Why it’s important to have a primary care provider

When it comes to your health, relationships really matter. But about one in four Americans don't have a personal doctor or primary care provider. The numbers are even higher for minority groups and younger adults. Here's my case for finding a primary provider of your own, and stat.

What is a primary care provider (PCP)?

A PCP is the quarterback of your care — the hub for everything related to your health. That means your PCP becomes an expert in you and your health goals, helping you navigate the system, translating test results, and working with specialists to make sure your care is on track. Your PCP is your partner and biggest health advocate. Simply put, they make sure you get better, more personalized care.

But what if I’m pretty healthy?

If you’re healthy, you might reasonably see different practitioners over time for acute needs, like a cold or an ankle injury. But it’s beneficial for even the healthiest people to build a relationship with a PCP.

Transactional health care works until it doesn’t. Whether it’s due to an unexpected injury or just getting older, everyone will eventually need more medical help.

It happens to all of us! At age 30, I was healthy and active, but after experiencing joint pain, I was diagnosed with a congenital hip condition that required invasive surgery and lengthy rehabilitation. At the time, as a physician-in-training myself, I thought: I can be my own primary care doctor.

Wrong. I had a world-class surgeon, an exceptional physical therapist, supportive friends and family, and, of course, a massive advantage in my medical training. But what I needed was an objective, knowledgeable third party to help me weigh the positives and negatives of having the procedure at all, and someone to help with me with what came next — several years of complications, a revision procedure, and ongoing pain and rehab. It took me a while to realize I didn’t need to manage all of that trial and error alone.

If even those of us who are clinicians benefit from having a medical expert on our team, surely you would, too. With a PCP, you have a partner you already know and trust. It eases your inevitable transition into more hands-on care, rather than leaving you to make an important decision about the right provider in the middle of a health crisis.

An ounce of prevention is worth a pound of cure. While I don't believe that everyone needs a comprehensive physical exam every year, it's important to get preventive care. That includes clinically appropriate screening tests and immunizations, as well as a conversation about your health goals and wellness issues like sleep, nutrition, physical activity, and mental health. If you have a chronic health condition, a PCP helps you manage symptoms and prevent complications.

Having a healthcare partner with whom you can think more holistically about your health helps in ways that may not be obvious right away but can make a big difference over time — physically, emotionally, even financially.

How do I pick the right person?

Here are some things you may want to consider when choosing your PCP.

Clinical approach. Some providers are more traditional in their approach, while some incorporate complementary and alternative recommendations. Others are more experienced with areas like sports medicine or mental health. What are your needs and values?

Personality. Whether you’re old-school and call it “bedside manner” or new-agey and call it “energy,” you want a provider who feels right to you. Are you looking for a great listener? Someone who’s more like a coach who can motivate you to reach your health goals? Or maybe you want a provider who’s straightforward and just-the-facts.

Expertise. Perhaps you’d like a provider who sees a lot of patients like you — other women or LGBTQ patients, for example. Maybe you have a thyroid disorder and prefer a provider who has an interest in hormone-related conditions. The right provider for you will have a strong foundation in your personal health concerns.

Insurance coverage: Fortunately, finding an in-network PCP is less challenging than finding a specialist. Go with a doctor or practice you've heard about and trust, and check to see if they take your insurance. Just don't let the tail wag the dog -- that is, it's best to avoid picking a doctor just because they're on the "covered" list with your insurance company.

Connections to specialists: If something complicated comes up with your health, you want a PCP who has relationships with the best specialists in your area -- preferably doctors based at your local academic medical center, where patient health outcomes are typically better than at smaller practices or community hospitals.

For some people, the most efficient route to a good primary care doctor is to ask your friends and family if they know of anyone they like, and then look on the practitioner's website or call to see if they take your insurance. Others find it easiest to first choose a practice through a nearby medical center or well-known direct primary care practice, such as One Medical, Iora Health, or Qliance (disclosure: I currently work for One Medical). Once you're an established patient, the doctors and support staff can help you choose a practitioner that's the right fit for you. 

However you go about it, get a primary care doctor! Once you find someone you like and who knows a lot about you, you won't regret it.

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A version of this article was originally published on the One Medical Blog.

Is it Strep or just a sore throat? Here’s how doctors tell the difference.

So you have a sore throat. Should you just rest and gargle, or schlep to the doctor’s office?

