Wednesday, December 16, 2015
Well, I was never really gone...just on a little blogging hiatus as the new office gets up and running.
It appears than many of my new and prospective patients are Googling me, and many seem to have questions about who, exactly, I am. Therefore, I figured I'd make a little Frequently Asked Questions list.
Q: How old am I?
A: Old enough. Seriously, though, I think people are really asking one of two questions: "Is she some wet-behind-the-ears-fresh-out-of-school newbie?" or "Is she as old as the hills and 6 months away from retirement?" This answer is that I'm neither. I'm firmly in the middle-aged category. I graduated from medical school in 2000. I finished residency and chief residency in 2004, and I practiced in New Hampshire for 11 years before moving here.
Q: Where did I come from? Why did I move here?
A: I grew up in New Jersey. I lived in New Hampshire for 11 years before moving to Florida. I moved here to be closer to family and to get away from the endless snow and cold of New England.
Q:Where did I go to school? Where did I do my residency? Am I board-certified?
A: I went to medical school at the University of Rochester. I did my residency (and stayed for an additional year as Chief Resident) at St. Vincent's Hospital in Manhattan. I am board-certified in Internal Medicine.
Q: Why is my schedule so open?
A: People say this like it's a bad thing! Don't you want to be able to get into see your doctor? We just opened about 2 1/2 months ago. If you want to get in quickly to see me, now's the time! However, even once I get really busy, I always leave openings in my schedule to see people the same day. If you can't get in to see your doctor when you're sick, what's the point?
Q: Will I have to wait forever in the waiting room?
A: No. I like to run a tight ship and stay on schedule. Patients can help me do this by making sure they arrive for their appointment on time.
Q: Will I listen to you? Or will I rush you out of the room and just push prescriptions at you?
A: I will listen to you. I am definitely not one to push prescriptions. When they're needed that's fine, but I like to emphasize lifestyle changes and healthy living.
Q: What hospital am I affiliated with?
A: I have privileges at Jupiter Medical Center.
Q: Can you call me Marni?
A: Sure. Call me whatever you want.
Q: What is "Marni" short for, anyway?
A: Nothing. That's my full name.
Q: What happens if you get sick when the office is closed?
A: Call my office and you'll get my answering service. I take my own calls, so they will patch you through to me, and we'll talk about what to do.
Q: You have a doctor up north. Do you need to see me, also?
A: If you're here for more than a couple of months, it's a good idea to have a local primary care doctor. You never know when you might need someone, and it's a good idea to have an existing relationship. I send copies of my office notes to your other primary care doctor.
Hopefully this answers your questions! If there's anything I haven't answered, feel free to write questions in the comments section!
Tuesday, September 29, 2015
Change is scary. When you're leaving behind a busy, successful medical practice, terrific friends, a nice house, and beautiful scenery, it's even more frightening.
Sometimes, though, you've just got to take the plunge, because change can also be a really, really good thing.
I'm happy to announce the opening of Primary Care Services of Jupiter Medical Specialists.
If anyone is in the Jupiter, FL area, stop on by to say hi!
Sunday, April 12, 2015
The Fitbit app also integrates seamlessly with MyFitnessPal, which is a terrific calorie tracker. Using the two apps together is a really powerful tool to help lose or maintain weight.
Wednesday, April 8, 2015
Case in point:
I saw a patient recently who is on methotrexate. It's a wonderful drug used for autoimmune conditions, such as rheumatoid arthritis. It works by inhibiting an enzyme that allows cells to metabolize folic acid, which is necessary for the growth of certain cells. Because of its mechanism of action, it's completely contraindicated in pregnancy since it will stop the growth of a fetus. Obviously, you need to be careful when prescribing it to a woman who may become pregnant.
Anyway, back to my patient. I got a copy of the note from the specialist who prescribed the patient methotrexate. It includes a very comprehensive accounting of the extensive counseling of the risks and benefits of prescribing the drug, including the risk to pregnancy.
Wednesday, April 1, 2015
Approved? Unable to approve? Which is it???
On a side note...the best thing someone can do for their health is quit smoking. Forget about losing weight, exercising, getting a Pap smear. If you want to get the best bang for your buck, quit smoking. With this in mind, why is it that Medicaid will cover Buproprion and nicotine replacement like the patch or gum, but won't cover Chantix? After all, the results for Chantix are superior to those for nicotine replacement. In the long term, it's even cheaper than trying and failing other therapies. So, what gives, Medicaid? I don't like requirements that my patients "try and fail" medications. I aim for success the first time out.
Monday, March 16, 2015
When I moved to New Hampshire 11 years ago, I was in for a bit of a medical culture shock. One of the biggest surprises was my first realization that there are "Doctors of Naturopathy," or "NDs" in New Hampshire who are licensed to practice medicine. In New York, I had had no experience with this. This is not to say that people there didn't see people who practiced "alternative medicine." What I'm talking about are practitioners who had attended a school of naturopathy and held themselves out to be primary care physicians with equivalent education and training to mine.
