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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Posted in Uncategorized

New medical interns start specialization training today!

It’s July 1, and new interns have already earned both an undergraduate degree and completed 4 years of medical school. What else do they need to do before “hanging their shingle” and seeing patients as an attending physician? Read on…

July 1 traditionally marks the start of residency and fellowship for new doctors and doctors who have completed residency.

On this momentous day, I am so excited to welcome the new interns into one of the most noble professions. It is the continuation of a crazy ride but an incredibly awesome and humbling one.

For those who don’t know what an intern, resident or fellow is:

-A resident team means you have a team of committed physicians, all looking over you and your chart, all under the supervision of an attending physician (like me!).

-Even new interns have already had at least 5000 hours of hands-on clinical training before arriving on July 1.

-New interns have already passed 2 of the 3 “steps” required to be licensed in the US: 3 days of testing, nearly 600 multiple choice questions, and 12 standardized patient encounters including assessment of history taking, physical exam skills, communication skills, and ability to form a plan of action based on findings.

-Intern year ( with an estimated 4000 hours of work!) is just the beginning of post medical school training.

-After those 4000 hours, your average pediatrician, family medicine physician and internist (all primary care physicians) will complete an additional 7000-8000 hours of training before taking their respective board exams (an additional 8-10 hours of testing).

Your average general surgeon will complete an additional 16,000 hours.

So, when you see your primary care physician, specialist, or surgeon, know that they’ve spent more than 10,000 hours of training to help you stay healthy.

#july1 #5000hoursandcounting #trainingtobeanexpert #seetheexpert #trainingmatters #knowyourdoctor #iwasajuly1intern #trainingtothetop

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What are the chances to be on opioids after initial use of opioids?

What are the chances a patient will be on opioids after initial use of opioids?  I recently attended a lecture discussing opiate addiction and its far-reaching aspects.

How soon does habituation to opioids occur? There was an interesting study out which confirms that opioids should be avoided if any other method will help.  This study shows opioid habituation is a real issue.

  • The probability of long-term use increased after 3-5 days.  So, if a patient is only given 3-5 days of opioids, the risk of long-term opioid use is low.
  • Contrary to that…. if you’re on opioids for 8 days, you have a 14% chance of being on opioids at 1 years.
  • If a patient is on opioids for 31 days, 30% are on opioids at 1 years.
  • 14% of patients that get a 2nd opioid prescription are on opioids at 1 year.

This data is extracted from Shah et al (2017) CDC Morbidity and Mortality Report.   https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm

Also, if you’d like to read a Freakonomics-type book about the opioid crisis, look at the book Dark Paradise : A History of Opiate Addiction in America by David Courtwright.

What is the government doing?  The Department of Justice is data mining to pinpoint physicians who prescribe more opioids than their peer physicians.  Physicians who give opioids outside of the CDC Guidelines, will need to document WHY a different amount or duration of opioids is given, or the physician may be liable.

What are medical schools doing?  Most physicians see 50,000 patients in our work lives.  So, the pain management standards and guidelines are changing and this will affect future generations of physicians and patients.  Medical schools are beginning to teach “multimodal pain education” to reform pain medicine  to avoid addictive medicines.  Even after a surgery, there are “enhanced recoveries” with protocols to maximize non-opioid pain management.

Providers want to give good care.  And, just know that NO opioids may be prescribed.  It’s for patient safety as opioids can cause memory disorder and endocrine issues AND, of course, opioid overdoses can cause death.

How to taper opioids?  Tapering opioids is technical and complex.  10% dose of opioids may be tapered per month.

If a patient is on opioids and benzodiazepine, this increases risk of overdose death by 400%. Have your physician help taper you off one of them! Gabapentin with opioids may also increase overdose risk.

Be careful.  See your physician.

Posted in General Medicine- Adults, medication issues, Uncategorized | Tagged , , , , , , , ,

Teens and drug use

Why do people use drugs?  They want to

  • change the way they feel
  • to fit in with peers,
  • to be less inhibited
  • they’re bored
  • life sucks (they’re angry, jealous, sad, abused)
  • “for the fun of it.”

Judgment in drug-use is not helpful for a physician as it does not help the patient.

