Update of COVID Infection, Exposure, and Testing

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

You have probably read news stories of a problem with the state system for reporting and tracking COVID testing, and the slow turnaround time for COVID test results from many lab vendors.  When this is combined with the substantial increase in cases and deaths we were seeing before the state database issue, this means the local health departments are hobbled in any attempts to try to control the pandemic with contact tracing, isolation and quarantine.  This impacts essential businesses and will impact  counties in the PHC region that will have the option of opening schools.

This affects us in three ways:

  1. A change in advice on the role of testing when we, or those in our family “bubble,” have symptoms or are exposed to someone with symptoms.
  2. Instead of relying on county contact tracers, we all need to become knowledgeable in the essential advice contact tracers give, and work collectively to spread this information in our families and the communities we interact with.
  3. We all need to redouble our efforts to slow the spread of infection: diligently practice physical distancing (especially by limiting travel, large gatherings, and crowded settings), appropriate use of masks/facial coverings (covering nose and mouth when in a public setting, especially indoors or when continuous physical distancing is not possible), as well as hand hygiene.

Potential COVID-19 Symptoms and Potential COVID-19 Exposure: Updated recommendations

General Principles

The two reasons you may be at higher risk of COVID-19 transmission:

  1. You are infected with COVID-19 and have symptoms.
  2. You are infected with COVID-19 and have no symptoms (and probably don’t know you’re infected).

Isolation and quarantine are different:

  • Isolation is for either laboratory confirmed COVID-19 infections or for individuals with symptoms suspicious for COVID-19.  The time period for isolation is 10 days after the symptoms began or after the date of the test (if the person was asymptomatic), provided the patient has no fever for 24 hours while not taking a medication that would suppress fever AND any symptoms are substantially improved.  If a person is severely immunocompromised, the isolation period is extended to 24 days.  COVID test results do not change the isolation period.
  • Quarantine is for asymptomatic close contacts of confirmed or suspected COVID-19 infection or situations with high risk of transmission, such as gatherings of un-masked individuals or returning from travel to a high prevalence area.  The time period for quarantine is 14 days after the last day of exposure to the person or situation that put the person at risk.  If a person under quarantine develops symptoms, they become a suspected case and must begin a 10 day isolation period.  Due to the shortage of COVID testing, testing for all those in quarantine may or may not be possible.

If one person in a household bubble is isolated due to confirmed or suspected COVID-19 infection, the entire household would be subject to quarantine.  The isolated person must be separated from everyone in their household bubble who are now in quarantine, to reduce ongoing spread of infection from the isolated person and the quarantined people.  Exceptions may be made for parents with small children.

If some members of the house are quarantined, say because of a workplace exposure or recent attendance at gathering without masks, they must be separated from those in their household “bubble” that are not under quaratine, for the entire period of the quarantine, to prevent infecting them in the pre-symptomatic or asymptomatic phases of infection.

What does separation mean?  Briefly, sleeping in a room by themselves, staying in that room as much as possible throughout the day, wearing a mask when leaving the room, and avoiding shared bathrooms if possible.  For more details, see this summary from the Mendocino County Health Department.

Symptoms of COVID-19

If you develop any of these symptoms, you should stay at home for 10 days, and call your primary care provider.

CDC list of symptoms:
  1. Fever (temperature over 100 degrees F)
  2. New or different cough
  3. Shortness of breath
  4. Sore throat
  5. Loss of taste or smell
  6. Chills
  7. Muscle aches
  8. New headache that persists for more than a few hours or is different from your usual headache

Other common symptoms seen in COVID-19 infections:

  1. Fatigue
  2. New nasal congestion that persists for more than a day after treatment for allergies
  3. New rash
  4. Chest pain
  5. Nausea, vomiting, and diarrhea
  6. Stroke-like symptoms, such as confusion, slurred speech, weakness on one side of your body

Common Scenarios:

I had a stuffy nose all day and some allergy symptoms; must I isolate at home? 

Other illnesses can cause any of the symptoms listed above, but with the prevalence of COVID-19 being so high, it is best to assume that any of these symptoms could be COVID-19, even if you have other medical conditions that could explain them.  Doctors are sometimes giving inappropriate reassurances over the phone, without testing for COVID-19.

If you have one of these symptoms that persists, and you have been evaluated by your PCP and tested negative for COVID-19, and you normally would work within the office, you should reach out to your supervisor or the Human Resources Department in your organization to make sure it is OK to come into the office.

If I have one of these symptoms and it resolves, can I get a COVID test to see if I can come out of isolation?

You should stay home for at least 10 days after the symptom is resolved.  Given the shortage of tests some providers are not ordering tests on everyone with symptoms.  Given the high rate of false negative COVID test results, even a negative test should not be considered a pass to come out of isolation early if you had symptoms suspicious for COVID.  A positive test is helpful for reinforcing the importance of isolation and quarantine.

What Constitutes a Close Contact?

If you know you had recent close contact and possible exposure with someone you know has or recently tested positive for COVID-19, you could be infected.

A close contact to a confirmed or suspected case is defined as an individual who:

    1. Lives in or has stayed at the case’s residence, OR
    2. Is an intimate sexual partner of the case, OR
    3. Provides or provided care to the case without wearing a mask, gown, and gloves, OR
    4. Was within 6 feet of a case for a prolonged period of time (10 minutes or more).


