DIRECTOR'S NOTE

The pandemic has spotlighted the inequities in health care that many people face in our communities and the importance of clear, respectful communication between patients and their healthcare team for good health outcomes. There are many steps that both healthcare workers and patients can take to improve the quality of our care, too many to cover in just one issue of PlaneTalk. This newsletter is meant to help start a conversation on improving two-way communication and include more suggestions in future iterations of PlaneTalk.

Also new in this issue, in an optimistic attempt to make room for “health news you can use” that isn’t all about COVID, We’ve decided to set aside a COVID corner in PlaneTalk for updates. Hopefully, updates will become less urgent in the months ahead!

Lise M. Dyckman
Executive Director

...seek reimbursement from my Flexible Spending Account (FSA) or Health Spending Account (HSA) for purchasing a home air purifying filter to use during extreme bad air days?

According to this source, while an “Air filter for general use not eligible” for reimbursement from a flexible spending account (FSA), health savings account (HSA), or a health reimbursement arrangement (HRA) but “air filter reimbursement is eligible with a Letter of Medical Necessity (LMN). An air filter reimbursement is not eligible with a limited care flexible spending account (LCFSA) or a dependent care flexible spending account (DCFSA).” That website quotes a U.S. Treasury Regulation 1.213-1(e)(1)(iii), Private Letter Ruling 8009080 as the source of that IRS opinion.

People with an FSA or HSA who have COPD, severe allergies, asthma, or another lung condition may be wise to check in advance with their healthcare provider to see if they qualify for a Letter of Medical Necessity (LMN) to purchase an expensive HEPA filter. The same link also details what portions are reimbursable when a purifying air filter is attached to HVAC systems.

…look for rip tides at the beach?

If you spend time in ocean water, you should learn how to identify a riptide and find out what to do if caught in one! As one former surf lifesaver points out, you must know what a rip tide looks like and identify those areas in the surf. They often occur inshore from a sandbar, and can be around a jetty, pier, or rocks in the water, says the National Ocean Service (NOAA, in English & Spanish). If you find yourself in one, try to stay afloat or, if possible, swim parallel to the shoreline to get out of the most substantial flow until it’s easier to come back to shore. Riptides are powerful at low tide, so it’s a good idea to check timetables for local tides and the National Weather Service’s Surf Zone Forecasts and Rip Current Statements before hitting the surf.

An “overwhelming need to move your legs when sitting or lying down” is the hallmark of restless leg syndrome, especially if accompanied by throbbing or tingling sensations. If restless leg syndrome interferes with a good night’s sleep, definitely talk to your healthcare team.

… worry about household molds?

According to NIH’s National Institute of Environmental Health Sciences, indoor molds can cause nasal and sinus congestion, irritate eyes or blur vision, cause a sore throat or chronic cough, or trigger a skin rash. The most problematic molds are caused by extra moisture, so check for drips, leaks, and places where groundwater seeps in (like a wet basement). The mold that blooms after a flood - whether from a burst hot water tank or a tropical storm - may require remediation with personal protective equipment (PPE). Look up health precautions before undertaking a significant clean-up.

… get an extra dose of COVID vaccine as a booster shot, if I’m a cancer survivor?

We don’t have good answers yet, to that and other questions about how the current COVID vaccines might affect cancer survivors - and everyone’s experience with cancer is different. The American Cancer Society’s information collection on vaccines for people with cancer and survivors is updated regularly. It would be an excellent place to check if this is a concern. 

While an encouraging percentage of people in Santa Clara County (and in the Bay Area) have already been vaccinated, there still are plenty of people who still need it - and plenty of locations to get it. See our resource guide on Coronavirus and COVID-19 for links to vaccination locations throughout the Bay Area. 

Ensuring that everyone who can get vaccinated does get their shot is still urgent (or urgent again), with most new cases in the last month from the more infectious Delta variant of SARS-CoV-2. New cases are surging in other areas of the U.S. that have lower vaccination rates. (As pointed out, a surge in severe instances of COVID harms different types of healthcare.)

Each of the currently-approved vaccines does a great job of protecting people from becoming seriously ill from any current variants. However, it is still possible to get infected after vaccination. If you are fully vaccinated, it’s doubtful that you would end up in the hospital. But the chances of becoming infected after vaccination are not as good, and if that happens, symptoms would likely be mild or perhaps undetectable. So it is entirely possible for vaccinated people to unknowingly spread the infection to someone who has not been vaccinated (like children under 13). Wearing a mask inside a public place significantly lowers the odds of getting infected or spreading the infection.