What drugs are kids using?  It depends on their age and their access to get drugs.  They can easily get marijuana, tobacco, and alcohol.  The easiest drugs for them to get are the deadliest: spray paint, cough medicine, or the parents prescription pills.  Coricidin Cough and cold (Triple C), Robitussin or delsym are cold medicines that are often taken in excess and used for a “high.”

I reviewed the YRBS for Nevada.  This is the Youth Risk Behavior Survey which gives statistics on regional risky behavior use.  Cocaine, Ecstasy, and meth use is decreasing in Nevada.

Of note, marijuana affects brain growth until age 25, even if it is legal.

Urine drug screens include two tests: an immunoassay which is for screening and then a gas chromatography-mass spectrometry is used as a confirmatory test if the screening test is positive.  The confirmatory test is to make sure there wasn’t a false positive test.  There are medications or foods that can make a urine drug screen look positive, when the patient has not taken that drug.  Physicians should know how long a urine drug screen will test positive after use.  Some drugs are detected in the system over 30 days, depending on length of use.

To screen for adolescent substance abuse.  CRAFFT Screening Interview.  http://www.caesar-boston.org/CRAFFT

How to reduce drug use? The only answer is multidimensional family therapy.  The kid is using for some reason, find the reason.  The whole family needs to have family sessions together.

 

Posted in Pediatrics, Uncategorized | Tagged , , , , , , , , , , ,

After 23 years, I’ve delivered my last baby.

 

IMG_1439 (1)

A happy customer!

After 23 years, I’ve delivered my last baby.  As a family physician, I have loved caring for patients— from conception til death.  And, honestly, prenatal visits and new parenting visits are some of my favorite times with patients!  I’ve juggled delivering my patient’s babies between delivering my own three children years ago.  My husband has met me in hospital parking lots at a moments notice to successfully hand-off our three young children as I run to deliver a crowning baby.  We’ve made it work.  Our crazy life has worked.

 

But, since moving and delivering babies at a new medical center, I have lost my passion for the juggle.  It takes a supportive network for a family physician to want to perform obstetrics in what has always been a high-stakes environment:

  • knowledgeable office staff to schedule prenatal patients appropriately,
  • a patient population that is compliant with lab tests, office visits and ultrasounds,
  • a medical center with collaborative, supportive staff,
  • and obstetricians happily willing to take my patient for an emergent C-section, if the need arises.

Indeed, I do not have the necessary environment…and after trying to re-shape the local environment for three years, I am redirecting my energy.  I tell resident physicians that their first job will not be their last.  And, indeed, all of the skills that I was trained with I will not continue to use.

 

I feel blessed to have delivered hundreds (maybe thousands?!) of babies.  I will cherish those times and relationships as I forge ahead.

Carpe diem.  Seize the day.

Posted in Ear, Obstetrics, Uncategorized | Tagged , , , , , , , , , , , ,

Travel medicine tips.

Travel medicine tips.  Most of us are excited to travel and would like to arrive both at our destination and back home safely and in good health.  Don’t let these problems derail your plans…

There are many types of travel-associated infections: digestive, respiratory, vector-borne (like from insects) and sexual.  Some can be life-threatening.  Travelers visiting friends and relatives in their country of origin were the travelers most likely to not seek pre-travel counseling from physicians and had a disproportionately high burden of serious infections.  So, if you are traveling overseas, consult your primary care physician about which vaccines and medications can help you not get sick.

As far as the airplane, I do not take any precautions except for washing my hands before eating (or touching my face in general) and after using the restroom.  I am unsure of any research showing that supplements significantly decreases cold symptoms while traveling. but if YOU feel like a supplement helps you (and it does no harm), continue taking it!  Prolonged immobilization during a flight may cause a blood clot, so be sure to exercise your legs in your seat or walk around the plane every 2-3 hours.  If you have sickle cell disease or lung disease, you may need supplemental oxygen on flights.  Decongestants can help with blocked Eustachian tubes or sinuses that can occur due to air pressure changes while the plane ascends or descends.

Be sure to take sufficient supplies of current medications in your carry-on bag as equivalent drugs may not be available at that location or very difficult for your physician to call into a pharmacy in a timely fashion.

Consider buying travelers insurance, including evacuation insurance.

