Hello Reno Families!

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.

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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Is anxiety getting in the way of your mask wearing?

Is anxiety getting in the way of your mask wearing? Masks help contain the coronavirus and it is each of our responsibilities to support our community.

Here’s a desensitization program which should help you wear one more comfortably.

Of note… N95 masks with valves spew the wearer’s respiratory viruses out the valve and do not protect others. I urge cotton masks, surgical masks, or N95s without valves.

This is me on hospital rounds—N95 with cotton mask on top ( with eye glasses and scrub hat for extra protection)…not glamorous, but necessary.
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Want a Covid test performed?

Want a Covid test performed in Washoe County?

Washoe county residents can now get Coronavirus testing even if asymptomatic.  They must still complete the questionnaire, then go to the site as directed to schedule an appointment.


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What does it mean if a medical resident doctor is caring for you?

What does it mean if a medical resident doctor is caring for you?

Medical school graduates are starting and they are awesome! I’ve been a physician, educating physicians for 22 years. It has been a pleasure to teach and me turnover 350 physicians. And, I’m not done yet…

For those who love Grey’s Anatomy, ER and Scrubs these terms may sound familiar but are great for review since a lot of us are more aware of healthcare resources right now during COVID!

𝐌𝐞𝐝𝐢𝐜𝐚𝐥 𝐒𝐜𝐡𝐨𝐨𝐥
Getting into medical school requires a college degree and taking a rigorous medical school admission test (MCAT). It is really difficult to get into medical school. So much so that many decide to have “back up plans” in case they don’t get (usually it is still a career in medicine in another healthcare discipline such as PA, NP and Nursing which are all amazing as well… but require far less schooling and training than physicians).

Medical School is tough. It is full of class/instruction all day with hours and hours of studying for the first two years. Then you have to take a standardized test (Step I Boards) to make it on to the last two years. That board exam is tough and can dictate your career path!

The last two years of medical school are just as rigorous but the hospitals and clinics are the classroom. And, yes, there’s still a lot of studying when you’re “off”. Right before you finish medical school you take ANOTHER board exam (Step II) to make sure you are ready to graduate!

After you graduate from medical school you’re still not done! You have to study for a minimum of 3 years to specialize in training called residency. Some residencies are up to 7 years depending on the field of practice (like Neurosurgery!).

I still remember my first day of internship! So much excitement and nervousness and it flew by! I’m so thankful for my senior residents, attending physicians, nurses and all the hospital staff that helped me along the way.

Interns are so full of knowledge and should be applauded for their accomplishments! So many people don’t even make it to internship! They are some smart and dedicated physicians!

𝗔𝗳𝘁𝗲𝗿 𝗥𝗲𝘀𝗶𝗱𝗲𝗻𝗰𝘆…
And just so the public knows – the studying and tests never end! There still is Step III Board Exam during your residency, Specialty Boards after you’re done with residency. Then, recertification exams every 10 years afterwards! So, seeing a board-certified physician means your doctor is keeping up with new medical knowledge.

To all the interns, congrats! You are starting your career in historic times. We THANK YOU for dedicating your life to medicine and I am invested in helping in your education as you will be MY doctor someday in the future!

Photo Graphic Credit: Christin Giordano McAuliffe

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Should you take your once-a-day blood pressure medication at night or in the morning?

Researchers randomized over 19,000 patients to find the answer to this question.  Patients who took their medications at bedtime had less likelihood of having an adverse event.  This means just changing the time of your blood pressure medication decreased your risk of  a heart attack, needing a heart catheterization, heart failure, stroke or cardiovascular death! In fact “all-cause mortality” was decreased in the patient population who took their blood pressure medication at night. 


What an easy (and free!) change.

I hope this helps.

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Should women under 50 add a screening breast ultrasound to their screening mammogram yearly?

Should women under 50 add a screening breast ultrasound to their screening mammogram yearly?

No.  A study looked at IF adding a breast ultrasound to a screening mammogram for women less than 50 years old (regardless of their breast cancer risk)  HELPED detect breast cancers. 

Breast cancer was detected at a similar rate across the groups (those with only screening mammogram and those with BOTH screening mammograms and ultrasounds).  5.4 versus 5.5 per 1,000 screens.  So, the additional screening test did not find more breast cancers than screening mammogram alone.

The downside to getting screening ultrasounds in addition to mammogram are unnecessary breast biopsies.  The breast biopsy rate was TWICE as high for the combination screening imaging compared to women who only received screening mammograms. 

Sometimes more testing is not better testing.

Want more information?  https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2728448

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Hemorrhoids. What are they? What can you/we do to make them better?

Hemorrhoids.  What are they? What can you/we do to make them better?

