December 11, 2014

And Now What?

Ebola virus has been in the news. The media has made it impossible not to be concerned or even scared. The virus was transmitted to the United States through an infected person. As we have made the world smaller, the ability for communicable diseases to spread rapidly, and somewhat silently, has been exposed. Are we to stop traveling? Hopefully not.

We need to be aware of diseases that may be contracted while traveling. All possible preventative measures, including vaccines, should be taken. An example is a virus relatively new to the Western Hemisphere, having arrived in 2013 - Chikungunya virus.

I was not aware of the virus until an unfortunate patient provided the opportunity to educate me. The patient had been on vacation in the Caribbean, contracting this virus from a mosquito bite. A vacation ruined, however, fortunately, a complete recovery.

This virus originated in West Africa, and subsequently spread to the islands about the Indina Ocean, to India, to the Caribbean, to Central America and to South America. Cases have been recently documented to have originated in Florida. On many occasions a tourist on vacation to one of these locations has been infected by the virus through mosquito bites of 1 or 2 specific common species of mosquitos, causing transmission to other parts of the world in which these mosquitos live.

Symptoms are flu-like illness with initial high fever, headache, back pain, muscle aches, and truncal rash. A key feature is severe joint pain primarily involving the hands (knuckles), wrists and ankles. The joint pains usually resolve with the recovery from the infection, usually in 7 to 10 days. However, the joint pain may last for months or years. Definitive diagnosis can be obtained through specific antibody blood tests. There is no specific treatment.

I bring this topic to you at this time because many people begin traveling to warmer climates for comfort and vacation. Diseases that are known to the medical community in these foreign locations may not be readily known to physicians and other providers in the United States, or specifically our local community. Please check with travel agents, the Internet or other sources to be sure you are adequately protected. In the case of the Chikungunya virus, mosquito protection with appropriate sprays or mosquito nets would be important.

Have a safe trip, be careful, bon voyage.


October 24,2014

Changes

On October 13, a significant change occurred within the practice. I am welcoming Nora Dyer as the Office Administrator for the practice. Shelley will become our Wellness Coordinator for the "Take  Shape For Life" and weight management programs, also working with me to expand the programs to reach more of you who have an interest and a need. Shelley can be reached through the office phone number: 909-945-2425 or cell phone number: 909-395-6517.

Nora has over 15 years experience as a medical office manager for 2 local physician's practices. Nora brings management skills, technical and procedural expertise and a priority in customer service to the practice. Please welcome her and I encourage you to give feedback as we turn the page into the next chapter of the history of this practice.

We all wish to thank Shelley for her service over the past almost 10 years.  She helped shepherd the practice through some difficult and trying times. She also played a huge role in the planning and movement of the practice to present location over 6 years ago. I am pleased she will continue to serve the practice by offering her expertise and nursing background for the Wellness Program.

Change.  Does it seem that every time I write to you I am starting with this word? In reality, everything changes. Yes, we all yearn for the familiar and enduring; comfortable and safe.

Health care is complex and simple, large and small, national and local, you and me. Were the old days of very personal, hand-holding but limited treatments with  "little black bag" home visiting doctors providing better care than the life-prolonging, life-saving, sophisticated technology, powerful medications, less invasive surgical procedures, intensive hospital care and sophisticated home treatments of today?

Are large medical provider groups, hospital chains, mail-order pharmacies, insurance companies and government funded health plans better than the neighborhood pharmacist, stand-alone nonprofit Community Hospital, solo pay-as-you-go "family" doctor?

This is just a small sampling of what was then and what is now. You may ponder your own conclusions regarding the merits of each of these.

The one aspect of healthcare where we both have the most significant input is between you and I. The relationship, which usually starts under trying circumstances (pain, discomfort, illness, despair) hopefully grows through the skill I offer, understanding and trust as we engender to build a long-lasting and fulfilling relationship. My relationship with you is the main reason I continue to practice in the present setting as a solo practitioner. I work to keep outside influences either as an asset or from interfering with my pursuit of what is, in my opinion, your best medical care. I always encourage your input and opinion because we do this together. Ultimately, it is your body, mind, and life. This can never change.

