Family Medicine: Straddling COVID-19, Influenza and Life

 What can we and our patients do as the cold and flu season nears and COVID-19 lingers?

First is to check what Dr. Google says about these infections, all of which are viruses.  What do we know about viruses?

Physicians have read a lot recently about SARS-CoV-2 also called COVID-19, coronavirus, Rona and other nick names.  Formally SARS-CoV-2 is the name, but COVID-19 is widely accepted and used, so I'll refer to it as COVID-19.  In spite of our reading and a wide variety of ongoing research, there are many mysteries about COVID-19.  With over 200,000 deaths in the United States attributed to COVID-19, it has generated a myriad of responses and expense from our whole society and its leaders. Most recently, schools have reopened with variations on the learning models including a lot of online and home learning.  

There is at least one dashboard for school data about the models of learning and COVID-19 impact.  School COVID-19 related data

How will physicians adjust the COVID-19 oriented systems we've organized for the Pandemic to respond to cold and flu season?

This question and many more pop up as we start to think about coughing, aching, febrile miserable patients who want to see their physician.  Will video visits suffice  for the coming viral onslaught this winter?  Will patients want to enter an office where coughing people have been?  Will we further develop the parking lot approach to patients with a drive through, service in your car approach?  Or a drive through or walk through tent in the parking lot for privacy during the physical exam?  Will we still do the ENT- ears, nose, throat - part of the exam or the lung exam which includes "take a deep breath in and out through your mouth" for each lung area? 

Many questions and many options arise as we ponder our response to the waves of mucous, droplets and mists of microbes that will greet us from our patients.   

One aspect of the viral mucous challenge is a major concern for physicians- the being unavailable for 14 days of practice.  Many patients will have needs for care during those 2 weeks of quarantine.  What will they do?  Will the physician have enough energy and focus to offer phone or video visits during the 14 days?  Will revenue generated or not generated during the time away from practice combined with losses during the first two months of the Pandemic lead to closing or selling the practice?  

Lots of family physicians went out of business already during the Pandemic.  There is very little in financial reserves for many who made it through the first half of 2020.  What's next?

Flu shots.  

Corona Sports: Buckeye Football, Buckeye Fans, and Buckeye Hearts

How do we understand the various football conferences "Postponing" their competition to spring?  As a Buckeye fan, I felt a vacuum suck out my gut when I heard the news.  As a Family Physician, graduate of The Ohio State University College of Medicine, former faculty in the Department of Family Medicine 1990-94 (when we, humbly, were honored as one of the top five primary care medical schools in America by US News and World Report twice), and a patient who had a 5.2 CM kidney stone removed at OSU Medical Center, I'm disappointed.

I love Ohio State.

OK, some people worship the Buckeyes, a concept I recognized by recognizing it with a song I wrote called:

"Jesus or the Buckeyes"

Jesus or the Buckeyes, Which one is your Lord?

Which one gives you hope Through the shouting of their word?

Do you need a touchdown To know that you’re alive,

Or prayer and praise and worship To learn how you should strive?

Jesus or the Buckeyes What can ease your stress?

Will script Ohio save your life And let you find your rest?

Will Urban Meyer call a play To save you from your boss?  

Will Jesus come and “dot your I” Just when all seems lost?

Jesus or the Buckeyes Which one makes you whole?

Which one gives you hope  For the healing of your soul? 

Will cheers and banners fill your heart With hope for victory?

Or heartfelt prayer and Jesus love At home upon your knees.

Chorus:

Jesus or the Buckeyes? Which one “dots your I?”

Which one gives you comfort When you’re about to die?

O-H, I -O may not set you free 

The I that you need dotted Is in B-I-B-L-E.

OK, I'm reminded that some priorities are above Buckeye football.  BUT... the decision to not play this fall seemed to be heavily weighted with a consideration/intense fear about athletes getting COVID-19 induced myocarditis and then, sudden death.  There are TWO examples of athletes having that problem, without the sudden death, in the news articles about the decision.  In hospitalized patients with COVID-19, many have a transient myocarditis.  BUT, the athletic and university leaders expect to have competition in the spring, when the corona virus will still be around and some may get the myocarditis, and it will get diagnosed and treated since they are in a good medical system with good team physicians. 

