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.

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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. 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%. 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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Why(?!) you may NOT need both pneumonia vaccines…

Why are there pneumonia vaccines?  Streptococcus pneumonia infection is the most common cause of bacterial pneumonia.  We know that older people often need hospitalization or they die from this type of bacterial pneumonia.  We added a pneumococcal conjugate vaccine to the childhood immunization schedules in 2000.  This led to herd immunity and a NINE-FOLD decrease in invasive pneumococcal disease in adults 65 and older.  Wow!

Timeline of 13-valent pneumococcal conjugate vaccine for older adults…

In 2014 the Advisory Committee on Immunization Practices (ACIP) expanded their recommendation for us to give the 13-valent pneumococcal conjugate vaccine (also known as PCV13 or Prevnar 13) to ALL patients older than 65, regardless if they had any risk factors.

Between 2014 and 2018 we have kept watch and despite 47% of Medicare patients older than 65 receiving PCV13 there has been no further decrease in noninvasive or invasive pneumococcal disease and no decrease in mortality from pneumonia.

ACIP met in 2019 and reviewed that information.  Now instead of suggesting PCV13 to ALL people older than 65 ACIP suggests that the patient and physician discuss IF this vaccine is appropriate for them.  Those at higher or highest risk for streptococcus pneumonia are still advised to get PCV13.

What are the risk factors that may lead to more dangerous infections due to streptococcus pneumonia?

  1. The highest-risk group should still get PCV13 regardless of age. Chronic diseases (renal failure, nephrotic syndrome, chronic cerebral spinal fluid leak), treatment with immunosuppressant medications, B and T cell lymphocyte deficiency, HIV infection, phagocytic disorders, cancers of any type, leukemia, lymphoma, radiation therapy, anatomic or functional splenia, sickle cell disease, cochlear implants, multiple myeloma, solid organ transplant.
  2. The group with higher risk (compared to the routine population) should consider shared decision-making with the patient’s physician. What are the higher risk conditions? Chronic heart, liver or lung disease, those living in a group situation (nursing home, assisted living facilities, jails, and shelters), prior pneumonia, those living near a high-rate of non-vaccinators, and substance abusers.

The vaccine is safe and effective at an individual level.  But, because of the decreased burden of pneumococcal disease from the monumental success of childhood vaccination, it decreases the benefit of the PCV-13 in older, well adults.

If a well 65 year old patient chooses to get the PCV13 vaccine, it should be given at age 65 and then the “other” pneumonia vaccine, PPSV23, is given a year later.  Medicare currently pays for the PCV13 vaccine.  If in the future Medicare denies financial coverage for the PCV13 vaccine, it may cost the patient about $200.

See your physician once a year for a well visit.  This is the perfect time to discuss screening tests and vaccines.

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Telemedicine. How to get the most from your telemedicine visit. And, pros and cons to this technology.

What is telemedicine?  Telemedicine is the use of telecommunications technology (telephone or videochat) to provide, enhance, or expedite healthcare.

Benefits of telemedicine?

  1. Convenience…for both the patient and the physician.  The patient does not need to leave home or work, find childcare, or travel to the medical office to get personalized medical advice.  The physician can use the time in the office more efficiently and use technology remotely or at odd hours (nights and weekends).
  2. Safety.  In this pandemic time, this decreases the patient’s exposure to other possibly ill patients in order to see the physician.

Drawbacks of telemedicine?

  1. Less personalized.  You and your physician are not in the same location which may decrease the connectedness of the visit.
  2. Less ability to appreciate the patient’s physical findings.  A joint exam may be difficult to perform well by having the patient do the exam themselves while the physician watches.
  3. No ability to perform procedures.  Need an abscess lanced? An IUD placed?  An ear drum visualized?

How can you prepare for your telemedicine visits?

  1. Find out from the front office staff what app the video chat is on?  Then, get a link to download it.
  2. Test the app (FaceTime? Zoom? Doximity) before the visit.
  3. Have a comfortable spot in your home that’s well lit and with little background noise in mind.
  4. Make a list of concerns you would like addressed
  5. Have your medication bottles nearby
  6. Keep your log of blood sugars or blood pressures to review with the physician
  7. Can you take your temperature, weight, or blood pressure before the visit?
  8. Do you want to discuss recent labs or imaging?  If so, ask the medical staff to confirm the results are in the chart before the visit.
  9. Be ready!

How can you best use your time with the physician?

  1. Confirm a backup form of communication.  If you have an alternate phone (landline or cell) give that to the physician in case your connection is lost.
  2. Please have a loved one in on the visit just as you might if it were in person.  They may add important details to the health history and will aide you in remembering the plan afterwards.
  3. If the visit is for your child, please have a parent/guardian with them for the visit to help with history and performing parts of the physical exam so the physician can visualize it.
  4. At the end of the visit, repeat back to the physician what you understand is the assessment and plan (if you will have a lab order mailed to you or faxed to your lab or if there are changes in medication).  We want you to be engaged and fully understanding your health plan.

I hope this helps.

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Too many medical school graduates?!

Please consider sharing on your page. We need patients to know how this all works.

Did you know that according to the Bureau of Labor Statistics and the Medical Board of California, there are only 3400 psychiatrists in California with a population close to 40 million? That’s one psychiatrist per 11,000 people. Yet suicide is the second leading cause of death for teens, fourth leading cause of death for women between 35-55 and the 11th leading cause of death overall.

While this kind of supply and demand may seem like a winning formula for job security, it is problematic when lives are at stake—patients and physicians.

According to the AMA, in the entire US, there are only 740k licensed physicians. Many of us work more hours than we want or need to, simply to meet the basic demands of our community hospitals. In fact, most physicians work more than 50 hrs per week—this is after residency. Twenty five percent work more than 60 hrs. Each Physician has on average 3k patient-contacts per year. And we’re burning out.

We want need more physicians. We don’t like rushing you out of the door or making you wait two months for an appt, or triple booking patients during our lunch. We hate it as much you do. Many physicians are barely holding on as the system adds more to their daily duties yet offers no long term solutions that will bring relief.

Would it be surprising to know that we want more physicians but we do not determine that?

The number of physicians made per year is tightly controlled as it is linked to Medicare funding.

Congress decides how many psychiatrists there will be in 2020. They determine the exact number of residency positions—these are needed for an MD/DO to become licensed and board certified. We must go through a 3-11 year hospital based residency. In exchange for the Medicare dollars, we offer 80hrs a week of hospital work for those years. We cannot license with any medical board without completing the first year (internship). The additional years are needed to qualify to take our specialty board certification exams.

In essence, an MD/DO is completely useless clinically without a secured residency position. Last year over 1000 US medical school grads were left without a residency position.

Why? Congress hasn’t done its part.

Medical schools have increased their class sizes by 22% in the last decade to meet the demand of an aging population and increase in access due to the ACA.

But Congress has only allowed for a 3% increase per year of residency positions, i.e the number of doctors that will actually be able to work.

So every year, we produce over 1000 Med school grads who can’t go on to practice. This leaves eager, optomistic medical students with huge debt and the inability to use their degrees to practice medicine.

Yet, everyday we hear of a doctor shortage.

For the second time, a congressional act has been introduced to increase residency positions through 2033.

Without this, Americans will have fewer and fewer doctors left to see or the time to get to seeing one will continue to increase.

Patients will continue to be directed toward non-physician “providers” first (seen as less costly than making more physicians).

And even the diehard among us left standing will eventually burnout.

Please consider reaching out to your politician and sharing. The goal is to protect quality healthcare access in the US.

Burning Man 2019
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