Q&A - #8: When can I get the COVID vaccine? (and similar questions)

Since my last post, one vaccine has been approved for use during the pandemic and another is likely to be approved within the week. This is great news and makes me hopeful for a more normal Christmas season next year.

The question we keep getting asked, is 1) Will you get the vaccine? 2) Will your office give out the vaccine? and 3) When can I get the vaccine?

-1) Yes I will get the vaccine, as will my family. Because of my job I’ll end up getting it before them (see below)

-2) Yes I think we will give out the vaccine. I’m not entirely sure how the roll out will be handled once there is enough to start giving out to the general public. I have applied for the ability to do so (for my own patients), but they could certainly decide that it makes more sense for small practices like mine to refer our patients to a more centralized location for efficiency sake.

-3) This is a longer answer.

Here are Michigan’s phases of vaccine rollout.

Phase 1A is to health care workers and nursing home residents. Just like when the stewardess tells you to put your own oxygen mask on first before helping others, we have to protect the frontline healthcare workers. Because this is the first phase, it will be the one with the least amount of vaccine to go around and so it is broken down even further into more specific priorities. For example, I’m one of the last to be vaccinated due to my comparatively low risk, outpatient office job, compared to my colleagues that work directly with COVID in the hospital who will be some of the first.

Phase 1B is to essential workers. It appears that teachers and critical infrastructure workers will be first in line here, the people that keep society running and can't do it from home.

Phase 1C would be those with high risk conditions(diabetes, obesity, etc), high risk environments (jail, homeless shelters, etc) and older adults (over 65).

Phase 2 is everyone else, over age 16.

Keep in mind these phases are not completely distinct - that is to say that 1A probably won't be completely finished when 1B starts, there will be overlap. The point here is that those at highest risk will be prioritized to get the vaccine first.

No one really knows for sure, and it depends on how many vaccines become available in the next couple months (and how many manufacturers are producing them), but based on what I’m reading, I would think phase 2 will happen in April at the earliest, potentially May.

Another question I get: Will I be forced to get the vaccine?

No, I think not. I’ve seen absolutely nothing indicating that anyone in any level of government is advocating mandating the vaccine. Even my own hospital system is not mandating it, but simply strongly encouraging it. I would encourage you to get it, when you are able to. I think its a good thing.

References:

https://www.michigan.gov/documents/coronavirus/MI_COVID-19_Vaccination_Prioritization_Guidance_710349_7.pdf

Q&A- #7: Should I get a COVID vaccine, if and when one becomes available?

I’ve gotten a lot of questions in the office from patients about the news these past couple week about Pfizer’s and now Moderna’s early results. Its pretty common for a vaccine trial to take an early look at results before the trial finishes and these early results were a welcome bit of good news, efficacy that far exceeded what we had hoped for and a side effect profile similar to other vaccinations (injection site reactions mainly). I get asked a lot if the COVID vaccine is something I will recommend/take myself/give to my family. My answer until 2 weeks ago was “We’ll see” , and now I’m cautiously optimistic that the answer will be “Yes”. If the final data when it comes out is as promising as the preliminary data, I will take it without hesitation.

Keep in mind there are other vaccines in the works as well. What is exciting to me is that most of them share the same target on the virus, which could mean good things for their efficacy as well. We will need as many manufacturers as possible operating at full capacity to vaccinate as many people as possible. There are a lot of people out there and it takes time to make these things.

Q&A- #6: What is contact tracing and why should I let an app do it?

Contact tracing means tracking down possible exposed contacts of those known to have COVID.

Currently most contact tracing is done by a real person, usually from the health department, making a real phone call to everyone who has COVID and then finding out from them who else they have been around. Realistically, we don’t have enough Contact Tracers to do this job 100%. We also are getting only partial information - our memories are not 100% accurate and even when we do have a good memory of where we’ve been and who we were around, we may not know all the names of everyone we were around.

