Family Practice and COVID

By Russ Herring, DNP, FNP-C, FNP-BC

Family practice is an odd little corner of the healthcare universe. Family practice is where we get to know families, grandparents, adult children, teenagers, kids, babies…. Family practice is where we’ll have three generations of a single family under our care at the same time. I have several 60+ year old patients, as well as their adult children who call me their doctor. At this time, I think there are only a couple families where I have the 9-year-old grandchild, her 12-year-old brother, their parents and grandparents.

What an honor, right?

It’s sort of like being part of the family.

I’ve gotten Christmas cards from patients. I received offers to help with my recent school board run, and condolence letters when I lost (which turned out to have its own silver lining, really). I get to meet people from everywhere, who do all manner of different things. Veterans who served in Vietnam, Korea, both Gulf Wars, the Global War on Terror. I have a patient who travels from Calgary.

My youngest patient is…. 7? and my oldest is 95, I think.

I have the best conversations with all these fascinating and wonderful people. “Why are we talking about my job instead of my blood pressure?” Because you’re the only (insert job here) person I’ve ever met, I’ll treat 10 people with high blood pressure today…

This week, I was advised by a patient that his father-in-law, who also happened to be a patient of mine, had passed in their sleep the night prior. The death certificate arrived for my signature the next day.

That hurt.

Family practice is primarily preventative care, or it’s supposed to be. There are levels of prevention within healthcare, primary, secondary, tertiary, quaternary…. My goal as a primary care provider is to prevent my patients from getting disease in the first place. Eat well and exercise before you develop obesity and high blood pressure. Wear your helmet on your bicycle and your seatbelt in your car. Prevent communicable disease by receiving vaccinations. Practice safe(r) sex. Wash your hands.

“I love prevention. I tell patients that my goal is to see them once a year. Make sure the tires are being rotated and the belts have been replaced. That done? Perfect. Take care, wash your hands, don’t talk to strangers and I’ll see you in a year.”

Failing outright prevention of disease, my goal as a primary care provider is the early detection of disease. This is secondary prevention. In clinic, we achieve secondary prevention, with annual vital signs to catch things like high blood pressure, irregular heartbeats or obesity, to name a few. We do this with tests such as colonoscopies and mammograms. We do this with labs that test your blood for high cholesterol, blood sugar changes, and altered liver or kidney function. The goal of secondary prevention is to treat the disease as early in the process as possible. I tell patients that the lifetime smoker whose lung cancer was found when it was the size of a pencil eraser fared better than the patient whose cancer had already devoured an entire lung at initial diagnosis. I tell patients that I’d get a colonoscopy every day of the week and twice on Saturday if it kept me from ever requiring the removal of my colon when a large tumor was found too late.

I mean it… Three times on Sunday…

If we’ve failed to prevent disease and hoping that we at least detected a disease process early, we’re left with tertiary prevention. The goal at this stage is to lessen the blow of the disease, to treat it, to deal with it and to limit long-term sequelae of the disease. The most pressing and current example I can provide of tertiary prevention in the current medical climate would be COVID antibody infusions. We’ve failed to prevent disease, but possibly found it early. This is a requirement for the emergency use authorizations which allows COVID antibody drugs to be used in the first place. The antibody drugs must be used within 10 days of onset of symptoms to qualify. The Great Falls emergency departments have been tasked with conducting these infusions, but they have been under such a deluge of demand, that you may or may not be able to get your infusion early enough to qualify under the 10-day rule.

The antibody drugs are under emergency use authorizations, just like the vaccines had been until the Pfizer vaccine received FDA approval in August, but I haven’t had a single patient refuse the antibody medications as “experimental”. All the rules change when you can’t breathe, and you’re scared. That’s when this becomes real for too many Montanans.

Never choose tertiary prevention over primary. Ever. Never trade a known for an unknown. Remember, the goal of tertiary prevention is to lessen the impact of a disease, or to reduce the long-term effects of that disease. I have friends who have profound memory impairment following COVID infections. I’ve lost patients to COVID. I’ve had many hospitalized. I haven’t had a single patient hospitalized because of a COVID vaccination reaction. Not one.

This is probably where I have to jump on my soapbox. My patients are my big family. I see the kids for their school vaccines, their sports physicals. I see mom and dad for their mammograms and colonoscopies. I sign grandpa’s death certificate. Welcome to family practice, we care about you and your family, because you are a part of ours.

