Welcome to our new Newsletter!
I am excited to announce the first Newsletter of 2023 as we try to make this a quarterly issue packed with useful information pertaining to Direct Access Internal Medicine and your overall health.
As 2022 ends and the new year is upon us, I would like to take the time to provide some updates regarding the practice, vaccines and Covid. I will also end the newsletter with a new clinical section which will provide information on a medical topic before sharing some personal thoughts.
I want to quickly let everyone know that we have been out at least one of our usual employees every day for several weeks. In addition, we have a medical student
rotating with us for the month of January. These dynamics may result in things appearing a bit hectic at times and lead to slight wait times. We apologize in advance and plan to get back up to full speed in the coming weeks. Thank you for your patience and understanding!
On that same note, DJ has been a valuable member of our team for over ten years. He has been suffering from significant back issues but has reached a point where he will be out of work intermittently for the foreseeable future and is awaiting surgery.
Bioreference will provide a substitute phlebotomist whenever possible. We ask that you pray for his healing and a speedy recovery.
COVID 19 & Vaccine Updates
Over the past several months, we have seen a steady number of both Covid and Influenza cases along with some other respiratory viruses. In our experience, the
outcomes in these cases have been very similar, with symptoms such as mild congestion and a cough for a few days with others experiencing high fever and severe sinus symptoms for a week or more. Some patients have suffered from residual cough and fatigue for several weeks. When it comes to Covid infections, we have seen no difference in infection rates, severity, or any other outcomes regardless of vaccination status. The only consistent finding has been the lack of infections in persons who have had a confirmed infection within the last few months.
With regard to Covid specifically, we are entering a new phase in the dynamics of the infection. The trend in the last year or more has been a predominant strain that rises and falls within a few months before another strain takes its place. When the Covid boosters with the original strain along with B4 and B5 variants was released, B5 was predominant at the time. However, it quickly waned over the next few weeks and has largely been replaced by the current rising variant which is XBB.1.5. This version of the virus is highly transmissible, and it appears that neither prior vaccinations or infections make much of a difference in preventing new infections. However, the incidence of severe infections and hospitalizations remains very low. With less
effectiveness of vaccines and monoclonal antibody treatments that targeted early variants, we are back to our original protocols that, fortunately, continue to work remarkably well against Covid and other respiratory viruses. These include Vit D3 5000-10,000 units per day, Vitamin C 1000 mg, Quercetin 250-500 mg per day and Zinc 50-200 mg daily. Additionally, I will usually prescribe Azithromycin which is quite effective for many viral infections, along with hydroxychloroquine and ivermectin when appropriate. We also find that a short course of steroids a week into the infection for those with residual symptoms will help knock down the inflammatory response and get patients back on their feet. Our whole team is well versed in our treatment options and ready and able to assist and treat each patient when needed.
It is worth noting that a recent editorial in the WSJ did an excellent job of detailing some of the issues with the newer strains and the current vaccines including boosters.
The current data strongly suggests that those with more vaccines against older variants may be at higher risk of severe infection than those with fewer or even no vaccinations, likely through a process called immune imprinting. Because of the proven lack of efficacy of Covid vaccines against current variants, the relatively benign nature of the infection (especially with any early treatment) and the potential harm that additional vaccination may cause in some individuals, I am no longer able to recommend any more vaccines to my patients, regardless of age or health status. As such, our current supply of vaccines has expired, and we will not be offering the Covid 19 booster from this point forward. If you do feel strongly about getting a booster shot, local pharmacies do still have them available.
Practice Updates
New Physician
I have had a lot of questions regarding when we may add another physician and some of you have expressed concern that we might become too big or too busy. I have spent a lot of time and energy in the past few years getting the practice to a point where we could potentially bring on another doctor. We now have the space and the personnel to handle the additional workload if we are fortunate enough to find the right person for the job. I plan to keep everyone updated on our search. That being said, our mission to provide the most accessible and highest quality health care available in our community will not be compromised. We will make sure that our growth is calculated and managed carefully so as not to affect these principles. The impetus for adding another physician will be to create a sustainable practice that will continue to provide an alternative to the volume driven practices of the major health systems and continue to be a fun and rewarding workplace for me and my employees.
Our Service Model
On that same note, I would like to address how our model is designed to provide this level of service to our patients. When I started this practice nearly twelve years ago, it was never intended that there would ever be just one provider. I always planned to have at least two providers in the practice with a high-quality support staff twice that of most traditional practices. Some patients express an expectation that because we are a concierge model practice, that the physician should always be available to provide the direct care to each patient. That is neither a feasible or sustainable model and in fact, does not exist. Our model is designed around a team concept. Our team is comprised of our physician and nurse practitioner providers, counselor, nurses, phlebotomist, and administrative staff. We all work together to make sure that all our patients get the best possible service and care, and we hold ourselves to a very high standard at every level. While we have different levels of experience, different strengths, and personalities, we have the same level of commitment and desire to give each patient the care they need and deserve. It is that team concept that allows us to stand out. While I am the team leader and I oversee nearly all that happens within the practice, I simply can’t do it alone.
Texting the practice
We have been more actively utilizing our texting capabilities to communicate with patients in recent months. While this provides a very convenient method of communication during regular business hours, there have been a couple of unforeseen issues. First, please do not text on the weekend. Only I, Lauri or Blair answer calls on the weekend. The texts do not roll to the on-call provider after hours, so those texts are not seen until Monday. If you have an issue that needs to be addressed on the weekends or evenings, please call the office number to speak directly to us. The second issue is that some of our patients have my cell phone number and confuse the office text with my cell phone. Please make sure these are separated in your phone if you are using the texting option.