In the meantime, thousands of college athletes won't be playing sports, but they will be catching the virus.  They may not do as well fighting the virus, since well conditioned people fight viruses better than deconditioned people.  Some will get the myocarditis.  Will they be feeling good enough to play?  Will it be diagnosed and treated as well as it would be in the OSU healthcare system (for example, considering our athletes)?  Will some of our student-athletes get more exposure to the virus in the less controlled setting of the campus or their hometown?

The athletes in the SEC and ACC and my alma mater team, The Army Black Knights of West Point are going to play.  Navy and Air Force are also intending to play.  Air Force conference has cancelled fall sports, but agrees to let them play, at least the other service academies.  Are their health risks any different than the Buckeyes?   Is their healthcare from sports physicians and their campus healthcare systems better than the Buckeyes? 

AND, in the rest of America, those with COVID-19 in the under 50 age groups usuallydon't even get examined by physicians if they get COVID-19.  They might call their doctor with symptoms and get sent to the drive through testing site.  In 2-7 days of self quarantine, they may call their doctor again to clarify how they're doing.  At the appropriate time after fever and some other symptoms have resolved, they go back to work, following CDC website guidelines.  Do they have to get an EKG, Echocardiogram, Troponin blood test and see a cardiologist?  NO.  The NBA does since they are perceived to have extra risks of myocarditis and, therefore, increased risk of sudden death.  Fed EX workers don't have to get cleared by a cardiologist, even though they may be lifting a lot and chased by dogs sometimes, even after having COVID-19.

I was Head Team Physician for Denison University (Woody Hayes alma mater, by the way) for over a decade and remember the intensity and commitment of the athletes.  They love the competition.  They generally know and follow the in season training rules.  They all signed the consent forms acknowledging the dangers of their respective sports ("even death", was on the forms they signed).  Their conference, The NCAC won't have fall sports due to issues related to COVID-19.

The athletic systems haven't supported their arguments by producing the estimated numbers of actual at risk players who might die because they played after COVID-19.  They could have said instead that they are so afraid of COVID in athletes that any athlete who caught it would be banned from playing.  That would eliminate the risk of sudden death at practice or in a game, if that's their ultimate concern.  They didn't even have to do that.  Each athlete and/ or their parents signs a document acknowledging that they could be seriously injured or even killed playing their sport.  Parents even have to sign a similar form for little league players.  The authorities have only to add a clause about possible exposure to infectious diseases such as COVID-19 and, not surprisingly, almost every athlete and/or their parents would sign it.  They want to play.  I believe they should have the right to make that decision, since they are the reason given by the Big 10 Conference and others for the decision to cancel the seasons.

"I would say we have seen enough to develop a safe plan.  They have not," Dr. Catherine O'Neal said as an infectious disease specialist at LSU in the SEC, referring to the Big 10 and Pac 12 decisions not to play.  The (so-called) "Medical Facts" are the same for all the physicians, they just interpret them differently.

That's my opinion..What's yours?

Jesus or the Buckeyes,Which one is your Lord?Which one gives you hopeThrough the shouting of their word?Do you need a touchdownTo know that you’re alive,Or prayer and praise and worshipTo learn how you should strive?Jesus or the BuckeyesWhat canease your stress?Will script Ohio save your lifeAnd let you find your rest?Will Urban Meyer call a playTo save you from your boss?Will Jesus come and “dot your I”Just when all seems lost?Jesus or the BuckeyesWhich one makes you whole?Which one gives you hope For the healing of your soul?Will cheers and bannersfill your heartWith hope for victoryOr heartfelt prayer and Jesus loveAt home upon your knees.

Chorus:Jesus or the Buckeyes?Which one “dots your I?”Which one gives you comfortWhen you’re about to die?O-H,I -Omaynot set you freeThe I that you need dottedIs in B-I-B-L-E.

Jesus or The Buckeyes by Pat JonasJesus or the Buckeyes,Which one is your Lord?Which one gives you hopeThrough the shouting of their word?Do you need a touchdownTo know that you’re alive,Or prayer and praise and worshipTo learn how you should strive?Jesus or the BuckeyesWhat canease your stress?Will script Ohio save your lifeAnd let you find your rest?Will Urban Meyer call a playTo save you from your boss?Will Jesus come and “dot your I”Just when all seems lost?Jesus or the BuckeyesWhich one makes you whole?Which one gives you hope For the healing of your soul?Will cheers and bannersfill your heartWith hope for victoryOr heartfelt prayer and Jesus loveAt home upon your knees.

