Hello Reno Families!

This is Leslie Greenberg.  I am a family medicine doctor in Reno, Nevada.  I attended University of Nevada School of Medicine and have recently relocated back in my hometown.  I trained and practiced medicine in the Midwest (Indiana and Kansas) for 20 years before moving back West.  I consider myself a teacher and educator.  I  have  taught family medicine residents for 18 years.  I currently teach at the family medicine residency program in Reno and also see private patients.  I invite you to read my blog.  If you would like to become a patient, please call 775-682-8200.

Medical Disclaimer

Please remember that medical information provided by myself, in the absence of a visit with a health care professional, must be considered an educational service only.  This blog should not be relied upon as a medical judgement and does not replace a physician’s independent judgement about the appropriateness or risks of a procedure or condition for a given patient.  I will do my best to provide you with information that may help you make your own health care decisions.

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Medical students have their own brand of “March Madness” and it’s called Match Day!

Medical School graduates in the Class of 2018 (at EVERY medical school) have their own brand of “March Madness” and it’s called Match Day!

When is it? March 16, 2018! At 9 am PST  all the medical students around the country open up their “match envelope” at the same time.

What does this mean? The National Resident’s Matching Day is when graduating medical students have essentially signed a contract for the next 3 to 7 years of post-doctoral education.


Wow! Every year I reflect on MY Match Day in 1995 (!) when we learned WHICH specialty and WHERE I was going to learn it. My then fiancee was also matching into a specialty and this added complexity to our joint decision.  This cemented our medical specialties of choice, family medicine.

The match changed the trajectory of our lives.   I cannot underscore what a monumental day this was for us and is for every single medical student around the country. Medical students have studied for at least 8 years after high school, incurred hundreds of thousands of educational debt, and honed their educational path to this culmination.

35,000 medical students are vying for 31,000 spots in US hospitals and health centers. (My son was horrified when he did the math and realized that 4000 medical students may not have a job).  So, looking at the math, you can appreciate that some medical students do not match into a residency program and may need to “scramble” (now called the SOAP –Supplemental Offer and Acceptance Program) into an open residency position or may need to work in an associated field and apply to the match next year and be involved in Match Day 2019.

University of Nevada Reno Family Medicine Residency Program received over 800 applicants; we interviewed over 100 candidates, and have matched 10 medical interns who will start with us after medical school graduation.

It is truly an exciting time for every graduating medical student and for those in medical education. The closing of one chapter… and the opening of another. I love it!

Want to know more?  Here’s the official website…   http://www.nrmp.org/

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I am featured in the recent AARP magazine! Read on…

I am featured in the recent AARP magazine!  Read on…


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Why are you hoarse? What should you do?

Why are you hoarse?  What should you do?  There are a multitude of causes of hoarseness.  Hoarseness is a common presentation to primary care physicians.  The causes range from inflammatory processes to psychiatric disorders to more serious systemic, neurologic or cancerous reasons.

Medication can also cause hoarseness.  The medications that may cause hoarseness are angiotensin-converting enzyme inhibitors (ACE) , antihistamines, diuretics, bisphosphonates, and inhaled corticosteroids.

How to evaluate hoarseness?  Your physician should perform a targeted history and physical exam.  Systemic conditions causing hoarseness should also be investigated.  Initial treatment may be voices rest including no whispering (as this can worsen hoarseness) and treatment of the presumptive cause.

If you have reflux, the acid from the stomach can affect the vocal cords and cause hoarseness or a chronic cough from acid reflux (or lung cancer) can also cause hoarseness.  Direct visualization with a nasolaryngoscope (a teeny tiny scope about 1/2 the size of your pinky finger) may be needed if hoarseness persists for 3 months if conservative management has not resolved the problem.  An ear, nose, throat surgeon may do this in their office.  If you have risk factors for oral cancer  like tobacco use or heavy alcohol consumption or blood with coughing should opt for ENT referral after 2 weeks of symptoms.

Don’t I need imaging?  Probably  not.  A CT scan is not done before visually examining the area with a nasolaryngoscope.

Voice therapy is effective for improving voice quality for patients with nonorganic difficulty with making sounds.