Hemorrhoids are when the veins near the anus are filled with blood.  Hemorrhoids are the most common benign condition that causes anal bleeding.  You do need to see your physician for diagnosis.  And you may need a work up for other causes of bleeding like anal fissures (a tear in the anal sphincter) or colon cancer. 

What is the initial treatment? Add water and fiber! Take 25 to 35 grams of insoluble fiber (like OTC psyllium).  Increase water intake to 64 ounces per day.  If you are dehydrated, the stool is also dehydrated and this makes it more difficult to pass.  Straining with a bowel movement sends more blood into those already engorged anal blood vessels.  The goal is to pass a daily soft stool, with no straining.  Sitz baths, sitting in lukewarm bathwater, also helps hemorrhoids.  Topical treatments (steroids, antiseptics and analgesics) are often used, but the research does not show overwhelming success.

What if the pain is excruciating and you cannot sit down?  Call your physician.  You may have an acute thrombosed hemorrhoid and this needs medical attention.  The pressure within the hemorrhoid is the uncomfortable part and your physician can incise (cut) the hemorrhoid and take out the blood clot within the hemorrhoid.  This gives most patients instant relief.

What if all of the above does not work?  Then I would send you to a surgeon.  They may perform an office procedure like rubber band ligation to get rid of the problem blood vessel, or they may inject sclerotherapy into the problem blood vessel.  A small number of patients need to be taken to the operating room for an excisional hemorrhoidectomy. 

How to avoid hemorrhoids?  Eat insoluble fiber (vegetable and fruit peels and whole grains) and adequate water intake.  Do not strain with bowel movements.  For occasional constipation, add OTC fiber or polyethylene glycol to your diet.

I hope this has helped.

flickr.com/photos/hygienematters/ 6034747101
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HIV in Nevada in 2020

I recently attended a lecture on HIV in Nevada.  Nevada is way ahead of the nation (read this: we are risky!) HIV Incidence rate is 20 people per 100,000.  The national average is 12.  Nevada has one of the highest rates of HIV in the country. 

Many people who live with HIV do NOT know that they have it.  40% of new infections are transmitted by people who do not know that they have the virus.  This is why widespread screening should be done. 

HIV and STIs go hand-in-hand.  In addition to high HIV rates, Nevada has one of the highest rates of syphilis and chlamydia infections.  Infections are often without symptoms, get tested!

There is a national HIV/AIDS strategy for the USA.  This was started in 2010.  There are 3 overarching goals:

  1. Reduce new HIV infections
  2. Improve health outcomes for those living with HIV
  3. Reduce HIV-related disparities

“Continuum of care” in HIV reveals our goals with HIV patients.  Once a person is diagnosed with HIV, the patient is encouraged to receive HIV care, retain them in HIV care, prescribing antiretroviral therapies, achieving viral suppression.

How are Nevadans doing?  Not well.  Nevada’s continuum of care shows that of those diagnosed in Nevada with HIV only 81% were “linked to care.”  This means 19% of HIV patients do not see a healthcare provider.  Of the 81% who initially saw a physician, only 28% of patients retain their healthcare relationship.  This means only 28% of patients are getting viral loads and medication.  26% of those with HIV in Nevada have reached viral suppression.  When the virus is suppressed, this decreases the risk of viral transmission to others.  So, viral suppression is the goal!

How can we end the HIV epidemic?

U = U.  Undetectable = Untransmissable.  The data is incredible relating to this. Thousands of sex acts have been studied and those HIV positive patients on effective HIV treatment with undetectable viral loads will not pass HIV on with sex. 

Treatment as Prevention.  Patients need access to testing and treatment.  Support needs to be available to maintain viral suppression as this will help retention.  Need access to viral load monitoring.  This needs resources. 

PrEP.  Pre-Exposure Prophylaxis.  This is for patients who are HIV negative which means patients need to know their HIV status.  They take one pill a day.  Two medications are in this one pill and there are two brands of pills with different doses of the two active medications.  It is 99% effective.  PrEP use in HIV-negative-Nevada is only 1% of the population, many don’t know that there is a VERY effective pill. Truvada or Descovy

nPEP.  Non-occupation Post exposure Prophylaxis.  (This is NOT a healthcare worker who has a needlestick).  This must be started within 72 hours of exposure.  28 day treatment (Truvada plus Raltegravir).  Highly effective.  Minimal side effects.  Does this patient want to start on PrEP after their 28 day treatment to decrease their risk of contracting HIV in the future?

STI (sexually transmitted infections).  Those with STIs are more at risk for HIV.  What body parts should be tested?  3 site testing: oral, rectal, urine-based.  Because different body parts are being used to have sex, all 3 need to be tested. Oral and rectal swabs can be done very effectively by the patient.  We miss 95% of gonorrhea and 73% of chlamydia because we often do not do 3 site testing.