Are your vaccines up to date?  If not, this is a great time.  Consider that some vaccines have more than one in the series and may take up to 6 months to get full benefit  Look on the www.cdc.gov website  under “travelers’ health/ destinations” for vaccines and prophylactic medicines to take,  depending on what is endemic in the area you are traveling.

Avoid consuming tap water or ice made from tap water or raw foods rinsed with tap water as the water may be contaminated and you can get travelers’ diarrhea or hepatitis A or E or a parasitic infection.  Avoid outdoor exposure during mosquito feeding time as an infected bite may give you malaria, West Nile virus, Japanese encephalitis, dengue fever, Zika and yellow fever.   ¼ of deaths abroad occur in Americans involved in motor vehicle accidents, so beware.  If you have sex with a new partner, wear a condom to help decrease sexually-transmitted infections, including HIV and hepatitis B.

I hope this helps.

Posted in General Medicine- Adults, medication issues, Sexually Transmitted Infections, Uncategorized | Tagged , , , , , , , , , ,

ADHD evaluation

I recently went to a lecture on ADHD.   There are different ADHD subtypes: combined (hyperactivity with impulsivity), predominantly inattentive, predominantly hyperactive without impulsivity.  The ADHD with hyperactivity is most likely diagnosed because of the child’s attention-getting (conduct disorder) behavior.  Stimulants make everyone improve their ability to concentrate.  3-7% of school children affected in US. Males have ADHD more common than females.

Other things to think of… Does the child have a seizure disorder, chronic ear infections, sleep apnea, narcolepsy, metabolic abnormality (like hyperthyroidism), toxic exposures (like lead poisoning or fetal alcohol syndrome)?  These are issues that can look like ADHD, but are not.  Your physician also needs to rule out learning or language disorder, autism spectrum disorder or sleep disorder.  The child may also have anxiety, depression or other mood disorders, psychotic disorders or substance use disorders (huffing or chugging Benadryl).  Tics are very common and the treatment for ADHD may make the tics worse.

ADHD disease course.  1/3 resolve spontaneously.  As ADHD patients age, the symptoms may seem to decrease even if they continue to have ADHD.  Must treat the co-morbidity.  Treat the parents.  The parents will often bring the patient to the doctor when they are fed-up.

MTA (Multimodal treatment of ADHD) Study of 1999.  This NIH-sponsored study showed medication (stimulants) are effective.  Behavioral treatments are not as effective as medication for core ADHD symptoms.  Increased physician contact improves outcomes.  More frequent and higher dosing may lead to less ADHD symptoms.  2-year follow up showed benefit with medication over behavioral therapy.  Stimulants are not found to help at 3-year or 8-year follow up compared to behavioral therapy.  For kids at 4-5 years of age, have parents work on parenting and scheduling.  Then try methylphenidate.  If there’s no benefit, your physician may start dextroamphetamine.  The side effects from medicine: insomnia and decreased eating.  There is a concern for decreasing growth velocity (the child may have an adult height 2 inches shorter than without stimulants).   When adolescents take stimulants, think of the potential for abuse and diversion.  The patient will need to see the physician monthly to confirm that the medication has helped and that side effects are kept to a minimum.

Posted in ADHD, colon, Pediatrics, Uncategorized | Tagged , , , , , , , , ,

Great definition of a family physician

img_0851Great definition of a family physician.

I am NOT a generalist. 

I am NOT a provider.

I am NOT a practitioner. 

I am a medical professional who cares for complex and healthy patients regardless of age.  I am best understood as an integrationist. 

I integrate the mental, spiritual, and physical wellbeing of my patients, in the context of their families and community, to help them become whole. 

I integrate the sometimes disparate recommendations of medical specialist to insure that treatments that benefit one organ system does not damage another. 

I integrate and apply complex medical research on populations to the unique biology, needs, and goals of my patient.

I am the “pluripotent stem cell” of the medical community.  I start with a broad education and then adapt to the needs of my community to fill the voids in healthcare.

I am the marine of medicine.  I get the job done, often under harsh conditions.  To my patients, Semper fidelis.

                By Bruce Bushwick, M.D., York, PA

Posted in General Medicine- Adults, Uncategorized | Tagged , , , , , , ,