There aren’t enough contact tracers out there, out memories are poor…If only there were a way to keep track of our movements automatically and anonymously and get in touch with those who have been unwittingly exposed to COVID. Turns out- there is. That phone you carry around with you everywhere you go, does more than take pictures and make phone calls. The state of Michigan just recently released an app that will anonymously and securely inform you if you have been exposed to COVID. Its an idea that makes a whole lot of sense, way more than making thousands of phone calls to sick people. Get the app here: MI COVID Alert App

Q&A- #4: What does it mean to quarantine or isolate?

Quarantine is what happens when you are avoiding others because you were exposed to someone with the disease, even though you are not necessarily sick yourself.

Isolation is what happens when you are avoiding others because you are known to be sick.

A COVID positive person should isolate for at least 10 days* because that’s about how long it takes after symptoms develop for the disease to no longer be contagious. We also make sure they’re no longer feverish and that they’re improving overall..

Some exposed to that person should quarantine for 14days after their exposure. This is longer than the isolation period because symptoms usually don’t start for a few days after exposure and 14 days gives the infection time to run its course in the exposed person.

How to Quarantine or Isolate:

• if at all possible live apart, or in different parts of the house, ideally in separate rooms, using separate bathrooms

• Avoid contact with pretty much anyone in your house or out of it. Even pets!

• Wear a mask while around others (even those in your house!)

• Monitor your symptoms. If you have trouble breathing, go to the ER

• If you were exposed to COVID, you should be tested after 3-5 days of quarantine . Waiting allows the viral levels to grow and decreases the chance of a false negative test.

• If you are isolating (you have COVID) and you can’t avoid close contact with someone, they will need to begin a quarantine period after your isolation period is over

• If you are quarantining (you were exposed to COVID but thus far don’t have it) and you can’t avoid close contact with someone, they do not need to quarantine….unless you develop symptoms or you have a positive test.

*in the severely sick (hospitalized) and those with certain conditions that weaken the immune system, we increase this to 20 days

References:

https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/isolation.html

https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html

Q&A - #3: How does COVID compare to the Flu in terms of survival?

Short answer: its worse.

The following numbers are rough*, but I think make the point the questioner was asking about.

So far in the U.S. there have been an estimated 10.5 million cases of COVID and 240,000 deaths as a result.

Last year it was estimated that in the U.S. around 38 million people got influenza. Of those around 400,000 ended up in the hospital, and around 22,000 people died as a result of the flu.

So that means that 2.3% of those with COVID died, while 0.057% of those with influenza died. That’s a big difference. Again rough numbers. And keep in mind, with flu we’re talking about something that we give a vaccine to hundreds of millions of people, we’ve been treating it for years so we know a bit about what we’re doing, there is some immunity in the population from previous infection, etc. With COVID we have no vaccine (yet), limited experience treating it, and hardly anyone has had it when you consider that if there have been 10 million cases, that means there are 320 million to go in the US.

*Very rough, but I think good enough to get a good idea. Both flu and COVID case and death numbers have a lot of caveats, more than what I want to deal with in this question. One significant caveat is that these COVID numbers are not including cases that are not reported or cases that were not even suspected. Some think this number could be 5-10 times the number of known cases. Additionally, there are also likely more deaths than are represented by this number.

Follow up question - What are the survival rates by age?

Here is a link to the CDC's data on how the cases and deaths break down by demographic factors.

As it relates to your question: when you compare the cases and the deaths between various age groups, only 14-15% of the cases are in those aged over 65, but 80% of the deaths are in that group.

References:

https://www.cdc.gov/flu/about/burden/past-seasons.html

https://covid.cdc.gov/covid-data-tracker/#cases_totalcases

https://covid.cdc.gov/covid-data-tracker/#demographics

https://twitter.com/trvrb?lang=en

Q&A - #2: Why are things getting worse right now?