    E. This contact occurred while the case was determined to be infectious. A                 case is infectious within 48 hours before that person’s symptoms began                 and until that person is no longer required to be isolated.

Close contacts should follow the same precautions as those listed for someone who had to travel or attended a social gathering and is returning to work: a 14-day quarantine at home.

If you travel out of the area or if you break from universal precautions (by attending a party or wedding, for example, or even a smaller gathering outside your usual “bubble” or “pod” without wearing a mask), you should stay out of the office (ideally at home) for 14 days of quarantine after your transgression.

Preventing COVID-19 transmission when you don’t have symptoms

Universal Precautions: Take actions that assume you may be infected with COVID-19 and don’t know it, to prevent accidental spread in your community.

The best way to prevent COVID-19 transmission is to:

  1. Stay at home, away from face-to face social gatherings with people outside your bubble/pod,
  2. Wear a mask as directed by the state order
  3. Maintain physical distancing, and
  4. Wash or sanitize your hands.

If you do this well in your everyday life, this certainly minimizes (but does not eliminate) the risk of asymptomatic transmission.

As testing becomes more available, some of these recommendations will change; stay tuned.

Good Medical Decision-Making: Much More than Applying Evidence

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Medicine is best described not as a science, but as a form of flexible practical reasoning that often uses science.”

Adam Rodman, MD

How do the best clinicians apply their knowledge?

Last year, this monthly newsletter reviewed the propensity for mental shortcuts, biases and prior experiences that lead to poor medical decision-making, and discussed options for minimizing the degree that these cognitive traps affect our clinical decisions. Think of this as the cognitive psychology of medical decision-making.

When mental shortcuts are minimized, and reasoning is applied, we might, at first blush, think that the best reasoning limits itself to “Evidence Based Medicine” where high quality, prospective, placebo-controlled, double blind, allocation concealed studies are consistently applied in making medical decisions. In reality, several sources of knowledge (sometimes conflicting with each other) are brought to bear. The study of the nature of knowledge is also known as epistemology, a branch of philosophy. Within the medical realm, this is known as medical epistemology, a branch of the study of the philosophy of medicine.

In a grand rounds at Beth Israel Hospital in October, 2019, clinical professor Adam Rodman, MD defines a historical framework of medical epistemologies that clinicians use to decide on what treatments to offer patients:

  1. Observation – This involves obtaining a careful and complete history and physical examination, with review of lab work to categorize the disease or diseases that a patient has, and recalling how similar patients/disease categories that the clinician has directly observed or heard/read about have responded to treatments given. The earliest example of this is the 4,000-year-old Edwin Smith papyrus, in which an ancient Egyptian healer carefully described a series of 48 surgical cases and their treatments.
  2. Theory – Pre-scientific theories, such as ancient Greek humoral theory of disease dominated medical practice until the mid-nineteenth century, when they were replaced by scientific theoretical frameworks, such as physiology, immunology, biochemistry. These frameworks are then used to interpret observations (such as a rising creatinine in a patient receiving a diuretic), and make judgements based on this understanding.
  3. Experimentation/Clinical Trials – While there are scattered examples of medical experimentation before 1900, it was not very commonly used. It is primarily a twentieth-century framework, and led to the Evidence-Based Medicine movement, starting in the late 1980s. It includes applying a hierarchy of different types of medical trials and studies, with expert opinion at the bottom of the pyramid and meta-analysis reviews at the top. This pillar of understanding has crumbled to be replaced with the current standard: grading of available evidence, which takes many other factors into account.
  4. “Population Medicine”/Epidemiology/Biostatistics – This began in the early 1800s, in Paris and was first called the “Numerical Method.” This involves collecting data on numbers of patients and analyzing this data statistically for insights that can then be used to improve clinical decision making for the individual patient being cared for. The most modern applications of this are decision rules (for example for osteoporosis screening or genetic testing), “big data” analyses, and augmented intelligence medical applications.

Rodman contends that whenever clinicians make treatment decisions on individual patients, we use some or all of these frameworks, even on the same patient, in the same day. The frameworks often might lead to conflicting treatment options which need to be sorted out rationally. Importantly, the third framework is the preferred framework for Evidence-Based-Medicine purists, but real-life excellent clinicians seamlessly integrate EBM with the other 3 frameworks. We need not feel guilty or inferior when we use these other frameworks; they have a vital role in the decision making of all excellent clinicians.

In the end, to the extent medicine uses science, it is in the application of science to deciding on individualized treatment of patients that matters.

The medical ethicist Jose Alberto Mainetti stated it best in his research, Embodiment, Pathology, and Diagnosis: “Diagnosis is not knowledge for knowledge’s sake. It is knowledge for the sake of action. Medicine exists to cure, to care, to intervene, or in limiting cases to know when not to intervene. Medicine is not a contemplative science.”

Knowing the noble history of these four epistemologies can help us balance their use thoughtfully, both in our continuing educational activities to better master them and in applying them to make therapeutic decisions that best serve our patients.