Recently-released California state guidelines for next fall in K-12 schools include masks for all students, teachers, and staff (even though the CDC has stated that these may not always be necessary). That caution, as explained in an LA Times article, also means that all students will be able to walk into school without worrying about whether they will feel different or singled out for being vaccinated of unvaccinated," in the words of CA HHS Secretary Mark Ghaly. 

As any of the roughly 12% of Americans who have migraines will tell you, a migraine is far more than just a headache! Chronic migraines can be debilitating. While some people can manage them with minimal interruptions to their daily life, others may not - and a change in the pattern of symptoms of headache - can be problematic. The Mayo Clinic advises: 

Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.

See your doctor immediately or go to the emergency room if you have any of the following signs and symptoms, which could indicate a more serious medical problem:

• An abrupt, severe headache like a thunderclap
• Headache with fever, stiff neck, confusion, seizures, double vision, numbness, or weakness in any part of the body, which could be a sign of a stroke
• Headache after a head injury
• A chronic headache that is worse after coughing, exertion, straining, or a sudden movement
• New headache pain after age 50

Among the many medications recommended over the years to manage and treat chronic migraines, recently:

• an effectiveness review of prescription drugs used to treat an acute migraine found that “triptans, nonsteroidal anti-inflammatory drugs [NSAIDS], acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited.”  
• a similar effectiveness review of non-prescription medications used to manage chronic migraines examined the scientific evidence for using herbs butternut and feverfew, and the supplements CoQ10, magnesium, and riboflavin 
• Migraine sufferers are advised to limit the foods that often trigger migraines. A recent study suggests not determining but adding — eating more fatty fish may improve symptoms for people with chronic migraines. “The diet lower in vegetable oil and higher in fatty fish produced between 30% and 40% reductions in total headache hours per day, severe headache hours per day, and overall headache days per month than the control group. Blood samples from this group of participants also had lower levels of pain-related lipids.”  (The Mayo Clinic lists salmon, sardines, Atlantic mackerel, cod, herring, lake trout, and canned light tuna as heart-healthy fatty fish; for a list of which varieties are healthiest to eat, see Seafood Watch’s recommendations.)
• And migraines’ connection with gastrointestinal problems may be more than just a reaction to pain.

Unfortunately, some migraine sufferers also face difficulties in dealing with health insurance policies or healthcare teams. The aptly named Patient Advocacy Foundation offers advice for navigating those challenges in their MigraineMatters web pages. 

Amy Paturel, who writes for AARP, describes the fundamental dilemma for anyone seeking care from the U.S. healthcare system: "If you've ever felt like your doctor isn't listening to you, it may be true."  

Studies have found that doctors let patients speak for only 23 seconds on average before cutting them off; in one University of South Carolina study, primary care patients were interrupted just 12 seconds after the physician entered the exam room."

And "when there's less doctor-patient dialogue, patients are not only more likely to leave the office frustrated, but they're also at greater risk of being misdiagnosed." "Most doctor visits last 13 to 16 minutes, according to Medscape's 2016 Physician Compensation Report".

With so little time and such distracted attention, how can we make sure that questions that are important to patients aren't left out? It often depends on how much advance preparation patients put into their medical appointments, how engaged they are in the office, and how involved they are in their care after the appointment. It also depends on how openly we're willing to talk about our health issues.

ASK QUESTIONS

As simple as it may sound, making a list of questions or issues in advance can be one of the most powerful communication tools. Bringing that list into the office with us, using it to make notes on conversations with the healthcare team, can be a life-saver. 

If not sure of what questions to ask, Agency for Healthcare Research and Quality (the lead federal agency charged with improving the safety and quality of America's health care system) can help. It has an interactive online Question Builder tool to help clarify questions while it makes a record of them, to print and take along to appointments. (Besides being useful for ourselves, it's especially useful when helping to care for a forgetful family member - you can go over their questions in advance, and review answers with them if they so choose.) There's also a mobile phone app version of Question Builder.

Once at the appointment, start with the list of questions prepared in advance - but don't stop there. UCSF's communication advice for cancer patients is great advice for all patients.

During Your Visit

• Tape-record your visit or bring a pencil and notebook to take notes. You also may bring a trusted friend or relative to take notes for you.
• Keep your discussion focused, making sure to cover your main questions and concerns, your symptoms, and how they impact your life.
• Ask for clarification if you don't understand what you have been told or have questions.
• Ask for explanations of treatment goals and side effects.

Or, if that advice is hard to remember, the Institute for Healthcare Improvement's Ask me three list is handy and shorter:

1. What's my main problem?
2. What do I need to do?
3. Why is it essential for me to do this?

Asking questions is the first step in good communication between patients and their healthcare teams - but it's only the start. More to come in future issues of PlaneTalk newsletter!