After a summer of low COVID case numbers (in most of Michigan), we are now joining the rest of the country in significantly increased numbers. I’m sure there are lots of reasons, but from what I can tell here are the main drivers:

• This virus is very contagious. Without full lockdowns and strict adherence to quarantine (and we’re not doing those things) it WILL spread, somewhat slowly at first, and then extremely rapidly, exponentially, until something happens to slow it back down (either a lockdown temporarily stalls the growth, or more definitively, we reach a certain level of community immunity) . This is the number one reason.

• The weather is getting colder. SarsCoV2 - the virus that causes COVID-19, is from a family of viruses called Coronaviruses. These viruses are always worse in the winter time when the temps go down, partially because they last longer in lower temperatures, and partially because we all tend to congregate inside in the winter.

• Schools? Not sure about that one. But, probably. Kids just don’t show the symptoms as much as adults do and so it is easily spread among them without them even knowing it. And then they bring it home to us.

• Masking helps, but only somewhat. Its a bit like wearing a helmet so you can go out and play in traffic. Sure you’re safer with the helmet on, but ideally you would have stayed home in the first place. But it DOES help, so please keep wearing a mask when you’re out in public, particularly in enclosed spaces.

• Finally, and this one is important - Its been almost a year since COVID became a thing. It was hard to lock everything down this spring and no one wants to do it again, even when they know we should. This pandemic “fatigue” is really getting in the way of being able to control it.

Q&A - #1: Do I need a flu shot?

The last time I wrote a post here, it was the beginning of June. Michigan, particularly the East side, was coming down from its COVID peak in April and overall things for our state were looking as good as to be expected. Michigan was starting to “reopen” and part of our life returned to normal. But only parts. We still had to deal with masks, which were and are annoying, and we still couldn’t do everything we really wanted to do, like join large groups of people for fun.

At that point in June, depending on where you lived in the state, you might have lost multiple family members or friends to COVID, or you might not have known a single person to have had it. You might have thought it was here to stay forever, or you might have thought it was going to go away on November 4th. Maybe you thought masks didn’t work and never wore them, or maybe you wore them just so you wouldn’t get yelled at. Or you maybe you thought masks worked and wore them religiously.

Then we went through the summer. Michigan, on the whole did pretty well for a lot of the summer.

But now its fall, in fact its closer to winter now than to summer. Schools have been in session for months, both K-12 and higher education. The temperatures have started to get cool. And we’re all sick of not seeing one another, sick of “distancing”, sick of wearing masks. And all these things together have meant that our numbers are going up. This time they’re not just going up in the Detroit area, its all over the state. And the country. And the world.

We are in a much different place than we were in June. As we head into what looks to be a far worse time than what we went through in April, I solicited questions on Facebook to try to get a pulse on what needs answering among my patients. I’m gonna try to pump out answers in the order they arrived, one at a time, every day or so. If you would like to suggest a question, find that thread on facebook, or shoot an email to us.

Do I need a flu shot this year? We’re all wearing masks, do I still need one?

Short answer: Yes.

I suspect that the measures we’re taking for COVID will help curtail our flu season, but not enough for me to skip the flu shot. Right now I am doing everything I can to keep my patients from landing in the urgent care or ER - both because that’s good for them in general, and because right now our hospitals are nearing or at capacity. If you get influenza it looks very much like COVID(remember “flu” is a respiratory bug- not a stomach bug) - so the flu shot is one of those things that can help avoid an ER visit or hospital stay.

And remember - flu shots are not 100% effective. (if they were 100% effective, you wouldn’t need to worry about anyone else taking the shot, your shot would be enough). When you get a flu shot you are helping to form a barrier around those who are most vulnerable to flu - our elderly, our pregnant women, our young children. The more people that take the shot, the stronger that barrier.