Chorus:Jesus or the Buckeyes?Which one “dots your I?”Which one gives you comfortWhen you’re about to die?O-H,I -Omaynot set you freeThe I that you need dottChorus:

Jesus or the Buckeyes?Which one “dots your I?”Which one gives you comfortWhen you’re about to die?O-H,I -Omaynot set you freeThe I that you need dottedIs in B-I-B-L-E.

50th Anniversary Vietnam Service Post 3

  I followed orders and flew to Cam Ranh Bay, reporting to the 18th Engineer Brigade, which sent me to their aviation unit.  I was instructed to meet with someone the next day to get my specific assignment.  In the mean time, they had a cookout and a volleyball game which was a pleasant way to meet some other pilots who flew for the Engineers.  

The next morning, I got the word from a captain in their aviation unit that my assigned unit would be the 45th Engineer Group headquarters, which had an aviation section.  The captain pointed on the map of Vietnam to the location of the Group in Phu Bai (which I was later told meant the "land of the dead ").  "What are those red pins on the map?" I asked.  "Oh, that's where the 45th Engineer Group Aviation Section had been taking fire from the enemy."  I already noticed that there were no such pins in the area around Cam Ranh Bay.  My assignment might be more "engaging" in I Corps where I was headed.  The area of operations of the 45th Engineer Group was I Corps which was the northernmost area of military operations in South Vietnam, extending north to the Demilitarized Zone - DMZ (there was a II, III, and a IV Corps).  

I flew from Cam Ranh Bay to Phu Bai that day and reported to Headquarters of the 45th Engineer Group.  Personnel assigned me to the Aviation section and a hooch - Vietnam War slang for a thatched hut or improvised living space- my plywood home for the next several months.

Our Aviation section shortly after my arrival in Phu Bai: Cpt Sherk, Cpt Holland, Cpt. Jonas, Lt Marsh, CW2 Leo Childress, ?, SSG Cooper (L to R standing) Sitting Sp4 L. Kawai, ?, Sp4 Washington, ?, ?, Sp4 M. Metro. 2nd row includes Sgt. Jones, Sp4 Steele, May, (Sorry I don't remember everyont)

Some facts about the 45th Engineer Group:

45th Engineer Group (Construction)

Arrived Vietnam: 8 June 1966
Departed Vietnam: 30 January 1972
Previous Station: Fort Bragg
Authorized Strength
HHC
1966 - 98
1968 - 111
1970 - 111

The 45th Engineer Group was under the 18th Engineer Brigade throughout its service in Vietnam, planning a coordinating the activities of its assigned and attached units. These consisted of construction or other units engaged in the field construction, rehabilitation, or maintenance of facilities in support of the U.S. Army or Air Force operations. The group arrived at Cam Rahn Bay and moved to Dong Ba Thin on 15 July 1966. It relocated to Tuy Hoa on 15 October 1966, moving to Qui Nhon that December. It moved north to the Phu Bai area in February 1968, where it assumed general construction support missions for the I Corps Tactical Zone. The group then remained in the Da Nang area until departing Vietnam. The following engineer battalions served the group one time or another;

14th Engineer Battalion       39th Engineer Battalion
19th Engineer Battalion       84th Engineer Battalion
20th Engineer Battalion      299th Engineer Battalion
27th Engineer Battalion      577th Engineer Battalion
35th Engineer Battalion      589th Engineer Battalion

More later

50 years of Vietnam Memories: Arriving in July 1970

 

50 years of Vietnam Memories: Arriving in July 1970

OK, off to Vietnam in July 1970.  That was 50 years ago and I've processed lots of thoughts about the Vietnam Conflict/ War in the interim.  I'm pleased to have served in Vietnam. 

 

My reflections are through a lens of awareness that 58,318 names, including twenty of my West Point classmates, representing those who died as a result of their service in Vietnam, are engraved on the Vietnam Veterans Memorial ("The Wall").  I have an array of books about Vietnam to try to better understand it from multiple perspectives.  Some are enlightening.  Some are troubling.  Some, such as Visions of War, Dreams of Peace -Writings of Women in the Vietnam War, edited by Lynda Van Devanter and Joan A. Furey (poetry) can be gut wrenching.  Here is an excerpt from Mellow on Morphine by Dana Shuster in 1967:

                                  "...Mellow on morphine, he smiles and floats

                                    above the stretcher over which i hover

                                    I snip an annular ligament

                                    and his foot plops unnoticed into the pail,

                                    ....His day was just starting when his hootch disappeared

                                    along with the foot and at least one friend...