Strep throat, or Streptococcal pharyngitis, is a bacterial infection that can be treated with antibiotics to shorten the duration of symptoms and prevent complications. It’s most common in young, school-age children. When an adult gets a sore throat, 90% of the time it’s caused by a common cold or virus that antibiotics won’t help. But they both feel like crap, so how do you tell the difference?

In health care we use an algorithm called the Centor Criteria to make the call. It’s a clinician’s quick-and-easy way to figure out the likelihood that someone with a sore throat has a bacterial infection that should be treated. It’s not usually used by people outside of the medical profession, and it’s filled with jargon meant for doctors and nurses — but I’ve translated it into plain English for you. You’re welcome. :)

If you come down with a sore throat, take the quiz below, add up your points, and find out what your primary care provider would do next.

Sore Throat Quiz

1) How old are you?

• 3–14 years old (1 point)

• 15–44 years old (0 points)

• 45 years or older (-1 point)

2) Do you have white pus (“exudate” in medical jargon) on your tonsils? (1 point)

Have a friend or family member take a look with a flashlight, or open wide and look in the mirror. I won’t post it here because it’s kind of icky, but if you want to know what pus on your tonsils really looks like, check out this Google Image Search for “tonsillar exudate."

Look for clear spots or streaks of white pus on your tonsils (credit: myclevelandclinic.org).

3) Do you have swollen, tender lymph nodes on the front sides of your neck? (1 point)

Lymph nodes make immune cells. They swell up and can become tender when they’re hard at work making white blood cells to fight infections. When you have an upper respiratory infection (URI), the lymph nodes on either side of your Adam’s apple will be swollen.

4) Do you have a fever? That’s over 100.4°F or 38°C. (1 point)

It’s common to have low, temporary fevers with viral URIs like the common cold. A higher fever that lasts longer than a couple days is more likely to be caused by a bacterial infection like Strep. If you haven’t checked your temperature but you’re pretty sure you have a fever, that counts, too.

5) Do you have a cough? (0 points if yes, 1 point if no)

If you do, it’s much more likely to be caused by a cold virus giving you sinus congestion that’s draining into your throat. You’re more likely to have Strep if you don’t have a cough.

Total up your points

If you got a 3, 4 or 5, you meet Centor Criteria. This doesn’t mean you necessarily have Strep throat, but  it does mean you should be tested for Strep in the office. Your provider will either do a Rapid Strep Test or take a swab from your throat for a bacterial culture, or both. The results will indicate whether you have Strep and should be treated.

I made this for you based on the Centor Criteria and the Infectious Disease Society of America’s 2012 guidelines.

Treating Strep Throat

The treatment for Strep throat is penicillin, usually taken for 10 days (ask your provider about alternative antibiotics if you’re allergic to penicillin). Taking an antibiotic for Strep alleviates your symptoms and makes you less contagious. It also lowers your risk of developing a more serious throat infection or a very rare complication called rheumatic fever, which primarily affects the heart and joints.

Here are some reasons you might not want to take antibiotics, even if you have a strep infection:

• You’re a healthy adult and you’d prefer to avoid antibiotics. If you rest and drink plenty of fluids, your immune system can actually handle a Strep infection on its own. You’ll get through it more comfortably if you treat your symptoms with the over-the-counter meds suggested below.

• You want to avoid common side effects of antibiotics such as upset stomach, diarrhea, and, if you’re a woman, yeast infections. Antibiotics can do quite a number on the helpful bacteria in your body.

If you do start antibiotic treatment, remember to take every single dose of the medication all the way to the end, even if you start feeling better earlier, in order to prevent the bacteria from developing resistance to the antibiotics.

Managing Your Symptoms

Treating your symptoms often doesn’t mean taking antibiotics. Whether your upper respiratory infection is viral like the common cold or bacterial like Strep, the same rules apply for symptom control:

• For sore throats, fever, headaches, and body aches: Take acetaminophen (Tylenol) or an anti-inflammatory pain reliever like ibuprofen (Advil, Motrin), naproxen (Aleve), or aspirin as directed. Special note: Never give aspirin to kids under 18 due to the risk of developing Reye’s Syndrome.

• For congestion or sinus pressure caused by a head or chest cold: Try steam inhalation, nasal irrigation with a neti pot, over-the-counter nasal steroids like fluticasone (Flonase), or a strong decongestant like real pseudoephedrine (show your ID at the pharmacy counter to get it).

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A version of this article was originally published on the One Medical Blog.

Juice Plus: Candy masquerading as health food

The other day while getting my hair cut, I mentioned I was hungry and a little spacey from low blood sugar, and the nice Marin lady in the chair next to me shared a bite to eat.