Brief COVID-19 Updates

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“When we have nations, institutions and advocates working on this collective response, we do see remarkable impact.”
     -Bill Gates at the 2020 COVID-19 Conference

There are several timely updates that we know would be of interest to primary care clinicians. Please forward on to your staff.

Surge of Cases Nation-wide Leads to Testing Delays
Public testing sites sponsored by the State in several counties have found long delays in results for the lowest risk groups, as the state announced criteria for prioritizing testing. OptumServe and Verily sites sponsored by the counties are affected. County health lab and local hospital lab turnaround (including Kaiser) is faster, but capacity is limited. Home testing is being rolled out by Lab Corps and soon Quest will join them. We will include more information on this in the next update.

Although point of care RNA testing (Abbott and others) is less sensitive than PCR-based testing, but some public health experts feel that a less sensitive point of care test that turns around results quickly, is better on a population level for screening than a more accurate PCR test with results available in 10-14 days.

All COVID tests are covered by PHC when done by any lab provider with a Medi-Cal provider number, up to 2 tests per day, for both diagnosis and screening.

Remdesivir Shortage Leads to Narrower Treatment Criteria
On a call with one of our local health officers, we understand that Remdesivir treatment is now being delivered to those who are inpatient requiring low-flow supplemental oxygen, as these patients have the most likely benefit for the treatment. Patients not requiring oxygen and those on high flow oxygen or intubated are less likely to benefit and are not being prioritized. A five-day treatment regimen has become standard for most patients.

Eye Protection Recommended in Health Care Settings with Moderate Community Transmission
The CDC recommends that eye protection be worn in health care settings where patients with unknown or positive COVID status are being cared for. The eye protection should not have gaps between the skin and should not rest on the protective covering around the face, meaning eyeglasses are not sufficient (see CDC recommendation for details). We understand that CDPH is considering making this recommendation into a requirement in California.

Familial Autosomal Recessive Mutations Associated with Higher Risk of Severe Disease in Younger Patients
In a study that gives insight into the pathogenesis of COVID-19, a case series of 4 young male patients with severe COVID-19, were found to have a previously undiagnosed immune deficiency: a relatively rare putative loss-of-function variants of X-chromosomal TLR7 were identified that were associated with impaired type I and II interferon responses.

Obesity an Independent Risk factor for Severe COVID-19
A report from the American College of Physicians noted that Obesity is associated with an increased risk for intubation and death in COVID-19 patients under age 65, but not for those over age 65.

“Broken Heart Syndrome” Increased During COVID-19
An observational analysis of patients without COVID-19, receiving echocardiograms at the Cleveland Clinic, found an increased percentage with stress cardiomyopathy (also known as takotsubo syndrome or broken heart syndrome). The rate ratio before COVID-19 was 1.5 to 1.8%, while the rate ratio during the lockdown rose to 4.6%.

Stress cardiomyopathy is a physical manifestation of sustained psychological stress. This study shows the degree of population stress that the response to the pandemic is having on the community.

Childhood Immunization Rate Rebounding (Somewhat)
The graphic below, from the California Immunization Registry, shows that the rate of immunization for MMR (a proxy for overall childhood immunization activity in young children) has mostly rebounded in California in the past month. Overall, though, there is a remaining backlog. Without in-person school in many parts of the state, the usual August bump in immunization rates may not occur this year. Next week, PHC will be starting a state-mandated phone outreach campaign to children under age 2 to remind them of the importance of vaccination and well-child visits.

De-identified Humorous Examples of Actual Medical Records

By Jeff Ribordy, MD, MPH, FAAP, Regional Medical Director

Back in 2018 we published a mildly humorous blog post highlighting medical bloopers that we have encountered as we peruse the chart notes we receive. Of course back then, EHRs were so new that most providers were still getting used to working with them. Nowadays, everyone is such an expert we rarely see charting mistakes…..

Just kidding!

Here is our long awaited sequel with upgraded oopsies – just like the EHRs we all use.

As we share these I want to mention as in the previous post – this is not to point fingers but with the understanding we all have made similar mistakes.

From the “Not Sure That’s How That Works” Department

–…he sleeps flat with 8 pillows <…>

–She lifts boxes which way 5200 pounds all day long while working in a warehouse.

–General: Pt is awake, alert and oriented. No acute distress. Husband present. PT is ambulating in a wheelchair.

–Born as full term at 51 weeks, no major complication reported during delivery.


–He was twin B (5 lb 11) needed chest compression for 3 days. Not intubated.

–Is a 56-year-old male – Alcohol: Currently does not drink; but did drink a sixpack of beer per day for 78 years.

–Sister states that patient carries a diagnosis of schizophrenia but patient refused to take medication. Main symptoms of her schizophrenia was shyness and not talking to others.

–Patient states she believes she has MS. She states she did some online research and wants to be tested for MS. When asked what sx she is currently having in regards to MS, Pt asked, “Can I have a phone to look up the symptoms of MS.”

–Ms. M… had a sudden loss of both eyes that occurred in December 2018.

Might Need Another Treatment Plan…

–If the injection helps, then consider radio frequency abrasion.

–He was diluted with x-rays and sent home.