                                                                                                                                      

 

In another book In Retrospect, the late Robert McNamara, Secretary of Defense in the Kennedy and Johnson administrations, laments, "This is the book I planned never to write.... I want to put Vietnam in context.          

    We of the Kennedy and Johnson  administrations who participated in the decisions on Vietnam acted according to what we thought were the principles and traditions of this nation.  We made our decisions in light of those values.

    Yet we were wrong, terribly wrong.  We owe it to future generations to explain why."

We arrived in Saigon after a very long flight, the last leg starting in Japan.  As we descended, I noticed what looked like a large section of countryside pockmarked with small bomb craters, which actually were graves in  a huge cemetery, I noticed as the lower altitude afforded a better focus.  Several buses transported the 200 or so Army men who had shared the flight from the landing strip around or across a part of Saigon via a rubber tree plantation to Long Binh where we would get our unit assignments at the Replacement Depot (or something like that- excuse the 50 year old fog).

I remember filing out some forms asking about assignment preferences that would accompany my personnel file and official orders for service in Vietnam to be reviewed as my unit assignment was decided.  I expressed a preference for assignment in an aviation role with an Engineer unit, since I was an officer in the Corps of Engineers.  I then waited in a bar with many other members of my flight school class for the listing of names and assignments as they were posted on a bulletin board.  Several of my fellow pilots were assigned to the !st Cav and we drank a toast to the Cav.  After a short while of wondering, my name showed up on a list as the only one assigned to the 18th Engineer Brigade in Cam Ranh Bay.  I laughed and drank another Budweiser, assuming that I would spend the year with the Engineers based at Cam Ranh Bay, which probably had some level of creature comfort.
  Some US Army pics at Cam Ranh Bay 1970-71

Here are the first pictures I took in Vietnam.  Just getting adjusted.

Departure for Vietnam: 50th Anniversary July 27, 1970- July 27, 2020

Fifty years ago.  Vietnam.  I left Rebecca, my wife of 7 months, at the Cincinnati airport, flew to California and left from Travis Air Force Base on July 27, 1970.  We landed in Alaska where I got a photo of a stuffed Kodiak bear that must have been 8 feet tall.  I called back to Ohio to find that my nephew, Matthew Jonas, was born in Ohio before we took off for Japan where we refueled, then into Vietnam.

I am a Vietnam Veteran.  I served in the Aviation Section of the 45th Engineer Group as a rotary wing aviator in UH-1D and OH58-A, instructor pilot in OH 58-A and maintenance officer.

I frequently think about the twenty members of my West Point Class of 1968 who died as a result of their injuries in Vietnam.  Their names are on The Wall.  Others have developed malignancies as a result of toxic exposures in Vietnam such as Agent Orange.  We were soldiers.

I loved the helicopter flying, from the DMZ in the north to Quang Ngai and My Lai in the southern area of our operations for the 45th Engineer Group.

I'll be reflecting on the Vietnam experience for the next year with regular blog post reflections.







Later Reflections about Vietnam

Family Medicine and COVID-19: Mucous Is the State Bird

"Mucous is the State Bird in Ohio"  I say that to a lot of people in my practice and in some of my holistic health presentations.  A normal adult head makes 2 liters of mucous daily, for many purposes.  Everyone in Ohio seems to have mucous generating allergies at one time of the year or another (or year round for many).  Why are we concerned?

COVID-19

We have to differentiate usual allergic mucous from infectious mucous and further sort out which of the infectious mucous might be a COVID-19 mucous.  One might think that people can tell if they're infected instead of "just" allergic, or COVID-19 instead of "just" a cold.  Unfortunately, it's not that easy.  A lot depends on how individuals sense and know themselves.  That's a challenge that is important as individuals have respiratory symptome, but go to Dot's Market or Kroger or Elsa's Restaurant or schedule an appointment with their Family Physician for their blood pressure or diabetic check-up.  Which mucous might be problematic in those venues?

If the patient is sensitive to what their mucous is saying, it helps a lot.  Many people are too stressed to notice anything about their mucous unless asked about it.  Sometimes it takes several questions from their physician to clarify that they even have extra mucous.  That's why so many medical visits have been shifted to video or phone visits.  They decrease the risk of spreading contagious infections, including, and especially, the COVID-19 infection

Many people sneeze, snort and blow their nose a lot is certain seasons and/or settings due to their allergies.  Many people also have those same symptoms as part of a respiratory infection.