I’d never heard of Juice Plus before, so I didn’t realize I was about to get a sales pitch. I opened the package and ate what tasted like fancy fruit snacks. I checked out the ingredients on the back, which were, in order:

1. Tapioca syrup
2. Maltodextrin
3. Organice evaporated cane juice

In other words, the first three ingredients are: sugar, sugar, and sugar.

Dear reader, anything that’s made of mostly sugar fits neatly into a food group that we might call “candy.” Seriously, even a Snickers would be preferable — its main ingredients are milk chocolate, peanuts, and corn syrup. At least you get some protein with your sugar and sugar!

I guess it shouldn’t surprise me that someone from the epicenter of antivaxxers and unflouridated water would believe that these gummies are nutritious.

Here’s the two-minute video my new salon friend had me watch on her iPhone, in which an obviously well-educated M.D./Ph.D. tries to convince you that Juice Plus fruit snacks and chocolate shake powder are “whole foods” that contain more servings of fruits and vegetables than you’d ever be able to eat in a day. LOL.

How to be rational about “alternative” medicine in cancer care

It’s easy to feel helpless in the face of cancer, a disease that turns our body’s very own cells into a reckless and mutinous army, destroying normal cell architecture and function. Learning about cancer as a medical student was even more vexing because it gave me a concrete sense of what we still don’t know about cancer and its overwhelming diversity of presentations.

Here’s an increasingly common scenario: a patient is faced with a terminal diagnosis, and after months or years of treatments, her doctor tells her that there’s nothing more medicine can offer. Instead of abandoning hope, many patients are turning to so-called alternative therapies. As far back as 1997, Americans spent the same amount of money out of pocket on alternative treatments as they did on conventional medicine.

So what is alternative medicine, and why are people using it in greater numbers? It’s rather tautologically defined as anything outside of conventional medicine. And that’s dynamic, as some treatments previously considered alternative, such as chiropractic care for back pain, are now supported by enough evidence that they’re largely accepted in mainstream medicine -- even covered by health insurance companies.

Western medicine excels at treating and preventing acute, life-threatening illness. Antibiotics and vaccines, in particular, have saved millions of lives over the last hundred years and dramatically increased our lifespan. But just like every modality of medicine, this new scientific brand is limited. What we, especially in the developed world, are left with in our longer lives is, inconveniently, exactly what Western medicine hasn’t really nailed down yet: chronic disease. Instead of dying within weeks of a smallpox infection, we succumb to years-long battles with coronary artery disease, autoimmune conditions, diabetes, hypertension, cancer, and their many complications. Most pharmaceutical drugs are band-aids that treat symptoms yet don’t resolve the underlying cause of someone’s chronic illness.

Patients turn to alternative medicine because when faced with our own mortality, many of us will exhaust every option available. Unlike Western medicine’s traditionally one-size-fits-all approach, alternative medicine examines each patient holistically, looking at every aspect of someone’s body and life to determine how best to manage their unique manifestation of illness. It encompasses a broad range of treatments, including mind-body therapies, massage, acupuncture, nutrition, yoga, and natural herbal therapies. And unlike the traditionally hierarchical physician-patient model of Western medicine, alternative practitioners see their patients as partners who hold equal responsibility in managing their care. This active engagement and the breadth of options in alternative medicine are what many patients crave when Western practitioners tell them there’s nothing more that can be done.

While pharmaceutical companies are unlikely to invest in research on naturally occurring and therefore un-patentable substances to determine their medicinal value, the National Institutes of Health saw the growing demand for alternative treatments and founded the National Center for Complementary and Integrative Health (NCCIH) to fund scientific research in this historically underfunded and understudied area. Researchers ought to look also to healers in ancient systems such as Traditional Chinese Medicine and Ayurveda who have honed treatments over thousands of years of empiric observation to find anti-inflammatory effects in turmeric or anti-cancer properties in the bark of a local tree. Case in point: Neanderthals didn’t need molecular biology or double-blind randomized clinical trials to tell them that the poppy seeds found in their graves contained opiates that would alleviate their pain.