What does the future hold? You may ponder.


August 27, 2014

I have done as I have asked

Many of you, having been to the office in the last six months, have noticed my weight loss. As a chronic and generally unsuccessful dieter, I know full well the difficulty many of you have in losing weight. One of my major difficulties has been decreasing my intake of sugars and starches. Sound familiar?

The U.S. food industry reminds us on a continuous basis to eat poorly: television, magazines, billboards, and Internet ads. The list goes on and on. The indoctrination begins early with baby food, and never ends. How do you really do this – eating and living healthy?

I have had occasional success counseling patients on techniques that I have found successful. But honestly I have had neither the time nor real expertise to help people adjust their mentality (habits) about food, exercise, and health. These are not included in reimbursements for healthcare and I have been unwilling to set up a secondary business to administer a program of smoke and mirrors full of pills, shots, and false promises.

Shelley, my wife and office manager, and I have been participating in a program called Take Shape for Life. In a nutshell, the program integrates weight loss, lifestyle, and habit changes to create an individual health environment that can be maintained for a lifetime.

This weight loss program focuses on caloric reduction, portion controlled meal replacements (Medifast), healthy eating, and low energy expenditure exercises. Lifestyle changes involve controlled learning and practicing healthful eating, individualized increase in intensity of exercise, as well as support and motivation techniques. Pursuing an individual healthy environment additionally involves stress reduction, and on going healthful eating.

As many of you gather, this process is on going – from creating this healthy lifestyle to maintaining it indefinitely. Shelley is a qualified independent health coach and is available if you are interested.

I am bringing this to you because so many of you have asked. I am not making this a part of the practice. I will support you and counsel you (and prescribe to you when appropriate) if you choose an alternative method for weight loss, exercise, and becoming healthier. Through this website I will place a special emphasis on educating you on obesity and its effect on health, since this condition is causing so much disability and illness in my practice and our community.

If you would like to contact Shelley about Take Shape for Life, you may call her at the office at (909) 945-2425. She is available for anyone: patient, friend, relative, neighbor, etc. You can also check our co-branded website here for more information on Take Shape for Life.


April 16, 2014

My Thoughts
I had the misfortune to ‘observe’ one of my patients abuse their disabled parking privilege. I was a bystander, my patient was in the passenger seat, and I do not know whom the car belonged to nor who prescribed the disabled plate. The driver appeared to be lacking a disability. There are so many assumptions made about this abuse problem, however, there is always a sliver of truth.

The California DMV form lacks specificity about disability that is obvious. Physical disabilities that are easy to spot are the use of walkers, crutches, wheelchairs, and leg prosthesis. One question on the form is that of limited mobility. Some examples that may not be so obvious include sore ankles, post-polio syndrome, and recent surgery. Specific disorders stated on the prescription relate to higher levels of heart failure and respiratory disorders with measured oxygen levels below a certain cutoff. But what if on this particular beautiful Southern California day, these disorders were not particularly ‘disabling’? I may have made the assumption that the driver was lazy and been wrong, in that they made have had a not-so-obvious disability.

If I fell for this assumption and misconception of ‘abuse,’ so could any of us. So please, to avoid the bad thoughts and wrath of your fellow citizens, if you own either a permanent or temporary disabled placard or plate, try to follow these tips:

  • Use the handicapped spaces when you need to
  • If you let someone who is not disabled use your car, instruct them to not use the handicapped spaces
  • Remember the times when you needed a handicapped space and wasted half a tank of gas circling or waiting for a space.

You want to use the privilege when you need it, and don’t let it be abused. Ultimately you will lose.

ACO Update
Foothill Accountable Care Group, the voluntary ACO I have joined, was certified by CMS (Center for Medicare Services) and began operations in January. As I mentioned in a previous blog, the goal is to improve coordination of care and the overall health of seniors and other Medicare patients in our community.