–Prognosis for controlling incontinence: Hyperlipidemia

–Discussed – Unfortunately kidney has failed to have any benefit from an L4 transforaminal epidural steroid injection.

–PLAN – Hyperlipidemia, unspecified, TraMADol HCI 50 MG tablet, 1 every 4-6 hours as needed, 30 days, 0 refills.

–Methamphetamine abuse  F15.10 – The patient appears interested in taking this habit.

Kid’s Doctors Say the Darnedest Things…

–3yo daughter Callie, works as a cashier

–SOCIAL HISTORY: The patient is in the fourth grade, denies use of alcohol and tobacco.

–10 year old female here with a chief complaint of eating.

–Please let mom know Xray from last week shows moderate poop.

Captain, the Universal Translator is malfunctioning…

–Ongoing tobacco use: Advised to quit yet another gallops left left knee surgery on their printer milligrams daily.

–Reminder of value of glucose level w/level of pain & why.

–Plan: Patient with hypoplastic left heart status post Norwood procedure N salmonella shunt mother with excellent Binder for following medical home we’ll need to clarify dosages of medications.

From The MD who was an undergrad Philosophy Major…

–The symptoms occur.

And more good advice for everyone:

–She married a drug dealer which she advises not to ever marry a drug dealer.





Poor Documentation Not Solved By Electronic Health Records

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“If it wasn’t documented, it didn’t happen.”
     -Aphorism passed on to all health care providers in their training

One of the promises of Electronic Health Records was that it would make medical information more legible, and complete.

While computer text is undoubtedly more legible than most handwritten clinical notes, it does not solve the issue of incompleteness, and may make it worse. A long progress note can be created using templates and short-cuts, but sometimes a clinician fails to record the core information of the history of present illness and the part of the physical exam relevant to that complaint. When this happens, anyone reviewing the record would come to the conclusion that the quality of care in that visit was poor and unacceptable.

For example, a patient comes to the office complaining of back pain. The progress note includes a depression/anxiety screen, smoking history, alcohol history, review of current medications, and the medical assistant’s note of the chief complaint of back pain, for the past week since moving a heavy couch. The clinician documents no further history, and the physical exam notes that the heart sounds are normal, the lungs are clear and the patient is in no acute distress. There is no recorded back or neurological exam. The assessment is back pain, and an MRI is ordered.

This electronic medical record generated note not only gives the Partnership HealthPlan of California (PHC) medical directors no details by which to judge the medical necessity of the MRI request, it reflects either poor quality care by the clinician, or poor documentation by the clinician, and possibly both.

The consequence of this: a denial of the MRI request, the need for a repeat visit to do the relevant history and physical exam, and a delay in getting appropriate care for the member.

This issue is definitely not universal. In the process of conducting utilization management reviews and investigations of potential quality of care issues, we also encounter very complete and appropriate documentation that reflects a logical collection of historical information, a thoughtful physical exam and a delineation of the differential diagnosis considered.

Sadly, we encounter many progress notes that incompletely address the reason for the patient’s visit. When we bring this to the attention to the Medical Director of the organization, they are often unaware of the issue. This is perhaps even more concerning, that health care organizations don’t closely monitor the quality of medical records and clinical decision making.

One of the best resources to offer a clinician with poor documentation practices is the UC San Diego PACE Medical Record Keeping course. Having your clinicians periodically audit each other’s charts is another way to promote attentiveness to the quality of medical recordkeeping and clinical decision making. Having a standard set of review criteria is important; Family Practice Management has an article on this topic.

Physician Assistants are required by the Medical Board to have a percentage of charts reviewed by their supervising clinician, a good opportunity to identify poor documentation practices. Although physician review of a sample of Nurse Practitioner Charts is not required by the State of California, it is also a best practice to do this on at least an annual basis, as part of a yearly performance evaluation.

One final note: excellent documentation practices help prevent medical liability lawsuits and licensure actions by California Medical Board/Nursing Board. It is better to have a system to improve documentation and decision making before such actions force the issue.

For a collection of de-identified humorous examples of actual medical records PHC has reviewed, see Dr. Jeff Ribordy’s blog.

Reinstating Patients Who Have Been Discharged

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Redemption comes to those who wait.  Forgiveness is the key.”

Tom Petty’s 1999 ballad Lonesome Sundown (part of Echo, his tenth album with The Heartbreakers) was written after completing inpatient rehabilitation, recovering from a 3-year period of heroin use. The line about redemption and forgiveness is a reflection of his need to be forgiven so he could again create new songs and genuinely share his art.

Some Partnership HealthPlan of California (PHC) members have experienced hard periods in their lives when their actions cause distress to those around them. In the health care setting, this may lead them to repeatedly missing medical appointments or have verbal outbursts with medical office staff. Sometimes, their behavior leads to disenrollment from a practice.