A particularly fascinating area of alternative medicine is its embrace of the placebo effect. In scientific research, it’s the noise in your data that you try to quiet to see the “real” effects of whatever treatment you’re testing. The marker of success for a new drug is if it’s more effective than a placebo. This means that for some conditions, the placebo is one of the most effective treatments that exists. So while researchers view the placebo effect as a nuisance, patients love it because it works. Our mind’s effects are incredibly powerful. Plus, they’re side effect-free, unlike every pharmaceutical drug. Health care providers should support their patient’s use of an herb, for example, as long as it’s not harmful, to help treat her cancer whether there’s scientific data supporting its efficacy or not. Simply put, if she feels like it will help her, then it necessarily will. Science usually dismisses these individual cases as anecdotal; instead, we ought to study the placebo effect and figure out how to harness this tremendous intrinsic power to heal our own bodies.

The real shame for cancer patients is when Western and alternative practitioners refuse to work together due to ideological differences. No modality of medicine has every answer, but we can use our clinical knowledge and each patient’s preferences to determine an optimal plan utilizing the most effective treatments from all modalities to give her the best fighting chance. For example, a patient with estrogen receptor positive breast cancer could adjust her diet and lifestyle, practice mindfulness meditation to lessen her anxiety and bolster her immune system, and take her tamoxifen treatments with ginger to minimize nausea, plus omega-3 to reduce the risk of blood clots associated with the drug. Another patient with inoperable tumors might forgo chemotherapy and radiation entirely and opt instead for gentle alternative treatments to prolong her life and ameliorate her symptoms. This synergy between Western and alternative medicine is practiced at top academic medical institutions, such as Harvard’s and UCSF’s Osher Centers for Integrative Medicine.

But when practitioners can’t work together, patients have to choose one system or the other and miss out on many options that might work together to save their lives. Or they face dangerous drug-drug interactions between their Western and alternative treatments because they’re afraid their oncologist will be angry if they admit that they’re taking Chinese herbs. For the sake of patients, we must abandon the false dichotomy of conventional versus alternative, and communicate with each other to find what works best, when, and for whom — whether it comes from a high-tech pharmaceutical lab in the U.S. or a hunter-gatherer tribe in Africa.

Cancer is one of the leading causes of death in the United States. We’re more prone to it as we age because it’s a disease of our DNA, which accumulates small mutations over time that can lead to unregulated cell proliferation. Unfortunately, cancer will never go away, and there is no single cure from either Western or alternative medicine. Each cancer is different. This is not simply to say that lung cancer is different from prostate cancer. People with the same type of cancer often have very different outcomes because one has more virulent cells or the other has a genetic type that responds better to a certain treatment. And we’re not very good yet at predicting who has the kind that will progress. Even within a single tumor, cancer cells are heterogeneous. A treatment that kills half of a tumor’s cells might leave the other half to grow and metastasize to other organs. Adding even more complexity, from birth, we all have distinctive genetic predispositions to certain cancers. Genetic breakthroughs are only just beginning to sort this out, but indications are that they will usher in a new era of personalized cancer medicine; we’ll diagnose and treat patients based on the genetic make-up of their particular tumor.

I see this as the perfect opportunity for Western medicine to align and integrate with alternative medicine and its broadest goal: to treat each patient as an individual with her own unique disease process and experience. We’ll need the tools of both of these systems to be truly competent and compassionate healers and give future cancer patients the best possible care — and a fighting chance.

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A version of this article was originally published on Surviving Mesothelioma in 2010.

Please stop going to the doctor for colds, flus, sinus infections, and bronchitis

A Dr. Amanda public service announcement!

One way to really do a solid for our strained primary care system is to stop going to the doctor for viral upper respiratory infections (URIs), including colds, flu, sinus infections, and bronchitis (chest cold).

You do not need our help. Stay home. Rest, drink fluids, and take over-the-counter medications for your symptoms.

Important exceptions

• You’ve been sick for a while, and then you start feeling much worse
• You have a sustained fever over 102 degrees Fahrenheit
• You’re really short of breath or wheezing
• You’re coughing up blood (not just a little speck)
• You’re having severe nighttime coughing fits that make you throw up (called post-tussive emesis), and/or you know you were exposed to whooping cough
• There’s anything else that’s really worrying you

(Different rules apply if you are a baby.)

A Western doctor’s job is to rule out the bad stuff that really needs antibiotic intervention, such as pneumonia, pertussis (whooping cough), or sinusitis that’s become complicated by a bacterial infection.  This happens in LESS THAN 2% of sinus infections, so probably not yours :).

If you’re experiencing any of the above, by all means please call or see your health care provider as soon as you can. Everybody else, read on to learn how to diagnose and manage your own viral URI!

What to expect with a cold

You’ll probably get colds dozens of times in your life. If you don’t already know the typical symptom progression and how to recognize it, now’s the time.

