This is Leslie Greenberg. I am a family physician in Reno, Nevada. I attended University of Nevada School of Medicine and relocated back to my hometown in 2015. 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 20 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.
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.
What is a POLST? POLST stands for Provider Order for Life-Sustaining Treatment form. Nevada defines “provider” as either a physician, APRN (advanced practice registered nurse) or PA (Physician Assistant). A POLST is both a legal document and a portal medical order. It allows you to express your wishes for current and future medical care, even when you no longer possess mental “capacity.” Capacity is determined by their provider at the time of the completion of the POLST and is their ability to understand and communicate their health care preferences for options in this medical order. If the patient is able to express their wishes, the POLST is not necessary and yet I believe that we each could become incapacitated (think traumatic accident or heart arrhythmia) at anytime. The POLST is what medical procedures (CPR, antibiotics, etc) the patient would want if they were incapacitated now.
Who should have a POLST? Anyone. Old age is not a requirement for a POLST, although the majority of POLSTs are completed for the elderly. If the patient’s physician would not be surprised should the patient die within one year. Patients who are terminally ill or frail would greatly benefit from a POLST.
When to fill out a POLST? Anytime. The POLST is filled out by the patient and their physician. The physician must sign the form in order for it to be legal. If the patient lacks capacity, then the Durable Power of Attorney/ legal guardian can fill out and sign the POLST. The POLST is best done when the patient has mental capacity to communicate their wishes for medical care. The document can be updated by the patient/guardian as wishes change.
Where to keep your POLST? Carry it with you…Or place it on your fridge (this is a common place EMS workers look if you are found down in your home). If you are in a care facility, they should have a copy.
Why is a POLST important? Medical professionals want to do what you want us to do. If we do not know your wishes, EVERYTHING is done. The treatments may not be what you want. The POLST avoids this by determining if you want aggressive treatment, specific intermediate measures or comfort-focused care. The POLST allows patients to communicate their desired health care treatment currently and in the future in the event they no longer have the ability to do so on their own.
POLST vs. DNR (Do Not Resuscitate) vs. AD (Advanced Directive): A POLST is a medical order that is valid in any setting. A DNR order is only valid in a healthcare facility. An AD is a legal document, not a medical order, so it cannot be followed by healthcare personnel such as EMS unless a provider writes a medical order to stop resuscitation. EMS must initiate CPR even in the presence of an AD stating the patient does not want CPR because an AD is not a medical order, it is a legal document.
DNR orders are used in circumstances when a patient has lost their pulse, is not breathing or is near death and can no longer communicate.
The POLST is much more than just a DNR order. It guides health care providers which treatments the patient wants. These decisions can include, but are not limited to the use of IV fluids, antibiotics, feeding tubes, intubation and placement on ventilators, or even whether or not a patient wants to be hospitalized or placed into the ICU (intensive care unit).
I encourage my patients to have a DPOA and to let all their loved ones know who is their DPOA. Then each of them needs to know what the patient’s wishes are if they are found down. Do you want CPR? Do you want a ventilator to help you breathe? What is the manner in which you would like to live? (walk? talk? eat independently? think well?) What if those cannot be met? Do you want your DPOA to withdraw care?
Let us do what you want us to do. If you do not express your wishes everything will be done and that may be against your wishes. Be proactive. A POLST is an easy, fast document that begins a conversation between you and your loved ones.
Intermittent fasting is a style of eating in which you have periods of eating and periods of fasting. There are not strict rules about which foods to eat, but rather when you should eat them.
You already fast every day, while you sleep. Intermittent fasting can be as simple as extending that fast a little longer. You can do this by skipping breakfast and then eating your first meal at noon and finishing your last meal at 8 pm. That way, you’re technically fasting for 16 hours every day, and restricting eating to an 8-hour eating window. This is the most popular form of intermittent fasting, known as the 16/8 method. Benefits have also been shown using a 12 hour fast and 12 hour eating window, but 16 hours of fasting is better if you can do it. Other people do a 5/2 method where they eat normally during 5 days of the week and fast completely for 2 days (24 hour period) per week.