Fever, aching all over, discolored mucous (e.g., green with living microbes or yellow caused by dead microbes) shakes, or chills are indications of infection- but not early in many respiratory infections.  So how do we sort out the people who may have the newest Corona virus, now known as COVID-19?

Usually, we don't sort well since evidence is mounting that millions of people have had the virus already.  The fact that we have over 100,000 deaths related to the virus so far makes us continue to be nervous about this particular microbe.  The statistics people will have to sort out the levels of certainty about the cause of death and the impact of the COVID-19 on life, death and the economy as we move ahead.  They have developed a good idea about who is most vulnerable to succumb to the infection, therefore also have some insights about strategies to protect the most vulnerable populations.  Each state/governor gets to make decisions and policies that apply this knowledge to their citizens.

What about your mucous or your children or your great grandmother in the nursing home?  Initially, notice that you have the mucous by increasing awareness to your "increased mucous"behavior.  Are you using more tissues, antihistamines, vitamins or supplements as you sneeze and cough more?  If you  notice it, look at it in the tissue that you coughed or blew your nose in.  Is it thin or thick?  What color is it (clear, green, brown, tan, yellow)?  If it's green, orange, tan or yellow- that usually means infection (some people with asthma, chronic obstructive pulmonary disease, chronic bronchitis may not have an acute or contagious infection in spite of varying color of sputum- but that's another story).

If your mucous implies infection, you may wish to take your temperature.  If it's 100.4 or above, that's an official fever.  If it seems to be one or more degrees higher than your "usual" (98.6 is just a line on a thermometer- not "normal"- your temperature varies by 1 degree Fahrenheit each 24 hour day).  Many businesses are taking daily temperatures on employees as a screen for undetected infection.  Medical professionals take their temperature daily.  People are often insensitive to a temperature elevation, so it pays to get an understanding about your temperature.  We now have the "scan the forehead" device (not as accurate as a thermometer type device, but there's no mucous involved).

If your mucous changes and/or you have a temperature elevation, reflect on your contacts.  Is anyone you know coughing or sneezing or blowing their nose?  If so, is it more than their usual levels of these behaviors?  Is anyone you know ill, missing work for illness, quarantined, taking antibiotics, going to urgent care or emergency rooms, just discharged from the hospital with pneumonia, just discharged from the hospital for any reason, working in a medical office, nursing home, assisted living, hospital or other high risk job/environment?  Are you exposed to young children such as your kids or grandchildren who may have respiratory signs or symptoms?

Are you infected?  Contagious?  Endangered?  A threat to others?  Just allergic to Ohio or the state where you live?

In a place such as Ohio where I live, where "mucous is the state bird", it's difficult to sort out the usual mucous from the potentially contagious mucous.  Together, we can become mucous sleuths and stay a bit safer.

Ehlers Danlos Syndrome : A Painful Surprise for Family Physicians

by A. Patrick Jonas, MD, ABFM at Neighborly Family Medicine

Ehlers Danlos Syndrome: Rare? Not so Rare? Not even Rare? Pain, Pain and Pain. It drips with clues to the possible presence of a connective tissue disorder. When I was in medical school, the more likely term was collagen vascular disease. Marfan's Syndrome became the poster child for this group of diseases/conditions. Now it should be Ehlers Danlos Syndrome (EDS).

Coming in at 1 in 100 women (per Dr. Nielson- EDS wizard at the University of Cincinnati, with whom I strongly agree), it races by hemochromatosis and others as a disease to know to provide care for patients in Family Medicine. Every Family Physician has 2-10 patients with this diagnosis that hasn't been made.

The categorization of EDS types was reorganized in March of 2017 for better understanding. The term Hypermobility Spectrum Disorders is added to better understand EDS and that which is between EDS and Marfan’s Syndrome. It will take a while for physicians to get acquainted with the clarification. Most family physicians are not aware of the prevalence of EDS in their daily practices, especially patients with pain syndromes.

What is Ehlers Danlos Syndrome?

From the EDS Society: "Ehlers-Danlos syndromes are a group of connective tissue disorders that can be inherited and are varied both in how they affect the body and in their genetic causes. They are generally characterized by joint hypermobility (joints that stretch further than normal), skin hyperextensibility (skin that can be stretched further than normal), and tissue fragility. (For information about the hypermobility spectrum disorders, please visit “About HSD”.)