These patients may sometimes turn their lives around, and be ready to re-engage productively in relationships with medical providers and offices. They are often ready to seek redemption and forgiveness from the medical office that disenrolled them.
At the June PHC Physician Advisory Committee meeting, several physicians related how their practices handle these situations. Here are some highlights:

  • Patients should write a letter (potentially with assistance from an advocate), requesting re-enrollment, acknowledging the reasons for their disenrollment, explaining how their life has changed and expressing a commitment to act differently.
  • The office/health center should have a process for reviewing such requests, ideally involving both clinical and administrative leaders.
  • Many practices require the patient to wait for at least a full year after the disenrollment to consider a request for reinstatement.
  • If the request is denied, the former patient is given a written response, indicating if and when they may apply again for reinstatement.
  • If the request is accepted, the patient has an orientation session outlining expectations of behavior, up-front. For PHC members, PHC needs to be notified, as well.

Tragically, Tom Petty ultimately died of an opioid-benzodiazepine overdose in October 2017, related to his attempts to treat severe pain from hip osteoarthritis, for which he was hesitant to have surgery. In the 18 years between his recovery from heroin addiction and his death, he produced 8 albums and 2 film documentaries—a pretty good redemption.

If your office doesn’t have a process for considering re-enrollment requests, please consider developing one to allow former patients who have turned their lives around to have a second (or third, or fourth) chance.

Key Questions for Suicide Prevention

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

Early data suggests that deaths due to suicide and overdose have increased since the beginning of the COVID-19 mitigation measures in the United States. Social isolation, financial insecurity, and unemployment increases the number of deaths from suicide, overdose, and illness. The factors leading to suicide disproportionately impacting communities of color. Individuals who have a history of Adverse Childhood Experiences (ACEs) are particularly at risk.

Primary care clinicians have the opportunity to screen, intervene and prevent these events. There is no way to know if someone is in trouble unless they are asked. When risk for suicide is identified, there are tools and resources that reduce the probability of suicide attempts.

One best practice is to routinely screen for depression using the PHQ-2 and PHQ-9 questions, adding some additional questions about depression risk for any patient screening positive for depression (PHQ-9 score of 10 or greater).

The National Institute on Mental Health (NIMH) developed the Ask Suicide-Screening Questions (ASQ), four questions in 20 seconds to identify people at risk of suicide. In a NIMH study, a “yes” response to one or more questions identified 97% of youth aged 10 to 21 at risk of suicide:

  1. In the past few weeks, have you wished you were dead?
  2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
  3. In the past week, have you been having thoughts about killing yourself?
  4. Have you ever tried to kill yourself?

What’s next?

If an individual responds “yes” to one or more of the four Ask Suicide-Screening Questions, they are at “imminent risk” or “potential risk” of suicide.

The next step to better understand risk-level, if any of the four questions above are answered “yes”, ask “are you having thoughts of killing yourself right now?” and if the individual says “yes,” then they are at imminent risk of suicide and need an urgent mental health evaluation to ensure immediate safety. If the individual answers “no,” then a potential risk is identified and they require a brief suicide safety assessment to determine next steps.

The Zero Suicide Model is an evidence-based practice outlining how to apply this model in a clinical setting. Practices include:

  • Make a safety plan the patient can follow if thoughts of suicide appear, including calling help lines such as the National Suicide Prevention Lifeline                        (1-800-273-255).
  • Discuss restricting access to things they might use to hurt themselves – especially firearms (firearms in the house are a major risk factor for completed suicide).
  • Create a follow-up monitoring plan to ensure the patient receives ongoing help and support.

All three of these activities are appropriate for those who answered “yes” to any of the four ASQ questions above.

Overdose and Suicide: An overdose or self-harm event in the emergency department indicates an extreme high risk. An opioid overdose indicated an 18-fold greater risk of suicide and over 100-fold greater risk of overdose in the next year, compared to the general population. A visit for suicidal ideation led to a 30-fold increase in the risk of suicide in the next year.

ACEs and Suicide: Individuals with four or more Adverse Childhood Events (ACEs) are 37.5 times as likely to attempt suicide, when compared to individuals with no ACEs. For more information on addressing ACEs in your clinical practice, visit www.ACEsAware.org.

Screening individuals for risk of suicide saves lives! Health care professionals can help people get needed care, support and resources. We recommend a refresher training for our clinical staff on this topic, in this time of increased risk of suicide.

Translating Black Lives Matter to Health Care

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

We at Partnership HealthPlan of California (PHC) are deeply saddened by the recent killings of George Floyd and many other Black Americans. Further, we recognize that systemic and historic racism remains the core cause of this violence.

As respected clinicians, we acknowledge that you are participating and advocating to address local policing practices. Additionally, we know you are involved in the broader community dialogue to address underlying causes of bias and discrimination, which disproportionately affect the Black members of our communities. Through your actions, you are also helping many other disenfranchised populations.

In the health care community, we are generally not part of a police force and think of our caring profession as one that serves everyone regardless of race, ethnicity, sexual orientation, gender identification, incarceration status, religion, disability, etc. However, there is a deep history of racial injustice in health care in our country ranging from early experiments in gynecological surgery done on American slave women, to the infamous Tuskegee study of the natural history of tertiary syphilis, which withheld curative penicillin from Black American men to document the progressive neurological symptoms of this curable disease.

Implicit and explicit bias is still present and impacts the health and well-being of all the patients we have taken an oath to serve as health care professionals. An example of the consequences of bias impacting Black Americans in healthcare today is the differential evaluation of pain symptoms of pregnant Black women in California, causing delay in diagnosis of serious complications and contributing to a maternal mortality rate in California that is three times the rate of all other ethnic groups.