Reference: https://www.cdc.gov/flu/weekly/

Reopening

As Michigan and the rest of the country ease the restrictions that we’ve placed during the worst of the pandemic, how do we as individuals and families safely and responsibly engage with society? I want to briefly outline some common sense, practical things to keep in mind:

1. Be ok with a change in plans.

It’s going to happen. And if you don’t flow with it someone could get sick. Our pre-COVID19 culture taught us never to miss work for a mild cough. We can’t tolerate that right now. It’s not an easy shift to make. It means telling grandma we can’t come visit because Johnny has a fever. It means postponing a birthday party because you have a new cough.

2. If you are traveling, be aware of the situation in the area.  

Within Michigan, this website can give you an idea of how the various regions in the state are doing controlling the pandemic, and how significant the restrictions are or aren’t.   If you are planning travel out of the state, this organization grades states on how they are doing with COVID cases, testing and hospital capacity, contact tracing and then collates it all into a color coded map.  This doesn’t necessarily tell you whether you should go there or not, but it will give you an idea of how another state is doing compared to us/others. A quick google search for the states health department will likely inform you of any restrictions. Some parts of the country are doing pretty well (MI for example) and others seem to be turning for the worse.

3. Remember what risk is.

Risk does not mean certainty, it’s a probability. Risk applies better to large groups of people, to populations. It’s hard to apply risk to one person or family. We all take risks every day. When we get in our car and drive to work, there is risk. Over the next year, there is a 1 in 106 chance that you will die in a car accident. That doesn’t mean we don’t drive cars anymore. It does mean that we recognize that there is a chance that things could go very wrong, and we do what we can to mitigate that risk - we wear seat belts, we stay sober, we don’t text while driving, we tell our kids to be quiet in the back so they don’t distract us.

4. Keep in mind that some settings/events are significantly riskier than others.

Higher risk: indoor events, large groups, being around others without masks

Lower risk: outdoor events, small groups, being around those wearing masks

5. Keep in mind the personal risk factors.

 These are things that should make you think twice about visiting certain people. Note what I said there – “think twice” - not a hard “don’t go”.   These are people who are more likely to die or have a harder time if they should catch COVID-19, and you should have a candid discussion with them about how much risk everyone is comfortable taking.  People you should think twice about are those:

• over age 50 but especially over 60,

• those with chronic lung diseases Such as asthma or COPD

• those with diabetes

• those with chronic liver or kidney disease requiring dialysis

• those with immune systems that are somehow compromised

• those with severe heart  Conditions

• those who are severely obese

6. Look out for others.

Keep in mind the things that you and your family do may put others at risk when you are around them. The family with children having  sleepovers every night with a different friend is placing Grandma at much higher risk than the family that has been fairly isolated in the past 2 weeks. Going out with any symptoms immediately increases the risk for those around you. When asymptomatic (without symptoms), wearing a mask is annoying, but definitely decreases the risk of you spreading COVID-19 to someone else before you know

7. Testing is wide open

Michigan has made it a goal to test 30,000 people every day, about double what we are currently doing. Testing sites are all over the place, and are free most of the time. Anyone with symptoms can get tested, anyone who has been exposed can get tested and a large number of people without symptoms can get tested if they meet certain criteria, such as leaving the house to go to work.

Sorry this went on so long. I hope it’s helpful as you think about the upcoming summer.

Pandemic Phases

EDIT 5/13/20: I think the oringal title of this article “Reopening Phases” made it seem like we were closed at some point. To be clear, we have not closed during the pandemic. Myself and at least 1 staff member have been here every day and seeing patients since this started. Its been a lot different of a day for us than it was in January and February, being in Phase 1/2 (see below), but still mostly full days of work. I changed the title to avoid confusion.

At some point the Governor’s stay at home order will expire. Assuming that it does expire and is not renewed, and that legally we are able to do such things, below I will outline how our office will enter into a phased reopening. I expect over the next 2 years we will have at least a few times that we will reenter quarantine conditions as the number of cases of COVID-19 will rise as soon as we stop our physical distancing. I hope that measures like contact tracing (potentially using an app) and mask wearing, will slow that rise and keep our hospitals from being overwhelmed.