The Ehlers-Danlos syndromes (EDS) are currently classified in a system of thirteen subtypes. Each EDS subtype has a set of clinical criteria that help guide diagnosis; a patient’s physical signs and symptoms will be matched up to the major and minor criteria to identify the subtype that is the most complete fit. There is substantial symptom overlap between the EDS subtypes and the other connective tissue disorders including hypermobility spectrum disorders, as well as a lot of variability, so a definitive diagnosis for all the EDS subtypes—except for hypermobile EDS (hEDS)—also calls for confirmation by testing to identify the responsible variant for the gene affected in each subtype."

Most patients with EDS have the Classical EDS (about 10%) for which there is a genetic test or the Hypermobile EDS (close to 90%) for which there is unfortunately not a genetic test. The initial diagnosis is done clinically by the history and physical. The Beighton Score is used to assess joint hypermobility. A Family Physician can assess this aspect of the patient in about one minute. This leads into further consideration of major and minor criteria for making the diagnosis, all of which are found at The Ehlers Danlos Society. A diagnostic checklist for the more common hypermobile type can seem to be confusing, but makes more sense with use.

A Family Physician can add Ehlers Danlos Syndrome to a position high on the differential diagnosis of all women with chronic musculoskeletal pain and start to find the women with EDS. Many are relieved to find that there is a diagnosis that explains their misery and treatments that may alleviate many aspects of their pain.

Per Genetics Home Reference Definition

What are the types of Ehlers Danlos Syndrome?

Chart of Types of EDS with detailed definitions.

Family Medicine: Human Centered Care in the Modern Era

Respect:  Myself, my office staff, the patients and their families, the system in which we are allowed to engage, the community in which we live and work, the nation in which we reside, the world with which we exist and interact, the biosphere which is amazing, God who is beyond understanding.

Protect:  The patients and persons involved in patient care in and through my office today; their time to express themselves; the objects, air and persons from toxins and pathologic microbes.

Connect: Via an appropriate medium to the patient and their values, goals and dreams.  Our humanity through our respective roles that support exploration via communication.  Our hearts as necessary during our interactions.

Detect:  Our individual and mutual alignment or misalignment with our values, goals and dreams as it relates to the purpose of the interaction today. The "Chief Complaint" and other issues to be considered during the visit and later.  The context in which the patient raises the "Chief Complaint" or purpose of the visit.  The differential diagnosis using a simple and complex model that expands the list of considerations for the cause of the patient's Chief Complaint and other problems/issues.

Inspect:  Information that is available and the patient to clarify the search/ testing strategy that will best explain the patient's problems and possible solutions.

Correct:  The phenomena that cause the patient's misalignment with current or future values, goals and Dreams.  The perspective of me and/or the patient about the context, information, processes, values , goals and dreams of both of us.

Reflect:  On the above in thought and by preserving a record of the interaction in appropriate media and form as desired/ required.  On the continuing connection between the patient and the process of health/ care.

Thursday in Family Medicine 2020. Technology and People

Wash hands, temperature taken, select mask for the morning, liberal use of hand sanitizer.
Check patient schedule (again, having checked it at the end of yesterday):  Who, What type of visit (video, phone, office), Why are they scheduled? Acute, chronic, preventive focus (although, since I'm a Family Physician, often we cover all three in one visit).  Set up context for the day and first visit.  Make space for two laptops- one for video visit, one for EMR- ,forms/paper space (since I'm a "Geezer", I still write in a paper record as the patient tells their story- suitably illegible at times, but meaningful to me) telephone, and a bottle of water or cup of green tea.

I don't yet have a green screen behind me or a variable background that I noted on a Zoom feed with one of my sons, an academic physician at the University of North Carolina, last week.  Geezers take a while to catch up to cool trends.  I don't have the headset that I would like yet, but the mic in the computer is incredibly good.  It's a start.

Connection difficulties arise with about 20% of patients, especially with the video visits, about issues with sound usually.  Sometimes they can't get the video connection.  There is a software download factor that is a stumbling block for some phones or computers.  My office had some WiFi problems til finally getting a new WiFi and new router.  We're making progress.

The video visits are especially informative about the life of the patient.  Sometimes family members show up as well as pets, art, memorabilia, etc.  We're learning.

More later.