When do you need surgery?  Surgery is needed for laryngeal or vocal fold dysplasia (or cancer!), airway obstruction, or benign pathology that is resistant to conservative treatment.  426658377_617b482154_o.jpg

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Who needs sleep apnea screening? And why?

The USPSTF (United States Preventive Services Task Force) is a conservative group that reviews data to give guidelines for physicians. The USPSTF has recently given recommendations on WHO should be screened for sleep apnea.

Who should NOT be screened for sleep apnea?

  • Asymptomatic patients should NOT be tested.

What are symptoms of obstructive sleep apnea?

  • Snoring (especially if it’s loud and followed with gasps)
  • Restless sleep
  • Insomnia
  • Night sweats
  • Morning headaches
  • Daytime sleepiness and frequent nodding off during the day
  • Falling asleep at the wheel of a car
  • Irritability
  • Anxiety
  • Depression
  • Forgetfulness
  • Blood pressure elevation and increased heart rate may occur

How can treatment of obstructive sleep apnea help patients?

  • May lower blood pressure
  • Improvement in the Epworth Sleepiness Scale (so patients may not fall asleep during the day or at stop signs) and
  • a decrease in the number of times breathing is stopped while asleep.
  • May decrease motor vehicle crashes.
  • People feel better when they use the CPAP (continuous positive airway pressure masks while asleep)

Does using CPAP decrease mortality or cardiovascular events (like heart attack and stroke)?

  • flickr.com/photos/ petahopkins/ 10113965984No.  The USPSTF did not find that CPAP decreases these outcomes.




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Radon. What is it? Should I test for it? Should I even be concerned?

Radon.  What is it?  Should I test for it?  Should I even be concerned?

Radon is a unique environmental health risk.  It comes from uranium and radium natural decay.  Radon is a greater source of natural radiation than exposure to the sun, x rays or other medical devices.

Is this important?  Yes.  The Environmental Protection Agency (EPA) estimates that radon causes approximately 100,000 lung cancer deaths in the US yearly.  Radon is considered the seventh-leading cause of cancer-associated death in the US.

How to measure radon?  Measure radon with a home kit.  Kits cost $15-25 and you use them in the home for 2-7 days.  If a home has a crawl space, test the living area above the crawl space.  Radon is measured in picocuries per liter of air (pCi/L).  If you smoke 8 cigarettes/day that equals 4.0 pCi/L.   Do not measure the soil level of radon.

What level is significant?  4.0 pCi/L is the level at which radon mitigation should be initiated.

How to mitigate radon?  Active or fan-powered soil depressurization is a standard approach to radon reduction and mitigation.  This may typically cost $1500.  Each state has different certification and license requirements to be a radon mitigation service.

Do you need to retest?  Yes, if the home has “settled” or the foundation has had structural changes.

How many homes have elevated radon levels?  6% of all US homes have radon levels over 4.0 Ci/L.  But, different parts of the country can vary greatly.  (70% of Iowa homes have elevated radon levels).

Want more information?  Call the National Radon Program Services (with the EPA) at 1-800-557-2366.  They are also known to have radon kits!  or radon kit coupons.

I hope this helps.

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Nevada has instituted a new controlled substance law for prescribers to follow… or else!

Nevada has instituted a new controlled substance law for prescribers to follow…. or else!

flickr.com/photos/ petahopkins/ 10113965984I recently attended a 2-hour evening session informing me of the details of the new Nevada AB474, Nevada’s opioid prescribing law.  Unless your head has been in the sand, you must know that there is an opioid crisis.  Nevada’s government has decided that to decrease the abuse, they should make the prescribing cumbersome and onerous.  I have had patients ask me for a benzodiazepine to take before a flight.  This now requires an online data search of the patient’s PMP, risk factors, alternatives, evaluation, and a signed informed consent form.  I took notes at my meeting and have included them below…

AB474. This is the Nevada law that was enacted January 1, 2018 and it has turned controlled substance prescribing on its head.

Here are the following requirements…

Controlled prescriptions needs to have four components written on the prescription.