A few things apply to multiple phases.

• Cleaning is being done in between patients, especially of all high touch surfaces. This is especially important in phases 0-1 but will continue to some degree in phase 2-3.

• Toys have been put away and will be put away until Phase 3

• Magazines are still out, but are now one time use. We get a ton - take the one you touch - its yours now… (phase 0-2)

I’m going to use the State of MI’s phases because its too confusing for me to make up my own phases, and its not necessary for me to do so - the important part here is naming/defining the phases and then coming up with plans (both for our office and for society more broadly)

Phase 1 (Uncontrolled Growth) and 2 (Persistent Spread)

The stay at home order reflects that fact that the number of cases in Michigan is too high to allow non-essential travel. For the times when patients do come to the office, we ask them to call us when in the parking lot, we bring things out to them if they’re picking something up, and we generally only have one patient in the office at a time. No waiting in the waiting room. We ask everyone to wear masks.

• We are utilizing doxy.me/machadomd for secure video visits. This encompasses all of our follow up visits, chronic disease visits, and most of our acute visits, including those with upper respiratory symptoms (fever and cough etc). This works amazingly well. When I was in medical school, my attendings would tell us how much of the diagnosis is in the patients history much more than the physical, and they were right - a lot can be done without being physically present. I do prefer video over phone, so I can pick up on the unspoken, but for those of my patients who are unable to use a video method we will use the phone. If you are an established patient and need an appointment, please call us to schedule.

  • The video service works pretty slick, but you do have to read and follow the prompts to allow the website access to your camera and microphone. After that its very simple. No download needed, its works entirely within the browser of your smartphone or laptop.

• Wellness visits - the screening and preventative visit done for those on medicare, are being performed via telemedicine.

• Well child visits - we are deciding to see these in person on a case by case basis - basically, if you are a child due for shots, or are a baby, we will see you in person. Otherwise we will postpone the visit.

• Physicals - by this I mean the screening and preventative visits done for those NOT on medicare. I don’t see this being covered via telemed by insurance, and because these patients are at less overall risk than my medicare (65&up) patients, we are postponing these.

• We are still seeing some patients in person, for things that can only be done in person, such as procedures that are not able to be postponed.

Phases 3 (Flattening) and 4 (Improving)

This is the time just after the stay at home order has been lifted. This might roughly begin after at least a 2 week decline in new cases. At this point we will start to allow more in-person visits but certainly not deny any requests for telemedicine for visits that we can do remotely. In-person visits will be spread out more to try to avoid patients contacting other patients. We will still prefer waiting in-car, but in this phase will allow waiting in the waiting room, which has far less chairs in it than it used to. We will ask everyone who does come in, to wear a mask.

• URI (upper respiratory infection) visits - cough and cold symptoms - for the vast majority of these we will continue to do these via telemedicine

• Wellness visits - the screening and preventative visit done for those on medicare, will be performed via telemedicine.

• Well child visits - preferring in-person, but if healthy and not due for shots, may be deferred

• Physicals - In office as requested. Not yet seeking out those who are not due for screenings/vaccinations.

Phase 5 (Containing)

This is the phase just before things are “normal” (whatever that is). This probably won’t happen until we’re seeing at least a 4 week decline in new cases. I suspect this will be a difficult phase to get to due to our desire to break quarantine. During phase 5, we will increase in-person visits but not deny any requests for telemedicine that we can do remotely. In-person visits will still be somewhat spread out more to try to avoid patients contacting other patients, and patients can decide to waitin-car or in the distanced waiting room. We will still ask everyone who does come in, to wear a mask.

• URI (upper respiratory infection) visits - cough and cold symptoms - for the vast majority of these we will continue to do these via telemedicine

• Other non-URI sick visits - we will give the patient the option of in person or via telemedicine.

• Wellness visits - the screening and preventative visit done for those on medicare, will be performed via telemedicine (preferred) or in-person.

