Monday, February 6, 2017

Face Pain? It Could be TMJ





In primary care we commonly see patients with ear pain, sinus pain or headache.  It's often hard for patients to self diagnose where the pain is originating and they want treatment for sinus or ear infections.   When examination of the ear or sinuses doesn't show a problem, many times we find out that it is from the jaw.


TMJ  (Temporomandibular Joint) or TMD (Temporomandibular Disorder) is a common cause of facial pain and can affect as many as 10-15% of adults.  It presents with pain, ear discomfort, headache and jaw pain. It is caused by inflammation in the joint that opens the jaw, right in front of the ear and sometimes there can be a snapping of the jaw as it is widely opened.  You can think of this joint as a hinge that connects the jawbone to the skull.  Like any joint, it can get inflamed and the surrounding muscles of the jaw hurt.


The treatment for TMJ is resting the jaw from wide opening and anti-inflammatory medication.  Most of the time it resolves within about 2 weeks.  Some patients get relief with a mouth splint that keeps them from grinding or clenching the jaw at night. For severe cases, physical therapy with ultrasound and ice can help.  Rarely a corticosteroid injection or botox can relieve pain and relax the muscles.


Remember, not all face pain is from sinuses or ears and antibiotics will not help if it is TMJ pain. Usually a course of anti-inflammatory medication (ibuprofen, aleeve)  is all that is needed.

Friday, February 3, 2017

What Defunding Planned Parenthood Really Means







Planned Parenthood clinics have been a  political football for over a decade. Planned Parenthood operates about 650 health centers across the United States and 2.7 million men and women visit the clinics each year.  In fact, an estimated 1 in 5 women has received care from PP at least once in her life.  For many women, Planned Parenthood may be the only place to receive reproductive health care near where they live.  They provide basic women's preventive care (pap smears, STD testing and treatment, counseling, contraception, IUD placement and long acting reversible contraception) and even basic primary care.


 Of all the health services Planned Parenthood provides, they report that about 3% are for abortion.  Most women receive other services at the same time (pregnancy testing, future contraception) that can skew this number and critics say the abortion percentage is higher, (calculated to as high as 7%), but there is no dispute that Planned Parenthood provides more needed health care for women that goes far beyond terminating pregnancies.


Repeal of the Affordable Care Act would ban Planned Parenthood from receiving Medicaid reimbursements and federal family-planning funds, accounting for loss of over $500 million in government funding per year, about 2/5 of its total revenue.  It is important to know that Medicaid funds already cannot be used for pregnancy termination unless the mother's life is in danger.  So defunding Planned Parenthood is really defunding women's health care.  Period.


We currently have a shortage of primary care doctors in the United States and fewer doctors have sufficient training and expertise in the full range of reproductive health services.  Planned Parenthood provides this needed care.


Defunding Planned Parenthood is an act that Congress should not undertake. American women deserve better.

Saturday, September 10, 2016

How to know if something is infected



How can you know if an injury is infected?  Patients are often concerned when wounds don't heal right away and this causes them to make needless visits to the doctor or emergency room.  Here is a pic of a wound that is about 6 days old.  My little dog scratched my arm while I was giving her a bath.  (Isn't she cute?)

 Is this scratch infected?

If you said no, it is healing well, you would be correct.  Even though it is still swollen around the scratch and it is obviously red and a little warm, these are signed of normal skin healing. I can picture my white blood cells and monocytes racing to the area to deal with bacteria from the scratch.  The redness and swelling are an inflammatory response that my immune system is producing to contain the bacteria and turn over new cells.

Signs of infection would be redness that continues to extend outside the wound that is worsening over time.  The swelling wouldn't stay the same, it would expand day by day.  The cut it self might start oozing under the scab that is forming.  If any of that occurred, it would be time to get it checked out.

As we get older (ahem!) we heal more slowly.  Cuts and lacerations might take weeks to heal, rather than the days of healing that occurred when we were youths. This is normal also.

The best thing to do when you get a scratch or cut is to wash it with regular soap and water.  Antimicrobial soaps do not offer any advantage and sterile water is not needed.  Cover the wound with a bandaid or clean gauze.  If it is a deep cut that continues to bleed, that is a sign that sutures (stitches) might be needed.  Otherwise just let your body do its magic and heal.`


Wednesday, July 6, 2016

Why Can't I Have a Dentist EHR?



Imagine my surprise and delight when I saw my dentist this week for a check-up and found the electronic health record to be both informative and patient friendly. As I sat in the dental chair, the large monitor screen was swung over in front of me and my dentist was at my side going over it with me. The monitor was not a barrier...it was part of my exam. The print was large, the information on the screen was easy to understand. Together we updated my health history, current meds and corrected errors. She held a small pad and changed things as we spoke. As the exam progressed she was able to swing the monitor over and show me X-rays, a fracture line in my tooth, a hazy spot that needed more investigation. We looked back in time and compared. The computer was a welcome addition in the exam room and the amount of clicking and recording of information was simple and intuitive.