The program will evolve over time. Electronic health care records from multiple providers – other physicians, hospitals, facilities, etc – will be available through a central repository to allow continuity of care in order to minimize duplication of services, tests, and procedures. When functional, these processes can only improve care while decreasing risk imposed on patients.

As my Medicare patients know, there is a need for transfer of information from Medicare to the ACO. Notices were sent to your home in February. We have discussed these forms at our office visit, and many of you have called the office to receive clarification and instruction. If any Medicare patients have questions about the ‘Transfer of Information’ from Medicare, please let the office know.

To reiterate, the ACO allows Fee-for-Service patients to seek medical care services without restriction. My request is for us to have open communication of the services you are seeking to allow for my guidance. This is just one of the many ways I try to manage your individual healthcare in the changing environment.

Tidbits
Sex, Drugs, and Rock & Roll..?!

  • Testosterone replacement in older men may increase the risk of heart attack or stroke. Two recent retrospective studies published late last year reviewing past data raised a red flag. The FDA has started an investigation of the risk.
  • Menopausal symptoms (hot flashes, vaginal dryness, etc) are troublesome, and sometimes worse, and may cause problems for middle aged and elderly women. Estrogen remains the most effective treatment, but it comes with an increased risk of heart attack, stroke, breast cancer, blood clots, and uterine cancer. Several new medications have become available for specific symptoms. These are expensive and have annoying side effects, but may be worth a try. Over the counter vaginal lubricants and moisturizers may help, but supplements have little evidence of any benefit.
  • Green tea may interfere with absorption of some medications. The intestinal transport protein – OATP – is inhibited by catechins in green tea. This may decrease the blood levels of Cipro, Levaquin, Atenolol, and Levothyroxine – both brand name and generic types. Drinking two 12-ounce drinks of green tea per day for two weeks can cause the effect. This can be avoided by switching to black tea, or letting me know so I can change medications.
  • There have been several local earthquakes of a large enough magnitude to catch our attention. Unless you are willing to move, you should be prepared for disruptions of essential services. Know how to turn off the gas coming into your residence. Keep at least three days of water and freeze-dried or canned food in stock, working flashlights, and battery operated radios. Contact the city or state for other suggestions. Be prepared.

Next Blog: Sometime in the future.


December 23, 2013

From all of us to all of you, we wish you all a very happy, safe, and healthy holiday season. Please take a few minutes to think about the last year: the good times and the trying times the happy times and the sad times, the heartbreaking times and the renewing times. Share the small victories and learn from the small mistakes. Mourn the terrible losses and rejoice in the additions and huge gains. Make your promises (resolutions) realistic and doable. Do not set yourself up for disappointment. Remember that those little victories are what make the big winners possible.

I thank all of you who continue to trust the care and concern that the staff and I give to you, your family, and your friends. That trust is our highest priority for you and in the community at large.


September 23, 2013

The following services are currently available:

  • Flu injection
  • Pneumonia injection
  • Whooping Cough vaccination

Happenings
Yours truly will be making his acting debut Sunday, September 29 at 2 pm at the Lewis Playhouse in Victoria Gardens. The San Antonio Community Hospital Medical Staff Variety Show will be raising funds for the new hospital tower and Emergency Room currently under construction. Tickets are still available. Please visit www.lewisfamilyplayhouse.com for ticketing and information. I hope to see you there.

Our Electronic Health Records
We are now receiving lab and x-ray reports directly from the hospital. You can now view your personal lab work on-line by visiting www.clinixvault.com and entering your login information. If you need assistance, give us a call and ask for Michael.

Obamacare (Affordable Care Act)
The situation with this complex legislation is apparently moving forward. The state will be marketing California Care, its insurance product to be offered as the State Exchange. Lower income families and workers lacking insurance are being targeted first. If you fit into one of these groups, please heed my warning: any insurance is better than no insurance, even if I lose you as a patient. Your health and safety has always been more important to me.