  1. Patient date of birth,
  2. Patient diagnosis with specific ICD10 code
  3. Lowest number of days the medication is intended for,
  4. Prescriber’s name and DEA number

As a physician, we are required to have 2 hours of continuing medical education per year specifically about opioid prescribing.  This evening met that requirement for this year.  Hooray!

The office note needs to document the following.

  1. The patient needs to be a “bonafide” (meaning you’ve seen them in the last 6 months) patient of the prescriber.
  2. The physician is expected to consider alternatives to the controlled substances.
  3. Patient’s previous medical records need to be obtained. Good faith is a reasonable standard meaning the patient has signed consent for records to be transferred.

“Informed consent” form needs to be obtained from the patient.  The informed consent must contain

  1. potential risks  and benefits of controlled substance treatment
  2. Proper use of controlled substance
  3. Alternative treatments instead of controlled substances
  4. Provisions of the treatment plan
  5. Risks of dependence, addiction, overdose during treatment
  6. Methods to safely store and legally dispose of controlled substance
  7. How refill requests will be addressed
  8. Risks to fetus (for women of childbearing age) and availability of antagonist of substance for overdoses
  9. If a minor, the risks of abuse, misuse and ways to detect.

How many days of medication can be prescribed for the first prescription?  14 day maximum for pain relief.  Some pharmacies only fill 7 days worth of pain medicine (this is the rule of those specific pharmacies).

Risk factors.  There are 16 risk factors to review with each patient before a prescription is written.

  1. Any other drugs illicit being used?
  2. Is the patient using prescription inappropriately?
  3. Is patient suspected of diverting prescription?
  4. PMP (Prescription Monitoring Program—a patient-specific online database of controlled substance use) indicates regular (and not excessive) behavior
  5. “Irregular” blood or urine screen
  6. Test negative for drugs that should be present.
  7. Current prescription ineffective
  8. Patient using drugs or alcohol
  9. # of patient’s refill requests?
  10. # of patient claims prescription lost/stolen?
  11. Patient has strange behavior or intoxication
  12. Patient reluctant to reduce or stop prescription
  13. Patient change in physician health
  14. Does the physician suspect chronic-use opioids, abuse, illegal drug use or diversion suspected?
  15. Patient not cooperative with exam, analysis or text?
  16. Patient increased dosage without physician authorization?

Prescription Medication Agreement (must be completed on all patients on controlled substances for more than 30 days) include

  1. Goals of treatment
  2. Consent to testing to monitor use
  3. Requirements that this controlled substance is only taken as prescribed
  4. Patient admits they are prohibited to share
  5. The patient is required to inform the doctor when other controlled substances are prescribed or taken
  6. Use of alcohol or marijuana
  7. Previous treatment for side effects or complications related to the use of controlled substance
  8. Each state previously resided in or that has a controlled prescription filled
  9. Authorization for doctor to conduct random inventory of controlled substance (this means the doctor can count your number of pills to confirm that it correlates with the number that should be remaining.
  10. Reasons doctor may change or discontinue controlled substance treatment.
  11. Any other requirements determined by doctor

The patient must perform a urine drug screen, if the physician asks for it.

The patient needs to inform the physician if they use any other drugs (including marijuana) and if they are having any side effects.

At 90 days, an evidence-based work up of the medical condition has been initiated.  For instance, if the pain medicine is being used for back pain, has the back pain been worked up appropriately?  Have non-controlled substances be tried and failed?

It the patient is taking more than 90 MME (morphine equivalents)? if so consider sending them to pain management physician as this falls outside the normal dosage range.

“Prescribe 365” This refers to the patients only receiving one years supply of rx in one year to help decrease duplicative rx. Or doctor shopping.

Long-term management of patients with controlled substance prescriptions. 

Must be seen every 3 months for long-term pain management. Three prescriptions, each for one month, can be given to the patient at one visit (as long as the physician feels comfortable doing this.)

Controlled substance agreement needs to be signed by the patient once a year.


Resources  www.nvdoctors.org or www.prescribe365nv.gov or http://bop.nv.gov/links/PMP/ or https://knowyourpainmeds.com is geared toward patients.

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This is a powerful read. Assault weapons are a medical problem.

This is a powerful read.  Assault weapons are a medical problem.  Read on to appreciate the “smashed melon…”



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