pad. But what if pills won’t help?

“The mind and the body are linked, physically, neurologically, as well as emotionally, and that things that affect the mind can affect the gut and vice versa. If you do something to alleviate mind stressors, you can improve body functions.”

Truer words have not been spoken, by Dr. Arnold Wald in a recent Reuters Health article on the mind-body connection and Irritable Bowel Syndrome (IBS). IBS is characterized by abdominal pain and constipation, diarrhea, or both. The abdominal pain is typically due to gas and bloating. While the cause is unknown, many factors appear to play a role in the development and treatment of IBS.

Infection. The risk of developing IBS is elevated after a bacterial, protozoan, helminth, or viral gastrointestinal infection, including travelers diarrhea.
Inflammation. The immune system is activated in some IBS patients, particularly those with diarrhea (though inflammatory blood markers will appear normal). Increased intestinal permeability may also be present.
Gut flora. Emerging data suggest that the microbiota of those with IBS differs from healthy individuals and varies with the predominant symptom (constipation versus diarrhea). Gut flora is often disrupted after taking antibiotics, especially repeatedly.
Food sensitivities. Some IBS sufferers have sensitivities to carbohydrates (like FODMAPs), fructose, gluten, and/or dairy.
Genetics. There may be gene polymorphisms that increase the risk of IBS. One study on twins did indicate that familial nature of IBS may be due to social learning as well as genetics.
Stress and mental health. Patients with IBS symptoms report more stress in life and day to day. They tend to have more anxiety, depression, phobias, somatization, and sleep problems. This isn’t surprising, as 90% of the neurotransmitters in the body are located in the intestinal nervous system. A problem in the mind can transmit to a problem in the gut, and vice versa.

Because of the many contributory elements to IBS, treatment is a multi-faceted approach. Because it is likely unclear what is causing your IBS, it is best to treat each possibility, one at at time. A first line of treatment will consist of dietary modifications like eliminating lactose, starting a no-FODMAPs diet, very low carb diet, or gluten free diet.

Diet and Supplements. An evolutionary, or “Paleo” diet plan combines several of these approaches and can be easier to implement. Fiber, probiotics, or anti-inflammatory supplements may be a next step if symptoms continue.

Mind-Body Medicine. Because of the apparent mind-body connection with IBS, psychotherapy may be very helpful in alleviating symptoms. A randomized controlled trial of 431 adults showed that cognitive-behavioral therapy (CBT) was effective at treating severe IBS, and probably more effective than medication. Other studied mind-body techniques include meditation and acupuncture. Medications can be effective, but the best long-term strategy often involves a multi-modal approach.

Physical activity is another natural option that may help alleviate stress and improve gut comfort and motility.

With so many options for treatment, it is important to try one thing at a time to see what helps your symptoms and what does not. Tracking the symptoms and changes is important for differentiating between what works and what doesn’t. Medically-supervised self tracking, using our model of a Quant Coach and Quant-Friendly Doctor, can guide you in your experiments and ensure that they are done in the most efficient and safe manner, as well as provide support on your journey, and keep an eye on your medical status.

Bitter Pill: Why Medical Bills are Crushing Us. Investigative reporting at its best from Steven Brill. #costsofcare

Required reading for everyone who lives in the United States, or who is thinking about doing so: Steven Brill delivered an amazing piece of investigative journalism in February 2013 on the U.S. health care system in Time Magazine. Hopefully everyone will read it before they develop a serious illness, but regardless it lays bare some of the reasons why the health care economy makes absolutely no sense. That in itself wouldn't be a problem, but it's also bankrupting individuals and the entire country, which is really a shame.

[We have updated this post to correct the spelling of Steven Brill's name, but also to republish it to keep this important topic in the public eye on an ongoing basis –Ed.]