A provision of the ACA allows the formation of Accountable Care Organizations, or ACOs. These organizations are groups of physicians aligning with each other, hospitals, nursing homes, home health agencies, and other health care providers to serve the Medicare fee-for-service population. The goal is to decrease the cost growth curve of Medicare by ACO providers coordinating the complex continuum of disease processes. This is to be accomplished by all providers following evidence based medical guidelines, use of connected information technology, establishing, modifying, and utilizing tools to achieve high quality coordinated care for population healthcare.

I understand this is a mouthful; a complicated and lofty goal. However, the ability to care for Medicare fee-for-service patients may, in theory, be enhanced. For one, there are no insurance companies as intermediaries. Therefore there is an immediate 20% more funds available to the ACO. Secondly, the ACO pays the hospital and all other providers. This will finally encourage all parties to work together to achieve the best outcome for the patient and population. ACOs will provide a communicative, high quality, coordinated, integrated, and aligned flow of healthcare for the patients. Compliance will be assured by the ACO contract with Medicare.

I have taken some time to introduce this concept to you. Obamacare was established as insurance reform. As the ACO process rapidly evolves, it may prove to be the beginning of healthcare reform as a whole.

It is my guess that all Medicare patients will soon be forced to choose a Medicare HMO, an exchange product, or an ACO. All three are ultimately designed to save money, however the first two will be more restrictive.

I have joined to a locally developed ACO, named Foothill Accountable Care Medical Group, presently awaiting approval from Medicare to begin providing services on January 1, 2014. By virtue of your receiving primary care services by me, you will automatically be assigned to this ACO which will enable me to continue to provide medical care for you. In essence, this will prevent Medicare from assigning you to another ACO or other primary care provider.

By law, you cannot be restricted to any provider, specialist, hospital, or any other Medicare provider. The hope is that you will remain within the ACO, where providers will communicate and work together, contract with highly regarded and trained specialists, and have continuous high quality care for you. This will benefit you the most by keeping communication open between all relevant parties.

Please do not be misled by others advertising and marketing. I will continue to update and expand your understanding of these entities as timely and completely as I can.

Medical Topic - “Are you Juiced?”

An article in the September issue of the American Journal of Medicine addressed a topic that is just beginning to be researched.

Some patients have been blending large volumes of fruits and vegetables for presumed improved health. However, there are risks of “juicing” you should be aware of.

One component in a large number of these vegetables is oxalate. In high concentrations, especially when mixed with fruits or taken with Vitamin C tablets, oxalate can lead to kidney stones and directly damage the kidneys.

The most common fruits and vegetables very high in oxalate include:

  • Beets (both roots and leaves)
  • Chard (Swiss)
  • Collards (greens)
  • Kiwi
  • Leek
  • Okra
  • Parsley
  • Sweet Potatoes
  • Rhubarb
  • Soybeans (and many soy products)
  • Spinach
  • Star fruit

Calcium is known to bind oxalate in the intestine, limiting absorption of calcium into the blood. Low dietary calcium at the time of Juicing can increase the toxic load delivered to the kidneys.

Oxalate is the end product of Vitamin C metabolism, and very high doses of Vitamin C have been known to cause kidney failure. In addition to this direct toxicity, foods or supplements containing a lower, yet still high, amount of Vitamin C result in oxalate stones and oxalate induced kidney damage by overwhelming the kidney’s ability to clear the oxalate.

If you are juicing, please consider different combinations to decrease exposure to very high amounts of oxalate containing foods, increase calcium intake daily, and avoid excessive (over 500 mg/day) amounts of Vitamin C.


May 6, 2013

Dear Patient,

Thank you for sticking with me as the practice continues to implement our electronic health record system. As you know, I have a problem with computer technology. I am slowly becoming more proficient with using the computer in small leaps and even smaller bounds. I recognize the benefits of this technology as it relates to your interaction with the practice. One advantage of using this technology is the potential to communicate through electronic means. With this in mind, I can pass along important and informative messages through our website.