Although this may be different from your normal habits in modern culture, intermittent fasting is fairly easy to do. Many people report feeling better and having more energy eating this way. Hunger in the fasting window is usually not that big of an issue, although it can be bothersome in the beginning while your body is getting used to not eating for extended periods of time. Most people find they don’t mind waiting until later in the day to eat.. and most fully adjust within 1 month.
No food is allowed during the fasting period, but you can drink sugarless beverages such as water, black coffee, plain tea, carbonated water, or other non-caloric beverages.
What are the benefits?
According to an article in the New England Journal of Medicine by Rafael de Cabo, Ph.D., and Mark P. Mattson, Ph.D published in December 2019, the benefits include:
Improved glucose (blood sugar) regulation
Increased stress resistance
Suppression or reduction of inflammation
Blood pressure and heart rate reduction
Significant effects decreasing Obesity, Diabetes, Heart disease, Arthritis, and Neurodegenerative brain diseases like Alzheimer’s and Parkinson’s
Improved mental and physical performance
Increased life span
Protection against cancer and positive effects on pre-existing tumor growth and response to chemotherapy
Here are physicians you may be interested in looking up who promote this style of eating
Dr. Jason Fung at thefastingmethod.com
Dr. Michael Mosley at thefast800.com
Dr. Clark-Ganheart at thefastingdoctor.com
How to get started…
Make a plan. Decide how you are going to proceed, when to start, and what you will do if you are feeling like quitting.
Find sugar-free beverages you enjoy. Flavorful herbal tea? or zero-calorie sparkling water? Or black coffee?
Ask your partner, friend, or adult child to be your accountability partner.
Track your progress. Take note of how you feel, how your body changes, and any weight you lose to feel motivated to continue.
2020 Colorectal Cancer Screening Recommendations, per the American College of Physicians consensus statement
Why is this so important? Colorectal cancer (CRC) is the second leading cause of cancer death in the US. There is a 65% overall five-year survival. Removal of adenomas can prevent cancer.
What does screening mean? Screening are baseline tests. This means that the CRC patient is asymptomatic (no rectal bleeding, no change in bowel habits, and no abdominal pain) AND has no increased risk (no history of polyps or no family history of colon cancer). These consensus statements are NOT generalized to people at elevated CRC risk.
Who to screen? The BMJ/MAGIC Group recommends calculating a patient’s CRC risk. https://qcancer.org/15yr/colorectal/ If the 15 year risk of CRC is less than 3% no screening for CRC is recommended. Routine recommendations are to perform CRC screening to average-risk asymptomatic adults from aged 50 to 79 with at least 15 years of life expectancy.
Methods of screening? Colonoscopy reduces incidence of premalignant adenomas by 34% because the GI doctor can remove polyps during a colonoscopy. Patients who have noninvasive tests like FIT tests of guaiac fecal occult blood testing cannot remove polyps with the testing.
Guidelines/Timelines for screening for CRC by method…
-Colonoscopy. Every 10 years. Benefits: may be fully paid by your insurance as it is a considered a screening test. Physician can remove polyps at the time of scope. Drawbacks: need to do a bowel prep.
-FIT. Every 2 years. Benefits: no bowel prep needed. Submit a single stool sample to the lab. No dietary restrictions. Drawbacks: If positive, you need a colonoscopy. Insurance, then, may code your colonoscopy as a diagnostic test and you may have a big insurance bill.
When to stop screening? CRC screening is not recommended after 75 years of age or when life expectancy is less than 10 years.
Heavy menstrual bleeding is considered more than 80 ml or more of menstrual blood loss per period. Truly, heavy menstrual bleeding (the diagnosis name is menorrhagia) is more often diagnosed on patient report of an amount of frequency of blood loss that interferes with psychosocial or physical well-being.