If you have ever consumed health care at a hospital and looked at the bills that resulted, you will instantly relate to his 36-page analysis of six hospital bills. But he documents in no uncertain terms the sheer brazenness of a health industry that sets prices arbitrarily, applies them unevenly, and often collects on ridiculous charges unmercifully.

I am hoping that this piece sets into motion a sea change where Americans demand in the health care economy basic things that are required in every other economy. But in a market where

the consumers (people with sudden severe illness) are really not free to shop around, I think hospitals should be held to a standard of transparency and ethics that are higher than, for example, the grocery store industry.

The article is here: Bitter Pill Why Medical Bills are Crushing Us, in Time Magazine.

YouTube: Video from Time Magazine on his article.

Brill's conclusion that we should simply expand Medicare to fix this problem is probably wrong. But he exposes some very fundamental flaws that every consumer should be aware of before they head to any hospital for anything, inpatient, outpatient, lab, imaging, surgical, or emergency.

He talks about billing advocates that helped people cut their bills after the fact. But it's also critical to have a doctor who's aware of the cost issue and can help you navigate before and during a health crisis. We are experts of this at My Doctor Medical Group in San Francisco, and it's one of the reasons our patients go out of network to choose us for primary care. After all, the costs of outpatient care are tiny compared to hospital care, and it's often a worthwhile investment to have a doctor on your team who works for you, not your insurance company, when the chips are down.

Sodium Butyrate: An Overlooked Supplement for #Crohn’s Disease #ibd

Sodium butyrate is a short chain fatty acid by-product of gut microbes and the primary energy source for cells lining the colon. Since it is sold as a dietary supplement in the United States, it is not regulated by the FDA as a medication. Sodium butyrate may be a beneficial supplement for those suffering from mild-to-moderate Crohn’s disease, especially since it seems generally safe and has few potential side effects.

Crohn’s disease is an autoimmune inflammatory bowel disease whose underlying cause is not yet known. Various etiologies have been proposed, ranging from immune responses to pathogenic parasites or bacteria, to the effects of certain foods, to imbalances in the normal intestinal flora. Unlike the other main form of inflammatory bowel disease, Crohn’s disease can affect any part of the gastrointestinal system, from the mouth to the anus. Symptoms can include abdominal pain, fevers, diarrhea, and rectal bleeding. Over time complications can include scarring and strictures, nutritional deficiencies, abscesses, fistulas and bowel obstructions.

A study. Di Sabatino, et al (2005) investigated the effect of sodium butyrate supplementation on a group of Crohn’s patients. The group was given enteric-coated sodium butyrate supplements for 8 weeks. An impressive 69% responded to treatment, with the majority of those people achieving full remission. Those who had a clinical response also had decreased mucosal levels of inflammatory markers NF-κB and IL-1β after treatment.¹

It appears that sodium butyrate may exert its positive effects by down-regulating inflammatory cytokines, thereby decreasing mucosal inflammation that is a core mechanism of Crohn's disease. Because it is an energy source to colonocytes, it is also thought to aid in the healing of the lining of the colon after injury.

Due to the lack of large controlled studies, sodium butyrate is not yet being used as a conventional treatment for IBD. But data from small studies appears promising. We have successfully added it to the regimens of some of our patients with Crohn's, and early “N of 1” experiments appear promising.

Medically-supervised Quant Coaching. Since people often respond differently to medications and supplements, we have found it very beneficial at My Doctor Medical Group to help our patients with Crohn's conduct carefully controlled experiments of dietary, supplement and medication interventions by using self-tracking technology. These experiments are usually conducted under the supervision of a Quant Coach (me) and licensed health professionals like our medical director Paul Abramson MD, and a registered dietitian like Denise Garbinski RD.

Please contact us if you would like more information on the ways we help patients with inflammatory bowel disease in our practice in San Francisco. And please talk to your treating physician before adding any dietary supplements to your regimen.

¹Di Sabatino et al., Alimentary Pharmacology & Therapeutics, Volume 22, Issue 9, pages 789–794, November 2005

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