Recently, it’s become popular to argue with us. About horrible things. The COVID vaccine has tracking chips. COVID itself is a Democratic hoax to win the White House. COVID vaccines are a government conspiracy to sterilize the population. COVID is flu A/B. I’ve been asked whether I’ve analyzed an isolated strain of COVID.

I’m a family practice doc, not a microbiologist/virologist.

I’m dealing with patients dying of COVID one minute and listening to somebody tell me it’s a conspiracy the next. It is soul-crushing. I see a patient who literally survived polio, patients who lived in a pre-vaccine world, and the next patient tells me there “wasn’t enough research.”

Nobody has been able to tell me how they’d have changed the clinical trials or defined their preferred level of evidence.

I’ve had to fight other healthcare providers over COVID misinformation. It’s wearing on me. After the patient referred to COVID as flu A/B, after working with COVID, losing patients and listening to these accusations for 18 months now, I actually had to take a mental health day because I’d completely hit the wall. If your response to the well-researched medical advice that I’m giving you is to argue, how are you not suggesting that I’m trying to place you in harm’s way? I would never. I cannot express how deeply offensive it is to imply that I would knowingly place you in harm’s way, injure you or put you in jeopardy. I have no agenda other than your health and wellness. A patient had asked about the COVID vaccine because their cardiologist had told them not to get it. Another patient said their GI doc had told them not to be vaccinated.

Both times I asked, “what’s worse, a vaccine that has been given safely, hundreds of millions, if not a billion or more times, given under controlled circumstances, or rolling the dice and seeing how you fair with a real COVID infection?” Unequivocally, receiving a generally benign vaccination, experiencing a weekend of headache and fatigue – caused by your immune system spinning up antibody production, and scheduled on your calendar, is preferable to a COVID infection showing up unexpectedly. Those were my personal side effects after receiving the Pfizer vaccine series in January of this year.

The mRNA vaccines, Pfizer and Moderna, provide your cells with instructions to build antibodies. Nothing more. They don’t interact with your DNA, they can’t even get to the nucleus. Anybody who tells you that the mRNA vaccines will alter your DNA lack understanding of the difference between RNA and DNA. Please do some additional reading about reverse transcriptase. Additionally, mRNA has a pretty short lifespan, so you shouldn’t be able to detect that the vaccine was ever there, other than the remaining antibodies it showed your cells how to produce, after about 2 weeks. Don’t be scared of antibodies, you have bazillions of them already, to all manner of different pathogens.

I’d never place you in harm’s way. Please, take the poke. It’s fine, truly. I’ve spent 9 months mystified that this is even a conversation. I made sure that I got my vaccines at the absolute earliest moment they were available. I wanted to tell my patients exactly how it went, and how it impacted me. I’ve talked to patients about their effects. I have a single 70+ year female who said she felt horribly for about a month, but she never required hospitalization. Again, I’ve had patients die from COVID 19, and haven’t had a single hospitalization from the vaccines. I’ve had dozens of my patients hospitalized with COVID 19.

I’ll only speak to the Pfizer vaccine, as it is the only COVID vaccine to have received FDA approval (though it sounds as though the Moderna shot is probably within several weeks). Pfizer is approved for folks 12 and up. Pregnant and nursing women included. Women and men who are trying to conceive. Delta variant COVID is not the same bug we’ve had for the past 18 months. Kids are getting sick. Pregnant women have received emergency C-sections in Montana ICUs before their 30th birthday. Healthy people are getting sick.

Please. You’re part of our family. We want our family to be healthy and well. We’d never put you in harm’s way. If you have questions, please ask your family practice provider. You’re our family and we’re trying to care for you all the way through whatever life throws at both of us.

Russell HerringAbout Russell Herring, DNP, FNP-C, FNP-BC

Russell R. Herring, DNP, joined the Great Falls Clinic in 2018 and is among the newer healthcare providers in the State of Montana. He works alongside Drs. David Engbrecht and Dr. Carey Welsh in Family Medicine at the Great Falls Clinic Northwest location. Russell specializes in diagnostic, preventive, and therapeutic healthcare and treatment plans for acute and chronic illness, and in education and guidance of patients regarding disease prevention and health promotion. He is currently accepting new patients at the Northwest Clinic, 1600 Division Road, Great Falls. For more information or to schedule an appointment, please call 406-268-1600.