Menorrhagia affects 30% of reproductive age females.
How to treat this? Nonsteroidal anti-inflammatory drugs (like Aleve and Ibuprofen) DO reduce heavy menstrual bleeding in premenopausal women when compared to placebo. But, NSAIDs are less effective than tranexamic acid and less effective than the levonorgestrel-releasing intrauterine device (Mirena IUD).
How expensive is tranexamic acid? Per the GoodRx app, I show that 30 pills of tranexamic acid 650 mg cost $26 near my zipcode. Not bad.
If you have life-altering menstrual periods, ask your family physician how she can help.
What to do for Nevada voter registration… for the Nov. 3 election
Is there a deadline to register to vote? Yes. In Nevada, online voter registration closes Oct. 29. You can also register and vote in person (!) at a polling location up through Election Day, Nov. 3.
Do you need to confirm that you are registered to vote? You can view your voter registration to confirm that your information is correct.
Are there voting changes due to the pandemic. Yes. Nevada is automatically mailing ballots to all active voters.
What is the deadline for voting? November 3. Mail-in ballots must be postmarked (or dropped off in person) by Nov. 3 AND received by Nov. 10. Considering giving the post office more time than one week AND/OR attach a USPS first-class (55 cent) stamp to the mail-in ballot.
What are the Washoe county polling locations? For in person voting during early-voting or on Election Day, a variety of Washoe County polling locations are available.
What should you do if you are a full-time college student? You can choose to vote in Washoe County, or in your home county if it’s outside of Washoe County. You must be registered in the county where you plan to cast your vote.
How have I benefited from RBG? The opportunities that I have had in my 50-year life are because of RBG. The benefits are innumerable and occur daily.
I chose with whom, when and how many children I had.
I am my spouse’s peer and equal partner, both at work and at home.
I can be pregnant and work.
I can be a mother and return to work.
I can have a credit card in my name only.
I can consent for my own medical procedures.
As a woman I am NOW paid 82 cents to the male dollar, compared to 60 cents to the male dollar before the 2009 Lilly Ledbetter Supreme Court Case.
“Whatever you choose to do, leave tracks (and that means do not do just for yourself as this will not be fully satisfying). You will want to leave the world a little better for your having lived.” I have dedicated my work life to teach new physicians how to be physicians AND to care for my own patients.
“There is no satisfaction… equal from knowing that you have made another’s life, your community a little better for your effort.” I have taught countless medical students and 400+ medical resident physicians in my career and put them out into the world to care for their communities.
“Men and women have one principal role… that of being people.” This notion of sex-equality was an organizing principle for RBG. I cannot agree more.
Thank you, RBG. Now, let’s get on with the act of living and exacting change.
2020 Flu vaccines! Drive-through flu shots available at the Reno-Sparks Livestock Events Center.
When is the flu season? The first week of October is considered the start of flu season. In the past, most offices have given flu vaccines inside… but, with the spread of COVID-19 in our community, the Washoe County Health District is offering drive-through flu shots. This starts tomorrow, Saturday, Sept. 19.
“Since flu and COVID-19 symptoms are similar, avoiding the flu can also help to preserve adequate testing capacity for COVID-19. A flu shot can prevent you from getting the flu, as well as help decrease the severity of the symptoms,” said Washoe County’s District Health Officer.
How to get flu vaccines at the Reno-Sparks Livestock Event Center? The drive-through flu clinics will be held on a first come, first serve basis. No appointment is required.
When? Saturday, Sept. 19, 9 a.m. to noon Tuesday, Sept. 22, 4 p.m. to 7 p.m. Wednesday, Sept. 23, 4 p.m. to 7 p.m
Who should get the flu vaccines? A yearly flu shot is recommended for everyone over 6 months of age, especially those with certain medical conditions, pregnant women and people over age 65. Flu shots are free with most insurance plans (remember to bring your insurance card). Patients without insurance will be vaccinated at no cost.