My first encounter with this was a patient who came to me because she had been diagnosed by her ND with "heavy metal poisoning." She actually was my partner's patient, but had been squeezed onto my schedule as an emergency appointment because she wanted to be admitted to the hospital immediately to begin treatment. My curiosity was piqued when I saw the chief complaint on my schedule. How does an adult in Portsmouth, NH end up with heavy metal poisoning? Had she had some kind of toxic exposure at work? What kind of neurological problems was she manifesting? Imagine my surprise when I walked into the room and saw a well-dressed, healthy looking woman in her late 40s. She told me that she had seen a local ND for fatigue and difficulty losing weight (her weight was perfectly normal, by the way). The ND had tested her for heavy metal poisoning. She told me she was given some sort of pill, and then had her urine tested for heavy metals. She handed me a lab report that looked something like this:
I never heard from her again. She transferred out of the practice.
That was my first experience. I've had many others through the years...and most of them have been similar. In my experience, most patients that see NDs around here end up being diagnosed with one of several diagnoses- heavy metal toxicity, chronic Lyme disease, adrenal fatigue, or systemic candidiasis. I'm not going to go into each of these issues, save to say that all of those diagnoses are controversial, so say the least. Perhaps in another post.
I was also quite surprised that in addition to NDs being licensed to practice medicine in the state of New Hampshire, they are able to prescribe pretty much anything I can. Here's a link to their formulary. Then, I found out that licensed naturopaths are considered primary care doctors here. Just like me. So, silly me, I figured that their education and licensing process must be just like mine, right? Well, here's a link to the requirements to get a naturopathic license in NH. Here's a link to what's required to get a license to practice medicine in NH. Keep in mind, in order to get a medical license in NH, you also have to submit an application to the Federal Credentialing Verification Service (FCVS). Here's a link to the FCVS requirements.
Equivalent? You be the judge.
Clearly the licensing requirements for MDs are much more stringent than for NDs. But what about the education? NDs claim that their education is actually more complete than traditional medical school, with more classroom hours. Since I've only gone to medical school and not naturopathic school, I've had to take their word for it.
There's a new blogger in town, and her name is Britt Hermes. She attended Bastyr University, which is really the premier naturopathic school in the US. She then practiced as a naturopath, and gradually became disillusioned with naturopathy and the practice thereof. She's blogging about her experiences and her move away from naturopathy, and in doing so has truly exposed the deficiencies in the education given at Bastyr.
Head on over to ScienceBasedMedicine for the full post. It's long, but definitely worth your time to read. Some highlights:
I recently scrutinized my transcript, course syllabi, and student clinician handbook. (Here is a table detailing my coursework into more readable categories based on my transcript; credits were translated to hours based on all of my courses syllabi.) I graduated with 1,224.5 hours of clinical training, of which 1,100 hours were in what Bastyr considers “direct patient contact.”.....More on what Bastyr considers "direct patient contact"...
On a clinic shift, one faculty member (a licensed naturopath) supervised several naturopathic students. ...Each clinic shift had a specific structure that included three elements: shift preview, patient appointments, and shift review.Let me tell you about direct patient care in medical school. Let's take my internal medicine third-year clerkship. It was 12 weeks long. The first 6 weeks were all on the inpatient side. We were part of a medical team on the wards, consisting of an attending physician, a resident, an intern (first-year resident) and the medical student. We would typically arrive around 5 AM to start pre-rounds on our patients, and there were usually between 15 and 20 patients to a team. Pre-rounding is where you check up on how your patient did overnight, examine them, check labs, etc. After pre-rounding is morning report, which would be a didactic presentation of an interesting case. Then comes formal ward rounds. This is where the team rounds with the attending. Presentations of the patient are made at the bedside. A care plan is made for the day. Interesting physical exam findings are shared among the team. This usually takes at least 2 or 3 hours. Then it's time for "lunch." Lunch is always eaten in the lecture hall, because there's a didactic lecture during lunch. After lunch, it's time to start doing any new admissions that have come in during the day so far. If you're the lucky team on call, this will last until 11 PM. If it's just a normal day, it'll last until about 6PM. At 6 PM, you do a final quick round on your patients, make sure they're figuratively tucked in for the evening, and then sign out their care to the night float team who will cover them until you come in at 5AM the next morning.
Shift preview and review took place in the first 30 minutes and final 30 minutes of shift. During these periods, primary students roundtabled their patients. The patient’s medical history, previous visits to the clinic, and previous naturopathic assessments were discussed. Patient cases were presented in a standardized S.O.A.P. (subjective, objective, assessment, and plan) format. The supervisor usually asked students about differential diagnoses and treatment protocols. Medical standards of care were almost never discussed on my clinic shifts, with notable exceptions for one or two of my supervisors who insisted on it, to the dismay of many students. I often heard statements such as, “the patient has a strong vital force and it is expected that the patient will heal in 3 to 4 weeks’ time with proper self-care and home hydrotherapy treatments.” Sometimes, the preview and review was attended by first-year students completing their Clinic Entry 1 requirements. These students generally did not contribute to the discussions but their time was considered “direct patient contact.”