Compare this with the EHR that I use, which by the way, is rated one of the best and is extremely expensive to purchase, install, and maintain.  The user interface is so busy and non-intuitive that to show it to a patient would be distracting and eye-numbing. The number of clicks, scrolling and entries needed to see even one piece of information makes it nearly impossible to use as education for a patient. In fact it is so time consuming and such a burden in the exam room that an entire new industry has sprung up to deal with the EHR called "scribes". It an attempt to free up the beleaguered physician and restore patient-physician eye contact and connection, many doctors are paying for a 3rd person to be there in the room just to record the visit notes and do the electronic paperwork.


My dentist was done charting by the time I left the exam room. I, on the other hand, face hours of after visit typing into my EHR, often long into the night. Even a simple ordering of an e-prescription requires about 6 clicks, entering diagnoses, proper ICD-10 codes,  dealing with alerts that tell me that diagnosis does not qualify to be covered by Medicare, secure sign-ins and special authorizations needed for schedule 2 and 3 drugs, and on and on. That's just one function and one medication. Multiply that my thousands.


No doctor wants to go back to paper charts but we shouldn't accept the current stock of medical electronic health records.


The dental EHR was clealy developed for true dentist workflow and user satisfaction. The medical EHRs were developed for billing, coding and government requirements. I want what the dentists have. And I bet my patients do too. 

Tuesday, May 24, 2016

What is Shingles?

Thanks to my patient for allowing me to use her photo to talk about a common condition known as Shingles.  The medical name is herpes zoster and it is caused by the re-activation of the chickenpox virus (varicella zoster).  This crazy virus lays dormant in the nerves and something causes it to flare up years or decades later.

The first signs of the rash
This patient noticed a small rash behind her right ear and thought it was insect bites after a camping trip.  She had some tingling (a common sign) and swollen and tender lymph nodes.  Two days later when I saw her, the rash had spread down her neck and shoulder and she definitely had lymph node swelling at the neck and above the clavicle. (nuchal and supraclavicular nodes).  She had no fever but felt a little down.

Most shingles occurs in older people but it is not uncommon in younger folks too, like this patient.
The rash takes about a week to develop and can last about 2 weeks with varying degrees of pain and annoying tingling.  Some patients have pain that lasts in the nerves long after the rash has resolved.

We treat Shingles with antiviral medication (Valcyclovir ) and pain control.  People over the age of 60 are recommended to get Zostavax vaccine to help prevent an outbreak.  It reduces the chances of Shingles by 51% and even higher reduction of post-herpetic neuralgia pain.

No special tests are needed to make the diagnosis. This is another reason everyone should have a primary care physician who can make the diagnosis and get the patient started on treatment.

Monday, May 16, 2016

Transparency Price Tools Did Not Lower Health Costs

For years experts have been saying if consumers knew the price of certain health care services they would be able to decide what services bring "value" and they could be better "shoppers" of health care.  Since so many patients have large deductibles and copays, it has been conventional wisdom that providing transparent prices would lower overall costs.  As people are spending their own money, giving them prices to compare should make them savvy consumers, right?
Wrong!  The Journal of American Medical Association, JAMA, did a study of employees that were given access to price transparency tools and it did not lower health care spending.

The authors compared the rate of change in health care spending among employees of two employers who offered a tool where they could compare prices of what they would pay out-of- pocket for various physician, lab and hospital services.  Top searches were for colonoscopies, obstetric services, office visits and gastric bypass surgery.  The majority of searches was for services over $500 and more than  half had price estimates over $1250.  They compared the spending of people who had access to these price estimators and those who did not.  They even found that people who had the price estimators, had increased out-of-pocket health care spending compared to those who did not. The study matched the two groups for age, sex, health condition and type of insurance plan.

What can we make of this strange result? First, only a small percent of employees who were offered the tool even used it.  Obviously it has to be used to be effective.  Maybe it was too cumbersome or difficult to use. Another reason may be patient perception of quality. Other studies have shown that patients erroneously think higher price means higher quality. If patients think a lower cost health service is inferior, they might shy away from it.  And since most of the searches were for expensive services, patients might think they were already using their entire deductible so they may as well go for the expensive ("perceived higher quality") medical service.  

It is also quite possible the health care is NOT like going to the grocery store or other retail purchases. Patients may not like price shopping and comparing when it comes to something as important as their health.  A recommendation from one's trusted physician about who to see and where to go may override a price comparison website.  Health care can be scary and baffling to many people and the risk of making the wrong choice is much more serious than buying the wrong Ketchup at the market.

This important study showed that we may need to look at other ways than price transparency tools to help patients bring down the cost of health care in the United States.

JAMA, May 3, 2016,Vol 315

Coffee, Tea and Heart Disease