This will be increasingly important to the practice as a whole. I know if I wish for you to check our website, I need to give you a good reason or two to do so. I have decided to update my blog every couple of weeks. This will allow me to keep you informed on the development of our patient portal, as well as how you will be able to use this to make it easier to interact with the practice. I am also planning to provide valuable information on a range of topics dealing with medicine in general as well as our practice. I thank you for patience.

And to let you know…

We have successfully completed Meaningful Use (of electronic data) Stage 1 recognized by the Center for Medicare Services (or CMS). I have been recognized by CMS as an electronic health record user.

Tennis Anyone?

Tennis Elbow (or Lateral Epicondylitis) is a common overuse injury. It is felt as pain in the outside of the elbow with grip and twisting movement of the wrist. The recommended first treatments are icing or stretching of the elbow, NSAIDS (Non-Seteroidal Anti-Inflammatory Drugs, i.e. Ibuprofen or Aspirin), and rest.

A study recently published in the Journal of the American Medical Association (JAMA) confirmed that physical therapy alone resulted in a better outcome than physical therapy while receiving cortisone injections. In this study, the group who received a placebo saline injection had a recurrence rate of 12% after four weeks of initial resolution of symptoms. This is compared to a 54% recurrence rate with the group who received an injection of corticosteroid.

If you have a non-traumatic injury of the elbow, try to rest, ice the elbow and take one dose of NSAID if it is not a danger to you. If there is no significant improvement in one to two weeks, please call for an appointment.

Sincerely,
Dr. Arnold Roth, MD


April 1, 2013

As many of you are aware, the practice has begun the transition to the electronic health record. Starting in September, the process has been time consuming, difficult, and frustrating. Information has to be reentered into the record, on time corrections made, billing processes altered and significant workflow changes have occurred in the office. However, as we enter into the sixth month of operation, I believe we have turned the corner and are becoming more comfortable with all these changes.

I anticipate that your wait times will decrease and return to normal, as was my goal. I anticipate the process of reviewing labs, x-rays, prior records, etc, will improve leading to more efficient use of our and your time. My record production is back to completion after the morning or afternoon sessions, which has allowed each encounter to be completed within the next 24 or 48 hours.

We are moving along. We are back to our previous workload and availability for acute and routine follow-up appointments. Please give us any feedback you may have. We are changing how we do things, so your ideas and comments are extremely important.

In my last communication I promised more detailed information on coronary artery events during marathon running. Having realized there are quite a few half and full marathon runners in the practice, it is important to understand the process and perform preventative treatment.

Although training provides a lower risk of heart disease, the actual race paradoxically elevates the risk of heart attack. The frequency of these attacks is 1 case of sudden cardiac death for every 126,000 runners, based on 26 events among 329,269 participants in marathon races over a nine-month period. The cause appears to be related to coronary artery plaque rupture with coronary thrombosis (or a blocked clot over the ruptured non-obstructing plaque) without warning in low-risk athletes. The process of unresolved actuation of inflammatory chemicals and proteins induced by the severe exercise produces leakage of muscle proteins into the bloodstream (also known as ‘hitting the wall’).

The most frequent time of attack was during the sprint over the last 500 yards. This process is the same in women, however it is probably secondary to hormonal proteins in those under the age of 40.

Aspirin confers protection and should therefore be taken on race day. It may be worthwhile to check a CRP (inflammatory marker) in long distance runners. This protein is pro-inflammatory, overlooked among racers, and can be treated with a statin.

NEXT BLOG ENTRY: SOONER THAN THE LAST


December 11, 2012

As many of you are aware, the practice has begun the transition to the electronic health record. Starting in September, the process has been time-consuming, difficult and frustrating. Information has to be reentered into the record in an electronic format, corrections completed in a timely fashion, billing processes have been altered, and significant workflow changes have occurred in the office. However, as we enter the fourth month, I believe we have turned the corner and are becoming more comfortable with all of these changes.