Why is the way sex is performed important?  There are different risks of contracting HIV from a partner depending on the manner of sex.  Receptive anal sex has 1.4% risk per episode which is remarkably higher than any other manner.    Insertive anal sex is 0.06 to 0.62%.  Receptive vaginal sex is 0.08%. 

flickr.com/photos/ hebe/ 3310171434/
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What should your doctor ask you about your sexual health?

The 5 Ps for sexual history taking

Partners.  Who? Men? Women? Transgender? All? How many? Do your partners have sex with others?

Practices.  What kind of sex: vaginal, anal, oral?  Do you use condoms?  Why/Why not?

Pregnancy.  Do you want a baby in 9 months? What are you doing to prevent pregnancy?

Protection from STIs.  What do you do to protect yourself from STIs and HIV?

Past history of STD. 

Have you ever had an STD?

Have any of your partners had STD? 

Have you been tested for HIV?  When was the last time? Any new partners during that interval?

Have your or your partners ever injected drugs? 

Have you or your partners exchanged money or drugs for sex?

 Is there anything else about your sexual practices that I need to know? 

I hope this helps.

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Will botox help your migraines?

Will botox help your migraines?

It depends.  If you have chronic migraines with more than 15 (!) headache days per month and at least 8 of those headaches being a migraine, YES! It will help you.  If you have fewer than 15 headache days per month, it may not help decrease your pain-free days.

In one study botox was shown to reduce the number of migraine days per month by two days compared with placebo (sugar pills).  Botox is FDA approved for treatment of chronic migraines.  This approval may give you a better chance at your insurance paying for this treatment, but of course, that is never guaranteed. 

There was a metaanalysis (a bunch of research studies with the results collated together) with nearly 4200 patients which showed that botox reduced the number of migraine days per month for 3.1 days in patients with chronic migraines.

What are the drawbacks to botox?  Botox is delivered by injections which inherently has some discomfort.  But, otherwise no serious adverse effects were noted.  Mild symptoms were arm muscle weakness, eyelid drooping, neck pain, and injection site pain. 

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Is this what I signed up for?

I Didn’t Sign Up For This…

(Medical school graduation 1995)

Many years ago, when I first considered pursuing a career in medicine, I thought long and hard before going down that road because I knew it would involve sacrifice. My dad was a surgeon, so, as much as any child can understand, I did. I understood the lifestyle of being called away, of working nights and weekends, of having healthcare decisions weigh on my mind. When I finally made the decision, I knew right away there were certain things I was signing up for. But medicine was my calling. I felt it what I was meant to do so whatever it took it was worth it.

I knew even then that I was signing up for a lot of nights studying instead of socializing or relaxing. I signed up for difficult classes and long nights. I signed up for volunteering in a hospital throughout college and stressing about grades and spending the summer studying for the MCAT. But I didn’t sign up for this.

When I got accepted to medical school I knew what I was signing up for. I willingly signed up for even more, even longer nights studying. I signed up for dissecting cadavers, high pressure tests, and losing touch with some of my best friends from college. I signed up for being at the hospital at 6 AM, losing 15 lbs during surgery rotation because I never had time to eat, and talking to friends on the phone to make sure they didn’t fall asleep driving home after a call shift. But I didn’t sign up for this.

When I entered Family Medicine Residency I signed up for moving halfway across the country (Kansas!). I signed up for working 80+ hour weeks, 30 hour shifts, and not sleeping in my own bed. I pushed my boundaries for what I felt comfortable doing: I worked as the solo physician in a small-town ER for 60-hour shifts so that those doctors can recharge. I signed up for spending my birthday on call and making an average of about $4 an hour. I am a good re-framer: I was on obstetrical call one birthday and felt blessed that I could welcome newborns to share my birthday. I signed up for stressed out patients and the responsibility of their health in my hands. But I didn’t sign up for this.

I followed my husband to rural Indiana while he completed his specialized medical training. I got a job teaching at the local medical school’s rural training site for family medicine and realized my love of academic medicine, for welcoming the new physician into my field. I put off having our first child until we had a more reasonable work schedule. But I didn’t sign up for this.

I didn’t sign up for spending more time with my computer than with my patients. I didn’t sign up for insurance companies dictating what tests and medications my patient can and cannot receive. I sure as hell didn’t sign up for a government official who doesn’t know a stethoscope from a horoscope telling me how often my patient needs to be in the hospital or cutting my reimbursement because someone was angry I didn’t refill their narcotic prescription early. I didn’t sign up for being told I’m not allowed to use the appropriate personal protective equipment in order to keep my immunocompromised patients, my colleagues, and myself safe because there’s not enough to go around.

I educate the new residents about how to become more efficient, how to work within the current cumbersome system. I encourage them to feel joy in everyday and to appreciate small accomplishments. I don’t want the next generation of physicians to throw in the towel, to not care for patients.

I knew what I was signing up for. I didn’t sign up for this.

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