These biases are more commonly manifested in less tragic ways and are found in the way non-white patients are treated by doctors, nurses and others within the healthcare delivery system. As an example, many years ago, a Latino nurse at a health center where I worked was injured when he worked on his car– the engine fell on his chest. He arrived to the ED in his grease-stained work clothes and pain in his chest. The ED nurses who cared for him did not know that he was nurse. While he was in their care, they were making comments, using body language and words that lacked compassion and respect, and withheld pain medication. The physician progress note referred to him as “greasy Mexican” in his chief complaint statement. He indeed had motor oil on his clothes and skin.

On a broader level, physical conditions are the manifestations of the environment/social conditions in which your patients live in and carry with them when they seek care.  When a significant portion of the patient population feels dismissed, disenfranchised or discarded, doing no harm then has to stretch beyond the mere facts and symptoms you see and face in the few minutes you have with your patients.  Instead, we must strive toward mindful and thoughtful consideration of a world in which our patients dwell.

We must take action to initiate changes within our health care delivery system to parallel to actions being carried out by our society to ameliorate the effects of bias and to decrease institutional racism that afflicts our patients and communities.
On an individual level, both in the health care arena and the broader societal arena, we need to have thoughtful and meaningful dialogue with:

  1. Ourselves
  2. Our friends
  3. Strangers

The rationale and tactics are different for each of these levels of dialogue.

Ourselves. The first level, dialogue with ourselves, is another way of describing introspection, where we seek to understand our own implicit biases and address them. This can be done by reading one of many excellent books on this topic like Thinking Fast and Slow, How to be an Antiracist and White Fragility, by enrolling in a class or community discussion group on racism, and by writing and reflecting about how the ideas in these books and groups affect you. Changing the brain pathways that cause implicit bias takes time and effort; we need to make it a life-long personal self-educational priority.

Our Friends. As we are better able to understand our values and biases, we are in a position to use this insight to influence those we interact with every day: friends, family, and co-workers (including those with a different set of political beliefs). Being an activist against bullying behavior and violence is especially important for addressing abuses in use of force and underlying policies promoting or allowing such abuses. However, influencing other people’s thinking in order to foster their better understanding of their own biases requires different and individualized approaches. This might mean responding to a gratuitous racial generalization with disagreement and a reflection of how it makes us feel. More subtle cases may be better addressed in a dialogue to promote introspection: “What did you mean by that?” or “What makes you think that?” A more round-about way of changing beliefs is through skillful storytelling, tapping into the human brain’s built-in capacity to absorb new values. Collecting a repertoire of stories to use requires being alert to examples in our everyday lives, and recording and using stories we hear from other sources.

Strangers. As clinicians, we frequently meet with new patients with very different racial, ethnic, religious, nationality, etc. backgrounds. These interactions may go very wrong, with lack of trust in the clinician, incorrect diagnoses, poor adherence to clinician recommendation, and general dissatisfaction by the patient. Each day PHC receives member complaints of poor communication or possible discrimination. These are a reflection of sub-optimal interaction with patients.

While many clinicians are experts at developing trust with their patients, others struggle and would benefit from training and mentoring, something not widely available after residency. In the January 7 issue of JAMA, an expert panel identified 5 elements of high quality patient interaction:

  1. Prepare with intention
  2. Listen intently and completely
  3. Agree on what matters most
  4. Connect with the patient’s story
  5. Explore emotional cues

Recently, resident physicians from across Northern California recommended adding a new aspect to the Prepare with Intention element. Very simply, pause before entering the room, (or starting a video or telephone visit) to acknowledge your own explicit and implicit biases that may exist when providing care to this patient. Pause to consider ways to customize your interaction with this particular patient to build trust and show respect.

Conversely, when our patients make biased, discriminatory or racist remarks, as clinicians we must be prepared with a menu of responses that balances our responsibilities to our individual patients to consider the larger societal imperative in which each member of our community learns to be cognizant of their own biases.

On June 10, scientists around the world took a day off from their research to reflect on issues around racism and contemplate changes they could make in their lives to dismantle the inequities left by racism. To be most effective in our dialogues with ourselves, our friends and strangers, clinicians must also periodically carve out time to do this hard work. Read books. Collect stories. Develop a repertoire of responses to racist comments.

What actions can PHC take to support this work in the health care arena? We have an internal team focused on many aspects of health equity, including education of PHC staff about implicit bias and review of health disparities data of our members, and planning interventions. One of our core organizational values is valuing diversity as a company and as a leadership team.

We investigate patient complaints involving potential discriminatory behavior, but most do not represent overt discrimination (e.g. “I’m not giving you pain medication because you are Black.”), but rather those patterns of sub-optimal verbal and non-verbal communication driven by implicit bias not subject to civil rights action. Still, such biased communication can be addressed. PHC will look at potential options to do this better in the months ahead.

We welcome your thoughts and suggestions on additional actions we might consider. We are most effective when we work in partnership with you, your organizations and the communities we serve.

May 20 Microdosing of Mindfulness

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

The data on the effectiveness of mindfulness in reducing stress, anxiety, and cravings for controlled substances is strong. Mindfulness is also demonstrated to increase happiness.