• Well child visits and non-Medicare physical - Will resume fairly normal in-person physicals as requested and seeking out to those who are overdue for certain screenings and preventative services..

Phase 6 (Post Pandemic)

This is the time when we start to get back to the normal levels of illness in the population. This might not be until 2022 and potentially later. We will still see season variation of viruses (both the old and the new) This phase is similar to the old normal, but with a few twists. I don’t think we’ll ever go back to a time where a mild to moderately “sick” patient with upper respiratory symptoms (cough, etc) will come to the office in-person (they are miserable and don’t want to come in anyway, and we don’t want to get sick, so its a win-win). We will do these via telemedicine - we’ve already seen this can work. Those who are sick with respiratory symptoms who need to be seen in person will wait in their car and go straight to a room, and will be asked to wear a mask. Other non-respiratory visits will be at times performed via telemedicine , as requested by patients, when covered by insurance.

Closing Thoughts

We will spend a lot of time in the coming months and years going up and down the phases, from 1 to 5. It will take a long time to get to 6. At the very least it will take longer than any of us wants.

This is the montage part of the movie. The music has started and now we’re shown clips of whats happening to the main character, while time goes by quickly. This is when the rag-tag band of misfits learns how to work together and become a team. Its when the work gets put in to make the weak character stronger for the 2nd half of the movie. Its when the character grows from a child to an adult and you see why they are the way they are. Sometimes montages tell us why that character is so great, and sometimes they explain why they’re not so great. The point of the montage is that these changes don’t happen overnight. They are boring. They take time. But they’re crucial.

How is your montage going? Who will you be after intermission?

Office operations as of mid March

For current patients here is our current workflow regarding appointments:

• We are utilizing doxy.me/machadomd for secure video visits. This encompasses all of our follow up visits, chronic disease visits, and most of our acute visits, including those with upper respiratory symptoms (fever and cough etc). This works amazingly well. I prefer video over phone, but for those of my patients who are unable to use a video method we will use the phone. If you need an appointment, please call us to schedule.

  • The video service works pretty slick, but you do have to read and follow the prompts to allow the website access to your camera and microphone. After that its very simple. No download needed, its works entirely within the browser of your smartphone or laptop.

• Physical/wellness visits - all preventative care - is being postponed at this time. We are postponing people the week before. A lot of time patients come to a wellness visit with things other concerns, so we’re offering a televisit in replacement, but still rescheduling the preventative part.

• We are still seeing some patients in person, for things that can be done in person, such as procedures that are not able to be postponed.

Business as usual

In case you’re just joining us, business as usual is out the window for a while. Unfortunately the best scenario here, is one that, by slowing spread/transmission of COVID-19, helps to avoid massively overwhelming our hospital system. This will also inevitably increase the duration of this outbreak.

This post is not about estimating the time frame. I suspect the best answer to that question right now is “longer than you think”.

No, I set out to write this post to encourage you during this time. None of us has lived through anything like this before, something so potentially life changing that it drove me to blogging. And no one really knows how to do it, how to get through it. Some are very scared right now. No one quite feels ready. This has led some to do silly and damaging things like hoard food and household supplies. It’s led others to take unprecedented steps toward new models of business and education.

Keep in mind:

• There is good evidence to suggest that symptoms of COVID-19 are must more likely to be present as we age, and that under 30 the infection may be present without any symptoms at all. This means that these stay at home recommendations apply to everyone, not just those with obvious symptoms.

• Minimize your own risk. As much as is in your power, that your job and household needs allow, stay home. I know you keep hearing this. If you have to go out, keep physically isolated and wash well when you get back home. By the way, going to the store to buy food for the next day only is not worth the risk, you can’t be heading to the store every day. I’m looking at you, baby boomers buying only 5 items at Meijer.

• Minimize the risk of others. Consider checking with your neighbors and family before you go out to see if you can turn three trips into one.