Day 1: Scratchy or sore throat, runny nose, sneezing, some fatigue.

Day 2: Mild-to-moderate nasal congestion kicks in. Low fever and more fatigue.

Day 3–4: Worsening nasal congestion. Sinus and ear pressure as the congestion backs up. Possibly a headache. Your snot might turn yellow or green, which is a normal immune response and, counter to conventional wisdom, doesn’t differentiate a bacterial infection from a viral one.

Day 5–7: Congestion improves and you’ll start to feel more like yourself, but coughing begins as your sinuses drain all of the goop they’ve produced over the last few days.

Week 2–3: Hacking, post-viral cough that usually goes away within a week or two but can linger for up to three. If you’re still coughing after eight weeks (and you’re a nonsmoker who’s not taking a blood pressure medicine called an ACE inhibitor that can cause a dry cough), then it’s finally time for you to head in to your primary care office for a chest X-ray. Something else may be up.

Source: U.S. Centers for Disease Control (CDC)

With influenza (“the flu”), add to the above symptoms a headache and all-over body ache that just about levels you. I’ve never had the flu, but I’ve heard it feels like death warmed over. Seriously, get a flu shot every year.

What actually helps

There are drugstore aisles full of over-the-counter (OTC) cold and flu medications, but what really works?

Interestingly, for a common cold and post-viral cough, the drugs that are together most effective at treating symptoms don’t exist as an OTC combination formula:

1. Pseudoephedrine, a powerful decongestant, also known by its brand name Sudafed. You have to ask the pharmacist behind the counter and show your ID to get the original pseudoephedrine because unfortunately some people use it to make meth. Don’t get the Sudafed “PE” that’s on shelves in the cold and flu aisle — it’s made with phenylephrine and doesn’t do much.
2. A first-generation antihistamine such as diphenhydramine (a.k.a. Benadryl), chlorpheniramine, or brompheniramine. Non-drowsy, second-generation antihistamines like fexofenadine (Allegra) are ineffective here. It’s unclear why.
3. A non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil, Motrin) or naproxen (Aleve).

This combination is what I’ve taken to calling the secret sauce for the common cold. When you combine an antihistamine with a strong decongestant like pseudoephedrine, it’s a one-two punch that dries up your sinuses. They have totally different mechanisms of action, but both help tighten up your blood vessels to reduce inflammation. It’s this synergy that really does it. Add an NSAID with its own anti-inflammatory effect (plus pain relief), and you’ve got yourself one badass cold remedy. The evidence is pretty solid, so I don’t know why we haven’t made it a thing.

Some other good options for symptom relief are a neti pot (like NeilMed Sinus Rinse) or a steroid nasal spray (like fluticasone, a.k.a. Flonase), both of which you can get over the counter in any drugstore. All evidence aside, the important thing is to find what you think works best for you.

Here’s the closest thing we have to a cure for the common cold: sleep and hydration. Curl up, watch some Netflix, and be patient with yourself and your body.

But say you have a presentation at work tomorrow, or you’re about to hop an international flight for a snorkeling trip in the Caribbean. “Doctor, I just can’t be sick right now.” There’s now research to show that at least a couple of so-called “natural” chemicals lessen the duration of your cold symptoms in addition to their severity, most likely by supporting your immune system: pelargonium (Umcka at Whole Foods) and zinc. For them to really work, you have to start taking them in the first 24 hours of symptoms and exactly as often as directed. Zinc can give you a gross tummy ache, so make sure you always eat at least a snack before you take it. In my personal experience, the “rapid melts” are less offensively metallic than the lozenges.

For the flu, the antiviral, prescription-only Tamiflu works, but only if you start taking it within the first 48 hours. After that it doesn’t do much to alleviate symptoms or shorten the duration of the infection. Clinical guidelines recommend Tamiflu for high-risk patients (over 65, under 2, pregnant women, people with chronic illnesses, etc); otherwise we leave it up to you. And always remember your old anti-inflammatory friends, ibuprofen and naproxen, for symptom relief. (Aspirin works, too, but don’t give it to kids under 18 with a viral infection because it puts them at risk for Reye’s Syndrome.)

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In conclusion, save the doctor’s office for when you (and your fellow humans) really need it! Learn to diagnose and manage your own viral upper respiratory infections, and it’ll pay off year after year. Re-read this post and bookmark it for later when you feel that scratchy throat coming on…

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Originally published on Medium.