In spite of this, many health care professionals and patients have difficulty fully embracing mindfulness as a therapy or practice, long term. Many authors have commented on this, with myriad different explanations and analyses. (For example, this essay contrasts mindfulness with psychotherapy.) Here are some underlying beliefs that may contribute:

  1. Mental illness and experiencing stress are signs of personal weakness to be covered-up or suppressed, instead of understood and addressed.
  2. The mind and body are separate. Those who strongly believe this cannot believe that trying to use their mind to make their body feel better or function better.
  3. Mindfulness takes too much time. Individuals who believe that mindfulness is helpful may conclude that it takes too much time to practice mindfulness regularly. Does one really need to go on a two-week meditation retreat to get into a better state of mind?
  4. Mindfulness equals deep breathing and meditation. Is breathing in through the nose and out through the mouth repeatedly always the best way to re-focus the mind?

The Greater Good Science Center at UC Berkeley embraces a broader conceptualization of mindfulness. Each person is encouraged to try different methods of becoming more mindful (using a broader understanding of mindfulness than its meditative Buddhist roots), finding a method that resonates especially with their personality and beliefs.

The Center performs original research to further the evidence base on different practices, which looks at the concept of micro-dosing mindfulness: spending very short periods of time several times per day to experience a sense of awe about something in your environment, and sharing this with your friends and family. This might be something beautiful, like a flower, a pet, a story or a piece of music. It might be something more intricate and complex, like a well-engineered race car, an innovative food dish, a piece of sculpture, a formal ceremony, or a novel gadget. Whatever it is, you should focus on it for a moment at the exclusion of all else, appreciating some of the intricacies and details, experience a sense of awe, and then perhaps share the details of the experience briefly with someone in your life. For example, take a picture of it with your phone and share it with a brief description of why it affected you!

This last step, the sharing, is critical for making this mindfulness practice not just a method to reduce stress but to increase happiness.  Sharing strengthens interpersonal connection, especially important in this time of physical distancing.  Interpersonal connections are necessary (but not sufficient) for a person to be happy, according to neuroscientist and author Laurie Santos.

Of course, when our friends, family, colleagues or patients share something that gave them a sense of awe, we should pause, give our attention to what is being shared, reflect back what we have heard, and allow ourselves to share some of that awe.

Robert Moore, MD MPH MBA
Chief Medical Officer

May 12 PCP and Public Health COVID Update

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

Last Thursday, California released the details of its previously announced “resilience roadmap,” giving requirements and recommendations for safely allowing resumption of activities based on public health risk.  This roadmap starts to give us some longer-term understanding of how the future will unfold in the months ahead. Stages 2 is fairly detailed now; stages 3 and 4 will have additional detail added later.  County health departments have been given important responsibilities in this process, ensuring sufficient community testing to allow opening up to occur, overseeing local implementation of the planning, workplace changes, and citizen communication.  We appreciate the difficult tradeoffs they are balancing in their decision-making; thank you!

The governor’s office is now shifting focus to developing strategies to address the massive budget shortfall being faced next year; their “May Revise” of the budget is due soon.  All programs that rely on state funding (education, health, public safety, transportation) are concerned about what cuts the state will use to prepare a balanced budget.

As of last week, six counties in the PHC service area (Marin, Sonoma, Napa, Yolo, Mendocino and Humboldt) now have mandates for facial coverings/masks when indoors or in crowded outdoor areas where physical distancing cannot be maintained.  Local community groups have stepped up to provide masks/facial coverings to vulnerable populations, including the homeless.  This demonstrates that a community need, combined with community spirit can ensure community-wide adherence to such requirements.

Here are a selection of updates gathered in the last 12 days, which we thought you would find helpful.  Thanks to everyone for sending suggestions and feedback!