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Social Distancing

I’m not a fan of buzzwords, but it is what it is. Social Distancing is a concept shy of full quarantine, meant to keep us from large groups of people where viruses spread like crazy. It means canceling large group meetings like church, sporting events, parties and certain types of vacations (e.g. cruises) and its not popular at all. A lot of the time it means someone is going to lose money and that’s never popular. No one wants to be the one to say “we’re going to cancel”, but we need more to say this.

If you are a civic leader, a business leader, a community leader, if you are in charge of your rotary club, your neighborhood watch, your PTA, this is the time to step up and cancel or postpone your next meeting, or move it online. If you’re not the leader, its time to start talking to them about this.

Why do this now? Maybe you think this is all overblown, or its too early to be worried yet. That’s the problem with exponential growth. By the time the problem is obvious, its already way too late.

This graph is from a well written article by Tomas Pueyo with lots of helpful graphs if you are a graph person. It showing the effects of implementing social distancing and the large effect even one day can make. The black line is business as usual. The red line is starting social distancing on day 21 of the outbreak and the green line is starting just one day earlier. The effect is profound, a 40% reduction in the number of cases. Another model I saw this week showed that just a 25% reduction in social contact would result in a 50% reduction of cases. Don’t like models? Want real world data? John Burn-Murdoch has taken data from Johns Hopkins and graphed out the case loads of the various countries battling COVID-19 with fairly predictable results. The only countries that have fairly flat curves are those with very strict quarantine rules. Everyone else is following the course that Italy is taking (we’re about 2 weeks behind them)

The point of all this data? Social distancing/quarantining can work, but it needs to be done now or it will soon be too late. Even a day can make a difference.

So there it is, I posted twice in 2 days. Given my loathing of most social media, that in an of itself should tell you something. Forgive me if I have grammar mistakes. If you need a reference for something I mentioned let me know and I’ll add it. I couldn’t find one of the graphs I mentioned, so I’ll keep looking.

COVID-19 protocols

There is a lot out there right now about COVID-19 and my suspicion is that if you are coming to this page its not to be told what it is. If you are, go to the CDC’s page on the novel coronavirus.

The purpose of this post is to update my patients about our office policies during this time. Currently I am treating this outbreak as a serious situation that has the potential to change the way medical care is delivered going forward, not to mention all the social and societal ramifications and the risks to population health. I hope and pray that things go better than we are anticipating, but in case they don’t:

Michigan last night (3/10/20) reports its first 2 cases of confirmed COVID-19. Our current protocols will mean a switch to phone call appointments for patients with mild Upper Respiratory Infection (URI) symptoms (fever and cough). More severe symptoms (shortness of breath) will be advised differently, potentially to go to the emergency room, depending on the situation. If you are advised to go the ER, it is recommended that you call ahead for their specific guidance. At this time other appointments will be seen in office, as long as the patient has no obvious symptoms of an upper respiratory infection at the time.

As the situation develops our protocols will change. As I said above, I sincerely hope that things stay mild and manageable, but if infection rates increase, there will be a need for further restriction of public gatherings, which will be hard for us all. Other offices will have different protocols, but in general, don’t bring others to any appointments that you have unless they are needed to help you get around, or to translate or communicate. Call ahead before entering any healthcare facility, it may be your appointment can be delayed or handled without being seen in person.

Wash your hands! A lot. Soap and water is best, hand sanitizer is good too as long as your hands aren’t visibly soiled.

Try not to touch your face. You’re doing it right now aren’t you? Me too, its hard. Now is a great time to break that nail biting habit.

We will not charge a “no show” fee for appointments canceled due to illness.

In case you were wondering, the Genesee County Health Department keeps us local docs updated about certain things, as does the State of Michigan health department, as does the American Academy of Family Practice and I get multiple emails daily from other organizations doing the same. I am doing my best to stay as educated as possible on latest developments as pertain to my role as a community physician.