Actual patient care accounted for three hours of a clinic shift. Patient care visits were typically attended by two students, a secondary and a primary. Appointments lasted anywhere from one to two hours. During an appointment, the primary student charted the patient’s current medical complaint and relevant history. This charting included a typical medical intake, such as the seven attributes of the medical complaint, a review of systems, past medical history, medications and supplements taken, family history, social history, dietary patterns, and so on. Vital signs, like blood pressure and temperature, were usually taken by a student. The patient intake also included information thought relevant to naturopathic diagnoses, like toxin and heavy metal exposure, use of plasticware in cooking and eating, birth history, pesticide exposure through eating non-organic foods, food intolerances, religious affiliations, and a host of subjective assessments relevant for energy therapies (homeopathy, flower essences, UNDA numbers, etc.).
And you do this six days a week. One day off for good behavior.
The next six weeks are luxurious in comparison, because they're outpatient. You work alongside a primary care physician in his or her office. So, it's much better hours. We'd start around 7AM with hospital rounds on their patients, then see patients in the office until 5 PM, and then go back to the hospital to check on any inpatients or do any admissions. But we got both Saturday and Sunday off!
By the way...the internal medicine rotation is considered to be one of the "easy" rotations, schedule-wise. During my surgery and OB/GYN rotations, for example, there were days where I didn't even bother going home for 2 or 3 days at a time, because it just wasn't worth it.
And check this out:
They were considered to be competent in treating all cardiovascular diseases by seeing two patients with any type of cardiovascular disease? This is incredible. Also, please take note of what Britt says about the dearth of patients with serious disease. This is incredibly important to note. You can't be a good primary care doctor unless you've seen a lot of serious disease. Here's the thing. Any idiot can diagnose and treat 90% of what we see on a daily basis in a primary care office. The problem is with the other 10%. Those are the patients with strange presentations of either common or rare illnesses. You need to have seen a ton of stuff to be able to accurately diagnose a patient who is presenting in this way.
Now, I posted above about patient contact during my third year medicine rotation. In the fourth year, I did a medicine sub-internship. This is basically where as a fourth-year student, you pretty much function as an intern. So it was more of the crazy rounding schedule above, plus some.
Once I graduated, the training wasn't finished. Internal medicine is a 3 year residency. You're not supposed to work more than 80 hours a week (what a luxury!) but in truth, we often did. By my calculations, going off of 80 hour weeks, I had more than 11,000 hours of patient care in my 3 years of residency.
Naturopaths don't do a residency.
Tell me again how they're qualified to call themselves primary care physicians?
Do you want to see the doctor who is considered competent to treat all cardiovascular disease after seeing two patients with hypertension? Or do you want the doctor who has completed over 12,000 hours of training in internal medicine alone, not to mention several thousand hours of surgery, OB/GYN, psychiatry, pediatrics, family medicine, and neurology?
Your choice. Your decision. After all, it's your life. Literally.
Monday, February 23, 2015
Some lawmakers in Idaho are trying to pass a bill to prevent doctors from prescribing medical abortions (the abortion pill) via telemedicine. Medically speaking, a medical abortion, if done early, is safe and effective. This is also an important option, as there are only four abortion providers in the whole state of Idaho. 95% of the counties in Idaho have no abortion provider. Of course, certain lawmakers can't but help to stick their nose into women's reproductive rights.
Well, get this:
An Idaho lawmaker received a brief lesson on female anatomy after asking if a woman can swallow a small camera for doctors to conduct a remote gynecological exam. The question Monday from Republican state Rep. Vito Barbieri came as the House State Affairs Committee heard nearly three hours of testimony on a bill that would ban doctors from prescribing abortion-inducing medication through telemedicine. Dr. Julie Madsen was testifying in opposition to the bill when Barbieri asked the question. Madsen replied that would be impossible because swallowed pills do not end up in the vagina.Yes. you read that right. This male lawmaker actually thought that if a woman swallowed a "small camera" a doctor could conduct a remote gynecologic exam. Look, I understand that not everyone is a doctor. I understand that not everyone is going to have knowledge of anatomy, although, really, this is pretty basic stuff we're talking about here. But is it too much to ask that people who are stupid enough to think that the vagina is connected somehow to the GI tract try to refrain from passing laws affecting said vaginas?
I've got news for you, Rep. Barbieri. You also can't get pregnant from oral sex. Surprise!
Anyway, I'm just appalled by this and really have nothing else to say. So, Captain Picard and Commander Riker, you have the bridge.