Insurance Issues
With this being the new year, please bring your new insurance cards to the office and give them to Kim and DJ to copy when you arrive for your first appointment.
Bioreference is no longer participating with Anthem as an in-network provider. However, due to our long standing relationship with Bioreference, they are working out details with Anthem to establish appropriate payments. However, you will notice, if you have Anthem, that you may receive an EOB (explanation of benefits) that suggests you may owe hundreds of dollars for your labs. Please wait for an actual bill and if it seems extreme at all, reach out to Roxanne.
Website
We are currently working on a complete revamp of our web presence. We have engaged Proximo Marketing and they are working hard to get our site up to speed and more user friendly for both current and future patients. More to come on this exciting change!
Upcoming Respite
As we all need a little break once in a while to recharge, I will be taking a week off in both January and February. During my absence, Lauri and Blair will be sharing evening and weekend call and of course, covering all the visits in the office. I will have a physician back up for them as well. Any patients requiring hospitalization will be cared for by the hospitalist team at Walter Reed.
Medical Spotlight
Vitamin D
I have long been an advocate for adequate Vitamin D levels and Vitamin D replacement. In this quarter’s newsletter, I would like to review the reasoning behind my strong support for this recommendation.
Vitamin D is what is referred to as an essential vitamin, meaning it is required for the body to function normally. It is actually a hormone, made through a complicated process beginning with a molecule made from cholesterol converted to Vitamin D by exposure to UV rays from the sun in the skin. It is further changed in the liver and kidney to its active form. Vitamin D acts on the intestine, the kidneys, and bones to maintain normal levels of blood calcium and phosphorus. Nearly every cell in the body has a Vit D receptor and it regulates the function of over 200 genes. These include regulating adrenaline and dopamine production in the brain. It also protects the brain from serotonin depletion which is why low Vitamin D levels are associated with a higher risk of depression.
A recent randomized trial using 2000 units daily as a supplement found a 22% reduction in autoimmune conditions like rheumatoid arthritis and psoriasis and a 17% reduction in advanced cancers, likely through the reduction of inflammation. Current research indicates vitamin D deficiency plays a role in causing seventeen varieties of different cancers as well as heart disease, stroke, autoimmune diseases, birth defects, and periodontal disease. Low levels of Vitamin D may also increase the risk of CV disease, the development of diabetes and multiple sclerosis. Supplementation may help with insomnia as well as chronic pain. In a recently published study in the Annals of Internal Medicine, researchers examining data from the UK Biobank suggested
lower overall mortality in those with Vit D levels > 50. Cardiovascular, cancer and respiratory mortality were all lower in that population.
Early on in Covid research, it was discovered that Vit D turns on the immune system’s ability to fight off viruses, while simultaneously tamping down the excessive immune response termed the cytokine storm. It was the cytokine storm that was responsible for the high mortality rates of earlier versions of Covid 19. Subsequent studies suggested that patients with Vit D levels above 30 had a much lower mortality, sometimes approaching zero. In a population of US veterans, a study showed that those who filled a prescription for Vitamin D2 and D3 showed reductions in COVID-19 infection of 28% and 20%, respectively. Mortality within 30-days of COVID-19 infection was similarly 33% lower with Vitamin D3 and 25% lower with D2.
https://www.nature.com/articles/s41598-022-24053-4
It is estimated that one would need to spend 15-20 minutes of sun exposure with 40% of skin exposed to achieve adequate Vit D levels. People who work indoors, wear extensive clothing, regularly use sunblock, are dark skinned, obese, elderly or consciously avoid the sun, are at risk of vitamin D deficiency. Typically, only 10% of the required Vitamin D is ingested. Most is made by the body. The Ideal level of Vitamin D is 50-80, but certainly at least 30. Levels should be monitored if you are low and/or supplementing. Because it is a fat-soluble vitamin, it can accumulate over time, and I have seen levels go from normal to above range over many months of supplementation. In those cases, we hold it for a month or so and then decrease the dosage. Supplementation, if required, generally starts at 400 iu daily. But I find that most people need 1000 iu (25 mcg) at a minimum and occasionally as high as 10,000 units/day. Rx doses of 50,000 units weekly or twice weekly are sometimes prescribed.
If supplementation causes stomach discomfort, sublingual formulations are also available that tend to get around that side effect and work well. This technique also works well for those patients who do not absorb Vit D well such as patients with Crohn’s disease or who have had gastric bypass.
Final Thought From Dr. Haggerty
As we embark on the coming year and reflect on the growth and success at Direct Access, I can’t help but recognize the true reason for our success. That, of course, is my incredible staff. During the Christmas Season especially, so many of you gave us gifts and notes to show your appreciation for the hard work and dedication that we put in every day. Those who went out of their way to thank us for our genuine care and concern remind me that each person working at our practice is performing at a high level, not because of an obligation or paycheck, but out of a deep concern for their fellow man. Your gratitude is not obligatory but comes from the recognition that we are freely and voluntarily going above and beyond what is required of us. That, I believe, is what sets us apart and what I hope and pray will be the care and service we will continue to provide to each of you.
Thank you to each of my dedicated staff members and to each of you who put your trust in us and Happy New Year!
Dr. Haggerty