  1. Policy updates
    1. Verizon offers FCC grants to promote telehealth deployment.  Since it is a federal grant program, the paperwork and steps are rather complicated.  See the online application to get started.
    2. Congregate living environments have been particularly susceptible to COVID outbreaks across the U.S.  The CDC has posted guidance for owners/managers of these facilities to prevent spread of COVID-19.  Please pass this on to the managers of facilities where your patients live.
  1. Public Health Update:  This pre-print article recalculates the estimated Ro (R-naught) of COVID-19 taking transmission of asymptomatically infected individuals into account.  Their revision increases the Ro to at least 5, with a mean likely Ro of 15.  This higher Ro helps explain the rapid spread in New York City, and the stubborn persistence of new cases and deaths in the California in spite of Public Health mitigation efforts.  The implication:  a higher level of herd immunity will ultimately be needed to eliminate outbreaks.
  1. Efficient use and access to PPE.  In previous communication, we presented some PHC-generated guidelines on re-opening outpatient medical practices.  The AMA released similar guidelines.  In our discussions with local PCPs, insufficient access to sufficient masks and other PPE is a major barrier to re-opening.  Here are some new resources:
    1. CDC guidelines on optimizing efficient use of PPE.  The Centers for Disease Control and Prevention have released optimization strategies for PPE offer options for use when PPE supplies are stressed, running low, or absent.
    2. Free PPE Decontamination for Reuse.  The State of California, in cooperation with federal partners, is offering Battelle Critical Care Decontamination Systems as a solution to the N95 shortages impacting California, which will be available to all practices, free of charge.  There was some early miscommunication indicating that it was only available for hospitals, but we have confirmed that this is not true; outpatient health care offices may also use this service.
  1. COVID Testing Updates
    1. Population Testing: Why is Open Testing a Goal?  The availability to test for SARS-CoV2 RNA is expanding steadily in our region, leading to rapid changes in local recommendations for testing.  While most PCPs are testing based on presence of symptoms or contacts with either cases or vulnerable populations, some external testing sites are encouraging anyone who wishes to be tested to get tested.  While on first blush this looks like an inefficient use of COVID tests, an interesting finding shows that there is some psychology to this policy.  When “asymptomatic” individuals who test positive are questioned, over half actually did have mild symptoms that they discounted at the time, suggesting that subconsciously these individuals were worried enough about these mild symptoms to seek out testing.
    2. Limits of “Rapid” RNA tests.  The first rapid COVID RNA test (Abbott) to come on the market has several important limitations.
      1. Once the specimen is collected, it must be run within 2 hours.
      2. Unlike the standard tests, no viral transport medium can be used; it can lead to false negative results.
      3. The company has not validated this test on asymptomatic individuals, and so recommends only using it for those with symptoms.  This recommendation may change in the future.
    3. Limitations of serology test interpretation.  The California COVID-19 Testing Task Force put together a succinct, easy to understand explanation of what serology tests help with and what they should NOT be used for.  The FDA has updated its policy on SARS-CoV2 antibody testing after a flood of serology tests came to market, some with poor performance and fraudulent labeling.
    4. New method of RNA testing.  Researchers are working to adapt the CRISPR gene editing methodology to identify SARS-CoV2.  Instead of amplifying, the viral sequence to the point of detection (done in PCR tests), the CRISPR method finds the viral sequence and then sends a signal, which is then detected.  The charming name for this testing methodology is SHERLOCK. If this technology is perfected, it will allow large scale rapid testing for RNA.
  1. COVID disparities.  The COVID-19 outbreak initially involved cruise ship customers, international travelers and their direct contacts, and evolved to a pattern of community spread, disproportionately affecting individuals who live in crowded conditions and who continue to work as essential workers.  A steady stream of epidemiological data has showed that community spread in cities has disproportionately affected socioeconomically disadvantaged individuals.  This is reflected in analysis of hospitalizations and deaths in New York City, which showed Manhattan (with a higher median income) with less burden of disease than The Bronx and Queens, which have a much lower median income.  Evaluating race/ethnicity disparities in context is important, as there are many subconscious biases and tropes which humans are prone to attribute as causes of these disparities (thoughtfully summarized in this excellent NEJM article).
  1. COVID Treatment Updates.
    1. Remdesivir:  Gilead asks Federal Government to Distribute for Compassionate Use:  Most Hospitals left out. Remdesivir is less available than previously as Gilead turned over responsibility for distribution of the drug to the Federal Government.  Remdesivir was approved under Emergency Use Authorization on 5/1/2020 for IV administration to hospitalized COVID-19 patients, based on preliminary data from the ACTT-1 study. Per the EUA factsheet, recommended adult dosing is 10 days for critically ill patients (intubated/ECMO) and 5 days for all others, with the ability to extend to 10 days if no clinical improvement. Per the distribution website, hospitals identified by the U.S. government as a recipient for donated remdesivir will be proactively contacted; to find out if your hospital has been designated to receive donated remdesivir, you can email remdesivir@amerisourcebergen.com Certain hospitals were given a supply, others were granted none.  The basis of this allocation has not been clear.
    2. Elevated PTT in serious COVIDAnticoagulate anyway!  This article found that the elevated Partial Thromboplastin Time (PTT) found in critically ill COVID patients is due to the presence of Lupus Anticoagulant, as part of an antiphospholipid syndrome.  As a result, it is an indication of a hypercoagulable state, needing anticoagulation.  Another study (added to several done before with similar findings) showed that critically ill patients with COVID had better outcomes if administered low molecular weight heparin.
    3. Pediatric Multisystem Inflammatory Syndrome (PMIS). A number have reports have been issued in the past two weeks on this topic, affecting 64 pediatric patients in New York and more in other countries with a serious condition that looks somewhat similar to Kawasaki disease:
      1. A child presenting with persistent fever, inflammation (e.g. neutrophilia, elevated C-reactive protein and lymphopenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). This may include children meeting full or partial criteria for Kawasaki disease.
      2. Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, and infections associated with myocarditis such as enterovirus.
      3. This literature is evolving quickly; any potential cases would warrant consultation with a pediatric infectious disease specialist for therapeutic advice.
    4. List of all clinical trials for treatment of COVID.  The Medical Letter has shared a comprehensive list of all drug trials being used to test    treatments of COVID.  It is worth a quick look to get a sense of the many strategies being considered.

That’s it for this week!  We at PHC continue to be proud to support and serve you as you support your community in your daily work.

Robert Moore, MD MPH MBA
Chief Medical Officer