I anticipate your wait times will decrease and return to minimal, as has been my goal since the start of this practice. I anticipate the process of review of laboratory and x-ray results, previous records, etc. will improve leading to more efficient use of your and our time. My daily entries into the electric health record has again returned to completion after the morning and afternoon sessions, making the billing, consults, lab and x-ray requests, medication changes requiring authorization, as well as your accessing your individual information possible within 24–48 hours.

We are moving along. We are back to our previous workload and are more available for acute and routine visits. Please give us your feedback. We are changing how we do things, so your ideas and comments are critically important at this time.

Practical clinical literature

In my last communication I promised more detailed information on coronary artery events during marathon racing. Having realized there are quite a few half and full marathon runners in the practice, it is important to understand the process and preventative treatment.

Though training provides a lowering of risk for heart disease, the actual race paradoxically markedly elevates the risk of a heart attack. The frequency is one case of sudden cardiac death for every 126,000 runners (0.8/100,000) based on 26 events among 329269 marathon races over 9-year period. The cause appears to be related to coronary artery plaque rupture with coronary thrombosis (blood clot over the ruptured non-obstructing plaque) without warning in low risk athletes. The process involves activation of inflammatory chemicals and proteins by the severe exercise, which induces leakage of muscle proteins (creatine kinase) that enter the blood stream (" hitting the wall"). The most frequent time of heart attack was during the sprint over the last 100 yards.

This process is more frequently seen for women. However, the frequency is decreased probably secondary to hormonal protection in women under the age of 40.

Aspirin confers protection and should therefore be taken on race day. It may be worthwhile to check a highly sensitive CRP (inflammatory protein marker) in this type of long distance runner. This protein is pro-inflammatory, increases during racing and can be treated with a "statin."

In ancient Greece, the basis for the 26-mile distance of the marathon was chosen because that was how far that Pheidippides ran to deliver a victory message to the Athenians. After running across the Plain of Marathon, he died.


September 4, 2012

Dear Folks,

I have most important news for the practice. We are going digital – electronic health records – on Friday, September 7th. This will impact almost every aspect of the workings of the practice.

The Staff has an excellent handle of this process. I have a coach (yes, my son, that voice that confirms appointments) and we anticipate a relatively smooth transition. As with anything new and this complex, there will be glitches. I ask for your patience and understanding during this process. I sincerely ask you to honestly tell us how this is affecting you. We want to have this transition to EHR work for you. The future capabilities of the system and anticipated interface with other physicians, labs, and San Antonio will lead to more efficient and effective care for you.

I apologize for not informing you of this transition in a more timely fashion. But, as most of you know, I am a traditionalist. I am making small steps and great leaps. This process is to ensure this practice can continue to provide you the personal care you have come to enjoy and deserve, and service you, your family, and our community in the best way possible.

Here are a few brief notes:

  • Flu and pneumonia vaccines being given – call either Leslie or Julie to set your time to minimize waiting.
  • If you are a long distance runner, especially those over 35 years, take 81mg of Aspirin per day to decrease the risk of sudden heart disease or death. Details to come in the next update.

Arnold Roth, MD


April 19, 2012

I have finally given into the 21st Century. With great pride and a little trepidation, the practice has established this website. I wish to thank my son, Michael Roth, without whose help and urging, this may not have occurred until the 22nd century.

In all seriousness, I look forward to using this column to inform you of significant events and happenings that will affect medicine in general as well as the practice and you, specifically. I will provide tidbits of medical information, occasional extended discussions of a specific medical topic, government and insurance coverage, and topics of interests suggested by you. I will also use this space for informing you of significant changes in CFMA, additions or subtractions, as they may affect you.

Our overriding goal remains to provide for you the best medical care in the most effective and efficient manner. I hope this website helps you and is an addition that makes part of your medical life a bit easier. The website will evolve as the practice incorporates evolving electronic capabilities in healthcare. If there is any way to improve the quality of care you receive as a patient, I encourage you to talk with myself or my office manager. Have a pleasant and healthy day.

Sincerely,
Arnold Roth, MD